1
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Ng JY, Liu H, Wang MC. Complementary and alternative medicine mention and recommendations in inflammatory bowel disease guidelines: systematic review and assessment using AGREE II. BMC Complement Med Ther 2023; 23:230. [PMID: 37434218 DOI: 10.1186/s12906-023-04062-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Accepted: 06/29/2023] [Indexed: 07/13/2023] Open
Abstract
BACKGROUND Many patients with inflammatory bowel disease (IBD) use complementary and alternative medicine (CAM) for disease management. There is, however, a communication gap between patients and healthcare professionals regarding CAM use, where patients are hesitant to disclose CAM use to providers. The purpose of this study was to identify the quantity and assess the quality of CAM recommendations in IBD clinical practice guidelines (CPGs) using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) instrument. METHODS MEDLINE, EMBASE, and CINAHL were systematically searched from 2011 to 2022 to find CPGs for the treatment and/or management of IBD. The Guidelines International Network (GIN) and National Center for Complementary and Integrative Health (NCCIH) websites were also searched. Eligible CPGs were assessed using the AGREE II instrument. RESULTS Nineteen CPGs made CAM recommendations for IBD and were included in this review. Average scaled domain percentages of CPGs were as follows (overall CPG, CAM section): scope and purpose (91.5%, 91.5%), clarity of presentation (90.3%, 64.0%), editorial independence (57.0%, 57.0%), stakeholder involvement (56.7%, 27.8%), rigour of development (54.7%, 45.9%), and applicability (14.6%, 2.1%). CONCLUSIONS The majority of CPGs with CAM recommendations were of low quality and their CAM sections scored substantially lower relative to other therapies in the overall CPG. In future updates, CPGs with low scaled-domain percentages could be improved in accordance with AGREE II and other guideline development resources. Further research investigating how CAM therapies can best be incorporated into IBD CPGs is warranted.
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Affiliation(s)
- Jeremy Y Ng
- Department of Health Research Methods, Evidence, and Impact, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada.
| | - Henry Liu
- Department of Health Research Methods, Evidence, and Impact, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Michelle Chenghuazou Wang
- Department of Health Research Methods, Evidence, and Impact, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
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2
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Weissman S, Fung BM, Bangolo A, Rashid A, Khan BF, Tirumala AKG, Nagpaul S, Cornwell S, Karamthoti P, Murugan V, Taranichi IS, Kalinin M, Wishart A, Khalaf I, Kodali NA, Aluri PSC, Kejela Y, Abdul R, Jacob FM, Manoharasetty A, Sethi A, Nadimpallli PM, Ballestas NP, Venkatraman A, Chirumamilla A, Nagesh VK, Gangwani MK, Issokson K, Aziz M, Swaminath A, Feuerstein JD. The overall quality of evidence of recommendations surrounding nutrition and diet in inflammatory bowel disease. Int J Colorectal Dis 2023; 38:98. [PMID: 37061646 DOI: 10.1007/s00384-023-04404-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/10/2023] [Indexed: 04/17/2023]
Abstract
BACKGROUND AND AIM Recently, there has been an increased focus on the role nutrition and diet play in maintaining health in inflammatory bowel disease (IBD). We aimed to assess the overall quality, strength, and transparency of conflicts among guidelines on nutrition/diet in IBD. METHODS A systematic search was performed on multiple databases from inception until January 1, 2021, to identify guidelines pertaining to nutrition or diet in IBD. All guidelines were reviewed for disclosure of conflicts of interest (COI) and funding, recommendation quality and strength, external document review, patient representation, and plans for update-as per Institute of Medicine (IOM) standards. In addition, recommendations and their quality were compared between guidelines/societies. RESULTS: Seventeen distinct societies and a total of 228 recommendations were included. Not all guidelines provided recommendations on key aspects of diet-such as the role of supplements or the appropriate micro/macro nutrition in IBD. Fifty-nine percent of guidelines reported on COI, 24% underwent external review, and 41% included patient representation. 18.4%, 25.9%, and 55.7% of recommendations were based on high-, moderate-, and low-quality evidence, respectively. 10.5%, 24.6%, and 64.9% of recommendations were strong, weak/conditional, and did not provide a strength, respectively. The proportion of high-quality evidence (p = 0.12) and strong recommendations (p = 0.83) did not significantly differ across societies. CONCLUSIONS Many guidelines do not provide recommendations on key aspects of diet/nutrition in IBD. As over 50% of recommendations are based on low-quality evidence, further studies on nutrition/diet in IBD are warranted to improve the overall quality of evidence.
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Affiliation(s)
- Simcha Weissman
- Department of Medicine, Hackensack Meridian Health Palisades Medical Center, North Bergen, NJ, USA
| | - Brian M Fung
- Division of Gastroenterology and Hepatology, University of Arizona College of Medicine-Phoenix, Phoenix, AZ, USA
| | - Ayrton Bangolo
- Department of Medicine, Hackensack Meridian Health Palisades Medical Center, North Bergen, NJ, USA.
| | - Atif Rashid
- Department of Medicine, Hackensack Meridian Health Palisades Medical Center, North Bergen, NJ, USA
| | - Badar F Khan
- Department of Medicine, Hackensack Meridian Health Palisades Medical Center, North Bergen, NJ, USA
| | | | - Sneha Nagpaul
- Department of Medicine, Hackensack Meridian Health Palisades Medical Center, North Bergen, NJ, USA
| | - Samuel Cornwell
- Department of Medicine, Hackensack Meridian Health Palisades Medical Center, North Bergen, NJ, USA
| | - Praveena Karamthoti
- Department of Medicine, Hackensack Meridian Health Palisades Medical Center, North Bergen, NJ, USA
| | - Vignesh Murugan
- Department of Medicine, Hackensack Meridian Health Palisades Medical Center, North Bergen, NJ, USA
| | - Ihsan S Taranichi
- Department of Medicine, Hackensack Meridian Health Palisades Medical Center, North Bergen, NJ, USA
| | - Maksim Kalinin
- Department of Medicine, Hackensack Meridian Health Palisades Medical Center, North Bergen, NJ, USA
| | - Annetta Wishart
- Department of Medicine, Hackensack Meridian Health Palisades Medical Center, North Bergen, NJ, USA
| | - Ibtihal Khalaf
- Department of Medicine, Hackensack Meridian Health Palisades Medical Center, North Bergen, NJ, USA
| | - Naga A Kodali
- Department of Medicine, Hackensack Meridian Health Palisades Medical Center, North Bergen, NJ, USA
| | - Pruthvi S C Aluri
- Department of Medicine, Hackensack Meridian Health Palisades Medical Center, North Bergen, NJ, USA
| | - Yabets Kejela
- Department of Medicine, Hackensack Meridian Health Palisades Medical Center, North Bergen, NJ, USA
| | - Rub Abdul
- Department of Medicine, Hackensack Meridian Health Palisades Medical Center, North Bergen, NJ, USA
| | - Feba M Jacob
- Department of Medicine, Hackensack Meridian Health Palisades Medical Center, North Bergen, NJ, USA
| | - Advaith Manoharasetty
- Department of Medicine, Hackensack Meridian Health Palisades Medical Center, North Bergen, NJ, USA
| | - Aparna Sethi
- Department of Medicine, Hackensack Meridian Health Palisades Medical Center, North Bergen, NJ, USA
| | - Preethi M Nadimpallli
- Department of Medicine, Hackensack Meridian Health Palisades Medical Center, North Bergen, NJ, USA
| | - Natalia P Ballestas
- Department of Medicine, Hackensack Meridian Health Palisades Medical Center, North Bergen, NJ, USA
| | - Aarushi Venkatraman
- Department of Medicine, Hackensack Meridian Health Palisades Medical Center, North Bergen, NJ, USA
| | - Avinash Chirumamilla
- Department of Medicine, Hackensack Meridian Health Palisades Medical Center, North Bergen, NJ, USA
| | - Vignesh K Nagesh
- Department of Medicine, Hackensack Meridian Health Palisades Medical Center, North Bergen, NJ, USA
| | - Manesh K Gangwani
- Department of Medicine, Toledo University Medical Center, Toledo, OH, USA
| | - Kelly Issokson
- Department of Medicine, Section of Digestive Diseases, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Muhammad Aziz
- Division of Gastroenterology, Toledo University Medical Center, Toledo, OH, USA
| | - Arun Swaminath
- Division of Gastroenterology, Inflammatory Bowel Disease Program, Lenox Hill Hospital, New York, NY, USA
| | - Joseph D Feuerstein
- Division of Gastroenterology, Hepatology, and Nutrition, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
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3
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Weissman S, Systrom HK, Bangolo A, Elias D, Awasi M, Zahdeh T, Ogbu CE, Kim MH, Kalra M, Khota K, Kasarapu RB, Mutabi E, Makrani M, Nemalikanti S, Thomas J, Jijo JP, Thwe HM, Salib Y, Narayan KL, Ahmed K, Aziz M, Elias S, Feuerstein JD. Health Maintenance and Preventative Care in Inflammatory Bowel Disease: A Systematic Review of the Overall Quality of Societal Recommendations. J Clin Gastroenterol 2023; 57:325-334. [PMID: 36753461 DOI: 10.1097/mcg.0000000000001833] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
Abstract
BACKGROUND AIMS Preventative care plays an important role in maintaining health in patients with inflammatory bowel disease (IBD). We aimed to assess the overall quality, strength, and transparency of conflicts among guidelines on preventative care in IBD. METHODS A systematic literature search was performed in multiple databases to identify all guidelines pertaining to preventative care in IBD in April 2021. All guidelines were reviewed for the transparency of conflicts of interest and funding, recommendation quality and strength, external guideline review, patient voice inclusion, and plan for update-as per Institute of Medicine standards. In addition, recommendations and their quality were compared between societies. RESULTS Fifteen distinct societies and a total of 89 recommendations were included. Not all guidelines provided recommendations on the key aspects of preventative care in IBD-such as vaccinations, cancer prevention, stress reduction, and diet/exercise. Sixty-seven percent of guidelines reported on conflicts of interest, 20% underwent external review, and 27% included patient representation. In all, 6.7%, 21.3%, and 71.9% of recommendations were based on high, moderate, and low-quality evidence, respectively. Twenty-seven percent, 23.6%, and 49.4% of recommendations were strong, weak/conditional, and did not provide a strength, respectively. The proportion of high-quality evidence ( P =0.28) and strong recommendations ( P =0.41) did not significantly differ across societies. CONCLUSIONS Many guidelines do not provide recommendations on key aspects of preventative care in IBD. As over 70% of recommendations are based on low-quality evidence, further studies on preventative care in IBD are warranted to improve the overall quality of evidence.
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Affiliation(s)
- Simcha Weissman
- Department of Medicine, Hackensack Meridian Health Palisades Medical Center, North Bergen, NJ
| | - Hannah K Systrom
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Ayrton Bangolo
- Department of Medicine, Hackensack Meridian Health Palisades Medical Center, North Bergen, NJ
| | - Daniel Elias
- Department of Medicine, NJMS School of Medicine, Newark, NJ
| | - Marcel Awasi
- Department of Medicine, Hackensack Meridian Health Palisades Medical Center, North Bergen, NJ
| | - Tamer Zahdeh
- Department of Medicine, Hackensack Meridian Health Palisades Medical Center, North Bergen, NJ
| | - Chukwuemeka E Ogbu
- Department of Medicine, Hackensack Meridian Health Palisades Medical Center, North Bergen, NJ
| | - Mishka Hoo Kim
- Department of Medicine, Hackensack Meridian Health Palisades Medical Center, North Bergen, NJ
| | - Meenal Kalra
- Department of Medicine, Hackensack Meridian Health Palisades Medical Center, North Bergen, NJ
| | - Kavya Khota
- Department of Medicine, Hackensack Meridian Health Palisades Medical Center, North Bergen, NJ
| | - Ritu B Kasarapu
- Department of Medicine, Hackensack Meridian Health Palisades Medical Center, North Bergen, NJ
| | - Erasmus Mutabi
- Department of Medicine, Hackensack Meridian Health Palisades Medical Center, North Bergen, NJ
| | - Moinulhaq Makrani
- Department of Medicine, Hackensack Meridian Health Palisades Medical Center, North Bergen, NJ
| | - Sanskrita Nemalikanti
- Department of Medicine, Hackensack Meridian Health Palisades Medical Center, North Bergen, NJ
| | - Jim Thomas
- Department of Medicine, Hackensack Meridian Health Palisades Medical Center, North Bergen, NJ
| | - Joseph P Jijo
- Department of Medicine, Hackensack Meridian Health Palisades Medical Center, North Bergen, NJ
| | - Hla M Thwe
- Department of Medicine, Hackensack Meridian Health Palisades Medical Center, North Bergen, NJ
| | - Yousstina Salib
- Department of Medicine, Hackensack Meridian Health Palisades Medical Center, North Bergen, NJ
| | - Kiran L Narayan
- Department of Medicine, Hackensack Meridian Health Palisades Medical Center, North Bergen, NJ
| | - Kareem Ahmed
- Department of Medicine, University of Washington, Seattle, WA
| | - Muhammad Aziz
- Division of Gastroenterology and Hepatology, University of Toledo Medical Center, Toledo, OH
| | - Sameh Elias
- Department of Medicine, Hackensack Meridian Health Palisades Medical Center, North Bergen, NJ
| | - Joseph D Feuerstein
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
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4
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Weissman S, Aziz M, Baniqued MR, Taneja V, El-Dallal M, Lee-Smith W, Elias S, Feuerstein JD. Quality measures in endoscopy: A systematic analysis of the overall scientific level of evidence and conflicts of interest. Endosc Int Open 2022; 10:E776-E786. [PMID: 35692919 PMCID: PMC9187391 DOI: 10.1055/a-1809-4219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Accepted: 03/15/2022] [Indexed: 11/30/2022] Open
Abstract
Background and study aims Quality measures were established to develop standards to help assess quality of care, yet variation in endoscopy exists. We performed a systematic review to assess the overall quality of evidence cited in formulating quality measures in endoscopy. Methods A systematic search was performed on multiple databases from inception until November 15, 2020, to examine the quality measures proposed by all major societies. Quality measures were assessed for their level of quality evidence and categorized as category A (guideline-based), category B (observational studies) or category C (expert opinion). They were also examined for the type of measure (process, structure, outcome), the quality, measurability, review, existing conflicts of interest (COI), and patient participation of the quality measure. Results An aggregate total of 214 quality measures from nine societies (15 manuscripts) were included and analyzed. Of quality measures in endoscopy, 71.5 %, 23.8 %, and 4.7 % were based on low, moderate, and high quality of evidence, respectively. The proportion of high-quality evidence across societies was significantly different ( P = 0.028). Of quality measures, 76 % were quantifiable, 18 % contained patient-centric outcomes, and 7 % reported outcome measures. None of the organizations reported on patient involvement or external review, six disclosed existing COI, and 40 % were published more than 5 years ago. Conclusions Quality measures are important to standardize clinical practice. Because over 70 % of quality measures in endoscopy are based on low-quality evidence, further studies are needed to improve the overall quality to effectively set a standard, reduce variation, and improve care in endoscopic practice.
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Affiliation(s)
- Simcha Weissman
- Department of Medicine, Hackensack Meridian Health Palisades Medical Center, North Bergen, New Jersey, United States
| | - Muhammad Aziz
- Division of Gastroenterology and Hepatology, University of Toledo Medical Center, Toledo, Ohio, United States
| | - Matthew R. Baniqued
- Hackensack Meridian Health School of Medicine, Hackensack, New Jersey, United States
| | - Vikas Taneja
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, United States
| | - Mohammed El-Dallal
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, United States
| | - Wade Lee-Smith
- Division of Gastroenterology and Hepatology, University of Toledo Medical Center, Toledo, Ohio, United States
| | - Sameh Elias
- Department of Medicine, Hackensack Meridian Health Palisades Medical Center, North Bergen, New Jersey, United States
| | - Joseph D. Feuerstein
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, United States
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5
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Weissman S, Systrom HK, Aziz M, El-Dallal M, Lee-Smith W, Sciarra M, Feuerstein JD. Colorectal Cancer Prevention in Inflammatory Bowel Disease: A Systematic Analysis of the Overall Quality of Guideline Recommendations. Inflamm Bowel Dis 2022; 28:745-754. [PMID: 34245270 DOI: 10.1093/ibd/izab164] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Indexed: 01/03/2023]
Abstract
BACKGROUND Owing to the increased risk of colorectal cancer (CRC) in patients with inflammatory bowel disease (IBD), numerous societies developed preventative guidelines. We aimed to assess the overall quality of CRC prevention guidelines in IBD. METHODS A systematic search was performed in multiple databases to identify all guidelines pertaining to CRC prevention in IBD in September 2020. All guidelines were reviewed for conflicts of interest (COIs)/funding, recommendation quality/strength, external guideline review, use of patient representation, and plans for update-as per Institute of Medicine standards. In addition, recommendations were compared amongst societies. RESULTS One hundred forty-nine recommendations from 14 different guidelines/societies were included. Not all guidelines provided recommendations on key elements surrounding (1) screening initiation and surveillance, (2) screening modality, (3) pharmacological chemoprevention, (4) dysplasia management and follow-up, and (5) molecular marker use. Only 71% of guidelines disclosed COIs, 43% reported industry funding, 14% were externally reviewed, 7% included patient representation, and 36% had plans for update. Of the total recommendations, 7.4%, 23.5%, and 69.1% were based on high,- moderate-, and low-quality evidence, respectively. Additionally, 20.1% of recommendations were strong, 14.1%, were weak/conditional, and 65.8% did not provide a strength. The proportion of high-quality evidence (P = 0.34) and strong recommendations (P = 0.57) did not significantly differ across societies. CONCLUSIONS Many guidelines do not provide recommendations on key aspects of CRC prevention in IBD. Over 90% of recommendations are based on low- to moderate-quality evidence; therefore, further studies on CRC prevention in IBD are needed to improve the overall quality of evidence.
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Affiliation(s)
- Simcha Weissman
- Department of Medicine, Hackensack Meridian Health Palisades Medical Center, North Bergen, New Jersey, USA
| | - Hannah K Systrom
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Muhammad Aziz
- Division of Gastroenterology and Hepatology, University of Toledo Medical Center, Toledo, OH, USA
| | - Mohammed El-Dallal
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.,Division of Hospital Medicine, Cambridge Health Alliance, Cambridge and Harvard Medical School, MA, USA
| | - Wade Lee-Smith
- Department of Library Sciences, University of Toledo Medical Center, Toledo, OH, USA
| | - Michael Sciarra
- Division of Gastroenterology and Hepatology, Hackensack Meridian Health Palisades Medical Center, North Bergen, NJ, USA
| | - Joseph D Feuerstein
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
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Christian A. Addressing Conflicts of Interest and Conflicts of Commitment in Public Advocacy and Policy Making on CRISPR/Cas-Based Human Genome Editing. Front Res Metr Anal 2022; 7:775336. [PMID: 35572153 PMCID: PMC9094628 DOI: 10.3389/frma.2022.775336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Accepted: 03/17/2022] [Indexed: 11/24/2022] Open
Abstract
Leading experts on CRISPR/Cas-based genome editing—such as 2020 Nobel laureates Jennifer Doudna and Emmanuelle Charpentier—are not only renowned specialists in their fields, but also public advocates for upcoming regulatory frameworks on CRISPR/Cas. These frameworks will affect large portions of biomedical research on human genome editing. In advocating for particular ways of handling the risks and prospects of this technology, high-profile scientists not only serve as scientific experts, but also as moral advisers. The majority of them currently intend to bring about a “responsible pathway” toward human genome interventions in clinical therapy. Engaging in advocacy for such a pathway, they issue moral judgments on the risks and benefits of this new technology. They declare that there actually is a responsible pathway, they draft resolutions on temporary moratoria, they make judgments on which groups and individuals are credible and should participate in public and semi-public debates, so they also set the standards for deciding who counts as well-informed, as well as the standards of evidence for adopting or rejecting research policies. This degree of influence on public debates and policy making is, at the very least, noteworthy. This contribution sounds a note of caution with regard to the endeavor of a responsible pathway to human genome editing and in particular scrutinizes the legitimacy of expert-driven research policies given commercial conflicts of interest and conflicts of commitment among first-rank scholars.
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Gholami R, Khan R, Ramkissoon A, Alabdulqader A, Gimpaya N, Bansal R, Scaffidi MA, Prasad V, Detsky AS, Baker JP, Grover SC. Recommendation Reversals in Gastroenterology Clinical Practice Guidelines. J Can Assoc Gastroenterol 2022; 5:98-99. [PMID: 35368318 PMCID: PMC8972276 DOI: 10.1093/jcag/gwab040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Accepted: 09/28/2021] [Indexed: 11/23/2022] Open
Abstract
Background Recommendations in clinical practice guidelines (CPGs) may be reversed when evidence emerges to show they are futile or unsafe. In this study, we identified and characterized recommendation reversals in gastroenterology CPGs. Methods We searched CPGs published by 20 gastroenterology societies from January 1990 to December 2019. We included guidelines which had at least two iterations of the same topic. We defined reversals as when (a) the more recent iteration of a CPG recommends against a specific practice that was previously recommend in an earlier iteration of a CPG from the same body, and (b) the recommendation in the previous iteration of the CPG is not replaced by a new diagnostic or therapeutic recommendation in the more recent iteration of the CPG. The primary outcome was the number of recommendation reversals. Secondary outcomes included the strength of recommendations and quality of evidence cited for reversals. Results Twenty societies published 1022 CPGs from 1990 to 2019. Our sample for analysis included 129 unique CPGs. There were 11 recommendation reversals from 10 guidelines. New evidence was presented for 10 recommendation reversals. Meta-analyses were cited for two reversals, and randomized controlled trials (RCTs) for seven reversals. Recommendations were stronger after the reversal for three cases, weaker in two cases, and of similar strength in three cases. We were unable to compare recommendation strengths for three reversals. Conclusion Recommendation reversals in gastroenterology CPGs are uncommon but highlight low value or harmful practices.
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Affiliation(s)
- Reza Gholami
- Division of Gastroenterology, St. Michael’s Hospital, Toronto, Ontario, Canada
| | - Rishad Khan
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Anushka Ramkissoon
- Division of Gastroenterology, St. Michael’s Hospital, Toronto, Ontario, Canada
| | | | - Nikko Gimpaya
- Division of Gastroenterology, St. Michael’s Hospital, Toronto, Ontario, Canada
| | - Rishi Bansal
- Division of Gastroenterology, St. Michael’s Hospital, Toronto, Ontario, Canada
| | - Michael A Scaffidi
- Division of Gastroenterology, St. Michael’s Hospital, Toronto, Ontario, Canada
| | - Vinay Prasad
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California,USA
| | - Allan S Detsky
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Department of Medicine, Mount Sinai Hospital and University Health Network, Toronto, Ontario, Canada
| | - Jeffrey P Baker
- Division of Gastroenterology, St. Michael’s Hospital, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Samir C Grover
- Division of Gastroenterology, St. Michael’s Hospital, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, Ontario, Canada
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8
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Elsolh K, Tham D, Scaffidi MA, Gimpaya N, Bansal R, Torabi N, Li J, Verma Y, Khan R, Grover SC. OUP accepted manuscript. J Can Assoc Gastroenterol 2022; 5:214-220. [PMID: 36196272 PMCID: PMC9527658 DOI: 10.1093/jcag/gwac018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Background Propensity score matching (PSM), a statistical technique that estimates a treatment effect by accounting for predictor covariates, has been used to evaluate biologics for inflammatory bowel disease (IBD). Financial conflicts of interest are prevalent in the marketing of biologic medications. It is unclear whether this burden of conflicts is present among authors of PSM studies comparing IBD biologics and biosimilars. Objective This study was aimed to determine the prevalence of financial conflicts of interest among authors of PSM studies evaluating IBD biologics and biosimilars. Methods We conducted a systematic search for PSM studies comparing biologics and biosimilars in IBD treatment. We identified 21 eligible studies. Two independent authors extracted self-declared conflicts from the disclosures section. Each participating author was searched on the Centers for Medicare & Medicaid Services Open Payments to identify payment amounts and undisclosed conflicts. Primary outcome was the prevalence of author conflicts. Secondary analyses assessed for an association between conflict prevalence and reporting of positive outcomes. Results Among 283 authors, conflicts were present among 41.0% (116 of 283). Twenty-three per cent (27 of 116) of author conflicts involved undisclosed payments. Studies with positive outcomes were significantly more likely to include conflicted authors than neutral studies (relative risk = 2.34, 95% confidence interval: 1.71 to 3.21, P < 0.001). Conclusions Overall, we found a high burden of undisclosed conflicts among authors of PSM studies comparing IBD biologics and biosimilars. Given the importance of PSM studies as a means for biologic comparison and the potential for undue industry influence from these payments, authors should ensure greater transparency with reporting of industry relationships.
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Affiliation(s)
- Karam Elsolh
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
- Division of Gastroenterology, St. Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Daniel Tham
- Division of Gastroenterology, St. Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Michael A Scaffidi
- Division of Gastroenterology, St. Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada
- Faculty of Health Sciences, School of Medicine, Queen’s University, Kingston, Ontario, Canada
| | - Nikko Gimpaya
- Division of Gastroenterology, St. Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Rishi Bansal
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
- Division of Gastroenterology, St. Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Nazi Torabi
- Li Ka Shing Knowledge Institute, Toronto, Ontario, Canada
| | - Juana Li
- Division of Gastroenterology, St. Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Yash Verma
- Division of Gastroenterology, St. Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Rishad Khan
- Division of Gastroenterology, St. Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Samir C Grover
- Correspondence: Samir C. Grover, MD, MEd, FRCPC, Division of Gastroenterology, St. Michael’s Hospital, Department of Medicine, University of Toronto, 30 Bond Street, 16-046 Cardinal Carter Wing, Toronto, Ontario M5B 1W8, Canada, e-mail:
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9
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Weissman S, Goldowsky A, Aziz M, Mehta TI, Sharma S, Lipcsey M, Walradt T, Iqbal U, Elias S, Feuerstein JD. Colorectal Cancer Screening Guidelines Are Primarily Based on Low-Moderate-Quality Evidence. Dig Dis Sci 2021; 66:4208-4219. [PMID: 33433802 DOI: 10.1007/s10620-020-06755-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Accepted: 12/01/2020] [Indexed: 01/05/2023]
Abstract
BACKGROUND Owning to colorectal cancer's (CRC) high mortality, multiple societies developed screening guidelines. AIMS We aimed to assess the overall quality of CRC screening guidelines. METHODS A systematic search was performed to review CRC screening guidelines for conflicts of interest (COI), recommendation quality and strength, external document review, use of patient representative, and recommendation age-as per Institute of Medicine (IOM) standards. In addition, recommendations were compared between guidelines/societies. Statistical analysis was conducted using R. RESULTS Twelve manuscripts were included in final analysis. Not all guidelines reported on COI, provided a grading method, underwent external review, or included patient representation. 14.5%, 34.2%, and 51.3% of recommendations were based on high-, moderate-, and low-quality evidence, respectively. 27.8%, 54.6%, and 17.5% of recommendations were strong, weak/conditional, and did not provide a strength, respectively. The proportion of high-quality evidence and strong recommendations did not significantly differ across societies, nor were significant associations between publication year and evidence quality seen (P = 0.4). CONCLUSIONS While the majority of the CRC guidelines contain aspects of the standards set forth by the IOM, there is an overall lack of adherence. As over 85% of recommendations are based on low-moderate quality evidence, further studies on CRC screening are warranted to improve the overall quality of evidence.
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Affiliation(s)
- Simcha Weissman
- Department of Medicine, Hackensack Meridian Health, Palisades Medical Center, North Bergen, NJ, USA
| | - Alexander Goldowsky
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Muhammad Aziz
- Division of Gastroenterology and Hepatology, University of Toledo Medical Center, Toledo, OH, USA
| | - Tej I Mehta
- Department of Medicine, Medical College of Wisconsin, Madison, WI, USA
| | - Sachit Sharma
- Department of Medicine, University of Toledo Medical Center, Toledo, OH, USA
| | - Megan Lipcsey
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Trent Walradt
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Umair Iqbal
- Department of Medicine, Geisinger Medical Center, Danville, PA, USA
| | - Sameh Elias
- Department of Medicine, Hackensack Meridian Health, Palisades Medical Center, North Bergen, NJ, USA
| | - Joseph D Feuerstein
- Center for Inflammatory Bowel Disease, Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Ave, Boston, MA, 02215, USA.
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10
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Goldowsky A, Sen R, Hoffman G, Feuerstein JD. Is there a standardized practice for the development of international ulcerative colitis and Crohn's disease treatment guidelines? Gastroenterol Rep (Oxf) 2021; 9:408-417. [PMID: 34733526 PMCID: PMC8560035 DOI: 10.1093/gastro/goab009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Revised: 09/17/2020] [Accepted: 10/25/2020] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Guidelines are published by international gastroenterology societies regarding the management of ulcerative colitis (UC) and Crohn's disease (CD) to help clinicians to provide high-quality patient care. We examined the guidelines for the quality and strength of evidence used to develop the recommendations, methods for grading evidence, differences in disease-specific recommendations, conflicts of interest, and plans for guideline updates. METHODS A systematic search was performed on PubMed using "ulcerative colitis," "Crohn's disease," and "guidelines" in April 2019. International gastroenterology society websites were searched for UC- and CD-specific guidelines. Guidelines from 12 societies were examined by two authors. Chi-squared tests were used for comparing evidence-level grades, strength of recommendations, and reported conflicts of interest. Linear-regression modeling was used to evaluate the relationship between the number of authors and the number of recommendations in a given guideline. RESULTS Of 28 guidelines reviewed, 25 (89%) used a total of three different systems to grade the level of evidence and 2 (7%) used an unknown system. Three (11%) reviewed guidelines did not provide a conflict-of-interest statement, while three (11%) provided a timeline for guideline updates. Of 1,265 total statements examined, 246 (19%) reported no grade of evidence quality or explicitly stated that the recommendation was based on "expert opinion." One hundred and thirty-five (22%) UC recommendations were noted to be "weak/conditional" and 95 (16%) did not have a recommendation strength. Two hundred and forty-two (37%) CD recommendations were noted to be "weak/conditional" and 151 (23%) did not have a recommendation strength. CONCLUSION The majority of UC and CD guidelines are based on a low/very low quality of evidence and are further weakened due to the lack of homogeneity in specific aspects of management recommendations as well as conflicts of interest.
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Affiliation(s)
- Alexander Goldowsky
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Rohan Sen
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Gila Hoffman
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Joseph D Feuerstein
- Department of Gastroenterology and Hepatology, Beth Israel Deaconess Medical Center, Boston, MA, USA
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11
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Weissman S, Aziz M, Baniqued MR, Ahmed M, Elias S, Feuerstein JD, Tabibian JH. Extra-Colonic Malignancy in Inflammatory Bowel Disease: a Paucity of Recommendations with Weak Evidence. J Gastrointest Cancer 2021; 53:669-673. [PMID: 34467516 DOI: 10.1007/s12029-021-00700-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/25/2021] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Little data is available surrounding societal recommendations regarding extra-colonic malignancy in patients with inflammatory bowel disease (IBD). As a result, we systematically analyzed these international guidelines to assess their overall quality as well as their adherence to standards for high-quality practice guidelines. METHODS A systematic search was performed in multiple databases to identify all guidelines pertaining to extra-colonic malignancy in IBD in April 2020. All guidelines were reviewed for conflicts of interest (COI)/funding, recommendation quality and strength, external document review, use of patient representation, and plans for update-as per Institute of Medicine standards. In addition, recommendations were compared between guidelines/societies. Statistical analysis was conducted using R. RESULTS A total of 11 recommendations on extra-colonic malignancy in IBD were put forth by 5 guidelines/societies. Zero percent of recommendations were found to be based on high-quality evidence, 36.4% of recommendations on moderate-quality evidence, and 63.6% of recommendations on low-quality evidence. 9.1% were strong recommendations, 0% were weak/conditional recommendations, and 90.9% of recommendations did not provide a strength. No guideline included patient representation or had plans for future update of their recommendations. CONCLUSION There is a consistent lack of high-quality recommendations for extra-colonic malignancy in IBD across different societal guidelines. The need for high-quality studies to improve the strength of recommendations is eminent, as this will ultimately lead to high-quality patient care.
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Affiliation(s)
- Simcha Weissman
- Department of Medicine, Hackensack Meridian Health Palisades Medical Center, 7600 River Road, North Bergen, NJ, 07047, USA.
| | - Muhammad Aziz
- Division of Gastroenterology and Hepatology, University of Toledo Medical Center, Toledo, OH, USA
| | - Matthew R Baniqued
- Department of Medicine, Hackensack Meridian Health Palisades Medical Center, 7600 River Road, North Bergen, NJ, 07047, USA
| | - Mohamed Ahmed
- Department of Medicine, Hackensack Meridian Health Palisades Medical Center, 7600 River Road, North Bergen, NJ, 07047, USA
| | - Sameh Elias
- Department of Medicine, Hackensack Meridian Health Palisades Medical Center, 7600 River Road, North Bergen, NJ, 07047, USA
| | - Joseph D Feuerstein
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - James H Tabibian
- Division of Gastroenterology, Department of Medicine, Olive View-UCLA Medical Center, Sylmar, CA, USA
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12
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Khan R, Elsolh K, Gimpaya N, Scaffidi MA, Bansal R, Grover SC. Characteristics and conflicts of interest at Food and Drug Administration Gastrointestinal Drug Advisory Committee meetings. PLoS One 2021; 16:e0252155. [PMID: 34038480 PMCID: PMC8153474 DOI: 10.1371/journal.pone.0252155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Accepted: 05/11/2021] [Indexed: 11/24/2022] Open
Abstract
Introduction The United States Food and Drug Administration (FDA) Gastrointestinal Drug Advisory Committee (GIDAC) is involved in gastrointestinal drug application reviews. Characteristics and conflicts of interest (COI) in GIDAC meetings are not well described. This study analyzed FDA GIDAC meetings and characteristics that predict recommendations. Methods In this cross-sectional study, all publicly available GIDAC meetings where proposed medications were voted on were included. Data were collected regarding indications, medication sponsor, primary efficacy studies, and voting member characteristics (e.g. committee membership, COI). Univariate analyses were conducted at per-meeting and per-vote levels to assess for predictors of committee recommendation and individual votes respectively. Results Thirty-four meetings with 476 individual votes from 1998–2018 were included. Twenty-three (68%) proposals were recommended for approval and 25 (74%) received FDA approval. Most proposals involved >1 primary study (n = 27, 79%). At least one voting member had a COI in 24 (71%) of 34 meetings. Twelve (35%) meetings had at least one sponsor COI. Among 476 individual votes, 74 (15.5%) involved a COI, with 33 (6.9%) sponsor COI. COI decreased significantly over time, with fewer COI in 2006–2010, 2011–2015, and 2016–2020 compared to 1996–2000 and 2001–2005 (p<0.01). There were no significant associations between pre-defined predictors, including COI, and committee level recommendations or individual votes (p>0.05 for all univariate analyses). Conclusions The GIDAC reviewed 34 proposals from 1998–2018. The majority were recommended for approval and later approved by the FDA, highlighting the GIDAC’s prominence in the regulatory process. COI are present among GIDAC panelists but decreasing over time and not associated with recommendations.
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Affiliation(s)
- Rishad Khan
- Department of Medicine, University of Toronto, Toronto, Canada
| | - Karam Elsolh
- Division of Gastroenterology, St. Michael’s Hospital, Toronto, Canada
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Canada
| | - Nikko Gimpaya
- Division of Gastroenterology, St. Michael’s Hospital, Toronto, Canada
| | - Michael A. Scaffidi
- Division of Gastroenterology, St. Michael’s Hospital, Toronto, Canada
- School of Medicine, Queen’s University, Kingston, Canada
| | - Rishi Bansal
- Division of Gastroenterology, St. Michael’s Hospital, Toronto, Canada
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Canada
| | - Samir C. Grover
- Department of Medicine, University of Toronto, Toronto, Canada
- Division of Gastroenterology, St. Michael’s Hospital, Toronto, Canada
- Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, Canada
- * E-mail:
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13
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Tabatabavakili S, Khan R, Scaffidi MA, Gimpaya N, Lightfoot D, Grover SC. Financial Conflicts of Interest in Clinical Practice Guidelines: A Systematic Review. Mayo Clin Proc Innov Qual Outcomes 2021; 5:466-475. [PMID: 33997642 PMCID: PMC8105509 DOI: 10.1016/j.mayocpiqo.2020.09.016] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Objective To systematically evaluate the prevalence of disclosed and undisclosed financial conflicts of interest (FCOI) among clinical practice guidelines (CPGs). Methods In this systematic review, we ascertained the prevalence and types of FCOI for CPGs from January 1, 1980, to March 3, 2019. The primary outcome was the prevalence of FCOI among authors of CPGs. FCOI disclosures were compared between medical subspecialties and societies producing CPGs. Results Among the 37 studies including 14,764 total guideline authors, 45% had at least one FCOI. The prevalence of FCOI per study ranged from 6% to 100%. More authors had FCOI involving general payments (39%) compared with research payments (29%). Oncology, neurology, and gastroenterology had the highest prevalence of FCOI compared with other medical specialties. Among the 8 studies that included the monetary values in US dollars of FCOI, average payments per author ranged from $578 to $242,300. Among the 10 studies that included data on undisclosed FCOI, 32% of authors had undisclosed industry payments. Conclusion There are numerous FCOI among authors of CPGs, many of which are undisclosed. Our study found a significant difference in FCOI prevalence based on types of FCOI and CPG sponsor society. Additional research is required to quantify the implications of FCOI on clinical judgment and patient care. Financial conflicts of interest (FCOI) may have an impact on the objectivity of clinical practice guidelines. Among the 37 studies included in this systematic review, 45% of the 14,764 guideline authors had an FCOI. Authors of oncology, neurology, and gastroenterology guidelines had higher prevalence of FCOI compared with other guidelines. Eight studies included monetary value of FCOI, which ranged from $578 to $242,300 per author. Little is known about the direct impact of FCOI on how authors of clinical practice guidelines vote on recommendations during guideline development.
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Affiliation(s)
- Sahar Tabatabavakili
- Department of Medicine, University of Toronto, Ontario, Canada.,Division of Gastroenterology, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Rishad Khan
- Department of Medicine, University of Toronto, Ontario, Canada
| | - Michael A Scaffidi
- Division of Gastroenterology, St. Michael's Hospital, Toronto, Ontario, Canada.,Faculty of Health Sciences, School of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Nikko Gimpaya
- Division of Gastroenterology, St. Michael's Hospital, Toronto, Ontario, Canada
| | - David Lightfoot
- Health Science Library, Unity Health Toronto, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Samir C Grover
- Department of Medicine, University of Toronto, Ontario, Canada.,Division of Gastroenterology, St. Michael's Hospital, Toronto, Ontario, Canada.,Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
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14
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Venus C, Jamrozik E. Evidence-poor medicine: just how evidence-based are Australian clinical practice guidelines? Intern Med J 2020; 50:30-37. [PMID: 31943616 DOI: 10.1111/imj.14466] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Revised: 07/09/2019] [Accepted: 08/02/2019] [Indexed: 12/29/2022]
Abstract
BACKGROUND Clinical practice guidelines aim to assist medical practitioners in making efficient evidence-based decisions in daily practice. However, international studies have shown that the majority of recommendations in American and European guidelines are not based on strong evidence. AIMS To review Australian clinical practice guidelines across a broad range of high-impact conditions and determine how evidence-based they are. METHODS Australian guidelines published from January 2010 to May 2018 relating to the top 10 causes of death in Australia were identified from the National Health and Medical Research Council (NHMRC) clinical practice guideline database and other relevant sources. The graded recommendations in these guidelines were extracted for analysis and the systems used for grading the recommendations were recorded. RESULTS Ten relevant Australian guidelines were identified, containing a total of 748 graded recommendations. All 10 guidelines used either the Grading of Recommendations Assessment, Development and Evaluation (GRADE) or NHMRC systems to assess recommendations. However, only 18% (n = 136) of these recommendations were based on Level I (or equivalent) evidence; 25% (n = 185) were based on Level II evidence, 29% (n = 218) on Level III, and 9% (n = 66) on Level IV. Consensus-based recommendations accounted for 19% (n = 143) of all recommendations. CONCLUSIONS Despite the enthusiasm of the evidence-based medicine movement and its documented successes, contemporary medicine appears to remain largely evidence-poor, not evidence-based. Future research should aim to provide reliable descriptions of what constitutes valid clinical reasoning in evidence-poor situations.
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Affiliation(s)
- Cameron Venus
- Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Victoria, Australia.,Department of General Medicine, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Euzebiusz Jamrozik
- Department of General Medicine, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
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15
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Desai AP, Go RS, Poonacha TK. Category of evidence and consensus underlying National Comprehensive Cancer Network guidelines: Is there evidence of progress? Int J Cancer 2020; 148:429-436. [PMID: 32674225 DOI: 10.1002/ijc.33215] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Revised: 07/04/2020] [Accepted: 07/10/2020] [Indexed: 11/09/2022]
Abstract
National Comprehensive Cancer Network (NCCN) guidelines are the most comprehensive and widely used standard for clinical care, financial reimbursements and quality improvement initiatives in oncology. We studied the distribution of categories of evidence and consensus (EC) in the guidelines for the common cancers in the United States. We evaluated the EC categories in staging, therapy and surveillance recommendations in 2019 guidelines and compared them with the same in 2010. The latest 2019 version of NCCN guidelines were obtained. The definitions for various categories of EC used were, Category 1 (high level evidence, uniform consensus), Category 2A (lower level of evidence [LOE], uniform consensus), Category 2B (lower LOE, no uniform consensus but with no major disagreement) and Category 3 (any LOE, major disagreement). We compared our results with previously published results from 2010 guidelines. Total number of recommendations increased by 77% from 1023 (2010) to 1818 (2019). Of the 1818 recommendations, Category 1, 2A, 2B and 3 EC were 7%, 87%, 6% and 0%, respectively, while in 2010 they were 6%, 83%, 10% and 1%. Breast (30%), lung (10%) and kidney (10%) cancer had the highest proportions of Category 1 therapeutic recommendations in their respective guidelines. No Category 1 recommendations were found in screening or surveillance guidelines or in pancreatic and uterine cancer guidelines. Recommendations in 2019 NCCN guidelines are largely Category 2A (lower levels of evidence, uniform expert opinion), unchanged from the previous study in 2010.
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Affiliation(s)
- Aakash P Desai
- Department of Medicine, University of Connecticut, Farmington, Connecticut, USA
| | - Ronald S Go
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Thejaswi K Poonacha
- Department of Internal Medicine, University of Minnesota Medical Center, Minneapolis, Minnesota, USA
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16
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Weissman S, Goldowsky A, Mehta TI, Sciarra MA, Feuerstein JD. Are Quality Metrics in Inflammatory Bowel Disease Rooted on Substantial Quality Evidence? A Systematic Review. J Crohns Colitis 2020; 15:jjaa123. [PMID: 32544248 DOI: 10.1093/ecco-jcc/jjaa123] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Indexed: 12/22/2022]
Abstract
BACKGROUND AND AIMS Quality metrics were established to develop standards to help assess quality of care, yet variation in inflammatory bowel disease (IBD) clinical practice exists. We performed a systematic review to assess the overall quality of evidence cited in formulating IBD quality metrics. METHODS A systematic search was performed on PubMed, MEDLINE, and EMBASE. All major national and international IBD societies were included. Quality metrics were assessed for evidence quality and categorized as category A (guideline based), category B (primarily retrospective and observational studies) or category C (expert opinion). Quality metrics were examined for the type of metric, the quality, measurability, review, existing conflicts of interest (COI), and patient participation of the metric. Statistical analysis was conducted in R. RESULTS A total of 143 distinct, and an aggregate total of 217 quality metrics were included and analyzed. 68%, 3.2%, and 28.6% of IBD quality metrics were based on low, moderate, and high quality of evidence, respectively. The proportion of high quality evidence across societies was significantly different (P <0.01). Five organizations included patients in quality metric development, three reported external review, not all reported measurable outcomes or stated the presence of a COI. Finally, 43% of quality metrics were published more than 5 years ago. CONCLUSIONS Quality metrics are important to standardize practice. As more than two-thirds of the quality metrics in IBD are based on low quality evidence, further studies are needed to improve the overall quality of evidence supporting the development of quality measures.
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Affiliation(s)
- Simcha Weissman
- Department of Medicine, Hackensack Meridian Health, Palisades Medical Center, North Bergen, New Jersey, USA
| | - Alexander Goldowsky
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Tej I Mehta
- Department of Medicine, University of South Dakota Sanford School of Medicine, Sioux Falls, South Dakota, USA
| | - Michael A Sciarra
- Division of Gastroenterology and Hepatology, Hackensack Meridian Health, Palisades Medical Center, North Bergen, New Jersey, USA
| | - Joseph D Feuerstein
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
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17
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González-Mariño MA. Evidencia sobre conflictos de intereses en medicina. REVISTA DE LA FACULTAD DE MEDICINA 2020. [DOI: 10.15446/revfacmed.v68n1.73475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Introducción. La principal responsabilidad de los médicos es la de actuar en beneficio de los pacientes; sin embargo, existen situaciones en las cuales surgen intereses secundarios que pueden afectar este compromiso y generar conflictos de intereses.Objetivo. Analizar las revisiones sistemáticas y los metaanálisis actualmente disponibles en la literatura sobre el conflicto de intereses en medicina para sintetizar la información al respecto.Materiales y métodos. Se realizó una búsqueda en las bases de datos MEDLINE y LILACS mediante la siguiente estrategia de búsqueda: revisiones sistemáticas y metaanálisis sobre conflictos de intereses en medicina publicados en revistas científicas seriadas; no se aplicaron restricciones de idioma o año de publicación. Los estudios que cumplieron con los criterios de inclusión fueron agrupados según la actividad médica evaluada; además, de cada uno de ellos se extrajo la cantidad y el tipo de estudios y las conclusiones.Resultados. Se seleccionaron 29 publicaciones que se agruparon en estudios basados en artículos de investigación, en guías de práctica clínica, en la práctica clínica, y en publicaciones orientadas a los pacientes.Conclusiones. Los estudios originales incluidos en las revisiones sistemáticas y los metaanálisis analizados en el presente estudio no siempre reportan los conflictos de intereses; sin embargo, cuando estos se mencionan, hay una tendencia a presentar resultados que favorecen el medicamento o la tecnología del patrocinador.
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18
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van Dijk WB, Grobbee DE, de Vries MC, Groenwold RHH, van der Graaf R, Schuit E. A systematic breakdown of the levels of evidence supporting the European Society of Cardiology guidelines. Eur J Prev Cardiol 2019; 26:1944-1952. [PMID: 31409110 PMCID: PMC6886117 DOI: 10.1177/2047487319868540] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
AIMS Reviews of clinical practice guidelines have repeatedly concluded that only a minority of guideline recommendations are supported by high-quality evidence from randomised controlled trials. The aim of this study is to evaluate whether these findings apply to the whole cardiovascular evidence base or specific recommendation types and actions. METHODS All recommendations from current European Society of Cardiology guidelines were extracted with their class (I, treatment is beneficial; II, treatment is possibly beneficial; III, treatment is harmful) and level of evidence (A, multiple randomised controlled trials/meta-analyses; B, single randomised controlled trials/large observational studies; C, expert opinion/small studies). Recommendations were categorised by type (therapeutic, diagnostic, other) and actions (e.g. pharmaceutical intervention/non-invasive imaging/test). RESULTS In total, 3531 recommendations (median 128, interquartile range 108-150) were extracted from 27 guidelines. Therapeutic recommendations comprised 2545 (72.1%) recommendations, 411 (16.1%) were supported by level of evidence A, 833 (32.7%) by B and 1301 (51.1%) by C. Class I/III (should/should not) recommendations on minimally invasive interventions were most supported by level of evidence A (55/183, 30.1%) (B [70/183, 38.3%], C [58/183, 31.7%]), while class I/III recommendations on open surgical interventions were least supported by level of evidence A (15/164, 9.1%) (B [34/164, 20.7%], C [115/164, 70.1%]). Of all (831, 23.5%) diagnostic recommendations, just 44/503 (8.7%) class I/III recommendations were supported by level of evidence A (B (125/503, 24.9%), C (334/503, 66.4%)). CONCLUSION Evidence levels supporting European Society of Cardiology guideline recommendations differ widely between recommendation types and actions. Attributing to this variability are different evidence requirements, therapeutic/diagnostic recommendations, different feasibility levels for trials (e.g. open surgical/pharmacological) and many off-topic/policy recommendations based on expert opinion.
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Affiliation(s)
- Wouter B van Dijk
- Department of Epidemiology, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, The Netherlands
| | - Diederick E Grobbee
- Department of Epidemiology, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, The Netherlands
| | - Martine C de Vries
- Department of Medical Ethics and Health Law, Leiden University Medical Center, The Netherlands
| | - Rolf H H Groenwold
- Department of Clinical Epidemiology, Leiden University Medical Center, The Netherlands
| | - Rieke van der Graaf
- Department of Medical Humanities, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, The Netherlands
| | - Ewoud Schuit
- Department of Epidemiology, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, The Netherlands.,Cochrane Netherlands, University Medical Center Utrecht, The Netherlands
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19
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Fanaroff AC, Califf RM, Windecker S, Smith SC, Lopes RD. Levels of Evidence Supporting American College of Cardiology/American Heart Association and European Society of Cardiology Guidelines, 2008-2018. JAMA 2019; 321:1069-1080. [PMID: 30874755 PMCID: PMC6439920 DOI: 10.1001/jama.2019.1122] [Citation(s) in RCA: 121] [Impact Index Per Article: 24.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
IMPORTANCE Clinical decisions are ideally based on evidence generated from multiple randomized controlled trials (RCTs) evaluating clinical outcomes, but historically, few clinical guideline recommendations have been based entirely on this type of evidence. OBJECTIVE To determine the class and level of evidence (LOE) supporting current major cardiovascular society guideline recommendations, and changes in LOE over time. DATA SOURCES Current American College of Cardiology/American Heart Association (ACC/AHA) and European Society of Cardiology (ESC) clinical guideline documents (2008-2018), as identified on cardiovascular society websites, and immediate predecessors to these guideline documents (1999-2014), as referenced in current guideline documents. STUDY SELECTION Comprehensive guideline documents including recommendations organized by class and LOE. DATA EXTRACTION AND SYNTHESIS The number of recommendations and the distribution of LOE (A [supported by data from multiple RCTs or a single, large RCT], B [supported by data from observational studies or a single RCT], and C [supported by expert opinion only]) were determined for each guideline document. MAIN OUTCOMES AND MEASURES The proportion of guideline recommendations supported by evidence from multiple RCTs (LOE A). RESULTS Across 26 current ACC/AHA guidelines (2930 recommendations; median, 121 recommendations per guideline [25th-75th percentiles, 76-155]), 248 recommendations (8.5%) were classified as LOE A, 1465 (50.0%) as LOE B, and 1217 (41.5%) as LOE C. The median proportion of LOE A recommendations was 7.9% (25th-75th percentiles, 0.9%-15.2%). Across 25 current ESC guideline documents (3399 recommendations; median, 130 recommendations per guideline [25th-75th percentiles, 111-154]), 484 recommendations (14.2%) were classified as LOE A, 1053 (31.0%) as LOE B, and 1862 (54.8%) as LOE C. When comparing current guidelines with prior versions, the proportion of recommendations that were LOE A did not increase in either ACC/AHA (median, 9.0% [current] vs 11.7% [prior]) or ESC guidelines (median, 15.1% [current] vs 17.6% [prior]). CONCLUSIONS AND RELEVANCE Among recommendations in major cardiovascular society guidelines, only a small percentage were supported by evidence from multiple RCTs or a single, large RCT. This pattern does not appear to have meaningfully improved from 2008 to 2018.
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Affiliation(s)
- Alexander C. Fanaroff
- Division of Cardiology and Duke Clinical Research Institute, Duke University, Durham, North Carolina
| | - Robert M. Califf
- Duke Forge, Duke University School of Medicine, Durham, North Carolina
- Department of Medicine, Stanford University, Stanford, California
- Verily Life Sciences (Alphabet), South San Francisco, California
| | - Stephan Windecker
- Department of Cardiology, Inselspital, University of Bern, Bern, Switzerland
| | - Sidney C. Smith
- Division of Cardiology, University of North Carolina School of Medicine, Chapel Hill
| | - Renato D. Lopes
- Division of Cardiology and Duke Clinical Research Institute, Duke University, Durham, North Carolina
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Grindal AW, Khan R, Scaffidi MA, Rumman A, Grover SC. Financial Conflicts of Interest in Inflammatory Bowel Disease Guidelines. Inflamm Bowel Dis 2019; 25:642-645. [PMID: 30295831 DOI: 10.1093/ibd/izy315] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2018] [Indexed: 12/09/2022]
Abstract
BACKGROUND Industry payments can lead to financial conflicts of interest (FCOI) among authors of clinical practice guidelines (CPGs). Guidelines for inflammatory bowel disease (IBD) may be at particularly high risk. We determined the prevalence of FCOI in IBD CPGs produced by various gastroenterology societies. METHODS We conducted a cross-sectional analysis of FCOI disclosure among CPGs related to the management of IBD. We ascertained the prevalence and types of FCOI for each guideline and determined adherence to National Academy of Medicine (NAM) standards. FCOI disclosures were compared between societies producing CPGs. RESULTS We identified 11 relevant CPGs with 173 total authors. There were 117 (68%) authors who declared a payment. A total of 107 (62%) authors declared FCOI related to a medication recommended in the guideline. There was a significant difference (P < 0.001) between the proportion of authors with FCOI between countries or regions. Authors of US CPGs had a significantly lower FCOI prevalence (19%) compared with other societies. Authors of UK CPGs had a significantly lower FCOI prevalence (56%) compared with Canadian (84%) and European (94%) CPGs. Three (27%) guidelines adhered to both NAM standards. CONCLUSIONS A substantial portion of authors of IBD CPGs had FCOI. Our study found a significant difference in FCOI prevalence based on CPG sponsor nationality. Most CPGs for IBD did not adhere to NAM standards for FCOI disclosure.
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Affiliation(s)
| | - Rishad Khan
- Division of Gastroenterology, University of Toronto, Toronto, Canada
| | | | - Amir Rumman
- Division of Gastroenterology, University of Toronto, Toronto, Canada
| | - Samir C Grover
- Division of Gastroenterology, University of Toronto, Toronto, Canada
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Shaughnessy AF, Vaswani A, Andrews BK, Erlich DR, D'Amico F, Lexchin J, Cosgrove L. Developing a Clinician Friendly Tool to Identify Useful Clinical Practice Guidelines: G-TRUST. Ann Fam Med 2017; 15:413-418. [PMID: 28893810 PMCID: PMC5593723 DOI: 10.1370/afm.2119] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2016] [Revised: 02/06/2017] [Accepted: 03/16/2017] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Clinicians are faced with a plethora of guidelines. To rate guidelines, they can select from a number of evaluation tools, most of which are long and difficult to apply. The goal of this project was to develop a simple, easy-to-use checklist for clinicians to use to identify trustworthy, relevant, and useful practice guidelines, the Guideline Trustworthiness, Relevance, and Utility Scoring Tool (G-TRUST). METHODS A modified Delphi process was used to obtain consensus of experts and guideline developers regarding a checklist of items and their relative impact on guideline quality. We conducted 4 rounds of sampling to refine wording, add and subtract items, and develop a scoring system. Multiple attribute utility analysis was used to develop a weighted utility score for each item to determine scoring. RESULTS Twenty-two experts in evidence-based medicine, 17 developers of high-quality guidelines, and 1 consumer representative participated. In rounds 1 and 2, items were rewritten or dropped, and 2 items were added. In round 3, weighted scores were calculated from rankings and relative weights assigned by the expert panel. In the last round, more than 75% of experts indicated 3 of the 8 checklist items to be major indicators of guideline usefulness and, using the AGREE tool as a reference standard, a scoring system was developed to identify guidelines as useful, may not be useful, and not useful. CONCLUSION The 8-item G-TRUST is potentially helpful as a tool for clinicians to identify useful guidelines. Further research will focus on its reliability when used by clinicians.
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Affiliation(s)
| | - Akansha Vaswani
- Department of Counseling and School Psychology, University of Massachusetts, Boston, Massachusetts
| | - Bonnie K Andrews
- Department of Counseling and School Psychology, University of Massachusetts, Boston, Massachusetts
| | | | - Frank D'Amico
- McAnulty College and Graduate School of Liberal Arts, Duquesne University, Pittsburgh, Pennsylvania
| | - Joel Lexchin
- School of Health Policy and Management, York University, Toronto, Canada
| | - Lisa Cosgrove
- Department of Counseling and School Psychology, University of Massachusetts, Boston, Massachusetts
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Morciano C, Basevi V, Faralli C, Hilton Boon M, Tonon S, Taruscio D. Policies on Conflicts of Interest in Health Care Guideline Development: A Cross-Sectional Analysis. PLoS One 2016; 11:e0166485. [PMID: 27846255 PMCID: PMC5113001 DOI: 10.1371/journal.pone.0166485] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2016] [Accepted: 10/28/2016] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVE To assess whether organisations that develop health care guidelines have conflict of interest (COI) policies and to review the content of the available COI policies. METHODS Survey and content analysis of COI policies available in English, French, Spanish, and Italian conducted between September 2014 and June 2015. A 24-item data abstraction instrument was created on the basis of guideline development standards. RESULTS The survey identified 29 organisations from 19 countries that met the inclusion criteria. From these organisations, 19 policies were eligible for inclusion in the content analysis. Over one-third of the policies (7/19, 37%) did not report or did not clearly report whether disclosure was a prerequisite for membership of the guideline panel. Strategies for the prevention of COI such as divestment were mentioned by only two organisations. Only 21% of policies (4/19) used criteria to determine whether an interest constitutes a COI and to assess the severity of the risk imposed. CONCLUSIONS The finding that some organisations, in contradiction of widely available standards, still do not have COI policies publicly available is concerning. Also troubling were the findings that some policies did not clearly report critical steps in obtaining, managing and communicating disclosure of relationships of interest. This in addition to the variability encountered in content and accessibility of COI policies may cause confusion and distrust among guideline users. It is in the interest of guideline users and developers to design an agreed-upon, comprehensive, clear, and accessible COI policy.
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Affiliation(s)
- Cristina Morciano
- Centro Nazionale Malattie Rare, Istituto Superiore di Sanità, Rome, Italy
| | - Vittorio Basevi
- Centro di Documentazione sulla Salute Perinatale e Riproduttiva, Servizio assistenza distrettuale, medicina generale, pianificazione e sviluppo dei servizi sanitari, Regione Emilia-Romagna, Bologna, Italy
| | - Carla Faralli
- Servizio Informatico, Documentazione, Biblioteca e Attività Editoriali, Istituto Superiore di Sanità, Rome, Italy
| | - Michele Hilton Boon
- MRC/CSO Social and Public Health Sciences Unit, University of Glasgow, Glasgow, United Kingdom
| | - Sabina Tonon
- Formerly Centro Nazionale Malattie Rare, Istituto Superiore di Sanità, Rome, Italy
| | - Domenica Taruscio
- Centro Nazionale Malattie Rare, Istituto Superiore di Sanità, Rome, Italy
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Feuerstein JD, Castillo NE, Akbari M, Belkin E, Lewandowski JJ, Hurley CM, Lloyd S, Leffler DA, Cheifetz AS. Systematic Analysis and Critical Appraisal of the Quality of the Scientific Evidence and Conflicts of Interest in Practice Guidelines (2005-2013) for Barrett's Esophagus. Dig Dis Sci 2016; 61:2812-2822. [PMID: 27307064 DOI: 10.1007/s10620-016-4222-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2015] [Accepted: 05/31/2016] [Indexed: 12/22/2022]
Abstract
BACKGROUND Barrett's esophagus (BE) is a condition that has a small but important risk of progressing to esophageal cancer. To date, no study has assessed the strength of evidence supporting the recommendations for BE. We sought to assess the overall quality of the recommendations and strength of the BE using the AGREE II instrument. METHODS A PubMed search was performed to identify guidelines published pertaining to BE. Every guideline was reviewed using the AGREE II format to assess the methodological rigor and validity of the guideline. Additionally, guidelines were reviewed for the level of evidence used to support recommendations, conflicts of interest (COI), and differences in recommendations. Statistical analysis was performed using Stata (version 12). RESULTS In total, 234 manuscripts were identified of which 8 guidelines published between 2005 and 2013 pertained to BE. Seventy-five percentage (6/8) graded the evidence used to formulate recommendations. Of the 126 recommendations with supporting evidence, 6 % were supported by level A evidence, 49 % level B evidence, and 45 % level C evidence. Using the AGREE II format, the highest overall assessment grade was the BSG BE guideline (6.5 ± 0.6) followed by the AGA (5.5 ± 0.6). The highest rated domains were scope and purpose (mean 77 range 24-96) and clarity of presentation (mean 75), while the lowest rated domains were editorial independence (mean 32 range 0-92) and applicability of the guideline (mean 35 range 7-90). There was significant variability in recommendations regarding who to screen for BE and surveillance intervals. Finally, only 50 % of the guidelines disclosed if COI were present and 75 % (3/4) reported potentially relevant COI. CONCLUSIONS Majority of the BE guideline fail to meet the AGREE II domains, and most of the recommendations are level B or C quality evidence. Further interventions are necessary to improve the overall quality of the guidelines.
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Affiliation(s)
- Joseph D Feuerstein
- Department of Medicine and Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, 110 Francis St 8E Gastroenterology, Boston, MA, 02215, USA.
| | - Natalia E Castillo
- Department of Medicine and Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, 110 Francis St 8E Gastroenterology, Boston, MA, 02215, USA
| | - Mona Akbari
- Department of Medicine and Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, 110 Francis St 8E Gastroenterology, Boston, MA, 02215, USA
| | - Edward Belkin
- Department of Medicine and Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, 110 Francis St 8E Gastroenterology, Boston, MA, 02215, USA
| | - Jeffrey J Lewandowski
- Department of Medicine and Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, 110 Francis St 8E Gastroenterology, Boston, MA, 02215, USA
| | - Christine M Hurley
- Department of Medicine and Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, 110 Francis St 8E Gastroenterology, Boston, MA, 02215, USA
| | - Samuel Lloyd
- Department of Medicine and Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, 110 Francis St 8E Gastroenterology, Boston, MA, 02215, USA
| | - Daniel A Leffler
- Department of Medicine and Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, 110 Francis St 8E Gastroenterology, Boston, MA, 02215, USA
| | - Adam S Cheifetz
- Department of Medicine and Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, 110 Francis St 8E Gastroenterology, Boston, MA, 02215, USA
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Prevalence of Upper Gastrointestinal Lesions at Primary Diagnosis in Adults with Inflammatory Bowel Disease. Inflamm Bowel Dis 2016; 22:1896-901. [PMID: 27057685 DOI: 10.1097/mib.0000000000000786] [Citation(s) in RCA: 64] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND The prevalence of upper gastrointestinal (GI) involvement in adult inflammatory bowel disease has mostly been studied in patients with long-standing disease. The aim of this study was to prospectively evaluate the prevalence of upper GI involvement in a consecutive series of newly diagnosed, treatment-naive adult patients with inflammatory bowel disease, irrespective of upper GI tract symptoms. METHODS Consecutive patients with suspected inflammatory bowel disease underwent combined ileocolonoscopy and upper endoscopy with biopsies. Patients diagnosed with either Crohn's disease (CD) or ulcerative colitis (UC), denying use of nonsteroidal anti-inflammatory drug, were included in the study. Helicobacter pylori infection was diagnosed histologically and positive patients were excluded from the analysis. Endoscopic and histologic lesions in the stomach and duodenum were recorded. Upper GI location (+L4) was defined as a combination of endoscopic and histological lesions. RESULTS A total of 152 patients (108 CD and 44 UC) were analyzed. Endoscopic lesions were only seen in patients with CD (60 of 108, 55%). Histological lesions were present in both patients with CD and patients with UC: focally enhanced gastritis in 58 CD (54%) and 10 UC (23%), granulomas in 30 CD (28%). Upper GI disease location was diagnosed in 44 patients with CD (41%) and no patients with UC. Upper GI tract symptoms were reported in 14 of 44 patients (32%) with upper GI location. CONCLUSIONS A high prevalence of upper GI involvement was observed in newly diagnosed patients with CD, with a majority of the patients being asymptomatic. Focally enhanced gastritis was common in both patients with CD and patients with UC, whereas granulomatous inflammation was restricted to patients with CD.
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Feuerstein JD, Castillo NE, Siddique SS, Lewandowski JJ, Geissler K, Martinez-Vazquez M, Thukral C, Leffler DA, Cheifetz AS. Poor Documentation of Inflammatory Bowel Disease Quality Measures in Academic, Community, and Private Practice. Clin Gastroenterol Hepatol 2016; 14:421-428.e2. [PMID: 26499928 DOI: 10.1016/j.cgh.2015.09.042] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2015] [Revised: 08/26/2015] [Accepted: 09/28/2015] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Quality measures are used to standardize health care and monitor quality of care. In 2011, the American Gastroenterological Association established quality measures for inflammatory bowel disease (IBD), but there has been limited documentation of compliance from different practice settings. METHODS We reviewed charts from 367 consecutive patients with IBD seen at academic practices, 217 patients seen at community practices, and 199 patients seen at private practices for compliance with 8 outpatient measures. Records were assessed for IBD history, medications, comorbidities, and hospitalizations. We also determined the number of patient visits to gastroenterologists in the past year, whether patients had a primary care physician at the same institution, and whether they were seen by a specialist in IBD or in conjunction with a trainee, and reviewed physician demographics. A univariate and multivariate statistical analysis was performed to determine which factors were associated with compliance of all core measures. RESULTS Screening for tobacco abuse was the most frequently assessed core measure (89.6% of patients; n = 701 of 783), followed by location of IBD (80.3%; n = 629 of 783), and assessment for corticosteroid-sparing therapy (70.8%; n = 275 of 388). The least-frequently evaluated measures were pneumococcal immunization (16.7% of patients; n = 131 of 783), bone loss (25%; n = 126 of 505), and influenza immunization (28.7%; n = 225 of 783). Only 5.8% of patients (46 of 783) had all applicable core measures documented (24 in academic practice, none in clinical practice, and 22 in private practice). In the multivariate model, year of graduation from fellowship (odds ratio [OR], 2.184; 95% confidence interval [CI], 1.522-3.134; P < .001), year of graduation from medical school (OR, 0.500; 95% CI, 0.352-0.709; P < .001), and total number of comorbidities (OR, 1.089; 95% CI, 1.016-1.168; P = .016) were associated with compliance with all core measures. CONCLUSIONS We found poor documentation of IBD quality measures in academic, clinical, and private gastroenterology practices. Interventions are necessary to improve reporting of quality measures.
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Affiliation(s)
- Joseph D Feuerstein
- Department of Medicine and Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts.
| | - Natalia E Castillo
- Department of Medicine and Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Sana S Siddique
- Department of Medicine, Mt Auburn Hospital, Harvard Medical School, Boston, Massachusetts
| | - Jeffrey J Lewandowski
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Kathy Geissler
- Rockford Gastroenterology Associates, Rockford, Illinois
| | - Manuel Martinez-Vazquez
- Gastroenterology Service, Dr. José Eleuterio González University Hospital, Monterrey, Nuevo León, Mexico
| | - Chandrashekhar Thukral
- University of Illinois at Chicago College of Medicine, Rockford, Illinois; Rockford and Rockford Gastroenterology Associates, Rockford, Illinois
| | - Daniel A Leffler
- Department of Medicine and Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Adam S Cheifetz
- Department of Medicine and Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
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Multicenter Study Assessing Physician Recommendations Regarding the Continuation of Aspirin and/or NSAIDs Prior to Gastrointestinal Endoscopy. Dig Dis Sci 2015; 60:3234-41. [PMID: 26123839 DOI: 10.1007/s10620-015-3781-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2015] [Accepted: 06/20/2015] [Indexed: 01/05/2023]
Abstract
BACKGROUND In 2009 the American Society for Gastrointestinal Endoscopy (ASGE) guidelines advised that both aspirin and NSAIDs be continued prior to low-risk gastrointestinal endoscopic procedures. We sought to determine physician knowledge regarding these guidelines. METHODS A survey questionnaire was developed based on the ASGE guidelines. Physicians were queried about whether they would continue/stop aspirin in a patient with cardiac disease and in a patient taking NSAIDs for arthritis whether they would continue/stop NSAIDs prior to endoscopy. The survey was administered at three academic medical centers. Demographic information: level of training, board certification, teaching trainees, percentage of time in clinical practice, year of medical school graduation, and location of medical school were all reviewed. The primary outcome was number of questions answered correctly and predictors of correct responses. RESULTS The survey was administered to 941 participants with 12 declining to participate, while 80% (740/929) of the subjects completed the survey; 20% (150/740) respondents answered both questions correctly and 42% (310/740) answered one question correctly. There was no significant difference between institutions (p = 0.6) or between attendings and trainees (p = 0.75). Multivariate predictors of correct answers were self-reported familiarity with the guideline (-0.029; 95% CI -0.003 to -0.056, p < 0.031), level of training (0.050; 95% CI 0.012-0.088, p = 0.010), and specialty (0.108; 95% CI 0.058-0.159, p < 0.0001). Finally, there was an inverse, linear relationship between postgraduate year and percent questions correct. CONCLUSION Physician knowledge of guidelines regarding the use of aspirin and NSAIDs prior to endoscopy is suboptimal. Interventions are necessary to improve knowledge of the current pre-procedure guidelines.
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Feuerstein JD, Pelsis JR, Lloyd S, Cheifetz AS, Stone KR. Systematic analysis of the quality of the scientific evidence and conflicts of interest in osteoarthritis of the hip and knee practice guidelines. Semin Arthritis Rheum 2015; 45:379-85. [PMID: 26522136 DOI: 10.1016/j.semarthrit.2015.09.002] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2015] [Revised: 08/17/2015] [Accepted: 09/26/2015] [Indexed: 01/19/2023]
Abstract
OBJECTIVE To determine the validity of the hip and knee osteoarthritis guidelines. METHODS A systematic search of PubMed using a combination of Mesh and text terms with limitations to guidelines was performed to identify hip and knee osteoarthritis guidelines. The study was performed from April 17, 2014 to October 1, 2014. Guidelines were reviewed for graded levels of evidence, methods used to grade the evidence, and disclosures of conflicts of interest. Additionally, guidelines were also assessed for key quality measures using the AGREE II system for assessing the quality of guidelines. RESULTS A total of 13 guidelines relevant to the diagnosis and/or treatment of hip/knee osteoarthritis was identified. The 180 recommendations reviewed were supported by 231 pieces of evidence. In total, 35% (n = 80; range: 0-26) were supported by level A evidence, 15% (n = 35; range: 0-10) were by level B, and 50% (n = 116; range: 0-62) were by level C. Median age of the guidelines was 4 years (±4.8; range: 0-16) with no comments on planned updates. In total, 31% of the guidelines included patients in the development process. Only one guideline incorporated cost consideration, and only 15% of the guidelines addressed the surgical management of osteoarthritis. Additionally, 46% of guidelines did not comment on conflicts of interest (COI). When present, there was an average 29.8 COI. Notably, 82% of the COI were monetary support/consulting. CONCLUSIONS In total, 50% of the hip/knee osteoarthritis guideline recommendations are based on lower quality evidence. Nearly half the guidelines fail to disclose relevant COI and when disclosed, multiple potential COI are present. Future hip/knee osteoarthritis guideline development committees should strive to improve the transparency and quality of evidence used to formulate practice guidelines.
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Affiliation(s)
- Joseph D Feuerstein
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, 110 Francis St 8E, Boston, MA 02215.
| | | | - Samuel Lloyd
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, 110 Francis St 8E, Boston, MA 02215
| | - Adam S Cheifetz
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, 110 Francis St 8E, Boston, MA 02215
| | - Kevin R Stone
- Stone Research Foundation, San Francisco, CA; Department of Orthopedics, The Stone Clinic, San Francisco, CA
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Avorn J, Sarpatwari A, Kesselheim AS. Forbidden and Permitted Statements about Medications--Loosening the Rules. N Engl J Med 2015; 373:967-73. [PMID: 26332553 DOI: 10.1056/nejmhle1506365] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Parian A, Lazarev M. Who and how to screen for cancer in at-risk inflammatory bowel disease patients. Expert Rev Gastroenterol Hepatol 2015; 9:731-46. [PMID: 25592672 DOI: 10.1586/17474124.2015.1003208] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Inflammatory bowel diseases (IBDs) include both Crohn's disease and ulcerative colitis and both diseases are marked by inflammation within the gastrointestinal tract. Due to long-standing inflammation, IBD patients are at increased risk of colorectal cancer, especially patients with chronic inflammation, pancolitis, co-diagnosis of primary sclerosing cholangitis and a longer duration of disease. Small bowel inflammation places Crohn's patients at an increased risk of small bowel cancer. A higher risk of skin cancers, lymphomas and cervical abnormalities is also seen in IBD patients; this is likely related to both disease factors and the presence of immunosuppressive medication. This article reviews which patients are at an increased risk of IBD-associated or IBD treatment-associated cancers, when to begin screening and which screening methods are recommended.
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Affiliation(s)
- Alyssa Parian
- Department of Gastroenterology, Johns Hopkins University, 4940 Eastern Avenue, Building A, Baltimore, MD 21224, USA
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Abstract
Guidelines on the appropriate use of perioperative steroids in patients with inflammatory bowel disease (IBD) are lacking. As a result, corticosteroid supplementation during and after colorectal surgery procedures has been shown to be highly variable. A clearer understanding of the indications for perioperative corticosteroid administration relative to preoperative corticosteroid dosing and duration of therapy is essential. In this review, we outline the basic tenets of the hypothalamic-pituitary-adrenal (HPA) axis and its normal response to stress, describe how corticosteroid use is thought to affect this system, and provide an overview of the currently available data on perioperative corticosteroid supplementation including the limited evidence pertaining to patients with inflammatory bowel disease. Based on currently existing data, we define "adrenal suppression," and propose a patient-based approach to perioperative corticosteroid management in the inflammatory bowel disease population based on an individual's historical use of corticosteroids, the type of surgery they are undergoing, and HPA axis testing when applicable. Patients without adrenal suppression (<5 mg prednisone per day) do not require extra corticosteroid supplementation in the perioperative period; patients with adrenal suppression (>20 mg prednisone per day) should be treated with additional perioperative corticosteroid coverage above their baseline home regimen; and patients with unclear HPA axis function (>5 and <20 mg prednisone per day) should undergo preoperative HPA axis testing to determine the best management practices. The proposed management algorithm attempts to balance the risks of adrenal insufficiency and immunosuppression.
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Renna S, Cottone M, Orlando A. Optimization of the treatment with immunosuppressants and biologics in inflammatory bowel disease. World J Gastroenterol 2014; 20:9675-90. [PMID: 25110407 PMCID: PMC4123358 DOI: 10.3748/wjg.v20.i29.9675] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2013] [Revised: 01/18/2014] [Accepted: 04/28/2014] [Indexed: 02/06/2023] Open
Abstract
Many placebo controlled trials and meta-analyses evaluated the efficacy of different drugs for the treatment of inflammatory bowel disease (IBD), including immunosuppressants and biologics. Their use is indicated in moderate to severe disease in non responders to corticosteroids and in steroid-dependent patients, as induction and maintainance treatment. Infliximab, as well as cyclosporine, is considered a second line therapy in the case of severe ulcerative colitis, or non-responders to intravenous corticosteroids. An adequate dosage and duration of therapy with thiopurines should be reached before evaluating their efficacy. Methotrexate is a valid option in patients with Crohn's disease but its use is confined to patients who are intolerant or non-responders to thiopurines. Evidence for the use of methotrexate in ulcerative colitis is insufficient. The use of thalidomide and mycophenolate mofetil is not recommended in patients with inflammatory bowel disease, these treatments could be considered in case of failure of all other therapeutic options. In patients with moderately active ulcerative colitis, refractory to thiopurines, the use of tacrolimus is considered an alternative to biologics. An increase of the dose or a decrease in the interval of administration of biological treatment could be useful in the presence of an incomplete clinical response. In the case of primary failure of an anti-tumor necrosis factor alpha a switch to another one should be considered. Data on the efficacy of combination therapy are up to now insufficient to consider this strategy in all IBD patients. The final outcome of the treatment should be considered the clinical remission, with mucosa healing, and not the clinical response. The evaluation of serum concentration of thiopurine methyl transferase activity, thiopurine metabolites, biologic serum levels and antibiologic antibodies could be useful for the management of the treatment but it has not been routinely applied in clinical practice. The evidence of high risk development of lymphoma and cutaneous malignancies should be considered in patients treated with immunosuppressants and biologics for a long period.
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Management of inflammatory bowel disease in France: a nationwide survey among private gastroenterologists. Dig Liver Dis 2014; 46:675-81. [PMID: 24809234 DOI: 10.1016/j.dld.2014.04.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2014] [Revised: 04/01/2014] [Accepted: 04/13/2014] [Indexed: 12/11/2022]
Abstract
BACKGROUND Data on the current management of inflammatory bowel disease are scarce. METHODS This was a nationwide survey among 65 private gastroenterologists treating patients with inflammatory bowel disease in France in 2012. RESULTS A total of 375 inflammatory bowel disease patients were analysed: 48% had ulcerative colitis. One third of inflammatory bowel disease patients had a history of hospitalisation, and 40% of Crohn's disease patients had prior surgery. Two thirds of inflammatory bowel disease patients had active disease. Significantly fewer ulcerative colitis patients were treated with anti-tumour necrosis factor therapy than Crohn's disease patients (18.9% vs. 38.9%; p<0.0001). Among patients treated with anti-tumour necrosis factor, only 4.5% were receiving concomitant immunomodulators. Half of inflammatory bowel disease patients had undergone a colonoscopy within the past year. For colorectal cancer screening, random biopsies and chromoendoscopy were performed in 75% and 40% of cases, respectively. An endoscopic score was used for only 10% of inflammatory bowel disease patients. About one third of inflammatory bowel disease patients had imaging studies within the past year (magnetic resonance enterography in 65%). An abdominal computed tomography scan was prescribed for 12% of inflammatory bowel disease patients. CONCLUSIONS Many patients still have active disease in the biologics era, and the number of patients receiving combination therapy is low in private practice. Chromoendoscopy and endoscopy scores are not often used.
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Feuerstein JD, Leffler DA, Cheifetz AS. In reply--Clinical practice guidelines: still miles to go.. Mayo Clin Proc 2014; 89:860-1. [PMID: 24943703 DOI: 10.1016/j.mayocp.2014.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2014] [Accepted: 03/25/2014] [Indexed: 11/25/2022]
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Mowat C, Bloom SL. Letter: international IBD practice guidelines. Aliment Pharmacol Ther 2013; 38:325. [PMID: 23808418 DOI: 10.1111/apt.12358] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2013] [Accepted: 05/10/2013] [Indexed: 12/08/2022]
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Feuerstein JD, Leffler DA, Cheifetz AS. Letter: inflammatory bowel disease guidelines and conflicts of interest--authors' reply. Aliment Pharmacol Ther 2013; 38:445-6. [PMID: 23855400 DOI: 10.1111/apt.12400] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2013] [Accepted: 06/16/2013] [Indexed: 12/14/2022]
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Eliakim R, Dignass A, Travis S. Letter: inflammatory bowel disease guidelines and conflicts of interest. Aliment Pharmacol Ther 2013; 38:445. [PMID: 23855401 DOI: 10.1111/apt.12395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2013] [Revised: 06/12/2013] [Accepted: 06/12/2013] [Indexed: 12/08/2022]
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Feuerstein JD, Leffler DA, Cheifetz AS. Letter: international IBD practice guidelines -- authors' reply. Aliment Pharmacol Ther 2013; 38:326-7. [PMID: 23808419 DOI: 10.1111/apt.12374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2013] [Revised: 05/17/2013] [Accepted: 05/24/2013] [Indexed: 12/08/2022]
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Abstract
IMPORTANCE Treatment of Crohn disease is rapidly evolving, with the induction of novel biologic therapies and newer, often more intensive treatment approaches. Knowing how to treat individual patients in this quickly changing milieu can be a challenge. OBJECTIVE To review the diagnosis and management of moderate to severe Crohn disease, with a focus on newer treatments and goals of care. EVIDENCE REVIEW MEDLINE was searched from 2000 to 2011. Additional citations were procured from references of select research and review articles. Evidence was graded using the American Heart Association level-of-evidence guidelines. RESULTS Although mesalamines are still often used to treat Crohn disease, the evidence for their efficacy is lacking. Corticosteroids can be effectively used to induce remission in moderate to severe Crohn disease, but they do not maintain remission. The mainstays of treatment are immunomodulators and biologics, particularly anti-tumor necrosis factor. CONCLUSION AND RELEVANCE Immunomodulators and biologics are now the preferred treatment options for Crohn disease.
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Affiliation(s)
- Adam S Cheifetz
- Division of Gastroenterology, Rabb-Rose 425, Beth Israel Deaconess Medical Center, 330 Brookline Ave, Boston, MA 02215, USA.
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