Certainty of evidence, why?

Optimal clinical decision-making requires understanding of evidence regarding benefits, harms, and burdens of alternative management options. Rigorously conducted systematic reviews and meta-analyses offer accurate summaries of the evidence. However, such summaries may review only low-certainty evidence, in the process highlighting that no single decision is likely to be best for all patients. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach offers a systematic and transparent method for rating certainty of evidence in systematic reviews. In this paper, we will address the importance of assessing the certainty associated with bodies of evidence; explain how the GRADE system rates the certainty of evidence from systematic reviews; and present the GRADE evidence to decision framework for moving from evidence to strong or weak recommendations in clinical practice guidelines.

Cognitive impairment in multiple sclerosis: "classic" knowledge and recent acquisitions

Multiple sclerosis (MS) is a central nervous system (CNS) disease characterized by inflammation, axonal demyelination, and neurodegeneration, which can have a strong impact on all aspects of the life of the patient. Multiple sclerosis causes motor, sensory, cerebellar, and autonomic dysfunctions, as well as cognitive and psychoemotional impairment. The most frequently compromised cognitive domains are complex attention/information processing, memory, executive and visuospatial functions. Recently, alterations have also been evidenced in complex cognitive functions, such as social cognition, moral judgment, and decision-making. Cognitive impairment is characterized by high variability and can affect work skills, social interactions, coping strategies and more generally the quality of life of patients and their families. With the use of sensitive and easy-to-administer test batteries, an increasingly accurate and early diagnosis is feasible: this allows to determine the effectiveness of possible preventive measures, to predict the future progression of the disease and to improve the quality of life of patients. There is currently limited evidence regarding the efficacy, on cognitive impairment, of disease-modifying therapies. The most promising approach, which has received strong empirical support, is cognitive rehabilitation.

Managerial Decision-Making of Nurses in Hospitals: creation and validation of a simulation scenario

OBJECTIVE

to build and validate a clinical simulation scenario on hospital nurse managerial decision-making competence for undergraduate nursing students.

METHOD

a descriptive and methodological study was carried out in a higher education institution, with the participation of 10 judges and five players. To do so, the conceptual simulation model proposed by Jeffries and standards of the International Nursing Association for Clinical Simulation and Learning were used to prepare the scenario and the checklist.

RESULTS

the scenario was called "Managerial decision-making of nurses in the face of adverse events in a hospital". The scenario script and checklist were built for validation. The checklist was face- and content-validated. Afterward, judges used the checklist to validate the scenario, which, in its final version, was composed of Prebriefing (seven items), Scenario in Action (18 items) and Debriefing (seven items).

CONCLUSION

the scenario proved to be a teaching strategy that anticipates the reality of future nurses, bringing them the self-confidence to perform their activities and helping them to act critically and reflectively during decision-making processes.

Clinical outcomes of patients with pancreatic tumors discussed in Tumor Board

OBJECTIVE

the recommendations of the decisions made by the Tumor Board (TB) should be followed to identify barriers that may interfere with the execution of the previously decided, best care for the patient. The aim of this study is to assess whether the TB conduct decision was performed in patients with pancreatic tumors, their life status 90 days after the TB decision, and to analyze the reasons why the conduct was not performed.

METHODS

we conducted a retrospective study with patients with pancreas tumors, evaluated between 2017 and 2019. We collected data on epidemiological status, whether the TB procedure was performed, the reason for not performing it, life status 90 days after the TB decision, and how many times each patient was discussed at a meeting. We compared categorical variables using the chi square test, numerical variables were presented as means and standard deviation.

RESULTS

we studied 111 session cases, in 95 patients, 86 (90.5%) diagnosed with cancer. After 90 days of TB, 83 patients (87.37%) remained alive, 9 had (9.47%) died, and 3 (3.16%) were lost to follow-up. The TB decision was not observed in 12 (10.8%) cases and the reasons were: 25% (3) for loss of follow-up, 8.33% (1) for patient refusal, and 66.67% (8) due to clinical worsening. The cases of patients with metastases had a lower rate of TB conduct compliance (p=0.006).

CONCLUSIONS

the TB conduct was performed in most cases and the most evident reason for non-compliance with the conducts is the patient's clinical worsening.

Evaluation of an educational intervention (edworkcases) involving clinical cases and Nursing students: a cross-sectional observational study

OBJECTIVE

to evaluate the impact of the (edworkcases) educational intervention on students' evaluation outcomes in their clinical practices, their attitudes towards Nursing diagnoses, and their satisfaction.

METHOD

this study used a cross-sectional observational design. The participants were 69 third-year Nursing students from a public university in Madrid, Spain. The data analysed in the study were the grades obtained by students for their clinical practices, as well as pre-post intervention scores on the Positions on Nursing Diagnosis Scale and a satisfaction survey. A means comparison by participation in the project (yes/no) was carried out using Student's t-test. A means comparison by professor was conducted using Kruskal-Wallis tests.

RESULTS

participation rate: 72.4%; 92% of the participants were women; median age = 21 years old. Statistically significant differences were found between participants and non-participants in terms of mean score in the Overall Evaluation and in the Case Study Evaluation, with higher scores found among the group of participants. The mean score for attitudes towards Nursing diagnoses was 99.9 (SD=2.8) before the intervention and 111.1 (SD=2.9) after the intervention [95% CI: 3.3-19.2].

CONCLUSION

the use of (edworkcases) as part of the practical training was considered satisfactory, enabling theory and practice to be combined and improving students' attitudes towards Nursing diagnoses.

"It was God's will": Continuing pregnancy after perinatal infection by Zika virus

OBJECTIVE

to understand the influence of the religious beliefs on the decision of a group of women residing in the Huila Department to continue their pregnancies despite perinatal infection by the Zika virus.

METHOD

a focused ethnography. The participants were 21 women who had presented a perinatal infection by the Zika virus and whose babies were born with congenital microcephaly. 2 discussion groups and 6 semi-structured interviews were conducted, and thematic analysis was used for data treatment.

RESULTS

three themes emerged, namely: "God, why me?" is the initial questioning of the women to God for the prenatal diagnosis of microcephaly in their babies, "Clinging to a divine miracle" describes how the women did not lose their faith and begged for a divine miracle for their babies to be born healthy, and "It was God's will" means acceptance, resignation, and respect for God's will, as well as the denial to abort despite the medical recommendations.

CONCLUSION

religiosity and religious beliefs were determinant factors in the women's decision to continue their pregnancies. It becomes necessary to continue investigating this theme to understand their experiences and to generate follow-up and support actions from nursing care.

Overview of systematic reviews - a new type of study. Part II

CONTEXT AND OBJECTIVE

Overviews of Systematic Reviews (OoRs) are a new type of study in which multiple evidence from systematic reviews (SRs) is compiled into an accessible and useful document. The aim here was to describe the state of the art and critically assess Cochrane OoRs that have been published.

DESIGN AND SETTING

Descriptive study conducted at a research center.

METHODS

The OoRs identified through the filter developed in Part I of this study were evaluated in five domains: methodological quality; quality of evidence; implications for practice; general profile of OoRs; and length of work.

RESULTS

All 13 OoRs included had high methodological quality. Some OoRs did not present sufficient data to judge the quality of evidence; using sensitivity analysis, the quality of evidence of the OoRs increased. Regarding implications for practice, 64% of the interventions were judged as beneficial or harmful, while 36% of them showed insufficient evidence for judgment. It is expected (with 95% confidence interval) that one OoR will include 9,462 to 64,469 patients, 9 to 29 systematic reviews and 80 to 344 primary studies, and assess 6 to 21 interventions; and that 50 to 92% of OoRs will produce meta-analysis. The OoRs generated 2 to 26 meta-analyses over a period of 18 to 31 months.

CONCLUSION

The OoRs presented high methodological quality; the quality of evidence tended to be moderate/high; most interventions were judged to be beneficial/harmful; the mean length of work was 24 months. The OoR profile adds power to decision-making.

Rational use of blood calcium determinations

CONTEXT AND OBJECTIVE

This study was motivated by the recent excessive increase in requests for blood calcium determinations and laboratory tests in general, in the Hospital das Clínicas complex of Faculdade de Medicina, Universidade de São Paulo (HCFMUSP). Its aim was to suggest rules for the determination of total and ionized calcium in our intensive care units, emergency department, wards and outpatient services, thus contributing towards improving the quality of medical care and achieving more appropriate use of human and financial resources.

DESIGN AND SETTING

Critical analysis on clinical and laboratory data and the pertinent scientific literature, conducted by the study group for rational clinical laboratory use, which is part of the Central Laboratory Division, HCFMUSP.

METHODS

The study group reviewed scientific publications, statistics and clinical and laboratory data concerning requests for total and ionized calcium determinations in the settings of intensive care units, emergency department, wards and outpatient services.

RESULTS

From this critical analysis, clinical decision flow diagrams aimed at providing guidance for ordering these tests were constructed.

CONCLUSIONS

Use of the proposed flow diagrams may help to limit the numbers of inappropriate requests for ionized and total calcium determinations, with consequent reductions in the number of tests, risks to patients and unnecessary costs.

Quantitative and qualitative analysis on the legislative production relating to healthcare in passage in the National Congress in the years 2007 and 2008

CONTEXT AND OBJECTIVES

The Federal Constitution of 1988 allowed the National Congress to contribute towards formulation of new public policies. The objective of this study was to analyze the legislative production that dealt with health issues that was in passage in the National Congress between January 2007 and December 2008.

DESIGN AND SETTING

Descriptive-exploratory cross-sectional study with quantitative and qualitative approaches, conducted in a federal university.

METHODS

The analysis material for the study comprised 144 draft bills that were classified and subsequently randomly evaluated by 155 professionals working within the healthcare system.

RESULTS

The analysis showed that the Workers' Party (PT) and Brazilian Democratic Movement Party (PMDB) were the parties that presented the largest proportions of the draft bills (12.5% and 11.1%); 25.4% of the draft bills were presented by congress members with academic qualifications within healthcare and only 1.4% of the draft bills became transformed into legal regulations. In questionnaire responses, 51.5% of the evaluators did not consider the draft bills to be viable, 40.6% did not consider them to be relevant and 52.5% said that if the draft bills were not approved it would not be harmful to Brazilian society.

CONCLUSION

In analyzing the data from this study, it was noted that the legislative production relating to healthcare was low and the transformation rate from draft bill to legal regulation was negligible. The results from the evaluation showed that the quality of legislative production was impaired.

Overview of systematic reviews - a new type of study: part I: why and for whom?

CONTEXT AND OBJECTIVE

Healthcare decision-making is complex and should involve healthcare professionals, patients and the best level of evidence. The speed of information production creates barriers against keeping up to date. In this light, methodologists have proposed a new type of study: overviews of systematic reviews (OoRs). The aim here was to introduce and demonstrate the role of OoRs in information synthesis for healthcare professionals, managers, researchers and patients.

DESIGN AND SETTING

Time-series study conducted at the Brazilian Cochrane Center, jointly with the Postgraduate Program on Internal Medicine and Therapeutics, Discipline of Emergency Medicine and Evidence-Based Medicine, Department of Medicine, Federal University of São Paulo.

METHODS

To show the growth in the numbers of published papers that provide high-level evidence and thus demonstrate the importance of OoRs for synthesis and integration of information, three filters for study designs were applied to two databases. An equation for predicting the expected number of published papers was developed and applied.

RESULTS

Over the present decade, the number of randomized controlled trials in Medline might reach 2,863,203 and the number of systematic reviews might reach 174,262. Nine OoRs and 15 OoRs protocols have been published in the Cochrane Library.

CONCLUSIONS

With the exponential growth of published papers, as shown in this study, a new type of study directed especially towards healthcare decision-makers was proposed, named "overview of systematic reviews". This could reduce the uncertainties in decision-making and generate a new hierarchy in the pyramid of evidence.

Ministers of Health: short-term tenure for long-term goals?

CONTEXT AND OBJECTIVE

Healthcare investments should consider short and long-term demands. The objectives here were to compare the average tenures of ministers of health in Brazil and in another 22 countries and to evaluate the relationship between ministers' tenures and a number of indicators.

DESIGN AND SETTING

Descriptive study conducted at Centro Paulista de Economia da Saúde (CPES).

METHODS

Twenty-two countries with the highest Human Development Indices (HDIs) and Brazil were included. The number of ministers over the past 20 years was investigated through each country's Ministry of Health website. Pearson's correlation coefficient was used to compare the number of ministers in each country with that country's indicators. The Mann-Whitney test was used to compare ministers' tenures in Brazil and other countries.

RESULTS

The mean tenure (standard deviation, SD) of Brazilian ministers of health was 15 (12) months, a period that is statistically significantly shorter than the mean tenure of 33 (18) months in the other 22 countries (P < 0.05). There was a moderate and statistically significant positive correlation between the number of ministers and mortality rates for several conditions. The number of ministers also presented moderate and statistically significant negative correlations with per capita total healthcare expenditure (r = -0.567) and with per capita government healthcare expenditure (r = -0.530).

CONCLUSION

On average, ministers of health have extremely short tenures. There is an urgent need to think and plan healthcare systems from a long-term perspective.