An additional basic science for clinical medicine: II. The limitations of randomized trials

Beraprost and Overall Survival in Cats with Chronic Kidney Disease

BACKGROUND

Overall survival is the most important outcome for treatment response in feline chronic kidney disease (CKD). Beraprost has been shown to reduce the kidney function decline in cats with International Renal Interest Society (IRIS) stage 2 and 3 CKD. However, the association with prolonged survival has not yet been examined.

OBJECTIVE

To assess the relationship between beraprost and overall survival in cats with CKD in real clinical practice.

ANIMALS

Client-owned cats with IRIS stage 3 CKD (n = 134) were evaluated between 2017 and 2020.

METHODS

A retrospective cohort study based on data from electronic medical records of one hospital.

RESULTS

The cohort was divided into "beraprost therapy" and "no beraprost therapy" groups, and survival analyses revealed that overall survival was significantly longer in the beraprost therapy group, using Kaplan-Meier curves (p = 0.004). However, baseline phosphate is known to be an important prognostic indicator and was not well balanced between the two groups. Therefore, a subcohort of 97 cats was selected (those having baseline phosphate <6.0 mg/dL) that allowed for this parameter to be balanced between groups. The survival data in this subcohort were consistent with those of the overall study cohort.

CONCLUSIONS

In feline patients with CKD, beraprost therapy is associated with better overall survival.

Understanding explanatory and pragmatic trials: Examples from randomized controlled trials on vertebroplasty

OBJECTIVES

To better understand the explanatory-pragmatic distinction in the design and interpretation of randomized controlled trials (RCTs).

METHODS

We review the explanatory-pragmatic distinction in clinical trial design. We use the PRECIS-2 tool to evaluate the trial design of selected RCTs on percutaneous vertebroplasty for osteoporotic vertebral compression fractures. We discuss difficulties in the selection of criteria and in the construction of PRECIS diagrams. We also examine how inconsistency in the selection of various items of trial design can cause confusion in the interpretation of results.

RESULTS

The selection of criteria and the scoring of multiple PRECIS domains were subjective and thus debatable. The pragmascope patterns of various vertebroplasty trials were heterogeneous. Many trials had both pragmatic and explanatory components. Some placebo-controlled trial goals seem to have been explanatory, but their design actually included enough pragmatic items such that the meaning of negative trial results remains ambiguous.

CONCLUSION

The results of a trial cannot be interpreted without understanding the various design choices made along the explanatory-pragmatic spectrum.

COVID-19 and the future of clinical epidemiology

Clinical epidemiology, the “basic science for clinical medicine”[1], has changed substantially over the last 50 years, moving its focus from clinician driven research and clinical settings to large cohorts and trials, NIH funding, and practice guidelines. The COVID-19 pandemic created major challenges for clinicians who needed to make urgent decisions about the management a new disease and for researchers who needed to understand the clinical syndrome and the questions of greatest importance to the pandemic response. Addressing these challenges reunited clinicians and researchers in collaborative efforts to inform decisions about disease risk, prevention, prognosis and treatment, at least in part because of the shared sense of the need to ration scarce resources, the rapid evolution of understanding of the clinical syndrome, the recognition of widespread uncertainty, and the emphasis on the common good over individual credit. Only time will tell whether the experience during COVID-19 will revive the original practice of clinical epidemiology as “the application by a physician who provides direct patient care, of epidemiologic and biometric methods to the study of diagnostic and therapeutic process in order to effect an improvement in health”[2].

Impact of intra-group coopetitive incentives on the performance outcomes of knowledge sharing: evidence from a randomized experiment

Purpose

Knowledge sharing, as a kind of social behavior that incorporates collective intelligence to achieve a certain goal, has become a remarkable developing trend in recent years. Under the context of traditional teaching, this study aims to explore the manner in which students become effective in sharing knowledge to help optimize course design and improve our existing education.

Design/methodology/approach

Among 195 university students taking an elective, the effects of different incentives on group performance in completing tasks is explored on the basis of a randomized experiment.

Findings

Results show that intra-group cooperation can be helpful to student performance, whereas intra-group competition neither improves nor worsens student performance. The former is mainly driven by reciprocity, especially for that stimulated by inter-group competition, whereas the latter is stimulated by egoism. Thus, proper reciprocity can promote student behavior to increase voluntary contribution. In addition, intra-group differences do not interfere with group performance, especially task-oriented groups.

Originality/value

Certain suggestions are proposed to improve the curriculum design in large classrooms. Forming groups is the best way to strengthen student knowledge sharing. Within task-oriented groups, the incentives of inter-group competition can encourage students to deepen intra-group cooperation and thus effectively improve group performance under the conditions of external competition.

Beware of on-treatment safety analyses

Introduction:

Assessing safety is important to evaluating new medications. In many randomized clinical trials, assessment of safety relies on so-called on-treatment analysis, where data on adverse events are collected only while the participant is taking study medication and perhaps for a few (7, 14, or 30) days after stopping. This article discusses the consequence of such failure to use intent-to-treat analyses in assessing safety.

Methods:

This article discusses two approaches to analysis of safety data: intention-to-treat and on-treatment analysis with reference to principles of the design of randomized clinical trial.

Results:

On-treatment analysis violates randomization and is often not well defined. Moreover, because the typical on-treatment analysis ignores the reason participants in clinical trials stop treatment, on-treatment analyses can lead to biased estimates of risk. Examples show biases that can result from failure to count all adverse events. An example from a study of rofecoxib shows an on-treatment analysis that led to likely underestimation of harm; an example from a study of saxagliptin shows an on-treatment analysis that led to a likely overestimate of harms.

Conclusion:

For major safety outcomes in long-term clinical trials, intention-to-treat analysis should be performed in the framework of benefit–risk evaluation. More generally, analyses of safety should be tailored to the specific question being asked with the specific study design under consideration. On-treatment analyses are subject to bias; however, the direction of that bias is not necessarily clear.

Clinical judgement in the era of big data and predictive analytics

Clinical judgement is a central and longstanding issue in the philosophy of medicine which has generated significant interest over the past few decades. In this article, we explore different approaches to clinical judgement articulated in the literature, focusing in particular on data-driven, mathematical approaches which we contrast with narrative, virtue-based approaches to clinical reasoning. We discuss the tension between these different clinical epistemologies and further explore the implications of big data and machine learning for a philosophy of clinical judgement. We argue for a pluralistic, integrative approach, and demonstrate how narrative, virtue-based clinical reasoning will remain indispensable in an era of big data and predictive analytics.

An Algorithm for Creating Virtual Controls Using Integrated and Harmonized Longitudinal Data

We introduce a strategy for creating virtual control groups-cases generated through computer algorithms that, when aggregated, may serve as experimental comparators where live controls are difficult to recruit, such as when programs are widely disseminated and randomization is not feasible. We integrated and harmonized data from eight archived longitudinal adolescent-focused data sets spanning the decades from 1980 to 2010. Collectively, these studies examined numerous psychosocial variables and assessed past 30-day alcohol, cigarette, and marijuana use. Additional treatment and control group data from two archived randomized control trials were used to test the virtual control algorithm. Both randomized controlled trials (RCTs) assessed intentions, normative beliefs, and values as well as past 30-day alcohol, cigarette, and marijuana use. We developed an algorithm that used percentile scores from the integrated data set to create age- and gender-specific latent psychosocial scores. The algorithm matched treatment case observed psychosocial scores at pretest to create a virtual control case that figuratively "matured" based on age-related changes, holding the virtual case's percentile constant. Virtual controls matched treatment case occurrence, eliminating differential attrition as a threat to validity. Virtual case substance use was estimated from the virtual case's latent psychosocial score using logistic regression coefficients derived from analyzing the treatment group. Averaging across virtual cases created group estimates of prevalence. Two criteria were established to evaluate the adequacy of virtual control cases: (1) virtual control group pretest drug prevalence rates should match those of the treatment group and (2) virtual control group patterns of drug prevalence over time should match live controls. The algorithm successfully matched pretest prevalence for both RCTs. Increases in prevalence were observed, although there were discrepancies between live and virtual control outcomes. This study provides an initial framework for creating virtual controls using a step-by-step procedure that can now be revised and validated using other prevention trial data.

Generalizability of Patients With Rheumatoid Arthritis in Biologic Agent Clinical Trials

OBJECTIVE

Randomized controlled trials (RCTs) have consistently demonstrated the efficacy of biologic agents in treating patients with rheumatoid arthritis (RA) who satisfy strict eligibility criteria, yet studies report that a majority of RA patients in the US have had biologic treatment exposure. We identified the proportion of RA patients in clinical practice satisfying entry criteria for biologic agent RCTs.

METHODS

Eligibility criteria of 30 RCTs of 10 Food and Drug Administration-approved biologic agents to treat RA were reviewed, summarized, and applied to 2 observational clinical cohorts: the Veterans Affairs Rheumatoid Arthritis registry (VARA; n = 1,523) and the Rheumatology and Arthritis Investigational Network Database (RAIN-DB; n = 1,548). Patients at a single clinical encounter were assessed for overall trial eligibility as well as eligibility across 3 domains: demographics, disease activity, and medication exposure.

RESULTS

The mean percentage of patients that satisfied eligibility criteria was 3.7% (interquartile range [IQR] 1.5-3.1) in VARA and 7.1% (IQR 4.4-7.7) in RAIN-DB. Ineligibility was most often due to low disease activity, specifically low joint counts. The mean Disease Activity Score in 28 joints at enrollment was 6.59 (range 6.1-7.1) across RCTs versus 3.87 (0.07-8.69) in VARA and 3.65 (0.49-7.21) in RAIN-DB. RCTs for non-tumor necrosis factor (TNF) inhibitor biologic agents were more restrictive than RCTs for TNF inhibitors. There was no trend in eligibility by RCT study publication or drug approval date.

CONCLUSION

The vast majority of RA patients from our clinical cohorts did not satisfy criteria for participation in biologic agent RCTs. These findings underscore the need for caution in extrapolating trial results to day-to-day management of RA patients and may provide insight into the differential responses to biologic agents reported in prior observational studies.

Randomised trials in context: practical problems and social aspects of evidence-based medicine and policy

Randomised trials can provide excellent evidence of treatment benefit in medicine. Over the last 50 years, they have been cemented in the regulatory requirements for the approval of new treatments. Randomised trials make up a large and seemingly high-quality proportion of the medical evidence-base. However, it has also been acknowledged that a distorted evidence-base places a severe limitation on the practice of evidence-based medicine (EBM). We describe four important ways in which the evidence from randomised trials is limited or partial: the problem of applying results, the problem of bias in the conduct of randomised trials, the problem of conducting the wrong trials and the problem of conducting the right trials the wrong way. These problems are not intrinsic to the method of randomised trials or the EBM philosophy of evidence; nevertheless, they are genuine problems that undermine the evidence that randomised trials provide for decision-making and therefore undermine EBM in practice. Finally, we discuss the social dimensions of these problems and how they highlight the indispensable role of judgement when generating and using evidence for medicine. This is the paradox of randomised trial evidence: the trials open up expert judgment to scrutiny, but this scrutiny in turn requires further expertise.

Clinical research quo vadis? Trends in reporting of clinical trials and observational study designs over two decades

Background

Multiple classifications have been developed that classify the medical literature into different levels of evidence to facilitate the evaluation of study results and practice of evidence-based medicine. The suggested hierarchies of evidence are generally based on the type of study design; randomized, controlled clinical trials constitute the top level of evidence while case reports rank the lowest among epidemiologic study designs. However, little is known about the frequency with which different study designs appear in the medical literature overall. The purpose of this study was to describe trends in the frequency of reports of randomized control trials (RCTs) as compared to other study designs in the medical literature over two decades.

Methods

Data about the prevalence of various types of study designs in the medical literature over the last two decades (years 1990 - 2009) were abstracted from PubMed, validated and subjected to cross-sectional and longitudinal analysis.

Results

In the last 20 years, the annual rate of publication of journal articles has more than doubled. During this period, the percentage of observational studies increased from 29.9% to 40.5%, the percentage of reports of RCTs increased minimally, and there was a striking decline in the percentage of case reports (from 49.8% to 33.6%) in the medical literature overall. In contrast, in three selected, highly cited medical journals, the percentage of reports of RCTs increased by almost 10%. Surprisingly, the percentage of articles classified as case reports also increased (from 36.3% to 43.8%) in these three journals, while the percentage of reports of cohort and case-control studies decreased.

Conclusion

Though the relative frequency of reports from RCTs has not changed substantially in the last 20 years, cohort studies and case-control studies have largely supplanted simple case reports. In contrast, in high impact journals, the representation of RCTs and case reports has increased, with corresponding declines in reports based on other study designs. Further research will be needed to determine whether those trends in publication have resulted in more robust evidence and faster advancement of medical knowledge.

Clinical trials documenting the efficacy of low-dose glucocorticoids in rheumatoid arthritis

Twelve clinical trials have documented that prednisone or prednisolone in doses of 10 mg/day or less is efficacious to improve function, maintain status and/or slow radiographic progression in patients with rheumatoid arthritis (RA). An early trial reported by de Andrade et al. [Ann Rheum Dis 1964;23:158-162] in 1964 indicated that 5 mg of prednisolone at night was preferred to 5 mg of prednisone in the morning. Harris et al. [J Rheumatol 1983;10:713-721] documented the efficacy of 5 mg/day of prednisone in a non-double-blind trial in 1983. Two important trials in the 1990s by Kirwan [N Engl J Med 1995;333:142-146] using 7.5 mg/day, and the COBRA study by Boers et al. [Lancet 1997;350:309-318] with step-down from 60 mg rapidly tapered to 5 mg/day led to strong advocacy of low-dose glucocorticoids. In 2002, the first Utrecht Study [Ann Intern Med 2002;136:1-12] indicated that 10 mg/day prednisone slowed radiographic progression, a finding confirmed and extended in 2005 by Svensson et al. [Arthritis Rheum 2005;52:3360-3370] with 7.5 mg/day, and Wassenberg et al. [Arthritis Rheum 2005;52:3371-3380] with 5 mg/day of prednisolone. In 2008, Buttgereit et al. [Lancet 2008;371:205-214] reported CAPRA-1, which documented that modified-release prednisone or prednisolone taken at bedtime led to lower morning stiffness and IL-6 levels compared to usual morning prednisone. In 2009, Pincus et al. [Ann Rheum Dis 2009;68:1715-1720] reported a withdrawal clinical trial, in which patients who took 3 mg/day were gradually withdrawn to placebo, and dropped out at a significantly higher rate than control patients who were 'withdrawn' to prednisone. In 2012, a second Utrecht Study [Ann Intern Med 2012;156:329-339], CAMERA-II, documented that 10 mg of prednisone added to a 'treat-to-target' strategy with methotrexate provided incremental slowing of radiographic progression. An Italian study of patients with early RA who received step-up disease-modifying antirheumatic drug therapy over 2 years plus prednisolone or not indicated higher rates of clinical remission and sustained remission associated with 7.5 mg/day of prednisolone [Arthritis Res Ther 2012; 14:R112]. The CAPRA-2 trial [Ann Rheum Dis 2013;72:204-210] documented that modified-release nighttime prednisone or prednisolone was significantly more efficacious than placebo. Taken together, these 12 clinical trials indicate that low-dose glucocorticoids prednisone or prednisolone provides symptomatic relief, improved functional status and slowing of radiographic progression for patients with RA. © 2014 S. Karger AG, Basel.

The past versus the present, 1980-2004: reduction of mean initial low-dose, long-term glucocorticoid therapy in rheumatoid arthritis from 10.3 to 3.6 mg/day, concomitant with early methotrexate, with long-term effectiveness and safety of less than 5 mg/day

Quantitative observations are presented concerning treatment with glucocorticoids of 308 patients with rheumatoid arthritis (RA) at a weekly academic rheumatology setting over 25 years from 1980 to 2004. A database of all visits included medications and multidimensional health assessment questionnaire scores for physical function, pain and routine assessment of patient index data (RAPID3; and a surrogate RAPID3-EST), completed by each patient at each visit in routine care. Over the 5-year periods of 1980-1984, 1985-1989, 1990-1994, 1995-1999 and 2000-2004, the mean initial prednisone daily dose declined from 10.3 to 6.5, 5.1, 4.1 and 3.6 mg/day, as initial doses were >5 mg/day in 49, 16, 7, 7 and 3% of patients, 5 mg/day in 51, 80, 70, 26 and 10%, and <5 mg/day in 0, 4, 23, 67 and 86%. Reduction of prednisone doses in the respective five-year periods was accompanied by increased and earlier use of methotrexate as the first disease-modifying antirheumatic drug (DMARD) in 10, 26, 57, 71 and 78%, and methotrexate treatment in 10, 26, 74, 82 and 92% of patients within the first year of disease. Higher methotrexate doses in the respective five-year periods were used after 1990, along with lower prednisone doses. Most patients were treated indefinitely with both low-dose prednisone and methotrexate; 80% continued both medications for more than 5 years. The primary adverse events were skin-thinning and bruising. New hypertension, diabetes and cataracts were seen in fewer than 10% of patients. While efficacy and safety cannot be analyzed definitively from observational data, the data suggest that many patients with RA might be treated effectively with weekly low-dose methotrexate along with initial and long-term, low-dose prednisone of <5 mg/day.

A clinimetric study of outpatient diabetes consultations: the potential for telemedicine substitution

BACKGROUND

The purpose of this study was to identify the clinimetric characteristics of specialist outpatient consultations for people with diabetes and to evaluate the possibility of providing such consultations remotely using telemedicine.

MATERIALS AND METHODS

The process of care was analyzed during the specialist consultations provided by five endocrinologists in a tertiary hospital diabetes outpatient clinic. The specialists' opinion of the possibility of providing each consultation remotely was also sought.

RESULTS

In total, 50 consultations were analyzed. The patients had type 1 and type 2 diabetes in 28% and 64% of the cases, respectively; 68% had at least one diabetes complication. Diabetic neuropathy was the most prevalent (42%) complication. Physical examination was not performed by the specialists in 34% of cases. General foot inspection, the most frequent examination, was performed in 54% of the consultations. After "general advice," ordering laboratory tests was the most frequent recommendation (80%), followed by adjustment of an insulin regimen (52%). In 86% of consultations, the specialists believed that it would have been possible to provide that consultation remotely via videoconferencing to a patient with the general practitioner present. In their opinion, communicating with the patients through e-mail was the least possible alternative means of providing the consultations.

CONCLUSIONS

Endocrinologists with little telemedicine experience believe that a considerable proportion of outpatient specialty consultations for people with diabetes can be provided remotely via videoconferencing. The clinimetric analysis of 50 consultations supports this opinion.

EULAR evidence-based and consensus-based recommendations on the management of medium to high-dose glucocorticoid therapy in rheumatic diseases

To develop recommendations for the management of medium to high-dose (ie, >7.5 mg but ≤100 mg prednisone equivalent daily) systemic glucocorticoid (GC) therapy in rheumatic diseases. A multidisciplinary EULAR task force was formed, including rheumatic patients. After discussing the results of a general initial search on risks of GC therapy, each participant contributed 10 propositions on key clinical topics concerning the safe use of medium to high-dose GCs. The final recommendations were selected via a Delphi consensus approach. A systematic literature search of PubMed, EMBASE and Cochrane Library was used to identify evidence concerning each of the propositions. The strength of recommendation was given according to research evidence, clinical expertise and patient preference. The 10 propositions regarded patient education and informing general practitioners, preventive measures for osteoporosis, optimal GC starting dosages, risk-benefit ratio of GC treatment, GC sparing therapy, screening for comorbidity, and monitoring for adverse effects. In general, evidence supporting the recommendations proved to be surprisingly weak. One of the recommendations was rejected, because of conflicting literature data. Nine final recommendations for the management of medium to high-dose systemic GC therapy in rheumatic diseases were selected and evaluated with their strengths of recommendations. Robust evidence was often lacking; a research agenda was created.

Hand-carried echocardiography by hospitalists: a randomized trial

BACKGROUND

Hospitalists can use hand-carried echocardiography for accurate point-of-care information, but patient outcome data for its application are sparse.

METHODS

We performed an unblinded, parallel-group randomized trial between July 2008 and March 2009 at one teaching hospital in Chicago, Illinois. We randomly assigned adult general medicine inpatients referred for standard echocardiography with indications investigatable by hand-carried echocardiography to care guided by hand-carried echocardiography or usual care. The main outcome measure was length of stay on the referring hospitalist's service. Secondary outcomes included a before-after analysis of reported changes in management due to hand-carried echocardiography and the diagnostic accuracy of hand-carried echocardiography.

RESULTS

The difference in length of stay between 226 participants randomized to care guided by hand-carried echocardiography (geometric mean 46.1 hours, interquartile range 29.0-70.9 hours) and 227 participants randomized to usual care (46.9 hours, interquartile range 34.1-68.3 hours) corresponded to a 1.7% reduction in length of stay that was not statistically significant (95% confidence interval, -12.1 to 9.8%). In post hoc subgroup analyses, care guided by hand-carried echocardiography reduced length of stay in participants who were referred for heart failure (P=.0008). Among participants who underwent both hand-carried and standard echocardiography, hospitalists changed management due to hand-carried echocardiography in 37%. Despite the favorable diagnostic accuracy of hand-carried echocardiography, most changes to the timing of hospital discharge occurred after standard echocardiography.

CONCLUSION

Hospitalist care guided by hand-carried echocardiography for unselected general medicine patients does not meaningfully affect length of stay. Whether or not it affects care quality remains unstudied.

A CTSA agenda to advance methods for comparative effectiveness research

Clinical research needs to be more useful to patients, clinicians, and other decision makers. To meet this need, more research should focus on patient-centered outcomes, compare viable alternatives, and be responsive to individual patients' preferences, needs, pathobiology, settings, and values. These features, which make comparative effectiveness research (CER) fundamentally patient-centered, challenge researchers to adopt or develop methods that improve the timeliness, relevance, and practical application of clinical studies. In this paper, we describe 10 priority areas that address 3 critical needs for research on patient-centered outcomes (PCOR): (1) developing and testing trustworthy methods to identify and prioritize important questions for research; (2) improving the design, conduct, and analysis of clinical research studies; and (3) linking the process and outcomes of actual practice to priorities for research on patient-centered outcomes. We argue that the National Institutes of Health, through its clinical and translational research program, should accelerate the development and refinement of methods for CER by linking a program of methods research to the broader portfolio of large, prospective clinical and health system studies it supports. Insights generated by this work should be of enormous value to PCORI and to the broad range of organizations that will be funding and implementing CER.

Evaluating the medical evidence for quality improvement

Neonatal-Perinatal Medicine has had both its triumphs and its disasters regarding the dissemination of new interventions. Evidence-based medicine (EBM), the integration of clinical expertise, patient values, and best evidence for decision making in patient care, provides a blueprint for how to safely and effectively continue make headway in our rapidly changing field. The principles of EBM have been discussed in multiple articles and primers. EBM involves formulating the appropriate question, finding the evidence, appraising the evidence, and evaluating the clinician's performance in implementing these practices. At an institutional level, this type of thorough evidence review is critical to successful quality improvement projects, particularly if these projects hope to improve clinical outcome. On evaluation of best practice, one sees great variation in the implementation of practices that are strongly evidence based (increased use of antenatal steroids, decreased use of postnatal steroids), practices rich in evidence lacking certainty regarding the best approach (prophylactic indomethacin to prevent intraventricular hemorrhage), and widespread dissemination of practices that have little evidence to support their use (stabilization on high-frequency ventilation).

A scale for distinguishing efficacy from effectiveness was adapted and applied to stroke rehabilitation studies

OBJECTIVES

To apply a tool that purports to differentiate between efficacy and effectiveness studies to stroke rehabilitation trials and to evaluate its applicability and reliability.

STUDY DESIGN AND SETTING

Three raters developed item operational definitions before independently applying the seven-item scale to 151 randomized controlled trials (RCT), published during or after 1997, that evaluated either a pharmacologic (P, n=78) or a nonpharmacologic (NP, n=73) intervention. Inter-rater reliability was assessed for both individual items and total scores, separately for P and NP trials.

RESULTS

Item inter-rater reliability (multiple-rater kappa) ranged from 0.00 (95% CI [confidence interval]: -0.13, 0.13) to 0.85 (95% CI: 0.73, 0.98) and from 0.21 (95% CI: 0.08, 0.34) to 0.79 (95% CI: 0.66, 0.92) for P and NP RCTs, respectively. For the total score (dichotomized), kappa values were 0.43 (95% CI: 0.31, 0.56) and 0.51 (95% CI: 0.37, 0.64) for P and NP trials, respectively.

CONCLUSIONS

The tool provides a solid foundation on which to base further discussion of the differential criteria of efficacy-effectiveness trial design. Scale items should be properly operationalized depending on the research question of interest and evaluated for reliability before the scale is used for definitively judging a given study's design or the external validity of its results.

Regional and national health care data repositories

Efforts are underway to define a national framework for secondary analysis of health-related data. In the meantime, regional health databases have been constructed using insurance claims data, clinical data from single large health care providers, clinical data from multiple collaborating health care providers, and public health data. Large-scale survey data also are available in government databases. Clinical laboratory results are an important component of all these databases because they can provide validation for manually assigned diagnostic and procedure codes and can support inference of key information not provided by coding, such as severity of disease and prevalence of risk factors.

Using the common sense model to design interventions for the prevention and management of chronic illness threats: from description to process

In this article, we discuss how one might use the common sense model of self-regulation (CSM) for developing interventions for improving chronic illness management. We argue that features of that CSM such as its dynamic, self-regulative (feedback) control feature and its system structure provide an important basis for patient-centered interventions. We describe two separate, ongoing interventions with patients with diabetes and asthma to demonstrate the adaptability of the CSM. Finally, we discuss three additional factors that need to be addressed before planning and implementing interventions: (1) the use of top-down versus bottom-up intervention strategies; (2) health care interventions involving multidisciplinary teams; and (3) fidelity of implementation for tailored interventions.

Personal view: a potential novel treatment for fatigue complicating chronic liver disease--how should its efficacy be evaluated?

Profound fatigue is a clinically significant complication of chronic liver disease. A mechanism of fatigue in experimental animals and male athletes appears to be increased serotoninergic neurotransmission in the brain. Recently, attempts have been made to assess the efficacy of a serotonin antagonist, specifically the 5-HT3 receptor subtype antagonist, ondansetron, in ameliorating fatigue in patients with chronic liver disease. However, the results of a randomized controlled trial of ondansetron for fatigue in patients with primary biliary cirrhosis did not indicate that ondansetron was either effective or ineffective. The reasons for the uncertain outcome of the randomized controlled trial are not clear. One contributing factor may have been the use of subjective indices of fatigue as primary efficacy endpoints. There is a need to develop objective quantitative primary efficacy endpoints for use in trials of therapy for fatigue. Another contributing factor may relate to the conduct of a randomized controlled trial not invariably being the optimal approach to resolve a specific clinical issue, particularly when the application of statistical methods yields equivocal findings. When the results of a randomized controlled trial are indecisive, findings based on clinical judgement, medicine's most important asset, should be carefully evaluated.

Care of hospitalized older patients: opportunities for hospital-based physicians

BACKGROUND

Half of patients admitted to hospital for reasons unrelated to childbirth are age 65 years or older. Nonetheless, few hospital-based physicians have received training in geriatric medicine, and few geriatricians practice in the hospital. This paper describes the state of the science of hospital care for older patients, and identifies opportunities and barriers to improving their care.

METHODS

General medical journals from 1980 to the present were selectively reviewed to identify original articles on the treatment of specific diseases and syndromes on hospitalized persons age 65 years or older. Information was synthesized to describe the course of these patients during and after hospitalization, and to identify effective management strategies and gaps in knowledge.

RESULTS

Older persons in hospitals pose substantial clinical challenges: they have high rates of cognitive impairment, delirium, disability, and difficulty walking, and they often require increased attention, longer lengths of stay, and higher hospital costs than younger patients with the same diagnoses. Disease-specific interventions have not been studied extensively in those older than 75 years. Multicomponent interventions can reduce short-term rates of disability and delirium without increasing costs, but they have not been widely disseminated. Interventions to treat or prevent other common conditions in hospitalized older patients have not been proven effective.

CONCLUSIONS

Fundamental discoveries in the science of hospital medicine are needed to prevent or treat geriatric syndromes, to treat common diseases in the very old, and to put into practice what is known. Hospital-based physicians can address these gaps in knowledge and practice with geriatricians, building from their shared perspectives on the care of the aged in complex health systems.

Patients seen for standard rheumatoid arthritis care have significantly better articular, radiographic, laboratory, and functional status in 2000 than in 1985

OBJECTIVE

A comprehensive quantitative analysis of measures of disease activity and joint damage has not been available to compare patients in different eras in the same clinical setting. This study was undertaken to determine whether the clinical status of patients with rheumatoid arthritis (RA) has improved on average in recent years.

METHODS

A quantitative cross-sectional evaluation, which included joint count, radiographic, laboratory, patient questionnaire, and physical function measures, and therapies, was performed in 125 consecutive RA patients seen from 1984 through 1986 ("1985 cohort"). A virtually identical assessment was performed in 150 patients seen from 1999 through 2001 ("2000 cohort"), in the same weekly academic clinic. Measures were compared using descriptive statistics and a median regression model, adjusted for age, duration of disease, level of formal education, and rheumatoid factor.

RESULTS

Patients in 1985 had significantly poorer status compared with those in 2000: median 12 versus 5 swollen joints, Larsen radiographic score 20 versus 3, erythrocyte sedimentation rate 33 mm/hour versus 20, and modified Health Assessment Questionnaire 1.0 versus 0.4 (P < 0.019). Severe Disease Activity Scores >5.1 were seen in 69% of 1985 patients, compared with 30% in 2000. Methotrexate was taken by 10% of patients in 1985, versus 76% in 2000. The proportion of patients not taking any disease-modifying antirheumatic drugs was 66% in 1985 versus 13% in 2000.

CONCLUSION

Patients receiving standard care for RA in this setting had significantly better status, including radiographic scores, in 2000 than in 1985, associated with aggressive treatment strategies, prior to the introduction of biologic agents.

Resolving methodological and clinical issues in the design of efficacy trials in assisted reproductive technologies: a mini-review

The validity, importance and relevance of randomized controlled trials depend on identifying an appropriate target population, ensuring adequate power, careful attention to the details of randomization and blinding, and selection of an endpoint that is important to the target population. With efficacy trials more than effectiveness trials, additional constraints are needed to reduce the variability that is typical of clinical practice: a narrowly defined sample, unvarying pre-randomization procedures and post-randomization treatments and follow-up that are as identical as possible for all patients. Efficacy trials comparing ovarian stimulation protocols should have strict protocol definitions, specific concomitant medications and minimal variability between centres with respect to stimulation goals and dose adjustments. Additionally, there should be narrowly defined criteria for administration of chorionic gonadotrophin, type of luteal support, embryo transfer and freezing policies. The goal of efficacy trials is to minimize the variability that is extrinsic to the comparison. When efficacy has been proven, effectiveness trials are needed to determine whether the effect of the new intervention is robust in the variability of typical clinical settings.

Clinical trials in rheumatic diseases: designs and limitations

Randomized controlled clinical trials provide the best method to distinguish a drug from placebo without the inevitable selection biases that are seen in standard clinical care. This article reviews designs and limitations of clinical trials that are used in rheumatic diseases. The primary design in clinical trials is a parallel, in which patients are randomized in parallel to different therapies at different dosages or placebo. In recent years, other designs have been used increasingly, including "step-up," "step-down," and "cross-over" designs. Limitations of clinical trials in chronic diseases include a short time frame versus the long duration of disease, inclusion and exclusion criteria, use of surrogate markers that may not represent clinically relevant markers, statistical significance does not necessarily indicate clinical significance necessarily, and the fact that a control group does not assure the absence of bias. Therefore, long-term databases are needed to supplement clinical trials in analyzing results of therapy for rheumatoid arthritis.

An Overview of Bee Venom Acupuncture in the Treatment of Arthritis

Bee venom acupuncture (BVA), as a kind of herbal acupuncture, exerts not only pharmacological actions from the bioactive compounds isolated from bee venom but also a mechanical function from acupuncture stimulation. BVA is growing in popularity, especially in Korea, and is used primarily for pain relief in many kinds of diseases. We aimed to summarize and evaluate the available evidence of BVA for rheumatoid arthritis and osteoarthritis. Computerized literature searches for experimental studies and clinical trials of BVA for arthritis were performed on the databases from PUBMED, EMBASE and the Cochrane Library. In addition, two leading Korean journals (The Journal of Korean Society for Acupuncture and Moxibustion and The Journal of Korean Oriental Medicine) were searched for relevant studies. The search revealed 67 studies, 15 of which met our criteria. The anti-inflammation and analgesic actions of BVA were proved in various kinds of animal arthritic models. Two randomized controlled trials and three uncontrolled clinical trials showed that BVA was effective in the treatment of arthritis. It is highly likely that the effectiveness of BVA for arthritis is a promising area of future research. However, there is limited evidence demonstrating the efficacy of BVA in arthritis. Rigorous trials with large sample size and adequate design are needed to define the role of BVA for these indications. In addition, studies on the optimal dosage and concentration of BVA are recommended for future trials.

Should contemporary rheumatoid arthritis clinical trials be more like standard patient care and vice versa?

The information used by rheumatologists when delivering care to patients with rheumatoid arthritis (RA) is derived mainly from two sources: randomised controlled clinical trials and experience in clinical care. However, these two sources differ significantly because (a) the extensive inclusion and exclusion criteria result in clinical trial participants being recruited from only a minority of patients seen in standard clinical care; (b) assessments in clinical trials are conducted according to standard quantitative measures and indices, while standard clinical care of most patients with RA is generally conducted empirically, without collection of any quantitative data other than laboratory tests to estimate prognosis and document change in status; and (c) although baseline databases of various clinical trials (and observational studies) are 60-90% identical in content, they are not standardised and therefore not amenable to direct comparisons. Strategies to promote similarities between clinical trials and standard clinical care in patients with RA may include: more generalised inclusion criteria; incorporation of quantitative measurement into standard care, easily accomplished by asking each patient to complete a simple questionnaire at each visit to a rheumatologist; and consensus among rheumatologists for databases with standard content and format in clinical care and research involving patients with RA.

The utility of insulin glargine in the treatment of diabetes mellitus

STUDY OBJECTIVES

To compare hemoglobin A1c (A1C) values at baseline with those after 1 year of insulin glargine therapy and, secondarily, to compare insulin dosage and patients' body weight at baseline and at 1 year.

DESIGN

Retrospective study.

SETTING

Private endocrinology practice.

PATIENTS

One hundred ninety-seven patients with diabetes mellitus who were first prescribed insulin glargine from May 2001-April 2002 and were evaluable after 1 year of therapy

INTERVENTION

Patients received insulin glargine instead of NPH insulin or in addition to their oral drug therapy

MEASUREMENTS AND MAIN RESULTS

Patients with diabetes type 1 (receiving insulin therapy) or type 2 (receiving oral drug therapy only, a combination of oral drug therapy and insulin, or insulin only) who had been treated with insulin glargine for 1 year were evaluated. Overall, A1C values decreased significantly (p<0.001) by 0.53 +/- 1.4% from a baseline mean of 8.1 +/- 1.7%. In 129 patients with type 2 diabetes previously treated with NPH insulin, A1C decreased significantly (p<0.001) 0.57 +/- 1.5% from baseline. The A1C decreased by 0.71 +/- 1.3% (p=0.0043) from baseline in 33 patients with type 2 diabetes who previously received oral agents only Thirty-five patients with type 1 diabetes demonstrated no significant change in A1C (-0.22 +/- 1.0%, p=0.217) from baseline. In patients receiving insulin at baseline, the number of daily injections increased significantly (p<0.0001) from a median of two at baseline to three at 1 year. Overall, no significant change was noted in total daily insulin requirement or in body weight in any of the patient groups over the 1-year period.

CONCLUSION

Compared with baseline, insulin glargine therapy at 1 year was associated with an overall significant reduction in A1C of 0.53 +/- 1.4%.

Willingness of dialysis patients to participate in a randomized controlled trial of daily dialysis

BACKGROUND

The National Institutes of Health (NIH) has proposed conducting randomized controlled trials comparing short, daily, in-center hemodialysis with conventional hemodialysis. However, there is concern that difficulties recruiting patients may prevent the successful completion of such trials if patients believe the inconveniences of daily dialysis outweigh any potential health benefits.

METHODS

To gauge willingness to participate in a daily dialysis trial, we described a hypothetical, randomized controlled trial comparing conventional to daily hemodialysis to 209 chronic hemodialysis patients, and assessed their motivations for and concerns about participating.

RESULTS

We found that 85 patients (41%) of 209 patients who agreed to be interviewed expressed some willingness to participate in the hypothetical trial. Patients who expressed greater willingness to participate were younger (OR for participating = 0.96 per year, 95% CI = 0.94 to 0.98, P= 0.001), less likely to smoke (OR = 0.38, 95% CI = 0.17 to 0.84, P= 0.017), more likely to have been hospitalized during the last 12 months (OR = 2.8, 95% CI = 1.5 to 5.5, P= 0.002), less likely to have reactive airway disease (OR = 0.21, 95% CI = 0.06 to 0.69, P= 0.01) or coronary artery disease (OR = 0.20, 95% CI = 0.08 to 0.53, P= 0.001), and less likely to be on the waiting list for a kidney transplant (OR = 0.23, 95% CI = 0.10 to 0.50, P < 0.0001).

CONCLUSION

The study suggests that less than half of eligible patients would be willing to participate in the randomized controlled trial. Differing willingness to participate across patient subgroups suggests that certain subgroups (i.e., older patients and those with coronary artery disease) will need to be targeted to ensure that results are generalizable to most hemodialysis patients.

A Practice-Based Study of Patients with Acute and Chronic Low Back Pain Attending Primary Care and Chiropractic Physicians: Two-Week to 48-Month Follow-Up

OBJECTIVE

This study reports pain and disability outcomes up to 4 years for chiropractic and medical patients with low back pain (LBP) and assesses the influence of doctor type and pain duration on clinical outcomes.

DESIGN

Prospective, longitudinal, nonrandomized, practice-based, observational study.

SETTING

Fifty-one chiropractic and 14 general practice community clinics.

SUBJECTS

A total of 2870 acute and chronic ambulatory patients with LBP of mechanical origin.

METHODS

Sixty chiropractic (DC) and 111 general practice (MD) physicians participated. Primary outcomes were pain, using a 100-point visual analogue scale (VAS), and functional disability, using the Revised Oswestry Disability Questionnaire. These were measured at baseline and 8 time points. Regression analysis compared acute and chronic DC and MD patients after correcting for baseline differences in the 4 cohorts.

RESULTS

Most improvement was seen by 3 months and sustained for 1 year; exacerbation was seen thereafter. Acute patients demonstrated greater relief at all time points. A clinically important advantage for chiropractic patients was seen in chronic patients in the short-term (>10 VAS points), and both acute and chronic chiropractic patients experienced somewhat greater relief up to 1 year (P<.000). The advantage for DC care was prominent for chronic patients with leg pain below the knee (P<.001). More than 50% of chronic patients had over 50 days of pain in the third year.

CONCLUSION

Study findings were consistent with systematic reviews of the efficacy of spinal manipulation for pain and disability in acute and chronic LBP. Patient choice and interdisciplinary referral should be prime considerations by physicians, policymakers, and third-party payers in identifying health services for patients with LBP.