Very large treatment effects in randomised trials as an empirical marker to indicate whether subsequent trials are necessary: meta-epidemiological assessment

OBJECTIVE

 To examine whether a very large effect (VLE; defined as a relative risk of ≤0.2 or ≥5) in a randomised trial could be an empirical marker that subsequent trials are unnecessary.

DESIGN

 Meta-epidemiological assessment of existing published data on randomised trials.

DATA SOURCES

 Cochrane Database of Systematic Reviews (2010, issue 7) with data on subsequent large trials updated to 2015, issue 12.

ELIGIBILITY CRITERIA

 All binary outcome forest plots were selected, which contained an index randomised trial with a VLE that was nominally statistically significant (P<0.05), included a subsequent large randomised trial (≥200 events and ≥200 non-events) for validation of the effect, assessed a primary outcome of the review, and was not a subgroup or sensitivity analysis.

RESULTS

 Of 3082 reviews yielding 85 002 forest plots, only 44 (0.05%) satisfied the inclusion criteria. Index trials were generally small, with a median sample of 99 (median 14 events). Few index trials were rated at low risk of bias (9 of 44; 20%). The relative risk was closer to the null in the subsequent large trials in 43 of 44 cases. Subsequent large trial data failed to find a statistically significant (P<0.05) effect in the same direction in 19 cases (43%, 95% confidence interval 29% to 58%). Even when the subsequent large trials did find a significant effect in the same direction, the additional primary outcomes in most of these trials would have to be considered before deciding in favour of using the intervention. Subsequent large trial data found a statistically significant effect in the same direction in 19 of 21 cases when the index trial also had a value of P<0.001.

CONCLUSIONS

 The frequency of VLEs followed by a large trial is vanishingly small, and where they occur they do not appear to be a reliable marker for a benefit that is reproducible and directly actionable. An empirical rule using a VLE in a randomised controlled trial as a marker that further trials are unnecessary would be neither practical nor useful. Caution should be taken when interpreting small studies with very large treatment effects.

Economic downturns, universal health coverage, and cancer mortality in high-income and middle-income countries, 1990-2010: a longitudinal analysis

BACKGROUND

The global economic crisis has been associated with increased unemployment and reduced public-sector expenditure on health care (PEH). We estimated the effects of changes in unemployment and PEH on cancer mortality, and identified how universal health coverage (UHC) affected these relationships.

METHODS

For this longitudinal analysis, we obtained data from the World Bank and WHO (1990-2010). We aggregated mortality data for breast cancer in women, prostate cancer in men, and colorectal cancers in men and women, which are associated with survival rates that exceed 50%, into a treatable cancer class. We likewise aggregated data for lung and pancreatic cancers, which have 5 year survival rates of less than 10%, into an untreatable cancer class. We used multivariable regression analysis, controlling for country-specific demographics and infrastructure, with time-lag analyses and robustness checks to investigate the relationship between unemployment, PEH, and cancer mortality, with and without UHC. We used trend analysis to project mortality rates, on the basis of trends before the sharp unemployment rise that occurred in many countries from 2008 to 2010, and compared them with observed rates.

RESULTS

Data were available for 75 countries, representing 2.106 billion people, for the unemployment analysis and for 79 countries, representing 2.156 billion people, for the PEH analysis. Unemployment rises were significantly associated with an increase in all-cancer mortality and all specific cancers except lung cancer in women. By contrast, untreatable cancer mortality was not significantly linked with changes in unemployment. Lag analyses showed significant associations remained 5 years after unemployment increases for the treatable cancer class. Rerunning analyses, while accounting for UHC status, removed the significant associations. All-cancer, treatable cancer, and specific cancer mortalities significantly decreased as PEH increased. Time-series analysis provided an estimate of more than 40,000 excess deaths due to a subset of treatable cancers from 2008 to 2010, on the basis of 2000-07 trends. Most of these deaths were in non-UHC countries.

INTERPRETATION

Unemployment increases are associated with rises in cancer mortality; UHC seems to protect against this effect. PEH increases are associated with reduced cancer mortality. Access to health care could underlie these associations. We estimate that the 2008-10 economic crisis was associated with about 260,000 excess cancer-related deaths in the Organisation for Economic Co-operation and Development alone.

FUNDING

None.

Guidance on feedback of outcome data to improve performance in vascular surgery

Feedback of performance data is a well-established method of performance improvement in the health-care setting, although guidance has been limited in the context of surgical performance. This article outlines how optimal feedback can be achieved using surgeon outcome data.

Implementation of a teaching programme to improve doctors' awareness of DVLA guidelines: a multicentre study

INTRODUCTION

Over half of the UK population holds a driver's licence. Driver and Vehicle Licensing Authority (DVLA) guidelines are available for conditions from most specialties. Despite this, no focused training occurs in the undergraduate or postgraduate setting. We evaluate the impact of a teaching programme to improve guideline awareness.

METHODS

A 25-point questionnaire was designed using the current DVLA guidelines. Five questions were included for the following fields: neurology, cardiology, drug and alcohol abuse, visual disorders and respiratory. This was distributed to doctors in training at five hospitals. Four weeks later, a single-session teaching programme was implemented. The questionnaire was redistributed. Preintervention and postintervention scores were compared using the Wilcoxon rank sum test.

RESULTS

139 preteaching and 144 post-teaching questionnaires were completed. Implementation of a single-session teaching programme significantly improved the knowledge of DVLA guidelines in all five areas explored. Median scores: neurology, preteaching 40%, post-teaching 100%, p<0.001; cardiology, 0%, 100%, p<0.001; drug and alcohol misuse, 0%, 100%, p<0.001; visual disorders, 40%, 100%, p<0.001; respiratory disorders, 20%, 100%, p<0.001; and overall, 28%, 92%, p<0.001.

CONCLUSIONS

Knowledge of DVLA guidelines among our cohort was poor. Implementation of a single-session teaching programme can significantly improve guideline knowledge and awareness, serving as a cost-effective intervention.

Comparative safety and efficacy of vasopressors for mortality in septic shock: A network meta-analysis

INTRODUCTION

Septic shock is a life-threatening condition requiring vasopressor agents to support the circulatory system. Several agents exist with choice typically guided by the specific clinical scenario. We used a network meta-analysis approach to rate the comparative efficacy and safety of vasopressors for mortality and arrhythmia incidence in septic shock patients.

METHODS

We performed a comprehensive electronic database search including Medline, Embase, Science Citation Index Expanded and the Cochrane database. Randomised trials investigating vasopressor agents in septic shock patients and specifically assessing 28-day mortality or arrhythmia incidence were included. A Bayesian network meta-analysis was performed using Markov chain Monte Carlo methods.

RESULTS

Thirteen trials of low to moderate risk of bias in which 3146 patients were randomised were included. There was no pairwise evidence to suggest one agent was superior over another for mortality. In the network meta-analysis, vasopressin was significantly superior to dopamine (OR 0.68 (95% CI 0.5 to 0.94)) for mortality. For arrhythmia incidence, standard pairwise meta-analyses confirmed that dopamine led to a higher incidence of arrhythmias than norepinephrine (OR 2.69 (95% CI 2.08 to 3.47)). In the network meta-analysis, there was no evidence of superiority of one agent over another.

CONCLUSIONS

In this network meta-analysis, vasopressin was superior to dopamine for 28-day mortality in septic shock. Existing pairwise information supports the use of norepinephrine over dopamine. Our findings suggest that dopamine should be avoided in patients with septic shock and that other vasopressor agents should continue to be based on existing guidelines and clinical judgement of the specific presentation of the patient.

The impact of team familiarity and surgical experience on operative efficiency: a retrospective analysis

OBJECTIVES

The independent impact of individual surgical experience and team familiarity on surgical performance has been widely studied; however, the interplay of these factors and their relative, quantified, contributions to performance is poorly understood. We determined the impact of team familiarity and surgeon, and cumulative team experience on operative efficiency in total knee replacement.

DESIGN

Retrospective analysis of all total knee replacements conducted at the host institution in 1996-2009. Multivariate generalised-estimating-equation regression models were used to adjust for patient risk and clustering.

SETTING

Tertiary care academic hospital.

PARTICIPANTS

All patients undergoing TKR at the host institution in 1996-2009.

MAIN OUTCOME MEASURE

Operative efficiency.

RESULTS

A total of 4276 total knee replacements were completed by 1163 different surgical teams. The median experience level was 17.6 years for consultant surgeons and 3.7 years for trainee surgeons. After patient-risk adjustment, consultant surgical experience (p < 0.0001), trainee surgical experience (p < 0.05), cumulative team operative experience (p < 0.0001) and team familiarity (p < 0.0001) were associated with significant reductions in operative time. Surgical experience and team familiarity demonstrated concave and linear relationships with operative time, respectively. For a consultant surgeon, the expected reduction in operative time after 25 years in practice was 51 min, compared to a 21-min reduction over the span of 40 collaborations with the same team members.

CONCLUSIONS

Surgical experience and team familiarity display important and distinct relationships with operative time in total knee replacement. Appreciation of this interplay may serve to guide implementation and allocation of procedure-specific quality improvement strategies in surgery.

Trends in UK regional cancer mortality 1991-2007

Background:

Until 1990, there was an upward trend in mortality from breast, lung, prostate, and colon cancers in the United Kingdom. With improvements in cancer treatment there has, in general, been a fall in mortality over the last 20 years. We evaluate regional cancer mortality trends in the United Kingdom between 1991 and 2007.

Methods:

We analysed mortality trends for breast, lung, prostate, and colon cancers using data obtained from the EUREG cancer database. We have described changes in age-standardised rates (using European standard population) per 100 000 for cancer mortality and generated trends in mortality for the 11 regions using Joinpoint regression.

Results:

Across all regions in the United Kingdom there was a downward trend in mortality for the four most common cancers in males and females. Overall, deaths from colon cancer decreased most rapidly and deaths from prostate cancer decreased at the slowest rate. Similar downward trends in mortality were observed across all regions of the United Kingdom with the data for lung cancer exhibiting the greatest variation.

Conclusions:

Mortality from the four most common cancers decreased across all regions of the United Kingdom; however, the rate of decline varied between cancer type and in some instances by region.

Effects of economic crises on population health outcomes in Latin America, 1981-2010: an ecological study

OBJECTIVES

The relative health effects of changes in unemployment, inflation and gross domestic product (GDP) per capita on population health have not been assessed. We aimed to determine the effect of changes in these economic measures on mortality metrics across Latin America.

DESIGN

Ecological study.

SETTING

Latin America (21 countries), 1981-2010.

OUTCOME MEASURES

Uses multivariate regression analysis to assess the effects of changes in unemployment, inflation and GDP per capita on 5 mortality indicators across 21 countries in Latin America, 1981-2010. Country-specific differences in healthcare infrastructure, population structure and population size were controlled for.

RESULTS

Between 1981 and 2010, a 1% rise in unemployment was associated with statistically significant deteriorations (p<0.05) in 5 population health outcomes, with largest deteriorations in 1-5 years of age and male adult mortality rates (1.14 and 0.53 rises per 1000 deaths respectively). A 1% rise in inflation rate was associated with significant deteriorations (p<0.05) in 4 population health outcomes, with the largest deterioration in male adult mortality rate (0.0033 rise per 1000 deaths). Lag analysis showed that 5 years after rises in unemployment and inflation, significant deteriorations (p<0.05) occurred in 3 and 5 mortality metrics, respectively. A 1% rise in GDP per capita was associated with no significant deteriorations in population health outcomes either in the short or long term. β coefficient comparisons indicated that the effect of unemployment increases was substantially greater than that of changes in GDP per capita or inflation.

CONCLUSIONS

Rises in unemployment and inflation are associated with long-lasting deteriorations in several population health outcomes. Unemployment exerted much larger effects on health than inflation. In contrast, changes in GDP per capita had almost no association with the explored health outcomes. Contrary to neoclassical development economics, policymakers should prioritise amelioration of unemployment if population health outcomes are to be optimised.

Knowledge of Driving Vehicle Licensing Agency guidelines among NHS doctors: a multicentre observational study

Objectives

Over half of the UK population holds a driver's licence. The DVLA have produced guidelines to ensure drivers with medical conditions drive safely. Doctors should ensure that patients are given appropriate information and advice if they have a medical condition affecting their driving. We sought to evaluate doctors' knowledge of DVLA guidelines.

Design

A 25-point questionnaire was designed from DVLA guidelines (‘The DVLA Questionnaire’). Five questions were included for each of neurology, cardiology, drug and alcohol abuse, visual, and respiratory disorders.

Setting

Ealing Hospital, Northwick Park Hospital, Watford General Hospital, Norfolk and Norwich University Hospital and Leeds Teaching Hospitals Trust.

Participants

140 UK doctors.

Main outcome measures

Questionnaire scores assessing knowledge of DVLA guidelines in five specialty areas.

Results

The median overall questionnaire score was 28%, interquartile range 20–36% and range 0–100% [Watford 28%, Leeds 30%, Norfolk and Norwich 36%, Ealing 30%, Northwick Park 28%]. There were no significant differences between the scores for each centre (p = 0.1332), Mean scores for specialty areas were: neurology 33.1%, standard deviation 22.1; cardiology 35.6%, standard deviation 26.9; drug and alcohol abuse 30.6%, standard deviation 23.8; visual disorders 33.9%, standard deviation 23.5 and respiratory disorders 20.3%, standard deviation 24.8; overall score 30.7%. There was no significant difference between the scores of the specialty areas (p = 0.4060).

Conclusions

Knowledge of DVLA guidelines in our cohort was low. There is a need for increased awareness among hospital doctors through focused education on driving restrictions for common medical conditions. Improving physician knowledge in this area may help optimise patient safety.

Changes in government spending on healthcare and population mortality in the European union, 1995-2010: a cross-sectional ecological study

OBJECTIVE

Economic measures such as unemployment and gross domestic product are correlated with changes in health outcomes. We aimed to examine the effects of changes in government healthcare spending, an increasingly important measure given constrained government budgets in several European Union countries.

DESIGN

Multivariate regression analysis was used to assess the effect of changes in healthcare spending as a proportion of total government expenditure, government healthcare spending as a proportion of gross domestic product and government healthcare spending measured in purchasing power parity per capita, on five mortality indicators. Additional variables were controlled for to ensure robustness of data. One to five year lag analyses were conducted.

SETTING AND PARTICIPANTS

European Union countries 1995-2010.

MAIN OUTCOME MEASURES

Neonatal mortality, postneonatal mortality, one to five years of age mortality, under five years of age mortality, adult male mortality, adult female mortality.

RESULTS

A 1% decrease in government healthcare spending was associated with significant increase in all mortality metrics: neonatal mortality (coefficient -0.1217, p = 0.0001), postneonatal mortality (coefficient -0.0499, p = 0.0018), one to five years of age mortality (coefficient -0.0185, p = 0.0002), under five years of age mortality (coefficient -0.1897, p = 0.0003), adult male mortality (coefficient -2.5398, p = 0.0000) and adult female mortality (coefficient -1.4492, p = 0.0000). One per cent decrease in healthcare spending, measured as a proportion of gross domestic product and in purchasing power parity, was both associated with significant increases (p < 0.05) in all metrics. Five years after the 1% decrease in healthcare spending, significant increases (p < 0.05) continued to be observed in all mortality metrics.

CONCLUSIONS

Decreased government healthcare spending is associated with increased population mortality in the short and long term. Policy interventions implemented in response to the financial crisis may be associated with worsening population health.

Incidence of prostate and urological cancers in England by ethnic group, 2001-2007: a descriptive study

Background

The aetiology of urological cancers is poorly understood and variations in incidence by ethnic group may provide insights into the relative importance of genetic and environmental risk factors. Our objective was to compare the incidence of four urological cancers (kidney, bladder, prostate and testicular) among six ‘non-White’ ethnic groups in England (Indian, Pakistani, Bangladeshi, Black African, Black Caribbean and Chinese) to each other and to Whites.

Methods

We obtained Information on ethnicity for all urological cancer registrations from 2001 to 2007 (n = 329,524) by linkage to the Hospital Episodes Statistics database. We calculated incidence rate ratios adjusted for age, sex and income, comparing the six ethnic groups (and combined ‘South Asian’ and ‘Black’ groups) to Whites and to each other.

Results

There were significant differences in the incidence of all four cancers between the ethnic groups (all p < 0.001). In general, ‘non-White’ groups had a lower incidence of urological cancers compared to Whites, except prostate cancer, which displayed a higher incidence in Blacks. (IRR 2.55) There was strong evidence of differences in risk between Indians, Pakistanis and Bangladeshis for kidney, bladder and prostate cancer (p < 0.001), and between Black Africans and Black Caribbeans for all four cancers (p < 0.001).

Conclusions

The risk of urological cancers in England varies greatly by ethnicity, including within groups that have traditionally been analysed together (South Asians and Blacks). In general, these differences are not readily explained by known risk factors, although the very high incidence of prostate cancer in both black Africans and Caribbeans suggests increased genetic susceptibility. g.

Electronic supplementary material

The online version of this article (doi:10.1186/s12885-015-1771-2) contains supplementary material, which is available to authorized users.

Enablers and Barriers in Implementing Integrated Care

Abstract-The integration of medical and social care aims to address the fragmentation in patient services observed in many health care systems. Increasing rates of chronic disease and multimorbidity have drawn attention to the often significant reforms necessary to address these problems. In this article we discuss how integration may be achieved. To date there is no single best practice model or well-defined guidelines for integration. We suggest that three groups of patients with complex health needs would experience the greatest benefit: multimorbid patients with two or more chronic diseases, patients with moderate or severe mental health conditions, and the elderly. Integration has been demonstrated to achieve improvements in the coordination, quality, efficiency, and cost control of health care. Considering these benefits, a broad effort should be made to implement integrated care.

The impact of feedback of intraoperative technical performance in surgery: a systematic review

OBJECTIVES

Increasing patient demands, costs and emphasis on safety, coupled with reductions in the length of time surgical trainees spend in the operating theatre, necessitate means to improve the efficiency of surgical training. In this respect, feedback based on intraoperative surgical performance may be beneficial. Our aim was to systematically review the impact of intraoperative feedback based on surgical performance.

SETTING

MEDLINE, Embase, PsycINFO, AMED and the Cochrane Database of Systematic Reviews were searched. Two reviewers independently reviewed citations using predetermined inclusion and exclusion criteria. 32 data-points per study were extracted.

PARTICIPANTS

The search strategy yielded 1531 citations. Three studies were eligible, which comprised a total of 280 procedures by 62 surgeons.

RESULTS

Overall, feedback based on intraoperative surgical performance was found to be a powerful method for improving performance. In cholecystectomy, feedback led to a reduction in procedure time (p=0.022) and an improvement in economy of movement (p<0.001). In simulated laparoscopic colectomy, feedback led to improvements in instrument path length (p=0.001) and instrument smoothness (p=0.045). Feedback also reduced error scores in cholecystectomy (p=0.003), simulated laparoscopic colectomy (p<0.001) and simulated renal artery angioplasty (p=0.004). In addition, feedback improved balloon placement accuracy (p=0.041), and resulted in a smoother learning curve and earlier plateau in performance in simulated renal artery angioplasty.

CONCLUSIONS

Intraoperative feedback appears to be associated with an improvement in performance, however, there is a paucity of research in this area. Further work is needed in order to establish the long-term benefits of feedback and the optimum means and circumstances of feedback delivery.

Unemployment and prostate cancer mortality in the OECD, 1990-2009

The global economic downturn has been associated with increased unemployment in many countries. Insights into the impact of unemployment on specific health conditions remain limited. We determined the association between unemployment and prostate cancer mortality in members of the Organisation for Economic Co-operation and Development (OECD). We used multivariate regression analysis to assess the association between changes in unemployment and prostate cancer mortality in OECD member states between 1990 and 2009. Country-specific differences in healthcare infrastructure, population structure, and population size were controlled for and lag analyses conducted. Several robustness checks were also performed. Time trend analyses were used to predict the number of excess deaths from prostate cancer following the 2008 global recession. Between 1990 and 2009, a 1% rise in unemployment was associated with an increase in prostate cancer mortality. Lag analysis showed a continued increase in mortality years after unemployment rises. The association between unemployment and prostate cancer mortality remained significant in robustness checks with 46 controls. Eight of the 21 OECD countries for which a time trend analysis was conducted, exhibited an estimated excess of prostate cancer deaths in at least one of 2008, 2009, or 2010, based on 2000-2007 trends. Rises in unemployment are associated with significant increases in prostate cancer mortality. Initiatives that bolster employment may help to minimise prostate cancer mortality during times of economic hardship.

The effect of economic downturns on maternal mortality among pregnancies with abortive outcomes in 81 countries, 1981-2010

OBJECTIVE

To determine the association between economic downturns and abortion-related maternal mortality in multiple countries over 30 years.

METHODS

In a retrospective study, WHO data were obtained for maternal deaths among pregnancies with abortive outcomes between January 1, 1981, and December 31, 2010. Economic data for the same period were obtained from The World Bank. An economic downturn was defined as an annual decline in gross domestic product per head. Multivariate regression-controlling for country-specific differences in infrastructure, population size, and demographic structure-and 5-year lag analyses were performed.

RESULTS

Data were available for 81 countries. Abortion-related maternal mortality was significantly increased in years of economic downturns (R=0.0708; 95% confidence interval [CI] 0.0264-0.1151; P=0.0018). The association was sustained for 4 years after an economic downturn (year 1: R=0.0709 [95% CI 0.0231-0.1187], P=0.0037; year 2: R=0.0634 [0.0178-0.1089], P=0.0065; year 3: R=0.0554 [0.0105-0.1004], P=0.0157; year 4: R=0.0593 [0.0148-0.1037], P=0.009). There was an annual 36% increase in deaths associated with unsafe abortion during economic downturn years.

CONCLUSION

Economic downturns were associated with increased abortion-related maternal mortality, possibly due to changes in government healthcare spending and service provision. A global economic downturn could impede a reduction in maternal mortality.