Evidence-poor medicine: just how evidence-based are Australian clinical practice guidelines?

Effect of Compression Garments on Post-Abdominoplasty Outcomes: A systematic Review of the current Evidence

Introduction

It is commonly believed that using abdominal binders or compression garments (CGs) after an abdominoplasty could encourage fluid to drain, which would prevent fluid from building up at the surgical site and reduce the risk of seroma and other similar problems.

Objective

To evaluate the effect of the use of abdominal binders or CG on the post-operative outcomes following abdominoplasty.

Design

Systematic review.

Method

Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines were followed to select relevant studies from 2004 to 2024. Data from the included studies were extracted to assess the quality and risk of bias using a modified Jadaad score.

Main outcome

Post-operative seroma formation.

Secondary outcome

Ventilatory function, intra-abdominal pressure (IAP), and subcutaneous edema were the outcomes of interest.

Results

Only 5 trials totaling 130 patients were included in this review. Utilizing post-operative CG following abdominoplasty showed a non-significant tendency to decrease seroma development, ventilatory function, and subcutaneous edema. The limited evidence available also suggested that using post-operative CG increases IAP.

Conclusion

Weak evidence supports the beneficial use of abdominal binders following abdominoplasty.

Limitations

Low-quality scientific evidence available from the scant data and low caliber of the literature support the use of CG post-abdominoplasty. Therefore, unified outcome reporting and rigid randomized clinical trials are necessary to obtain valid data.

Clinical Practice Guideline for Best Practice Management of Pediatric Patients by Chiropractors: Results of a Delphi Consensus Process

Objective: To build upon existing recommendations on best practices for chiropractic management of children by conducting a formal consensus process and best evidence synthesis. Design: Best practice guide based on recommendations from current best available evidence and formal consensus of a panel of experienced practitioners, consumers, and experts for chiropractic management of pediatric patients. Methods: Synthesis of results of a literature search to inform the development of recommendations from a multidisciplinary steering committee, including experts in pediatrics, followed by a formal Delphi panel consensus process. Results: The consensus process was conducted June to August 2022. All 60 panelists completed the process and reached at least 80% consensus on all recommendations after three Delphi rounds. Recommendations for best practices for chiropractic care for children addressed these aspects of the clinical encounter: patient communication, including informed consent; appropriate clinical history, including health habits; appropriate physical examination procedures; red flags/contraindications to chiropractic care and/or spinal manipulation; aspects of chiropractic management of pediatric patients, including infants; modifications of spinal manipulation and other manual procedures for pediatric patients; appropriate referral and comanagement; and appropriate health promotion and disease prevention practices. Conclusion: This set of recommendations represents a general framework for an evidence-informed and reasonable approach to the management of pediatric patients by chiropractors.

The overall quality of evidence of recommendations surrounding nutrition and diet in inflammatory bowel disease

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.

Clinical practice guideline adherence in oncology: A qualitative study of insights from clinicians in Australia

BACKGROUND

The burden of cancer is large in Australia, and rates of cancer Clinical Practice Guideline (CPG) adherence is suboptimal across various cancers.

METHODS

The objective of this study is to characterise clinician-perceived barriers and facilitators to cancer CPG adherence in Australia. Semi-structured interviews were conducted to collect data from 33 oncology-focused clinicians (surgeons, radiation oncologists, medical oncologists and haematologists). Clinicians were recruited in 2019 and 2020 through purposive and snowball sampling from 7 hospitals across Sydney, Australia, and interviewed either face-to-face in hospitals or by phone. Audio recordings were transcribed verbatim, and qualitative thematic analysis of the interview data was undertaken. Human research ethics committee approval and governance approval was granted (2019/ETH11722, #52019568810127).

RESULTS

Five broad themes and subthemes of key barriers and facilitators to cancer treatment CPG adherence were identified: Theme 1: CPG content; Theme 2: Individual clinician and patient factors; Theme 3: Access to, awareness of and availability of CPGs; Theme 4: Organisational and cultural factors; and Theme 5: Development and implementation factors. The most frequently reported barriers to adherence were CPGs not catering for patient complexities, being slow to be updated, patient treatment preferences, geographical challenges for patients who travel large distances to access cancer services and limited funding of CPG recommended drugs. The most frequently reported facilitators to adherence were easy accessibility, peer review, multidisciplinary engagement or MDT attendance, and transparent CPG development by trusted, multidisciplinary experts. CPGs provide a reassuring framework for clinicians to check their treatment plans against. Clinicians want cancer CPGs to be frequently updated utilising a wiki-like process, and easily accessible online via a comprehensive database, coordinated by a well-trusted development body.

CONCLUSION

Future implementation strategies of cancer CPGs in Australia should be tailored to consider these context-specific barriers and facilitators, taking into account both the content of CPGs and the communication of that content. The establishment of a centralised, comprehensive, online database, with living wiki-style cancer CPGs, coordinated by a well-funded development body, along with incorporation of recommendations into point-of-care decision support would potentially address many of the issues identified.

Research Priorities of the Australian Chiropractic Profession: A Cross-Sectional Survey of Academics and Practitioners

OBJECTIVE

The purpose of this study was to explore the research priorities of Australian practicing chiropractors and academics across a set of research domains to determine the agreement or disagreement based on these domains.

METHODS

We conducted a pilot-tested online survey focusing on the following 5 principal research domains: basic science, conditions (disorders chiropractors may encounter), patient subgroups, clinical interventions, and practice and public health/health services. Responses were sought regarding support for funding research scholarships, practice-based research networks, scientific conferences/symposia, journals, and existing research agendas. Data were collected (February 19 to May 24, 2019) from a sample of chiropractic academics (n₁ = 33) representing 4 Australian programs and practicing chiropractors (n₂ = 340). Collected data were ranked and analyzed to determine agreement across domains and items.

RESULTS

There was agreement between the 2 groups across the majority (>90%) of domain items. The closest agreement and highest rankings were achieved for the "clinical interventions and practice" and "conditions" domains. Disagreement was observed within specific domain items, such as patient subgroups (infants), and for 1 intervention (chiropractic-specific techniques). Disagreement also occurred outside of the main domains, including research agenda support and funding.

CONCLUSIONS

There was overall agreement between practicing chiropractors and academics across most research area domain items, which should help facilitate consensus-led development of any potential Australian Chiropractic research agenda. Disagreements across specific domain items, such as population subgroups, interventions, and funding require further investigation.

Broad Medical Uncertainty and the ethical obligation for openness

This paper argues that there exists a collective epistemic state of 'Broad Medical Uncertainty' (BMU) regarding the effectiveness of many medical interventions. We outline the features of BMU, and describe some of the main contributing factors. These include flaws in medical research methodologies, bias in publication practices, financial and other conflicts of interest, and features of how evidence is translated into practice. These result in a significant degree of uncertainty regarding the effectiveness of many medical treatments and unduly optimistic beliefs about the benefit/harm profiles of such treatments. We argue for an ethical presumption in favour of openness regarding BMU as part of a 'Corrective Response'. We then consider some objections to this position (the 'Anti-Corrective Response'), including concerns that public honesty about flaws in medical research could undermine trust in healthcare institutions. We suggest that, as it stands, the Anti-Corrective Response is unconvincing.

Developing the RIGHT extension statement for practice guideline protocols: the RIGHT-P statement protocol

Background: A protocol for a practice guideline can facilitate the guideline development process, ensure its transparency, and improve the quality of the guidelines. However, there are currently no reporting guideline for guideline protocols. Methods: We intend to develop an extension of the Reporting Items for Practice Guidelines in HealThcare (RIGHT) statement for guideline protocols (RIGHT-P). We will follow the toolkit for developing a reporting guideline developed by the Enhancing the QUAlity and Transparency Of health Research (EQUATOR) network. We will form a multidisciplinary international team of experts. The development of RIGHT-P will be conducted in 12 steps grouped in three stages over a two-year period. Results: The results of RIGHT-P statement will be presented in an article to be published later. Conclusion: This report describes the process of RIGHT-P statement development. We believe RIGHT-P will help guideline developers improve the reporting of guideline protocols and indirectly improve their quality and the quality of guidelines. Registration: We registered the protocol on the EQUATOR network.

High court should not restrict access to puberty blockers for minors

Gender dysphoria (GD) is a clinically significant incongruence between expressed gender and assigned gender, with rapidly growing prevalence among children. The UK High Court recently conducted a judicial review regarding the service provision at a youth-focussed gender identity clinic in Tavistock. The high court adjudged it 'highly unlikely' that under-13s, and 'doubtful' that 14-15 years old, can be competent to consent to puberty blocker therapy for GD. They based their reasoning on the limited evidence regarding efficacy, the likelihood of progressing to cross-sex hormone therapy and the 'life-changing consequences' of puberty blockers. In this article, I offer two concurrent arguments to dispute their reasoning. First, I argue that minors can be competent to consent to puberty blockers for GD, because the decision to undergo puberty blocker therapy is no more complex or far-reaching than other medical decisions that we accept a child should be able to make. Second, I argue that-irrespective of competence-such legal restriction for all children fundamentally contradicts the central ethical tenet of child healthcare: best interests. For these two reasons, the high court should not restrict access to puberty blockers for competent GD children.

Treatment recommendations for the management of persistent pelvic pain: A systematic review of international clinical practice guidelines

BACKGROUND

Females with persistent pelvic pain (PPP) report great variability in treatments they are recommended despite the availability of clinical practice guidelines (CPGs) that aim to standardise care. A clear consensus for the best practice care for PPP is required.

OBJECTIVE

Identify and summarise treatment recommendations across CPGs for the management of PPP, and appraise their quality.

SEARCH STRATEGY

MEDLINE, CENTRAL, EMBASE, EmCare, SCOPUS, the Cochrane Database of Systematic Reviews, Web of Science Core Collection, and relevant guideline databases were searched from their inception to June 2021.

SELECTION CRITERIA

Included CPGs were those for the management of urogynaecological conditions in adult females published in English, of any publication date, and endorsed by a professional organisation or society.

DATA COLLECTION AND ANALYSIS

We screened 1,379 records and included 20 CPGs. CPG quality was assessed using The Appraisal of Guidelines for Research and Evaluation II (AGREE-II) tool. Descriptive synthesis compiled treatment recommendations across CPGs.

MAIN RESULTS

CPGs for seven conditions provided 281 individual recommendations. On quality appraisal, guidelines on average scored 'excellent' for the domains 'scope and purpose' (80.6%, SD=13.3) and 'clarity and presentation' (74.4%, SD=12.0); for other domains, average scores were satisfactory or poor. Four guidelines (Endometriosis, NICE, RANZCOG, ESHRE; PCOS, Teede et al. 2018) were deemed recommended for use. Recommendations were most frequent for pharmaceutical and surgical interventions. Recommendations were variable for psychological, physiotherapy, and other conservative interventions.

CONCLUSIONS

The quality of CPGs for PPP is generally poor. Several CPGs endorse the consideration of biopsychosocial elements of PPP. Yet most recommend pharmaceutical, surgical, and other biomedical interventions.

Machine Learning Approaches to Retrieve High-Quality, Clinically Relevant Evidence From the Biomedical Literature: Systematic Review

BACKGROUND

The rapid growth of the biomedical literature makes identifying strong evidence a time-consuming task. Applying machine learning to the process could be a viable solution that limits effort while maintaining accuracy.

OBJECTIVE

The goal of the research was to summarize the nature and comparative performance of machine learning approaches that have been applied to retrieve high-quality evidence for clinical consideration from the biomedical literature.

METHODS

We conducted a systematic review of studies that applied machine learning techniques to identify high-quality clinical articles in the biomedical literature. Multiple databases were searched to July 2020. Extracted data focused on the applied machine learning model, steps in the development of the models, and model performance.

RESULTS

From 3918 retrieved studies, 10 met our inclusion criteria. All followed a supervised machine learning approach and applied, from a limited range of options, a high-quality standard for the training of their model. The results show that machine learning can achieve a sensitivity of 95% while maintaining a high precision of 86%.

CONCLUSIONS

Machine learning approaches perform well in retrieving high-quality clinical studies. Performance may improve by applying more sophisticated approaches such as active learning and unsupervised machine learning approaches.

Making the move to a learning healthcare system: has the pandemic brought us one step closer?

The notion of a learning healthcare system (LHS) is gaining traction to advance the objectives of high-quality patient-centred care. Within such a system, real-world data analysis, clinical research and health service research are core activities of the health system. To support the transition to an LHS, the Australian Government is implementing the National Clinical Trials Governance Framework, which extends health service accreditation standards to the conduct of clinical trials. This initiative encourages the integration of clinical trials into clinical care and the fostering of a culture of continuous improvement. However, implementing this initiative may prove challenging if health system leaders, clinicians and patients fail to recognise the value of clinical trials as a core health system activity. In this article we describe the enduring value of clinical trials and how the COVID-19 pandemic has enhanced their value by addressing longstanding deficiencies in the way trials are conducted. We also summarise best-practice advice on the embedding of trials into routine health care to enable their integration into health system operations. What is known about this topic? Many healthcare organisations seek to transition to a learning health system. In Australia, National Safety and Quality Health Service Standards, which support the embedding of clinical trials as a core health system activity, have been implemented to catalyse the move. What does this paper add? Because there is little practical advice on how to embed clinical trials into health system operations, this paper summarises best practice. It also provides a rationale for embedding trials as a core health system activity, because the creation of a strong research culture is an important determinant of success. What are the implications for practitioners? The successful transition to an LHS would significantly advance the goals of value-based care.

Opening up on airways: the purported effect of nasorespiratory obstruction on dentofacial growth

Nasorespiratory obstruction has been purported to influence dentofacial growth adversely. This has sparked considerable debate for decades with a resurgence in interest in 'airway friendly orthodontics' among both general and specialist dental practitioners. This critical review aims to evaluate the current literature relating to two questions: does nasorespiratory obstruction alter dentofacial growth, and does early intervention targeted at alleviating nasorespiratory obstruction improve dentofacial growth? The strength of association between nasorespiratory obstruction, mouth breathing and a long face is weak. The common methodological flaws in research include unblinded and cross-sectional study designs, a lack of adequate controls, inadequate follow-up, subjective assessments and inadequate statistical power. Vertical dentofacial growth has a strong genetic influence, which implies a relatively minor contribution of environmental factors including airway obstruction. The current evidence does not support recommending procedures, such as adenotonsillectomy and maxillary expansion, with the singular aim of negating a hyperdivergent (vertical) dentofacial growth pattern. In light of low-quality evidence, both the World Health Organization guidelines and ethical principles dictate that greater emphasis is placed on avoiding harm and wastage of resources over alternative options. These findings call for quality improvement in undergraduate and postgraduate curricula and continuing professional development for health professionals.

Embedding clinical trials within routine health-care delivery: Challenges and opportunities

The COVID-19 pandemic provides a pertinent reminder of the imperative to generate timely reliable clinical evidence. Delivery of optimal paediatric care is predicated on the availability of comprehensive, high quality, clinical evidence in a relevant population. However, over 80% of current clinical guidelines and bedside decisions are not based on direct high-level evidence. Integration of research activities into routine clinical care is paramount to address this shortfall. Active engagement of patients, families and hospital administrations is required to reframe integrated clinical trials as a tenet of quality health-care delivery. Current research funding in health care is 1-2 orders of magnitude below that of other industries. At an institutional level, investment in research should be prioritised with enhanced funding and supportive policies. Thoughtful integration of trials into routine bedside care will enable pragmatic research outcomes, tangible returns on financial investments and improved decision-making for patients in the medium- to long-term.

Transparency in clinical practice guidelines: the problem of consensus-based recommendations and practice points

Clinical practice guidelines often provide 'consensus-based recommendations' for issues where there is a lack of evidence to support an evidence-based recommendation, and 'practice points' to assist clinicians in various aspects of everyday clinical care. However, Australian clinical practice guidelines often fail to define these terms clearly, and there is significant inconsistency in how they are used. This lack of clarity presents an impediment to the effective practice of evidence-based medicine and an opportunity for reform in Australian clinical guideline development.

Closing schools for SARS-CoV-2: a pragmatic rapid recommendation

BACKGROUND

In Belgium, schools closed during the first lockdown in March 2020, with a partial reopening in May. They fully reopened in September. During the summer, infections started to increase in the general population, speeding up in September. Some measures were taken to limit social contacts but those were insufficient to mitigate the exponential rise of infections in October. Children were still receiving all lessons at school at that time and it was questioned whether this position was tenable. We systematically compared the benefits and harms of closing primary and secondary schools and developed a recommendation.

METHODS

A multidisciplinary panel, including school pupils and teachers, educational experts, clinicians and researchers, produced this recommendation in compliance with the standards for trustworthy rapid guidelines. The recommendation is based on data collected through national surveillance or studies from Belgium, and supported by a rapid literature review.

RESULTS

Closing schools during the first lockdown probably resulted in a large learning delay and possibly led to more cases of child abuse. We are uncertain about the effect on the infection rate, hospitalisations, transmission rates, mental health of children, teachers and parents. The panel concluded that the balance of benefits and harms of closing schools clearly shifts against closing schools. Detrimental effects are even worse for vulnerable children. This recommendation is affected by the local virus circulation.

CONCLUSION

The guideline panel issues a strong recommendation against closing schools when the virus circulation is low to moderate, and a weak recommendation against closing schools when the virus circulation is high. It does not apply when the school system cannot function due to lack of teachers, too many children who are at home or a shortage of support services. As the results of international studies are consistent with Belgian study results, this recommendation may also be relevant internationally.

Integrated Guidance for Enhancing the Care of Familial Hypercholesterolaemia in Australia

Familial hypercholesterolaemia (FH) is a dominant and highly penetrant monogenic disorder present from birth that markedly elevates plasma low-density lipoprotein (LDL)-cholesterol concentration and, if untreated, leads to premature atherosclerosis and coronary artery disease (CAD). There are approximately 100,000 people with FH in Australia. However, an overwhelming majority of those affected remain undetected and inadequately treated, consistent with FH being a leading challenge for public health genomics. To further address the unmet need, we provide an updated guidance, presented as a series of systematically collated recommendations, on the care of patients and families with FH. These recommendations have been informed by an exponential growth in published works and new evidence over the last 5 years and are compatible with a contemporary global call to action on FH. Recommendations are given on the detection, diagnosis, assessment and management of FH in adults and children. Recommendations are also made on genetic testing and risk notification of biological relatives who should undergo cascade testing for FH. Guidance on management is based on the concepts of risk re-stratification, adherence to heart healthy lifestyles, treatment of non-cholesterol risk factors, and safe and appropriate use of LDL-cholesterol lowering therapies, including statins, ezetimibe, proprotein convertase subtilisin/kexin type 9 inhibitors and lipoprotein apheresis. Broad recommendations are also provided for the organisation and development of health care services. Recommendations on best practice need to be underpinned by good clinical judgment and shared decision making with patients and families. Models of care for FH need to be adapted to local and regional health care needs and available resources. A comprehensive and realistic implementation strategy, informed by further research, including assessments of cost-benefit, will be required to ensure that this new guidance benefits all Australian families with or at risk of FH.