A search for the evidence supporting community paediatric practice

Paediatric patient family engagement with clinical research at a tertiary care paediatric hospital

BACKGROUND

Subject recruitment is essential for conducting clinical research; however, there are very few studies evaluating research uptake by families in a paediatric setting.

OBJECTIVES

To determine how frequently paediatric patients and their families receiving care at a tertiary paediatric hospital participated in research. The secondary objectives were to explore factors that influence patient families' decisions to participate in research and how they perceived their experiences.

METHODS

A cross-sectional study surveying families of children receiving care in a sample of clinical areas at a tertiary care paediatric hospital in British Columbia was conducted. A self-administered questionnaire was used, and was facilitated by trained interviewers. Descriptive statistics were used to report the proportion of patient families that have previously been invited to participate in research and, among these, the proportion who had agreed to participate. Patient families' perceptions of research and their past experiences therein were also reported.

RESULTS

A total of 657 families were approached, of which 543 were enrolled (82.6% response rate). Among the 439 families that had visited the hospital previously, 114 (26.0%) had been invited to participate in research and 99 (87%) had consented to participate. Of these 99 families, only one had a negative experience, and 84 (85%) of these participant families were at least somewhat likely to participate in research again in the future.

CONCLUSIONS

Only one-quarter of families that had previously visited the hospital had been invited to participate in a research project. Of the families approached previously, there was a high rate of participation and willingness to participate in future research.

The evidence base for interventions delivered to children in primary care: an overview of cochrane systematic reviews

BACKGROUND

As a first step in developing a framework to evaluate and improve the quality of care of children in primary care there is a need to identify the evidence base underpinning interventions relevant to child health. Our objective was to identify all Cochrane systematic reviews relevant to the management of childhood conditions in primary care and to assess the extent to which Cochrane reviews reflect the burden of childhood illness presenting in primary care.

METHODOLOGY/PRINCIPAL FINDINGS

We used the Cochrane Child Health Field register of child-relevant systematic reviews to complete an overview of Cochrane reviews related to the management of children in primary care. We compared the proportion of systematic reviews with the proportion of consultations in Australia, US, Dutch and UK general practice in children. We identified 396 relevant systematic reviews; 358 included primary studies on children while 251 undertook a meta-analysis. Most reviews (n = 218, 55%) focused on chronic conditions and over half (n = 216, 57%) evaluated drug interventions. Since 2000, the percentage of pediatric primary care relevant reviews only increased by 2% (7% to 9%) compared to 18% (10% to 28%) in all child relevant reviews. Almost a quarter of reviews (n = 78, 23%) were published on asthma treatments which only account for 3-5% of consultations. Conversely, 15-23% of consultations are due to skin conditions yet they represent only 7% (n = 23) of reviews.

CONCLUSIONS/SIGNIFICANCE

Although Cochrane systematic reviews focus on clinical trials and do not provide a comprehensive picture of the evidence base underpinning the management of children in primary care, the mismatch between the focus of the published research and the focus of clinical activity is striking. Clinical trials are an important component of the evidence base and the lack of trial evidence to demonstrate intervention effectiveness in substantial areas of primary care for children should be addressed.

'Tell me about your pain': abdominal pain and a history of bullying

A 7-year-old girl was brought to our outpatient clinic to investigate recurrent abdominal pain. She was unwilling to attend the school. Her mother reported bullying at school and nosebleeds. The girl rated her pain 9 on a visual analogue score card ranging from 1 to 10. Physical examination disclosed painful bruising and haematomas. Emergency laboratory blood tests indicated by the history, physical examination and the pain intensity showed reduced numbers of white blood cells and platelets. A bone marrow smear on admission disclosed 100% blasts and suggested an initial diagnosis of leukaemia but also disclosed the pseudo-rosettes typically seen in neuro-ectodermic tumours. The diagnosis of stage IV primary neuroblastoma was confirmed by trephine biopsies and high urinary catecholamines. The girl died 10 months later. This unusual case underlines the need for outpatient paediatricians to involve children in their initial diagnostic work-up by asking them about their pain thus expediting the diagnosis.

Making a difference: the clinical research programme for children

High quality paediatric clinical research will ensure that tomorrow's children receive new and better treatments

The child’s right to participate in research: myth or misconception?

The growing acceptance of the need for children's participation in any issues that affect them, including research, has been fuelled by the 'children's rights' agenda, which has occurred in the UK since the ratification in 1991 of the UN 'Convention on the Rights of the Child' (UNCRC, 1989), which provides a framework for the development of national policies and laws to protect the rights of children (O'Hallorhan, 1999). There is a clear indication of this both within the UNCRC (1989) and the growing 'sociology of childhood', where the importance of children actively constructing their own lives by, for example, participating in and negotiating their own health care, education and social welfare by utilizing skills that go unrecognized (Mayall, 1998). With the current emphasis in the NHS on evidence-based care there is a need for those working with children and young people to include best evidence from research with children (as opposed to 'on' children) in both clinical and healthcare decisions. Recommendations for future research with children include the use of more innovative methodologies, such as action research and focus groups that will enable children to actively participate and to describe personal experiences through their own unique points of view.

Treatment in the pediatric emergency department is evidence based: a retrospective analysis

BACKGROUND

Our goal was to quantify the evidence that is available to the physicians of a pediatric emergency department (PED) in making treatment decisions. Further, we wished to ascertain what percentage of evidence for treatment provided in the PED comes from pediatric studies.

METHODS

We conducted a retrospective chart review of randomly selected patients seen in the PED between January 1 and December 31, 2002. The principal investigator identified a primary diagnosis and primary intervention for each chart. A thorough literature search was then undertaken with respect to the primary intervention. If a randomized control trial (RCT) or a systematic review was found, the intervention was classified as level I evidence. If no RCT was found, the intervention was assessed by an expert committee who determined its appropriateness based on face validity (RCTs were unanimously judged to be both unnecessary and, if a placebo would have been involved, unethical). These interventions were classified as level II evidence. Interventions that did not fall into either above category were classified as level III evidence.

RESULTS

Two hundred and sixty-two patient charts were reviewed. Of these, 35.9% did not receive a primary intervention. Of the 168 interventions assessed, 80.4% were evidence-based (level I), 7.1% had face validity (level II) and 12.5% had no supporting evidence (level III). Of the evidence-based interventions, 83.7% were supported by studies with mostly pediatric patients.

CONCLUSION

Our study demonstrates that a substantial proportion of PED treatment decisions are evidence-based, with most based on studies in pediatric patients. Also, a large number of patients seen in the PED receive no intervention.

Parents' perspectives on research involving children

Children's participation in research is essential for the development of safe and age-appropriate treatments. However, children's participation is limited. The aim of this study was to determine (1) mothers' and fathers' views on which agencies/persons should evaluate the level of acceptable risk for children and (2) parents' willingness to allow children to participate in research. Medical factors, sociodemographics, and research attitudes were related to willingness. The study used a cross-sectional and longitudinal design with 863 expectant parents (435 women; 428 men) consecutively recruited at gestational week 19 during routine ultrasound examination at 2 hospitals in Uppsala County, Sweden. 123 women at gestational week 34 were followed-up. Parental ratings of agencies/persons' degree of involvement in risk-evaluation for. child research participants and parents' willingness to allow children to participate in research were the main outcome measures. Most parents believed that more pediatric research was needed. Attitudes played a major role in willingness, indicating a potential for information that could modify willingness. Over 80% of mothers and fathers rated the attending physician as needing to be "fully involved" in risk evaluation for research participants. Parents' views contradict current trends in research ethics which place evaluation of risk in the hands of regional agencies. Instead, the majority of parents would like the decision to be individually based on the attending physicians advise. We conclude that children's participation in research could be improved by actively incorporating the attending physician and by educating the public so that research attitudes can be based on accurate information.

Child health care centres: an academic model for comprehensive child health care in the community

The challenge of the discipline of paediatrics in the 21st century is to promote health and development of children in a way that will enable them to maximize their biological and social potential. The community child health centre (CHC) in Israel is a model of community health care service built to provide comprehensive health care to children and adolescents, as well as an academic setting for under- and postgraduate paediatric training. Today there are 34 CHCs in Israel, serving a population of 220 000 children from birth to 18 years of age. The CHC combines the advantages of group practice with those of an academic medical centre and enables flexibility and mutual learning. Further expansion and development are required to realize the CHC's mission of a true comprehensive academic centre for paediatric community health.

Audit of therapeutic interventions in inpatient children using two scores: are they evidence-based in developing countries?

Background

The evidence base of clinical interventions in paediatric hospitals of developing countries has not been formally assessed. We performed this study to determine the proportion of evidence-based therapeutic interventions in a paediatric referral hospital of a developing country

Methods

The medical records of 167 patients admitted in one-month period were revised. Primary diagnosis and primary therapeutic interventions were determined for each patient. A systematic search was performed to assess the level of evidence for each intervention. Therapeutic interventions were classified using the Ellis score and the Oxford Centre for Evidence Based Medicine Levels of Evidence

Results

Any dehydration due to diarrhoea (59 cases) and pneumonia (42 cases) were the most frequent diagnoses. Based on Ellis score, level I evidence supported the primary therapeutic intervention in 21%, level II in 73% and level III in 6% cases. Using the Oxford classification 16%, 8%, 1% and 75% therapeutic interventions corresponded to grades A, B, C, and D recommendations, respectively. Overall, according to Ellis score, 94% interventions were evidence based. However, out of the total, 75% interventions were based on expert opinion or basic sciences. Most children with mild to moderate dehydration (52 cases) were inappropriately treated with slow intravenous fluids, and most children with non-complicated community acquired pneumonia (42 cases) received intravenous antibiotics

Conclusions

Most interventions were inappropriate, despite the availability of effective therapy for several of them. Diarrhoeal dehydration and community acquired pneumonia were the most common diagnoses and were inappropriately managed. Existing effective interventions for dehydration and pneumonia need to be put into practice at referral hospitals of developing countries. For the remaining problems, there is the need to conduct appropriate clinical studies. Caution must be taken when assigning the level of evidence supporting therapeutic interventions, as commonly used classifications may be misleading

Gaps between best evidence and practice: causes for concern

Overseas studies that aim to quantify the evidence base of conventional medical care give varying estimates, but many of these studies have potential for bias. We do not know how much of the total healthcare Australians receive is based on the best available evidence; studies of a number of specific conditions show that there are gaps between what is known and what happens in practice. The National Institute of Clinical Studies aims to identify and test systemic approaches to embed ongoing review and uptake of evidence into routine clinical care.

Decisiones terapéuticas en los pacientes hospitalizados

BACKGROUND AND OBJECTIVE

The aim of this study was to identify the extent to which treatment decisions for medical in-patients in three hospitals in Catalunya are supported by published evidence.

PATIENTS AND METHOD

In a retrospective, cross-sectional study, main diagnosis-treatment pairs (DTPs) were identified for 980 hospital discharges. The Cochrane library and MEDLINE from 1966 to 1998 were searched for systematic reviews or, in their absence, randomized controlled clinical trials (RCT) that supported the treatment given for each diagnosis. The level of evidence found for each DTP was classified. Descriptive analyses for patients and different DTP were performed.

RESULTS

A systematic review or RCT (level I) was found for 65.4% of the 980 patients. In 32.6% of cases, there was only non-experimental or consensus evidence (level II) and in 2% there was no good evidence for the treatment given (level III). An analysis of the 598 unique pairs reduced the percentage of cases supported by level I evidence (55.7) with a proportionate increase in level II (41%). There were some differences in the proportion of cases in each evidence level by diagnostic group.

CONCLUSIONS

For about two thirds of patients and a half therapeutic decisions in these three centres, there was a published RCT or a systematic review, with variations according to diagnostic groups. More robust and objective instruments are needed to assess the degree to which scientific evidence is applied in clinical practice.

Mind-Body Medicine in Ambulatory Care

Ambulatory medicine is a frequent clinical setting where practitioners can effectively apply Mind-body interventions ranging from basic stress management therapies to the sophisticated biomedical instrumentation of clinical biofeedback. Given the rather extensive and growing body of clinical research in this area, the intent of this article is to provide an evidence-based assessment of the evidence underlying the clinical efficiency of such interventions. Such an evidence-based approach can help ambulatory care providers to identify those Mind-body interventions with specific clinical indication so that they can be utilized both safely and effectively in ambulatory medicine.

Is the practice of paediatric inpatient medicine evidence-based?

OBJECTIVE

To determine whether management provided to paediatric inpatients in general units was supported by high-level evidence.

METHODS

A retrospective review was carried out of all patients (n = 142) admitted during one calendar month to two general paediatric units in the USA and Australia. For each patient, the primary diagnosis and primary treatment were determined. A literature review was performed to determine whether the therapy used was evidence-based. The main outcome measure was the level of evidence supporting the primary intervention for the primary diagnosis of each patient.

RESULTS

Level I evidence (at least one randomized trial) supported the primary intervention used in 31% of paediatric admissions and level II evidence (convincing non-experimental evidence) supported the primary intervention in 44% of admissions. Primary interventions were not supported by evidence (level III) in only two patients. The remaining 24% of patients were admitted for observation or evaluation only, and received no primary medical or surgical intervention. Most patients whose interventions were supported by randomized trials were admitted with either asthma or appendicitis.

CONCLUSIONS

Most primary interventions (75%) in paediatric inpatients were supported by high-level published evidence (level I or II). A large number of patients were admitted for evaluation or observation only, and received no therapeutic intervention. Evidence to support this action is not available.

The effectiveness of routine health examinations at 2, 6, 9 and 12 months of age: experiences based on data from a Swedish county

AIM

The aim of this study was to elucidate the role of health surveillance for infants during the first year of life in detecting severe health problems. Two central questions were addressed: (1) what health problems were detected by routine health examinations at the Child Health Centre at the 2-, 6- and 12-month check-ups by a physician and at the 9-month check-up by a nurse; and (2) to what extent did the health examinations contribute to early identification of children with following key abnormalities: congenital heart disease, congenital dislocation of the hip, abnormalities as registered at the habilitation centre and severe hearing impairments? MATERIAL AND INCLUSION CRITERIA: The study population included all children in Uppsala county, born January 1995 to October 1996, who had participated in at least one of the four health check-ups. There were 3107-3487 children in the respective check-ups.

METHOD

Data from a county health register as well as child health records and information regarding referrals were analysed to categorize the health problems by type, severity and action taken. Data on children with key abnormalities were obtained from specialist units.

RESULTS

The rate of suspected new health problems varied between 1.9% and 2.8% at the respective check-ups. Of the new problems detected by the physician, 21%-36% were false-positive, 34%-44% were minor and 10%-15% were moderate. Only two severe health problems were detected among all the children during the four check-ups. Of all key abnormalities, 20% were detected by way of child health surveillance during the first year of life.

IMPLICATIONS

Severe health problems and key abnormalities in infants were detected only to a limited extent through routine health examinations at 2, 6, 9 and 12 months of age. The minor and moderate problems detected justify a health surveillance programme, but the organization and content of the programme could be reconsidered.