A best practice position statement on the role of the nephrologist in the prevention and follow-up of preeclampsia: the Italian study group on kidney and pregnancy

Preeclampsia (PE) is a protean syndrome causing a transitory kidney disease, characterised by hypertension and proteinuria, ultimately reversible after delivery. Its prevalence is variously estimated, from 3 to 5% to 10% if all the related disorders, including also pregnancy-induced hypertension (PIH) and HELLP syndrome (haemolysis, increase in liver enzyme, low platelets) are included. Both nephrologists and obstetricians are involved in the management of the disease, according to different protocols, and the clinical management, as well as the role for each specialty, differs worldwide. The increased awareness of the role of chronic kidney disease in pregnancy, complicating up to 3% of pregnancies, and the knowledge that PE is associated with an increased risk for development of CKD later in life have recently increased the interest and redesigned the role of the nephrologists in this context. However, while the heterogeneous definitions of PE, its recent reclassification, an emerging role for biochemical biomarkers, the growing body of epidemiological data and the new potential therapeutic interventions lead to counsel long-term follow-up, the lack of resources for chronic patients and the increasing costs of care limit the potential for preventive actions, and suggest tailoring specific interventional strategies. The aim of the present position statement of the Kidney and Pregnancy Study Group of the Italian Society of Nephrology is to review the literature and to try to identify theoretical and pragmatic bases for an agreed management of PE in the nephrological setting, with particular attention to the prevention of the syndrome (recurrent PE, presence of baseline CKD) and to the organization of the postpartum follow-up.

A critical appraisal of the quality of adult dual-energy X-ray absorptiometry guidelines in osteoporosis using the AGREE II tool: An EuroAIM initiative

Objectives

Dual energy X-ray absorptiometry (DXA) is the most widely used technique to measure bone mineral density (BMD). Appropriate and accurate use of DXA is of great importance, and several guidelines have been developed in the last years. Our aim was to evaluate the quality of published guidelines on DXA for adults.

Methods

Between June and July 2016 we conducted an online search for DXA guidelines, which were evaluated by four independent readers blinded to each other using the AGREE II instrument. A fifth independent reviewer calculated scores per each domain and agreement between reviewers’ scores.

Results

Four out of 59 guidelines met inclusion criteria and were included. They were published between 2005 and 2014. Three out of four guidelines reached a high level of quality, having at least five domain scores higher than 60%. Domain 1 (Scope and Purpose) achieved the highest result (total score = 86.8 ± 3.7%). Domain 6 (Editorial Independence) had the lowest score (total score = 54.7 ± 12.5%). Interobserver agreement ranged from fair (0.230) to good (0.702).

Conclusions

Overall, the quality of DXA guidelines is satisfactory when evaluated using the AGREE II instrument. The Editorial Independence domain was the most critical, thus deserving more attention when developing future guidelines.

Main messages

• Three of four guidelines on DXA had a high quality level (>60%).

• Scope/purpose had the highest score (86.8 ± 3.7%).

• Editorial Independence had the lowest score (54.7 ± 12.5%).

• Interobserver agreement ranged from fair (0.230) to good (0.702).

Electronic supplementary material

The online version of this article (doi:10.1007/s13244-017-0553-6) contains supplementary material, which is available to authorized users.

The HOSPITAL score and LACE index as predictors of 30 day readmission in a retrospective study at a university-affiliated community hospital

Introduction

Hospital readmissions are common, expensive, and a key target of the Medicare Value Based Purchasing (VBP) program. Validated risk assessment tools such as the HOSPITAL score and LACE index have been developed to identify patients at high risk of hospital readmission so they can be targeted for interventions aimed at reducing the rate of readmission. This study aims to evaluate the utility of HOSPITAL score and LACE index for predicting hospital readmission within 30 days in a moderate-sized university affiliated hospital in the midwestern United States.

Materials and Methods

All adult medical patients who underwent one or more ICD-10 defined procedures discharged from the SIU-SOM Hospitalist service from Memorial Medical Center (MMC) from October 15, 2015 to March 16, 2016, were studied retrospectively to determine if the HOSPITAL score and LACE index were a significant predictors of hospital readmission within 30 days.

Results

During the study period, 463 discharges were recorded for the hospitalist service. The analysis includes data for the 432 discharges. Patients who died during the hospital stay, were transferred to another hospital, or left against medical advice were excluded. Of these patients, 35 (8%) were readmitted to the same hospital within 30 days. A receiver operating characteristic evaluation of the HOSPITAL score for this patient population shows a C statistic of 0.75 (95% CI [0.67–0.83]), indicating good discrimination for hospital readmission. The Brier score for the HOSPITAL score in this setting was 0.069, indicating good overall performance. The Hosmer–Lemeshow goodness of fit test shows a χ² value of 3.71 with a p value of 0.59. A receiver operating characteristic evaluation of the LACE index for this patient population shows a C statistic of 0.58 (95% CI [0.48–0.68]), indicating poor discrimination for hospital readmission. The Brier score for the LACE index in this setting was 0.082, indicating good overall performance. The Hosmer–Lemeshow goodness of fit test shows a χ² value of 4.97 with a p value of 0.66.

Discussion

This single center retrospective study indicates that the HOSPITAL score has superior discriminatory ability when compared to the LACE index as a predictor of hospital readmission within 30 days at a medium-sized university-affiliated teaching hospital.

Conclusions

The internationally validated HOSPITAL score may be superior to the LACE index in moderate-sized community hospitals to identify patients at high risk of hospital readmission within 30 days.

Process for developing rehabilitation practice recommendations for individuals with traumatic brain injury

Background

Attempts at measuring quality of rehabilitation care are hampered by a gap in knowledge translation of evidence-based approaches and lack of consensus on best practices. However, adoption of evidence-based best practices is needed to minimize variations and improve quality of care. Therefore, the objective of this project was to describe a process for assessing the quality of evidence of clinical practices in traumatic brain injury (TBI) rehabilitative care.

Methods

A multidisciplinary team of clinicians developed discipline-specific clinical questions using the Population, Intervention, Control, Outcome process. A systematic review of the literature was conducted for each question using Pubmed, CINAHL, PsychInfo, and Allied Health Evidence databases. Team members assessed the quality, level, and applicability of evidence utilizing a modified Oxford scale, the Agency for Healthcare Research and Quality Methods Guide, and a modified version of the Grading of Recommendations, Assessment, Development, and Evaluation scale.

Results

Draft recommendations for best-practice were formulated and shared with a Delphi panel of clinical representatives and stakeholders to obtain consensus.

Conclusion

Evidence-based practice guidelines are essential to improve the quality of TBI rehabilitation care. By using a modified quality of evidence assessment tool, we established a process to gain consensus on practice recommendations for individuals with TBI undergoing rehabilitation.

The evaluation stage of the Hoeven Outcome Monitor (HOM): Towards an evidence based groundwork in forensic mental health

This study examined if a macro-, meso-, and micro outcome measurement instrument that constitutes the evaluation stage of a Dutch forensic psychiatric outcome monitor, the Hoeven Outcome Monitor (HOM), can provide a first step towards a more evidence based groundwork in forensic mental health. General, serious, very serious, special, and tbs meriting recidivism during treatment, after treatment, and overall were charted for forensic psychiatric patients discharged from a Dutch forensic psychiatric centre between 1999 and 2008 (N=164). Re-conviction data were obtained from the official Criminal Records System, and the mean follow-up time was 116.2months. First, the results showed that the macro-measurements provide comparative outcome measures to generate insight into the overall effectiveness of forensic psychiatric treatment. Second, the meso-measurements yielded clinically relevant treatment outcome data for all discharged patients to generate a complete view of treatment effectiveness. Finally, the micro-measurements allowed access to detailed patient and treatment effectiveness assessments that provides the empirical foundation to conduct aetiological research into the prediction and control of high-risk behaviour. Thus, an outcome measurement instrument in line with Evidence Based Medicine and best practice guidelines was designed that provides an empirically sound evaluation framework for treatment effectiveness, and an impetus for the development of effective interventions to generate an evidence based groundwork in forensic mental health.

Does Body Mass Index Affect Mortality in Coronary Surgery?

Introduction:

The Body Mass Index (BMI) quantifies nutritional status and classifies humans as underweight, of normal weight, overweight, mildly obese, moderately obese or morbidly obese. Obesity is the excessive accumulation of fat, defined as BMI higher than 30 kg/m². Obesity is widely accepted to complicate anaesthesia and surgery, being a risk factor for mediastinitis after coronary artery bypass grafting (CABG). We sought the evidence on operative mortality of CABG between standard BMI groups.

Materials and Methodology:

A simple literature review of papers presenting the mortality of CABG by BMI group: Underweight (BMI ≤ 18.49 kg/m²), normal weight (BMI 18.5–24.9 kg/m²), overweight (BMI 25.0–29.9 kg/m²), mild obesity (BMI 30.0–34.9 kg/m²), moderate obesity (BMI 35.0–39.9 kg/m²), or morbid obesity (BMI ≥ 40.0 kg/m²).

Results:

We identified 18 relevant studies with 1,027,711 patients in total. Their variability in size of samples and choice of BMI groups precluded us from attempting inferential statistics. The overall cumulative mortality was 2.7%. Underweight patients had by far the highest mortality (6.6%). Overweight patients had the lowest group mortality (2.1%). The group mortality for morbidly obese patients was 3.44%.

Discussion:

Patients with extreme BMI’s undergoing CABG (underweight ones more than morbidly obese) suffer increased crude mortality. This simple observation indicates that under nutrition and morbid obesity need be further explored as risk factors for coronary surgery.

An interpretive review of consensus statements on clinical guideline development and their application in the field of traditional and complementary medicine

BACKGROUND

Despite ongoing consumer demand and an emerging scientific evidence-base for traditional and complementary medicine (T&CM), there remains a paucity of reliable information in standard clinical guidelines about their use. Often T&CM interventions are not mentioned, or the recommendations arising from these guidelines are unhelpful to end-users (i.e. patients, practitioners and policy makers). Insufficient evidence of efficacy may be a contributing factor; however, often informative recommendations could still be made by drawing on relevant information from other avenues. In light of this, the aim of this research was to review national and internationally endorsed consensus statements for clinical guideline developers, and to interpret how to apply these methods when making recommendations regarding the use of T&CM.

METHOD

The critical interpretive review method was used to identify and appraise relevant consensus statements published between 1995 and 2015. The statements were identified using a purposive sampling technique until data saturation was reached. The most recent edition of a statement was included in the analysis. The content, scope and themes of the statements were compared and interpreted within the context of the T&CM setting; including history, regulation, use, emerging scientific evidence-base and existing guidelines.

RESULTS

Eight consensus statements were included in the interpretive review. Searching stopped at this stage as no new major themes were identified. The five themes relevant to the challenges of developing T&CM guidelines were: (1) framing the question; (2) the limitations of using an evidence hierarchy; (3) strategies for dealing with insufficient, high quality evidence; (4) the importance of qualifying a recommendation; and (5) the need for structured consensus development.

CONCLUSION

Evidence regarding safety, efficacy and cost effectiveness are not the only information required to make recommendations for clinical guidelines. Modifying factors such as burden of disease, magnitude of effect, current use, demand, equity and ease of integration should also be considered. Uptake of the recommendations arising from this review are expected to result in the development of higher quality clinical guidelines that offer greater assistance to those seeking answers about the appropriate use of T&CM.

I-SWOT as instrument to individually optimize therapy of thoracoabdominal aortic aneurysms: Effective, norm-compliant and meeting the needs

Background

Guidelines summarize medical evidence, they identify the most efficient therapy under study conditions and recommend this therapy for use. The physician now has the challenge to translate a therapy that is efficient under laboratory conditions to a patient who is an individual person. To accomplish this task the physician has to make sure that (I) the ideal typical therapy is applicable and effective in this individual patient taking the special features into consideration, that (II) therapy is compliant with the norm including guidelines, laws and ethical requirements (conformity) and that (III) the therapy meets the patient’s needs.

Objective

How can physicians together with the patients translate the medical evidence into an individually optimized therapy?

Material and methods

At the German Aortic Center in Hamburg we use I‑SWOT as an instrument to identify such individually optimized therapy. With I‑SWOT, we present an instrument with which we have developed an (I) efficient, (II) conform and (III) needs-oriented therapeutic strategy for individual patients.

Results

I-SWOT cross-tabulates strengths (S) and weaknesses (W) related to therapy with opportunities (O) and threats (T) related to individual patients. This I‑SWOT matrix identifies four fundamental types of strategy, which comprise “SO” maximizing strengths and opportunities, “WT” minimizing weaknesses and threats, “WO” minimizing weaknesses and maximizing opportunities and “ST” maximizing strengths and minimizing threats. We discuss the case of a patient with asymptomatic thoracoabdominal aneurysm to show how I‑SWOT is used to identify an individually optimized therapy strategy.

Studies in using a universal exchange and inference language for evidence based medicine. Semi-automated learning and reasoning for PICO methodology, systematic review, and environmental epidemiology

The Q-UEL language of XML-like tags and the associated software applications are providing a valuable toolkit for Evidence Based Medicine (EBM). In this paper the already existing applications, data bases, and tags are brought together with new ones. The particular Q-UEL embodiment used here is the BioIngine. The main challenge is one of bringing together the methods of symbolic reasoning and calculative probabilistic inference that underlie EBM and medical decision making. Some space is taken to review this background. The unification is greatly facilitated by Q-UEL's roots in the notation and algebra of Dirac, and by extending Q-UEL into the Wolfram programming environment. Further, the overall problem of integration is also a relatively simple one because of the nature of Q-UEL as a language for interoperability in healthcare and biomedicine, while the notion of workflow is facilitated because of the EBM best practice known as PICO. What remains difficult is achieving a high degree of overall automation because of a well-known difficulty in capturing human expertise in computers: the Feigenbaum bottleneck.

The prone position during surgery and its complications: a systematic review and evidence-based guidelines

Surgery in the prone position is often a necessity when access to posterior anatomic structures is required. However, many complications are known to be associated with this type of surgery, as physiologic changes occur with increased pressure to anterior structures. While several studies have discussed postoperative vision loss, much fewer studies with lower levels of evidence have addressed other complications. A systematic literature review was conducted using 2 different databases, and 53 papers were regarded as appropriate for inclusion. Qualitative and quantitative analysis was performed. Thirteen complications were identified. Postoperative vision loss and cardiovascular complications, including hypovolemia and cardiac arrest, had the most number of studies and highest level of evidence. Careful planning for optimal positioning, padding, timing, as well as increased vigilance are evidence-based recommendations where operative prone positioning is required.

[Minimally invasive surgery in childhood]

Similar to surgery in adults, minimally invasive techniques have also become established in pediatric surgery for a wide variety of indications and partially replaced the corresponding conventional open surgical procedures. This applies not only to laparoscopy for abdominal surgical interventions but also to thoracoscopic procedures. The therapy spectrum in pediatric surgery includes all congenital and acquired diseases of the growing organism, from neonates to adolescents and for this reason the indications that are suitable for minimally invasive surgical procedures are corresponding versatile. According to the literature almost every operation in pediatric surgery was performed via a minimally invasive access route. Of course, not every generally feasible minimally invasive technique can be considered as being suitable to replace proven and established open conventional procedures in pediatric surgery.

Chronic fatigue syndrome - an update

BACKGROUND

Chronic fatigue syndrome is a widespread condition with a huge impact not only on a patient's life, but also on society as evidenced by substantial losses of productivity, informal costs, and medical expenses. The high prevalence rates (0.2-6.4%) and the low employment rates (27-41%) are responsible for the enormous burden imposed on society, with loss of productivity representing the highest cost. The objective of this review is to systematically review the recent literature on chronic fatigue syndrome/myalgic encephalomyelitis.

METHODS

The published literature between 1 January 1990 and 1 April 2015 was searched using the MEDLINE, Cochrane Library, and Web of Sciences databases. The reference lists of the selected articles were screened for other relevant articles.

RESULTS AND CONCLUSIONS

Despite extensive research, none of the proposed etiological factors have shown strong, reproducible scientific evidence. Over the years, the biopsychosocial model integrating many of the proposed hypotheses has been gaining popularity over the biomedical model, where the focus is on one physical cause. Since the etiological mechanism underlying chronic fatigue syndrome is currently unknown, disease-specific treatments do not exist. Various treatments have been investigated but only cognitive behavior therapy (CBT) and graded exercise therapy (GET) have shown moderate effectiveness.

Insights in Hypothesis Testing and Making Decisions in Biomedical Research

It is a fact that p values are commonly used for inference in biomedical and other social fields of research. Unfortunately, the role of p value is very often misused and misinterpreted; that is why it has been recommended the use of resampling methods, like the bootstrap method, to calculate the confidence interval, which provides more robust results for inference than does p value. In this review a discussion is made about the use of p values through hypothesis testing and its alternatives using resampling methods to develop confidence intervals of the tested statistic or effect measure.

Clinical trials in Ayurveda: Analysis of clinical trial registry of India

Ayurveda is one of the complementary and alternative systems of medicine requiring generation of high quality evidence for rational practice. Evidence can be generated from study designs and the present study is an attempt to critically assess the registered studies in the field of Ayurveda from clinical trial registry of India. We found low number of trials conducted with more focus required on the quality of these studies to contribute to high quality evidence.

Outcome reporting in randomized controlled trials and systematic reviews of gastroschisis treatment: a systematic review

BACKGROUND

Core outcome sets (COS) facilitate clinical research by providing an agreed set of outcomes to be measured when evaluating treatment efficacy. Gastroschisis is increasing in frequency and evidence-based treatments are lacking. We aimed to identify initial candidate outcomes for a gastroschisis COS from existing literature.

METHODS

Using a sensitive search strategy we identified randomized controlled trials (RCTs) and systematic reviews (SRs) of treatment interventions for gastroschisis. Outcomes were extracted and assigned to the core areas, 'Pathophysiological Manifestations', 'Life Impact', 'Resource Use', 'Adverse Events' and 'Mortality'.

RESULTS

A total of 50 outcomes were identified. RCTs reported 6-9 outcomes each; SRs reported 9-25. The most frequently reported outcomes were 'Length of hospital stay' (reported in 8 studies), 'Duration of ventilation' and 'Time to full enteral feeds' (7 studies). Outcomes identified could be assigned to all five core areas.

CONCLUSIONS

There is wide heterogeneity in outcomes reported in studies evaluating treatment interventions for gastroschisis. It is unclear which outcomes are of highest importance across stakeholder groups. Developing a COS to standardize outcome measurement and reporting for gastroschisis is warranted.

The presentation of plastic surgery visual data from 1816 to 1916: The evolution of reproducible results

All scientific data should be presented with sufficient accuracy and precision so that they can be both analyzed properly and reproduced. Visual data are the foundation upon which plastic surgeons advance knowledge. We use visual data to achieve reproducible results by discerning details of procedures and differences between pre- and post-surgery images. This review highlights how the presentation of visual data evolved from 1816, when Joseph Carpue published his book on nasal reconstruction to 1916, when Captain Harold Gillies began to treat over 2000 casualties from the Battle of the Somme. It shows the frailties of human nature that led some authors such as Carl von Graefe, Joseph Pancoast and Thomas Mutter to record inaccurate methods or results that could not be reproduced, and what measures other authors such as Eduard Zeis, Johann Dieffenbach, and Gurdon Buck took to affirm the accuracy of their results. It shows how photography gradually supplanted illustration as a reference standard. Finally, it shows the efforts that some authors and originators took to authenticate and preserve their visual data in what can be considered the forerunners of clinical registries.

That's not how the learning works - the paradox of Reverse Innovation: a qualitative study

Background

There are significant differences in the meaning and use of the term ‘Reverse Innovation’ between industry circles, where the term originated, and health policy circles where the term has gained traction. It is often conflated with other popularized terms such as Frugal Innovation, Co-development and Trickle-up Innovation. Compared to its use in the industrial sector, this conceptualization of Reverse Innovation describes a more complex, fragmented process, and one with no particular institution in charge. It follows that the way in which the term ‘Reverse Innovation’, specifically, is understood and used in the healthcare space is worthy of examination.

Methods

Between September and December 2014, we conducted eleven in-depth face-to-face or telephone interviews with key informants from innovation, health and social policy circles, experts in international comparative policy research and leaders in the Reverse Innovation space in the United States. Interviews were open-ended with guiding probes into the barriers and enablers to Reverse Innovation in the US context, specifically also informants' experience and understanding of the term Reverse Innovation. Interviews were recorded, transcribed and analyzed thematically using the process of constant comparison.

Results

We describe three main themes derived from the interviews. First, ‘Reverse Innovation,’ the term, has marketing currency to convince policy-makers that may be wary of learning from or adopting innovations from unexpected sources, in this case Low-Income Countries. Second, the term can have the opposite effect - by connoting frugality, or innovation arising from necessity as opposed to good leadership, the proposed innovation may be associated with poor quality, undermining potential translation into other contexts. Finally, the term ‘Reverse Innovation’ is a paradox – it breaks down preconceptions of the directionality of knowledge and learning, whilst simultaneously reinforcing it.

Conclusions

We conclude that this term means different things to different people and should be used strategically, and with some caution, depending on the audience.

Electronic supplementary material

The online version of this article (doi:10.1186/s12992-016-0175-7) contains supplementary material, which is available to authorized users.

PET Imaging of Skeletal Metastases and Its Role in Personalizing Further Management

In oncology, the skeleton is one of the most frequently encountered sites for metastatic disease and thus early detection not only has an impact on an individual patient's management but also on the overall outcome. Multiparametric and multimodal hybrid PET/computed tomography and PET/MR imaging have revolutionized imaging for bone metastases, but irrespective of tumor biology or morphology of the bone lesion it remains unclear which imaging modality is the most clinically relevant to guide individualized cancer care. In this review, we highlight the current clinical challenges of PET imaging in evaluation and quantification of skeletal tumor burden and its impact on personalized cancer management.

Diagnostic delay in psychogenic seizures and the association with anti-seizure medication trials

PURPOSE

The average delay from first seizure to diagnosis of psychogenic non-epileptic seizures (PNES) is over 7 years. The reason for this delay is not well understood. We hypothesized that a perceived decrease in seizure frequency after starting an anti-seizure medication (ASM) may contribute to longer delays, but the frequency of such a response has not been well established.

METHODS

Time from onset to diagnosis, medication history and associated seizure frequency was acquired from the medical records of 297 consecutive patients with PNES diagnosed using video-electroencephalographic monitoring. Exponential regression was used to model the effect of medication trials and response on diagnostic delay.

RESULTS

Mean diagnostic delay was 8.4 years (min 1 day, max 52 years). The robust average diagnostic delay was 2.8 years (95% CI: 2.2-3.5 years) based on an exponential model as 10 to the mean of log10 delay. Each ASM trial increased the robust average delay exponentially by at least one third of a year (Wald t=3.6, p=0.004). Response to ASM trials did not significantly change diagnostic delay (Wald t=-0.9, p=0.38).

CONCLUSION

Although a response to ASMs was observed commonly in these patients with PNES, the presence of a response was not associated with longer time until definitive diagnosis. Instead, the number of ASMs tried was associated with a longer delay until diagnosis, suggesting that ASM trials were continued despite lack of response. These data support the guideline that patients with seizures should be referred to epilepsy care centers after failure of two medication trials.

[Pioneering surgical innovations in Germany : Part 2: public funding and origins of surgical innovations]

BACKGROUND

In recent years research that conforms with evidence-based medicine (EBM) has been demanded even in surgery. Uniform studies were carried out to prove the benefits of new procedures; however, compared to other research sectors, public third party funding for surgical research was significantly cut back.

OBJECTIVE

Collation of special features in surgery with respect to external funding of surgical top level research. Examination of the benefits of a continuous promotion and of organizations involved in research.

MATERIAL AND METHODS

Part one of this investigation presented the methods used to identify and analyze pioneering research in surgery.

RESULTS

Out of a total of 15 revolutionary innovations only 3 projects were financed by external funding and 2 projects received indirect financial support as a result of a cooperation with the medical industry. This demonstrates that the majority of projects were neither directly nor indirectly subsidized. Apart from one instance the majority of innovations were generated by university hospitals highly active in research.

DISCUSSION

In effect, the non-existing external funding for outstanding surgical innovations and hospitals suggests that a reformation of surgical research is required. To strengthen the quality of innovations in surgery a concentration of funding to institutions that are highly active in research makes sense. Institutional funding directly linked to a project should form a key component of support particularly in the early stages of development.

Blended learning in CME: the perception of GP trainers

INTRODUCTION

Blended learning (the combination of electronic methods with traditional teaching methods) has the potential to combine the best of traditional education with the best of computer-mediated training. We chose to develop such an intervention for GP trainers who were undertaking a Continuing Medical Education (CME) course in evidence-based medicine (EBM). This study reports on our experience and investigated the factors influencing the perception on usefulness and logistics of blended learning for learners in CME.

METHODS

In total, 170 GP trainers participated in the intervention. We used questionnaires, observations during the four face-to-face meetings and evaluations in the e-course over one year. Additionally we organised focus groups to gain insight in some of the outcomes of the questionnaires and interpretations of the observations.

RESULTS

The GP trainers found the design and the educational method (e-course in combination with meetings) attractive, instructive and complementary. Factors influencing their learning were (1) educational design, (2) educational method, (3) topic of the intervention, (4) time (planning), (5) time (intervention), (6) learning style, (7) technical issues, (8) preconditions and (9) level of difficulty. A close link between daily practice and the educational intervention was considered an important precondition for the success of the intervention in this group of learners.

CONCLUSION

GP trainers were positive about blended learning: they found e-learning a useful way to gain knowledge and the meetings a pleasant way of transferring the knowledge into practice. Although some preconditions should be taken into consideration during its development and implementation, they would participate in similarly designed learning in the future.

A best practice position statement on pregnancy in chronic kidney disease: the Italian Study Group on Kidney and Pregnancy

Pregnancy is increasingly undertaken in patients with chronic kidney disease (CKD) and, conversely, CKD is increasingly diagnosed in pregnancy: up to 3 % of pregnancies are estimated to be complicated by CKD. The heterogeneity of CKD (accounting for stage, hypertension and proteinuria) and the rarity of several kidney diseases make risk assessment difficult and therapeutic strategies are often based upon scattered experiences and small series. In this setting, the aim of this position statement of the Kidney and Pregnancy Study Group of the Italian Society of Nephrology is to review the literature, and discuss the experience in the clinical management of CKD in pregnancy. CKD is associated with an increased risk for adverse pregnancy-related outcomes since its early stage, also in the absence of hypertension and proteinuria, thus supporting the need for a multidisciplinary follow-up in all CKD patients. CKD stage, hypertension and proteinuria are interrelated, but they are also independent risk factors for adverse pregnancy-related outcomes. Among the different kidney diseases, patients with glomerulonephritis and immunologic diseases are at higher risk of developing or increasing proteinuria and hypertension, a picture often difficult to differentiate from preeclampsia. The risk is higher in active immunologic diseases, and in those cases that are detected or flare up during pregnancy. Referral to tertiary care centres for multidisciplinary follow-up and tailored approaches are warranted. The risk of maternal death is, almost exclusively, reported in systemic lupus erythematosus and vasculitis, which share with diabetic nephropathy an increased risk for perinatal death of the babies. Conversely, patients with kidney malformation, autosomal-dominant polycystic kidney disease, stone disease, and previous upper urinary tract infections are at higher risk for urinary tract infections, in turn associated with prematurity. No risk for malformations other than those related to familiar urinary tract malformations is reported in CKD patients, with the possible exception of diabetic nephropathy. Risks of worsening of the renal function are differently reported, but are higher in advanced CKD. Strict follow-up is needed, also to identify the best balance between maternal and foetal risks. The need for further multicentre studies is underlined.

Evidence for Health II: Overcoming barriers to using evidence in policy and practice

Even the highest quality evidence will have little impact unless it is incorporated into decision-making for health. It is therefore critical to overcome the many barriers to using evidence in decision-making, including (1) missing the window of opportunity, (2) knowledge gaps and uncertainty, (3) controversy, irrelevant and conflicting evidence, as well as (4) vested interests and conflicts of interest. While this is certainly not a comprehensive list, it covers a number of main themes discussed in the knowledge translation literature on this topic, and better understanding these barriers can help readers of the evidence to be more savvy knowledge users and help researchers overcome challenges to getting their evidence into practice. Thus, the first step in being able to use research evidence for improving population health is ensuring that the evidence is available at the right time and in the right format and language so that knowledge users can take the evidence into consideration alongside a multitude of other factors that also influence decision-making. The sheer volume of scientific publications makes it difficult to find the evidence that can actually help inform decisions for health. Policymakers, especially in low- and middle-income countries, require context-specific evidence to ensure local relevance. Knowledge synthesis and dissemination of policy-relevant local evidence is important, but it is still not enough. There are times when the interpretation of the evidence leads to various controversies and disagreements, which act as barriers to the uptake of evidence. Research evidence can also be influenced and misused for various aims and agendas. It is therefore important to ensure that any new evidence comes from reliable sources and is interpreted in light of the overall body of scientific literature. It is not enough to simply produce evidence, nor even to synthesize and package evidence into a more user-friendly format. Particularly at the policy level, political savvy is also needed to ensure that vested interests do not undermine decisions that can impact the health of individuals and populations.

Methodological development of the Hoeven Outcome Monitor (HOM): A first step towards a more evidence based medicine in forensic mental health

To comply with the need for a more evidence based risk assessment and management in forensic mental health, an outcome monitor is being developed in the Dutch forensic psychiatric centre Van der Hoeven Kliniek in Utrecht, the Hoeven Outcome Monitor (HOM). Conform evidence based medicine (EBM) guidelines, the HOM is subdivided into three consecutive stages, (1) the evaluation stage, (2) the aetiology stage and (3) the implementation stage. In this article an account is provided for the design of the evaluation stage. To account for predicaments in previous research that pertain to a lack of uniformity and disregard of specific context- and patient-related characteristics, a macro-, meso- and micro-treatment evaluation instrument is developed. This instrument provides for the first step to build an evidence base for specific interventions and treatments in forensic psychiatry.

[Good practice guidelines for health information]

Evidence-based health information is distinguished by the provision of an unbiased and trustworthy description of the current state of medical knowledge. It enables people to learn more about health and disease, and to make health-related decisions - on their own or together with others - reflecting their attitudes and lifestyle. To adequately serve this purpose, health information must be evidence-based. A working group from the German Network for Evidence-based Medicine (Deutsches Netzwerk Evidenzbasierte Medizin) has developed a first draft of good practice guidelines for health information (Gute Praxis Gesundheitsinformation) with the aim of providing support for authors and publishers of evidence-based health information. The group included researchers, patient representatives, journalists and developers of health information. The criteria for evidence-based health information were developed and agreed upon within this author group, and then made available for public comment. All submitted comments were documented and assessed regarding the need to revise or amend the draft. Changes were subsequently implemented following approval by the author group. Gute Praxis Gesundheitsinformation calls for a transparent methodological approach in the development of health information. To achieve this, evidence-based information must be based on (a) a systematic literature search, (b) a justified selection of evidence, (c) unbiased reporting of relevant results, (d) appropriate factual and linguistic communication of uncertainties, (e) either avoidance of any direct recommendations or a strict division between the reporting of results and the derivation of recommendations, (f) the consideration of current evidence on the communication of figures, risks and probabilities, and (g) transparent information about the authors and publishers of the health information, including their funding sources. Gute Praxis Gesundheitsinformation lists a total of 16 aspects to be addressed in methods papers. Gute Praxis Gesundheitsinformation is a tool that puts forward methodological aspects to be considered when developing health information. In order to be transparent, descriptions of the underlying methods and processes need to be published in easily accessible methods papers describing the general procedure.

Does a research article's country of origin affect perception of its quality and relevance? A national trial of US public health researchers

OBJECTIVES

The source of research may influence one's interpretation of it in either negative or positive ways, however, there are no robust experiments to determine how source impacts on one's judgment of the research article. We determine the impact of source on respondents' assessment of the quality and relevance of selected research abstracts.

DESIGN

Web-based survey design using four healthcare research abstracts previously published and included in Cochrane Reviews.

SETTING

All Council on the Education of Public Health-accredited Schools and Programmes of Public Health in the USA.

PARTICIPANTS

899 core faculty members (full, associate and assistant professors)

INTERVENTION

Each of the four abstracts appeared with a high-income source half of the time, and low-income source half of the time. Participants each reviewed the same four abstracts, but were randomly allocated to receive two abstracts with high-income source, and two abstracts with low-income source, allowing for within-abstract comparison of quality and relevance

PRIMARY OUTCOME MEASURES

Within-abstract comparison of participants' rating scores on two measures--strength of the evidence, and likelihood of referral to a peer (1-10 rating scale). OR was calculated using a generalised ordered logit model adjusting for sociodemographic covariates.

RESULTS

Participants who received high income country source abstracts were equal in all known characteristics to the participants who received the abstracts with low income country sources. For one of the four abstracts (a randomised, controlled trial of a pharmaceutical intervention), likelihood of referral to a peer was greater if the source was a high income country (OR 1.28, 1.02 to 1.62, p<0.05).

CONCLUSIONS

All things being equal, in one of the four abstracts, the respondents were influenced by a high-income source in their rating of research abstracts. More research may be needed to explore how the origin of a research article may lead to stereotype activation and application in research evaluation.

Patient-centred management of polypharmacy: a process for practice

Medicines are the most common intervention to improve health. The number of medicines taken by older people in the UK has been steadily increasing for the last three decades. Polypharmacy is a term that refers to either the prescribing or taking many medicines. Concerns about the risks of polypharmacy in primary and secondary care are growing, supported by evidence which associates polypharmacy with increased adverse drug events, hospital admissions, increased healthcare costs and non-adherence. In the UK, this can largely be attributed, over the last 20 years, to the greater availability of evidence-based treatments promoted through therapeutic guidelines which are designed for single conditions, rather than addressing the multimorbidity that affects many older people. There is also currently a paucity of evidence-based national guidance around reducing and stopping medication and incorporating the patient perspective. This paper reviews current UK literature around polypharmacy including a description of four key resources which all make use of international literature and all focus on the medication aspects of polypharmacy from a clinician's perspective. The patient-centred approach combines both clinical health professionals and patient perspective. Developed using existing resources, it is designed to assist with collaborative (patient and clinician based) medication review to inform decisions around deprescribing and address polypharmacy as part of overall strategies to optimise medicines for the patient. Presented as a diagrammatic representation in seven steps, it also includes guidance on points to consider, actions to take and questions to ask in order to reduce polypharmacy and undertake deprescribing safely.

[General health checks and individual out-of-pocket health services]

General health checks are intended to identify risk factors or detect early signs of disease and to reduce mortality and morbidity from the disease by early interventions. Screening tests are not always beneficial; therefore, they have to be critically assessed with respect to the benefits and harms. Especially for general health checks there seems to be less awareness for potential harms than for other screening procedures because the diagnostic interventions are mostly less invasive and have low-risks of direct harms, such as ultrasonography or electrocardiography (ECG). Healthcare providers increasingly offer screening tests as individual out-of-pocket health services (Individuelle Gesundheits-Leistungen, IGeL) to patients without providing comprehensive information about the benefits and harms which would be necessary to enable informed decision-making. The article describes the current evidence and the methodological issues in the benefit assessment of general health checks in order to encourage a critical discussion on screening tests.

Key concepts that people need to understand to assess claims about treatment effects

OBJECTIVE

People are confronted with claims about the effects of treatments and health policies daily. Our objective was to develop a list of concepts that may be important for people to understand when assessing claims about treatment effects.

METHODS

An initial list of concepts was generated by the project team by identifying key concepts in literature and tools written for the general public, journalists, and health professionals, and consideration of concepts related to assessing the certainty of evidence for treatment effects. We invited key researchers, journalists, teachers and others with expertise in health literacy and teaching or communicating evidence-based health care to patients to act as the project's advisory group.

RESULTS

Twenty-nine members of the advisory group provided feedback on the list of concepts and judged the list to be sufficiently complete and organised appropriately. The list includes 32 concepts divided into six groups: (i) Recognising the need for systematic reviews of fair tests, (ii) Judging whether a comparison of treatments is fair comparison, (iii) Understanding the role of chance, (iv) Considering all the relevant fair comparisons, (v) Understanding the results of fair comparisons of treatments, (vi) Judging whether fair comparisons of treatments are relevant.

CONCLUSION

The concept list provides a starting point for developing and evaluating resources to improve people's ability to assess treatment effects. The concepts are considered to be universally relevant, and include considerations that can help people assess claims about the effects of treatments, including claims that are found in mass media reports, in advertisements and in personal communication.

Which factors may determine the necessary and feasible type of effectiveness evidence? A mixed methods approach to develop an instrument to help coverage decision-makers

OBJECTIVES

Reimbursement decisions require evidence of effectiveness and, in general, a blinded randomised controlled trial (RCT) is the preferred study design to provide it. However, there are situations where a cohort study, or even patient series, can be deemed acceptable. The aim of this study was to develop an instrument that first examines which study characteristics of a blinded RCT are necessary, and then, if particular characteristics are considered necessary, examines whether these characteristics are feasible.

DESIGN

We retrospectively studied 22 interventions from 20 reimbursement reports concerning medical specialist care made by the Dutch National Health Care Institute (ZIN) to identify any factors that influenced the necessity and feasibility of blinded RCTs, and their constituent study characteristics, that is, blinding, randomisation and a control group. A literature review was performed to identify additional factors. Additional expertise was included by interviewing eight experts in epidemiology, medicine and ethics. The resulting instrument was called the FIT instrument (Feasible Information Trajectory), and was prospectively validated using three consecutive reimbursement reports.

RESULTS

(Blinded) RCT evidence was lacking in 5 of 11 positive reimbursement decisions and 3 of 11 negative decisions. In the reimbursement reports, we found no empirical evidence supporting situations where a blinded RCT is unnecessary. The literature also revealed few arguments against the necessity of a blinded RCT. In contrast, many factors influencing the feasibility of randomisation, a control group and blinding, were found in the reimbursement reports and the literature; for example, when a patient population is too small or when an intervention is common practice, randomisation will be hindered.

CONCLUSIONS

Policy regarding the necessity and feasibility of different types of evidence of effectiveness would benefit from systematic guidance. The FIT instrument has the potential to support transparent, reproducible and well-founded decisions on appropriate evidence of effectiveness in medical specialist care.

A systematic review of quality of life in head and neck cancer treated with surgery with or without adjuvant treatment

Quality of life (QoL) is an important consideration in the management of head and neck cancers (HNC). We systematically reviewed the literature to assess the impact of curative surgical resection (+/- adjuvant therapy) of HNC on QoL. Eligible studies (participants>age 18 years, reported fully in English, and prospectively assessed QoL) were filtered using quality criteria, and classified according to the added value, using a published taxonomy. MEDLINE and EMBASE searching yielded 302 distinct reports, 49 met eligibility, and 26 met quality criteria. Among the eligible studies, achievement of certain quality criteria was poor: a priori hypothesis (8%), statistical accounting of missing data (8%), reporting of assessment interval (35%) and rationale for chosen measure (53%). The most frequent ways QoL added value were: understanding of treatment benefit and risk (100%), comparing treatments for QoL effect (92%) and advancing QoL research methodology (50%). QoL (physical/social functioning and various symptom domains) deteriorated with treatment, gradually recovering to baseline (cancer diagnosis) level. Swallowing, chewing, saliva, taste, eating disruption, and aesthetic deficits may persist. Advanced tumors, extensive surgical resection, need for flap reconstruction, neck dissection, and postoperative radiation are associated with worse QoL outcomes. Knowledge of these trends can be applied in shared decision making, identification of commonly faced QoL issues, and to develop and provide survivorship resources. Future research should focus on routinely incorporating QoL in randomized studies, reporting the result according to guidelines, and following knowledge translation principles to maximize the clinician's and patient's ability to use QoL data.

[Evidence based surgery. A necessary tool]

BACKGROUND

Evidence-based surgery is a tool that has been adopted worldwide by surgeons. As all decisions must be current and have a scientific basis, the approach for performing it must be standardised. Five important steps are required to perform surgery based on evidence. Convert the need for information into a question that can be answered, finding the best information to answer that question, critical evaluation of the evidence, and its validity, impact and applicability, integrating the evidence with your own experience, and with the evaluation of the patients. This should take into account their biology, values and specific circumstances, as well as to evaluate the effectiveness and efficiency of the execution of steps 1-4 and propose how to improve them.

CONCLUSION

This article presents the main tools to perform surgery properly based on evidence.

Testing treatments interactive (TTi): helping to equip the public to promote better research for better health care

Testing Treatments is a book written to help everyone understand why testing treatments is so important, why treatment tests have to be fair, and how everyone can help to promote better research for better health care. The book proved to be very popular and its second edition has already been translated into a dozen languages, with more translations in the pipeline. The texts of the original English and all the translations are feely downloadable from Testing Treatments interactive at www.testingtreatments.org. The editors of all the different language websites have established an TTi Editorial Alliance, to share experiences and provide each other with mutual support. The TTi Editorial Alliance seeks to promote a world in which health professionals, patients and the public use reliable research to inform their health decisions. Its missions are (i) To promote a global network, involving members of the public in partnership with professionals, to communicate and discuss basic principles and general knowledge about testing treatments; (ii) to help the public increase critical thinking and skills in accessing, apprehending, appraising and using research evidence; and (iii) to help patients and the public to participate more actively in health research.

Evidence-based surgery: The obstacles and solutions

Surgeons are often accused of lagging behind their medical colleagues in embracing evidence based medicine and utilizing new research tools to conducting high quality randomized controlled trials. Although there has been a noticeable improvement in the quantity and quality of high quality studies in surgical journals, the widespread practice of evidence based surgery is still poor. Unlike evidence based medicine, the practice of evidence based surgery is hampered by inherent problems and obstacles. This article reviews these difficulties and the limitations of randomized controlled trials in surgical practice. It also outlines some solutions that may help remedy this ongoing problem.

Smoke and mirrors: Limited value of relative risk reductions for assessing the benefits of disease-modifying therapies for multiple sclerosis

A reduction in relapse rate is the main primary outcome in most clinical trials in patients with multiple sclerosis (MS), with the effect of a treatment commonly expressed as relative risk reduction for this outcome. Physicians often assume that a drug with a higher relative risk reduction demonstrated in one trial is more effective than a drug with a lower relative risk reduction in another, and may pass this idea on to younger physicians and to patients. The use of the relative risk reduction as a measure of drug efficacy can be misleading, as it depends on the nature of the population studied: a treatment effect characterized by a lower relative risk reduction may be more clinically meaningful than one with a higher relative risk reduction. This concept is especially important with regard to clinical trials in patients with MS, where relapse rates in placebo groups have been declining in recent decades. Direct, head-to-head comparisons are the only way to compare the efficacy of the different treatments for MS.

Randomized placebo-controlled clinical trial of a chewable formulation of amlodipine for the treatment of hypertension in client-owned cats

Background

There is an unmet clinical need for a cat‐specific formulation of amlodipine to treat hypertensive cats.

Objectives

To assess the efficacy of chewable amlodipine tablets in reducing systolic blood pressure (SBP) in cats diagnosed with systemic arterial hypertension.

Animals

Seventy‐seven client‐owned cats with systemic hypertension were included (median age 14 years).

Methods

The study was randomized, double‐blinded, and placebo‐controlled. Forty‐two cats received 0.125–0.50 mg/kg amlodipine once daily for 28 days; 35 cats received placebo. After 28 days all cats continued with amlodipine for 2–3 months in an open‐label phase. Blood pressure was measured using high definition oscillometry. A responder was defined as a cat showing a decrease of SBP to <150 mmHg at 28 days or a decrease from baseline ≥15%.

Results

Sixty‐one cats completed the study. The responder rate was 63% in amlodipine group and 18% in placebo group. Cats receiving amlodipine were 7.9 (95% CI 2.6–24.1) times more likely to be classified as responders when compared to those receiving placebo (P < .001). From a mean (±SD) baseline value of 181 (±12) mmHg, SBP decreased to 154 (±17) mmHg with amlodipine and to 170 (±21) mmHg with placebo (P < .001). The voluntary acceptance rate of amlodipine formulation was 73%.

Conclusions and Clinical Importance

The chewable amlodipine tablet effectively reduced SBP compared with placebo in hypertensive cats, and was well‐tolerated. It can be used concomitantly with angiotensin‐converting enzyme inhibitors and in cats with chronic kidney disease.

An audit of best evidence topic reviews in the International Journal of Surgery

INTRODUCTION

IJS launched best evidence topic reviews (BETs) in 2011, when the guidelines for conducting and reporting these reviews were published in the journal.

AIMS

(1) Audit the adherence of all published BETs in IJS to these guidelines. (2) Assess the reach and impact of BETs published in IJS.

METHODS

BETs published between 2011 and February 2014 were identified from http://www.journal-surgery.net/. Standards audited included: completeness of description of study attrition, and independent verification of searches. Other extracted data included: relevant subspecialty, duration between searches and publication, and between acceptance and publication. Each BET's number of citations (http://scholar.google.co.uk/), number of tweets (http://www.altmetric.com/) and number of Researchgate views (https://www.researchgate.net/) were recorded.

RESULTS

Thirty-four BETs were identified: the majority, 19 (56%), relating to upper gastrointestinal surgery and none to cardiothoracic, orthopaedic or paediatric surgery. Twenty-nine BETs (82%) fully described study attrition. Twenty-one (62%) had independently verified search results. The mean times from literature searching to publication and acceptance to publication were 38.5 weeks and 13 days respectively. There were a mean 40 (range 0-89) Researchgate views/article, mean 2 (range 0-7) citations/article and mean 0.36 (range 0-2) tweets/article.

CONCLUSIONS

Adherence to BET guidelines has been variable. Authors are encouraged to adhere to journal guidelines and reviewers and editors to enforce them. BETs have received similar citation levels to other IJS articles. Means of increasing the visibility of published BETs such as social media sharing, conference presentation and deposition of abstracts in public repositories should be explored. More work is required to encourage more submissions from other surgical subspecialties other than gastrointestinal specialties.

Diabetes, diabetic complications, and blood pressure targets

Association of diabetes with hypertension is frequent and it well known that high blood pressure potentiates the probability of diabetic patients to develop macrovascular and microvascular complications. Strong evidence obtained in a number of large scale prospective studies indicates that adequate blood pressure control in diabetic patients is highly beneficial for prevention of cardiovascular events. Nonetheless, only a limited proportion of hypertensive-diabetic individuals included in studies on anti-hypertensive treatment has met the predefined blood pressure goal. The optimal blood pressure goal to be pursued in diabetic patients with hypertension to guarantee effective protection from cardiovascular outcomes is still under intense debate and recommendations of current guidelines on hypertension treatment are still inconsistent. We comment here on the most important studies and conclude that current evidence does not conclusively support the need to reach a blood pressure target in hypertensive patients with diabetes different from nondiabetic hypertensive individuals.

A review of the expected effects of antimicrobials in bovine respiratory disease treatment and control using outcomes from published randomized clinical trials with negative controls

Bovine respiratory disease (BRD) remains a major disease from an economic and an animal welfare standpoint in beef production systems. Antimicrobial administration is a mainstay in the control of and therapeutic treatment of acute BRD. Judicious use of antimicrobials remains paramount to ensure efficacy of treatment remains acceptable. A systemic review was conducted in the scientific literature, the objective of which was to present a cumulative review of the data from published randomized clinical trials using a negative control in the treatment and control of BRD and using the number needed to treat as a means to effectively convey this information to bovine practitioners.

Correlation between clinicians-assigned weights to findings and their diagnostic odd ratio; case of congestive heart failure

BACKGROUND

Incorrect estimation of pretest probability and misinterpretation of test results can change post-test probability in medical decision making. The aim of this study was to evaluate how physicians assess weight of findings of congestive heart failure (CHF) and how much their estimation is correlated with findings' Diagnostic Odd Ratio (DOR).

METHODS

The participants were asked to answer a questionnaire based on a scenario of a patient having dyspnea. Eighteen findings in 3 categories including: history, examination and radiographic findings were inserted along a column and a row as a matrix. The respondents had to compare each finding in the column with all other findings in the row and insert a mark in boxes below the findings of the row that had greater weight compared to the finding in the column. The weight of each finding was considered as total number of "marked boxes" in front of that finding. DOR of findings was calculated using their positive and negative likelihood ratios (LRs) based on current best evidence. Findings ranked in the order of their DOR and were compared with the ranking in the order of participants-assigned weights. We examined correlation between average weights assigned by physicians and DOR of findings. In subgroup analysis correlations between average weights assigned by physicians and DOR of history, examination and radiographic findings were examined.

RESULTS

Seventy five physicians completed the questionnaire. Correlation between ranking in the order of findings' DOR and ranking in the order of clinicians-assigned weights was significant (p-value = 0.005 r = 0.64). In contrast correlations between participants-assigned weights and DOR of history, examination and radiographic findings were positive but non- significant (r = 0.181, p-value = 0.7, r = 0.343, p-value = 0.506 and r = 0.219, p-value = 0.723 respectively).

CONCLUSION

Our result show that although correlation between clinicians-assigned weights and DOR of entire findings was significant, correlations between clinicians-assigned weights to the different categories of findings and their DOR were not significant. Reevaluating probabilistic reasoning by emphasis on using LRs can make pretest probability estimating and interpretation of test results more objective and would ultimate in more precise and homogenous post-test probabilities.

Long-term effect of computer-assisted decision support for antibiotic treatment in critically ill patients: a prospective 'before/after' cohort study

OBJECTIVES

Antibiotic resistance has risen dramatically over the past years. For individual patients, adequate initial antibiotic therapy is essential for clinical outcome. Computer-assisted decision support systems (CDSSs) are advocated to support implementation of rational anti-infective treatment strategies based on guidelines. The aim of this study was to evaluate long-term effects after implementation of a CDSS.

DESIGN

This prospective 'before/after' cohort study was conducted over four observation periods within 5 years. One preinterventional period (pre) was compared with three postinterventional periods: directly after intensive implementation efforts (post1), 2 years (post2) and 3 years (post3) after implementation.

SETTING

Five anaesthesiological-managed intensive care units (ICU) (one cardiosurgical, one neurosurgical, two interdisciplinary and one intermediate care) at a university hospital.

PARTICIPANTS

Adult patients with an ICU stay of >48 h were included in the analysis. 1316 patients were included in the analysis for a total of 12,965 ICU days.

INTERVENTION

Implementation of a CDSS.

OUTCOME MEASURES

The primary end point was percentage of days with guideline adherence during ICU treatment. Secondary end points were antibiotic-free days and all-cause mortality compared for patients with low versus high guideline adherence.

MAIN RESULTS

Adherence to guidelines increased from 61% prior to implementation to 92% in post1, decreased in post2 to 76% and remained significantly higher compared with baseline in post3, with 71% (p=0.178). Additionally, antibiotic-free days increased over study periods. At all time periods, mortality for patients with low guideline adherence was higher with 12.3% versus 8% (p=0.014) and an adjusted OR of 1.56 (95% CI 1.05 to 2.31).

CONCLUSIONS

Implementation of computerised regional adapted guidelines for antibiotic therapy is paralleled with improved adherence. Even without further measures, adherence stayed high for a longer period and was paralleled by reduced antibiotic exposure. Improved guideline adherence was associated with reduced ICU mortality.

TRIAL REGISTRATION NUMBER

ISRCTN54598675.