Grading quality of evidence and strength of recommendations in clinical practice guidelines part 3 of 3. The GRADE approach to developing recommendations

This is the third and last article in the series about the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to grading the quality of evidence and the strength of recommendations in clinical practice guidelines and its application in the field of allergy. We describe the factors that influence the strength of recommendations about the use of diagnostic, preventive and therapeutic interventions: the balance of desirable and undesirable consequences, the quality of a body of evidence related to a decision, patients' values and preferences, and considerations of resource use. We provide examples from two recently developed guidelines in the field of allergy that applied the GRADE approach. The main advantages of this approach are the focus on patient important outcomes, explicit consideration of patients' values and preferences, the systematic approach to collecting the evidence, the clear separation of the concepts of quality of evidence and strength of recommendations, and transparent reporting of the decision process. The focus on transparency facilitates understanding and implementation and should empower patients, clinicians and other health care professionals to make informed choices.

Grading quality of evidence and strength of recommendations in clinical practice guidelines: Part 2 of 3. The GRADE approach to grading quality of evidence about diagnostic tests and strategies

The GRADE approach to grading the quality of evidence and strength of recommendations provides a comprehensive and transparent approach for developing clinical recommendations about using diagnostic tests or diagnostic strategies. Although grading the quality of evidence and strength of recommendations about using tests shares the logic of grading recommendations for treatment, it presents unique challenges. Guideline panels and clinicians should be alert to these special challenges when using the evidence about the accuracy of tests as the basis for clinical decisions. In the GRADE system, valid diagnostic accuracy studies can provide high quality evidence of test accuracy. However, such studies often provide only low quality evidence for the development of recommendations about diagnostic testing, as test accuracy is a surrogate for patient-important outcomes at best. Inferring from data on accuracy that using a test improves outcomes that are important to patients requires availability of an effective treatment, improved patients' wellbeing through prognostic information, or - by excluding an ominous diagnosis - reduction of anxiety and the opportunity for earlier search for an alternative diagnosis for which beneficial treatment can be available. Assessing the directness of evidence supporting the use of a diagnostic test requires judgments about the relationship between test results and patient-important consequences. Well-designed and conducted studies of allergy tests in parallel with efforts to evaluate allergy treatments critically will encourage improved guideline development for allergic diseases.

Universal newborn hearing screening: summary of evidence

CONTEXT

Each year, approximately 5000 infants are born in the United States with moderate-to-profound, bilateral permanent hearing loss (PHL). Universal newborn hearing screening (UNHS) has been proposed as a means to speed diagnosis and treatment and thereby improve language outcomes in these children.

OBJECTIVES

To identify strengths, weaknesses, and gaps in the evidence supporting UNHS and to compare the additional benefits and harms of UNHS with those of selective screening of high-risk newborns.

DATA SOURCES

We searched the MEDLINE, CINAHL, and PsychINFO databases for relevant articles published from 1994 to August 2001, using terms for hearing disorders, infants or newborns, screening, and relevant treatments. We contacted experts and reviewed reference lists to identify additional articles, including those published before 1994.

STUDY SELECTION

We included controlled and observational studies of (1) the accuracy, yield, and harms of screening using otoacoustic emissions (OAEs), auditory brainstem response (ABR), or both in the general newborn population and (2) the effects of screening or early identification and treatment on language outcomes. Of an original 340 articles identified, 19 articles, including 1 controlled trial, met these inclusion criteria.

DATA EXTRACTION

Data on population, test performance, outcomes, and methodological quality were extracted by 2 authors (D.C.T., H.M.) using prespecified criteria developed by the US Preventive Services Task Force. We queried authors when information needed to assess study quality was missing.

DATA SYNTHESIS

Good-quality studies show that from 2041 to 2794 low-risk and 86 to 208 high-risk newborns were screened to find 1 case of moderate-to-profound PHL. The best estimate of positive predictive value was 6.7%. Six percent to 15% of infants who are missed by the screening tests are subsequently diagnosed with bilateral PHL. In a trial of UNHS vs clinical screening at age 8 months, UNHS increased the proportion of infants with moderate-to-severe hearing loss diagnosed by age 10 months (57% vs 14%) but did not reduce the rate of diagnosis after age 18 months. No good-quality controlled study has compared UNHS with selective screening of high-risk newborns. In fair- to poor-quality cohort studies, intervention before age 6 months was associated with improved language and communication skills by ages 2 to 5 years. These studies had unclear criteria for selecting subjects, and none compared an inception cohort of low-risk newborns identified by screening with those identified in usual care, making it impossible to exclude selection bias as an explanation for the results. In a mathematical model based on the literature review, we estimated that extending screening to low-risk infants would detect 1 additional case before age 10 months for every 1441 low-risk infants screened, and result in treatment before 10 months of 1 additional case for every 2401 low-risk infants screened. With UNHS, 254 newborns would be referred for audiological evaluation because of false-positive second-stage screening test results vs 48 for selective screening.

CONCLUSIONS

Modern screening tests for hearing impairment can improve identification of newborns with PHL, but the efficacy of UNHS to improve long-term language outcomes remains uncertain.

Telemedicine for the Medicare population: pediatric, obstetric, and clinician-indirect home interventions

BACKGROUND

This report is a supplement to an earlier evidence report, Telemedicine for the Medicare Population, which was intended to help policymakers weigh the evidence relevant to coverage of telemedicine services under Medicare. That report focused on telemedicine programs and clinical settings that had been used with or were likely to be applied to Medicare beneficiaries. While we prepared that report, it became apparent that there are also telemedicine studies among non-Medicare beneficiaries--e.g., children and pregnant women--that could inform policymakers and provide more comprehensive evidence of the state of the science regarding telemedicine applications. In addition, the first evidence report only partially included a class of telemedicine applications (called self-monitoring/testing telemedicine) in which the beneficiary used a home computer or modern-driven telephone system to either report information or access information and support from Internet resources and indirectly interact with a clinician. Self-monitoring/testing applications in the first report required direct interaction with a clinician. The goal of this report is to systematically review the evidence in the clinical areas of pediatric and obstetric telemedicine as well as home-based telemedicine where there is indirect involvement of the health care professional. (In this report, we will refer to the latter as clinician-indirect home telemedicine.) Specifically, the report summarizes scientific evidence on the diagnostic accuracy, access, clinical outcomes, satisfaction, and cost-effectiveness of services provided by telemedicine technologies for these patient groups. It also identifies gaps in the evidence and makes recommendations for evaluating telemedicine services for these populations in the future. The evidence is clustered according to three categories of telemedicine service defined in our original report: store-and-forward, self-monitoring/testing, and clinician-interactive services. The three clinical practice areas reviewed in this report are defined as follows. The term pediatric applies to any telemedicine study in which the sample consisted wholly or partially of persons aged 18 or younger, including studies with neonatal samples. The term obstetric applies to any telemedicine study in which the sample consisted entirely of women seeking pregnancy-related care. The term clinician-indirect home telemedicine applies to home-based telemedicine (called self-monitoring/testing in our original report) where a telemedicine application used in the home has only indirect involvement by the health care professional. Interactive home telemedicine was applied in this report to all patient populations.

KEY QUESTIONS

The key questions that served as a guide for reviewing the literature in the evaluation of pediatric, obstetric, and clinician-indirect home telemedicine applications were derived by consensus among the evidence-review team based on the analytic framework established for the original evidence report. For the current report, the questions were applied to studies in all three practice areas as a whole group within each of the three categories of telemedicine services: store-and-forward; self-monitoring/testing; and clinician-interactive. The specific key questions were: 1. Does telemedicine result in comparable diagnosis and appropriateness of recommendations for management? 2. Does the availability of telemedicine provide comparable access to care? 3. Does telemedicine result in comparable health outcomes? 4. Does telemedicine result in comparable patient or clinician satisfaction with care? 5. Does telemedicine result in comparable costs of care and/or cost-effectiveness?

METHODS

We searched for peer-reviewed literature using several bibliographic databases. In addition, we conducted hand searches of leading telemedicine journals and identified key papers from the reference lists of journal articles. For our original evidence report on telemedicine for the Medicare population, we designed a search to find any publications about telemedicine and used it to search the MEDLINE, CINAHL, and HealthSTAR databases for all years the databases were available. Through this process, we captured studies of pediatric, obstetric, and clinician-indirect home telemedicine; however, they were excluded from the original report since they were outside its scope. For this supplemental report, we reviewed our original search results and identified studies relevant to this report. We identified additional studies from the reference lists of included papers and from hand searching two peer-reviewed telemedicine publications, the Journal of Telemedicine and Telecare and Telemedicine Journal. We critically appraised the included studies for each study area and key question and discussed the strengths and limitations of the most important studies at weekly meetings of the research team. We also developed recommendations for research to address telemedicine knowledge gaps. To match these gaps with the capabilities of specific research methods, we classified the telemedicine services according to the type of evidence that would be needed to determine whether the specific goals of covering such services had been met. We emphasized the relationship between the type and level of evidence found in the systematic review of effectiveness and the types of studies that might be funded to address the gaps in knowledge in this growing field of research.

FINDINGS

We identified a total of 28 eligible studies. In the new clinical areas, we found few studies in store-and-forward telemedicine. There is some evidence of comparable diagnosis and management decisions made using store-and-forward telemedicine from the areas of pediatric dental screening, pediatric ophthalmology, and neonatalogy. In self-monitoring/testing telemedicine for the areas of pediatrics, obstetrics, and clinician-indirect home telemedicine, there is evidence that access to care can be improved when patients and families have the opportunity to receive telehealth care at home rather than in-person care in a clinic or hospital. Access is particularly enhanced when the telehealth system enables timely communication between patients or families and care providers that allows self-management and necessary adjustments that may prevent hospitalization. There is some evidence that this form of telemedicine improves health outcomes, but the study sample sizes are usually small, and even when they are not, the treatment effects are small. There is also some evidence for the efficacy of clinician-interactive telemedicine, but the studies do not clearly define which technologies provide benefit or cost-efficiency. Some promising areas for diagnosis include emergency medicine, psychiatry, and cardiology. Most of the studies measuring access to care provide evidence that it is improved. Although none of these studies were randomized controlled trials, they provide some evidence of access improvement over prior conditions. Clinician-interactive telemedicine was the only area for which any cost studies were found. The three cost studies did not adequately demonstrate that telemedicine reduces costs of care (except comparing only selected costs). No study addressed cost-effectiveness.

CONCLUSIONS

This supplemental report covering the areas of pediatrics, obstetrics, and indirect-clinician home telemedicine echoes the findings of our initial report for the Medicare domain, which is that while the use of telemedicine is small but growing, the evidence for its efficacy is incomplete. Many of the studies are small and/or methodologically limited, so it cannot be determined whether telemedicine is efficacious. Future studies should focus on the use of telemedicine in conditions where burden of illness and/or barriers to access for care are significant. Use of recent innovations in the design of randomized controlled trials for emerging technologies would lead to higher quality studies. Journals publishing telemedicine evaluation studies must set high standards for methodologic quality so that evidence reports need not rely on studies with marginal methodologies.

Screening high-risk populations for thyroid cancer

BACKGROUND

Children treated with radiotherapy to the neck or exposed to environmental radiation are at risk for developing thyroid cancer later in life. The best method for screening these high-risk patients is unclear. We systematically reviewed evidence on the accuracy of ultrasound and palpation to detect thyroid nodules and of fine needle aspiration (FNA), a confirmatory test, to diagnose thyroid cancer.

PROCEDURE

We searched the MEDLINE database for papers published since 1966, using the MeSH term thyroid neoplasms and terms related to diagnostic test performance. To supplement our MEDLINE searches, we searched reference lists from recent reviews and articles recommended by thyroid cancer experts. We recorded the tests used, the gold standard determination of disease, the test performance results, and the presence of biases that could affect the reported results. We also abstracted the number of patients who underwent surgery and the final diagnoses. We created two decision models: one for screening 10,000 medically irradiated patients, and one for screening 10,000 environmentally irradiated patients.

RESULTS

Using ultrasound as the gold standard determination of the presence of a nodule, the sensitivity of palpation for all sized nodules was 10-41 percent, indicating that a high proportion of nodules detected by ultrasound are too small to be palpated. Sensitivity of palpation increased with nodule size. The specificity of palpation ranged from 95 to 100%. In studies from referral centers, the reported sensitivity and specificity of FNA were 71-95 and 52-99%, respectively. However, most authors excluded the proportion of patients (6-33%) who had inadequate or nondiagnostic FNA results when calculating sensitivity and specificity, even though 6-100% of these patients went on to have a diagnostic lobectomy. When each study was reanalyzed so that patients with nondiagnostic FNA results who went directly to surgery were reclassified as positive tests, sensitivity increased slightly, but specificity dropped by 4-20 percentage points per study. The decision model for screening 10,000 medically irradiated patients revealed that if ultrasound were used as an initial screen, 2,741 patients would have nodules at least 1 cm in size; assuming no patients with smaller nodules had surgery, 1,964 patients would have surgery; 275 patients would have a diagnosis of thyroid cancer. Screening with ultrasound as an initial test would detect an additional 150 cases of thyroid cancer compared to those screened with palpation. However, an additional 1,689 patients would have surgery for nonmalignant nodules (compared to 480 patients with nonmalignant nodules screened with palpation). The yield for screening 10,000 environmentally irradiated patients was several times smaller than for screening 10,000 medically irradiated patients. If 10,000 environmentally irradiated patients were screened initially with ultrasound, approximately 708 patients would have nodules at least 1 cm in size; 89 patients would have surgery; and 38 patients would be diagnosed with thyroid cancer.

CONCLUSIONS

Regardless of type of exposure, testing initially with ultrasound detects several times more cases of thyroid cancer than palpation. However, when ultrasound is the initial test, many more patients also have surgery for nonmalignant nodules. Screening with palpation is not very reassuring, particularly to medically irradiated patients with negative tests, since almost half (46%) of these patients may have undetected nodules.

Current methods of the US Preventive Services Task Force: a review of the process

The U.S. Preventive Services Task Force (USPSTF/Task Force) represents one of several efforts to take a more evidence-based approach to the development of clinical practice guidelines. As methods have matured for assembling and reviewing evidence and for translating evidence into guidelines, so too have the methods of the USPSTF. This paper summarizes the current methods of the third USPSTF, supported by the Agency for Healthcare Research and Quality (AHRQ) and two of the AHRQ Evidence-based Practice Centers (EPCs). The Task Force limits the topics it reviews to those conditions that cause a large burden of suffering to society and that also have available a potentially effective preventive service. It focuses its reviews on the questions and evidence most critical to making a recommendation. It uses analytic frameworks to specify the linkages and key questions connecting the preventive service with health outcomes. These linkages, together with explicit inclusion criteria, guide the literature searches for admissible evidence. Once assembled, admissible evidence is reviewed at three strata: (1) the individual study, (2) the body of evidence concerning a single linkage in the analytic framework, and (3) the body of evidence concerning the entire preventive service. For each stratum, the Task Force uses explicit criteria as general guidelines to assign one of three grades of evidence: good, fair, or poor. Good or fair quality evidence for the entire preventive service must include studies of sufficient design and quality to provide an unbroken chain of evidence-supported linkages, generalizable to the general primary care population, that connect the preventive service with health outcomes. Poor evidence contains a formidable break in the evidence chain such that the connection between the preventive service and health outcomes is uncertain. For services supported by overall good or fair evidence, the Task Force uses outcomes tables to help categorize the magnitude of benefits, harms, and net benefit from implementation of the preventive service into one of four categories: substantial, moderate, small, or zero/negative. The Task Force uses its assessment of the evidence and magnitude of net benefit to make a recommendation, coded as a letter: from A (strongly recommended) to D (recommend against). It gives an I recommendation in situations in which the evidence is insufficient to determine net benefit. The third Task Force and the EPCs will continue to examine a variety of methodologic issues and document work group progress in future communications.

The art and science of incorporating cost effectiveness into evidence-based recommendations for clinical preventive services

As medical technology continues to expand and the cost of using all effective clinical services exceeds available resources, decisions about health care delivery may increasingly rely on assessing the cost-effectiveness of medical services. Cost-effectiveness is particularly relevant for decisions about how to implement preventive services, because these decisions typically represent major investments in the future health of large populations. As such, decisions regarding the implementation of preventive services frequently involve, implicitly if not explicitly, consideration of costs. Cost-effectiveness analysis summarizes the expected benefits, harms, and costs of alternative strategies to improve health and has become an important tool for explicitly incorporating economic considerations into clinical decision making. Acknowledging the usefulness of this tool, the third U.S. Preventive Services Task Force (USPSTF) has initiated a process for systematically reviewing cost-effectiveness analyses as an aid in making recommendations about clinical preventive services. In this paper, we provide an overview and examples of roles for using cost-effectiveness analyses to inform preventive services recommendations, discuss limitations of cost-effectiveness data in shaping evidence-based preventive health care policies, outline the USPSTF approach to using cost-effectiveness analyses, and discuss the methods the USPSTF is developing to assess the quality and results of cost-effectiveness studies. While this paper focuses on clinical preventive services (i.e., screening, counseling, immunizations, and chemoprevention), the framework we have developed should be broadly portable to other health care services.

Screening for skin cancer

CONTEXT

Malignant melanoma is often lethal, and its incidence in the United States has increased rapidly over the past 2 decades. Nonmelanoma skin cancer is seldom lethal, but, if advanced, can cause severe disfigurement and morbidity. Early detection and treatment of melanoma might reduce mortality, while early detection and treatment of nonmelanoma skin cancer might prevent major disfigurement and to a lesser extent prevent mortality. Current recommendations from professional societies regarding screening for skin cancer vary.

OBJECTIVE

To examine published data on the effectiveness of routine screening for skin cancer by a primary care provider, as part of an assessment for the U.S. Preventive Services Task Force.

DATA SOURCES

We searched the MEDLINE database for papers published between 1994 and June 1999, using search terms for screening, physical examination, morbidity, and skin neoplasms. For information on accuracy of screening tests, we used the search terms sensitivity and specificity. We identified the most important studies from before 1994 from the Guide to Clinical Preventive Services, second edition, and from high-quality reviews. We used reference lists and expert recommendations to locate additional articles.

STUDY SELECTION

Two reviewers independently reviewed a subset of 500 abstracts. Once consistency was established, the remainder were reviewed by one reviewer. We included studies if they contained data on yield of screening, screening tests, risk factors, risk assessment, effectiveness of early detection, or cost effectiveness.

DATA EXTRACTION

We abstracted the following descriptive information from full-text published studies of screening and recorded it in an electronic database: type of screening study, study design, setting, population, patient recruitment, screening test description, examiner, advertising targeted at high-risk groups or not targeted, reported risk factors of participants, and procedure for referrals. We also abstracted the yield of screening data including probabilities and numbers of referrals, types of suspected skin cancers, biopsies, confirmed skin cancers, and stages and thickness of skin cancers. For studies that reported test performance, we recorded the definition of a suspicious lesion, the "gold-standard" determination of disease, and the number of true positive, false positive, true negative, and false negative test results. When possible, positive predictive values, likelihood ratios, sensitivity, and specificity were recorded.

DATA SYNTHESIS

No randomized or case-control studies have been done that demonstrate that routine screening for melanoma by primary care providers reduces morbidity or mortality. Basal cell carcinoma and squamous cell carcinoma are very common, but detection and treatment in the absence of formal screening are almost always curative. No controlled studies have shown that formal screening programs will improve this already high cure rate. While the efficacy of screening has not been established, the screening procedures themselves are noninvasive, and the follow-up test, skin biopsy, has low morbidity. Five studies from mass screening programs reported the accuracy of skin examination as a screening test. One of these, a prospective study, tracked patients with negative results to determine the number of patients with false-negative results. In this study, the sensitivity of screening for skin cancer was 94% and specificity was 98%. Several recent case-control studies confirm earlier evidence that risk of melanoma rises with the presence of atypical moles and/or many common moles. One well-done prospective study demonstrated that risk assessment by limited physical exam identified a relatively small (<10%) group of primary care patients for more thorough evaluation.

CONCLUSIONS

The quality of the evidence addressing the accuracy of routine screening by primary care providers for early detection of melanoma or nonmelanoma skin cancer ranged from poor to fair. We found no studies that assessed the effectiveness of periodic skin examination by a clinician in reducing melanoma mortality. Both self-assessment of risk factors or clinician examination can classify a small proportion of patients as at highest risk for melanoma. Skin cancer screening, perhaps using a risk-assessment technique to identify high-risk patients who are seeing a physician for other reasons, merits additional study as a strategy to address the excess burden of disease in older adults.

Screening for bacterial vaginosis in pregnancy

CONTEXT

Bacterial vaginosis (BV) is a strong independent risk factor for adverse pregnancy outcomes. BV is found in 9% to 23% of pregnant women. Symptoms include vaginal discharge, pruritus, or malodor, but often women with BV are asymptomatic.

OBJECTIVES

To determine whether screening and treating pregnant women for BV reduces adverse pregnancy outcomes, as part of an assessment for the U.S. Preventive Services Task Force.

DATA SOURCES

Randomized clinical trials of BV treatment in pregnancy that measured pregnancy outcomes were identified from multiple searches in MEDLINE from 1966 to 1999, the Cochrane Controlled Trials Register and Library, and national experts.

STUDY SELECTION

All randomized controlled trials of BV treatment in pregnancy that specifically measured pregnancy outcomes.

DATA EXTRACTION

The following information was abstracted: study design and blinding, diagnostic methods, antibiotic interventions, timing of antibiotic treatment in pregnancy, criteria for treatment, comorbidities, demographic details, risk factors for preterm delivery such as previous preterm delivery, compliance, rates of spontaneous and total preterm delivery less than 37 weeks and less than 34 weeks, preterm premature rupture of membranes, low birth weight less than 2500 grams, spontaneous abortion, postpartum endometritis, and neonatal sepsis. For each study, we measured the effect of treatment by calculating the difference in the rate of a given pregnancy outcome in the control group minus the treatment group (the absolute risk reduction [ARR]). A stepwise procedure based on the profile likelihood was applied to assess heterogeneity, to pool studies when appropriate, and to calculate the mean and 90% confidence intervals (CIs) for the effect of treatment.

DATA SYNTHESIS

Seven randomized controlled trials met inclusion criteria for the meta-analysis. We found no benefit to BV treatment in average-risk women for any pregnancy outcome. Results of studies of high-risk populations, women with previous preterm delivery, were statistically heterogeneous. They clustered into two groups; one showed no benefit (ARR=-0.08, 90% CI=-0.19 to 0.04), whereas the three homogeneous studies showed potential benefit of BV treatment (pooled ARR=0.22; 90% CI=0.13 to 0.31) for preterm delivery before 37 weeks. Four high-risk studies reported results for preterm delivery less than 34 weeks. The pooled estimate showed no benefit (ARR=0.04; 90% CI=-0.02 to 0.09), but variation was noted among individual studies. Two trials of high-risk women found an increase in preterm delivery less than 34 weeks in women who did not have BV but received BV treatment. Comparisons of patient populations, treatment regimens, and study designs did not explain the heterogeneity among studies.

CONCLUSIONS

We found no benefit to routine BV screening and treatment. A subgroup of high-risk women may benefit from BV screening and treatment; however, there may be a subgroup for whom BV treatment could increase the occurrence of preterm delivery.

Screening for chlamydial infection

OBJECTIVES

To examine data on the effectiveness of screening for chlamydial infection by a physician or other health care professional. Specifically, we examine the evidence that early treatment of chlamydial infection improves health outcomes, as well as evidence of the effectiveness of screening strategies in nonpregnant women, pregnant women, and men, and the accuracy of tests used for screening. This review updates the literature since the last recommendation of the U.S. Preventive Services Task Force published in 1996.

SEARCH STRATEGY

We searched the topic of chlamydia in the MEDLINE, HealthSTAR, and Cochrane Library databases from January 1994 to July 2000, supplemented by reference lists of relevant articles and from experts in the field. Articles published prior to 1994 and research abstracts were cited if particularly important to the key questions or to the interpretation of included articles.

SELECTION CRITERIA

A single reader reviewed all English abstracts. Articles were selected for full review if they were about Chlamydia trachomatis genitourinary infections in nonpregnant women, pregnant women, or men and were relevant to key questions in the analytic framework. Investigators read the full-text version of the retrieved articles and applied additional eligibility criteria. For all topics, we excluded articles if they did not provide sufficient information to determine the methods for selecting subjects and for analyzing data.

DATA COLLECTION AND ANALYSIS

We systematically reviewed three types of studies about screening in nonpregnant women that relate to three key questions: (1) studies about the effectiveness of screening programs in reducing prevalence rates of infection, (2) studies about risk factors for chlamydial infection in women, and (3) studies about chlamydial screening tests in women. Our search found too few studies on pregnant women to systematically review, although pertinent studies are described. We systematically reviewed two types of studies about screening in men: (1) studies about prevalence rates and risk factors for chlamydial infection in men and (2) studies about chlamydial screening tests in men.

MAIN RESULTS

Nonpregnant women. The results of a randomized controlled trial conducted in a large health maintenance organization indicate that screening women selected by a set of risk factors reduces the incidence of pelvic inflammatory disease (PID) over a 1-year period. Changes in population prevalence rates have not been well documented because few studies have employed a representative population sample. Age continues to be the best predictor of chlamydial infection in women, with most studies evaluating cut-offs at age younger than 25 years. Other risk factors may be useful predictors, but these are likely to be population specific. To determine the accuracy of screening tests for women, we retrieved and critically reviewed 34 articles on test performance. Results indicate that endocervical swab specimens and first-void urine specimens have similar performance when using DNA amplification tests and have better sensitivity than endocervical culture. Recurrent chlamydial infections in women have been associated with increased risks for PID and ectopic pregnancies. Pregnant women. The Second Task Force recommendations for screening pregnant women were based on two major studies demonstrating improved pregnancy outcomes following treatment of chlamydial infection. We identified no recent studies on this topic in our literature search. Very few studies describe risk factors for chlamydial infection in pregnant women. Nonculture testing techniques appear to perform well in pregnant women, although studies are limited. Men. No studies described the effectiveness of screening or early treatment for men in reducing transmission to women or in preventing acute infections or complications in men. Studies of prevalence rates and risk factors for chlamydial infection in men are limited. Age lower than 25 years is the strongest known risk factor cited so far. Results of urethral swab specimens compared to first-void urine specimens were similar for DNA amplification tests. DNA amplification techniques are more sensitive than culture.

CONCLUSIONS

Screening women for Chlamydia trachomatis reduces the incidence of PID, and it is associated with reductions in prevalence of infection in uncontrolled studies. No studies were found to determine whether screening asymptomatic men would reduce transmission or prevent acute infections or complications. Age is the strongest risk factor for men and women. A variety of tests can detect chlamydial infection with acceptable sensitivity and specificity, including new DNA amplification tests that use either endocervical swabs in women, urethral swabs in men, or first-void urine specimens from men and women.

Colonic neoplasia in patients with nonspecific GI symptoms

BACKGROUND

The purpose of this study was to determine the prevalence rate of colonic polyps or masses 1 cm or greater in diameter in patients with nonspecific abdominal symptoms, from diverse practice settings, using a national endoscopic database.

METHODS

Consecutive patients undergoing colonoscopy were included based on procedure indication. Endoscopic data were generated with a computer database at each practice site, transmitted to a central data bank and merged with data from multiple sites for analysis. Group 1 patients had nonspecific abdominal symptoms, which were defined as pain, constipation and diarrhea. Group 2 patients had a positive fecal occult blood test. Group 3 patients were asymptomatic, undergoing screening colonoscopy. Serious colon pathology was defined as a polyp or mass greater than 9 mm in size.

RESULTS

Data were collected from 31 practice sites in 21 states during a period of 18 months. Of the 20,745 colonoscopy examinations, 9.2% were performed to evaluate patients with nonspecific abdominal symptoms, excluding other indications. Among patients with nonspecific symptoms 7.27% had polyp(s) 1 cm or greater in diameter compared with 17.05% of patients with positive fecal occult blood test (odds ratio 2.12: CI [1.73, 2.60]; p < 0.001). Patients with nonspecific symptoms had similar rates of large polyps as asymptomatic patients (7.27% vs. 6.45%, p = 0.32). Multivariate analysis identified several independent variables including increasing age, male gender and practice site at a Veterans Affairs Medical Center.

CONCLUSIONS

In diverse, practice-based settings, patients with nonspecific abdominal symptoms who are referred for colonoscopy do not have a higher risk of serious colonic pathology than asymptomatic patients.

Cost of treating an episode of variceal bleeding in a VA setting

OBJECTIVES

The specific aims of this study were to develop a demographic description of a sample of patients presenting with bleeding esophageal varices and determine the direct health care costs of variceal bleeding.

METHODS

This was a retrospective evaluation of patients who underwent esophagogastroduodenoscopy at the Portland VA Medical Center between January 1993 and May 1997. Data sources included both electronic databases and patient medical charts. The primary unit of analysis was an episode of care, defined as an index bleed plus 6 months of follow-up or death, whichever came first.

RESULTS

The total inpatient direct cost was $1,566,904 and outpatient direct cost was $104,611, for a total of $1,671,515 for 100 bleeding episodes in 79 patients. Episodes of care for patients receiving < or =2 units of packed red blood cells were approximately a third as costly as those receiving >2 units of packed red blood cells (n = 17, $6,470 and n = 83, $17,553). The difference in costs was statistically significant (p < 0.05), and primarily attributable to hospital bed costs.

CONCLUSIONS

There is a substantial financial burden associated with this illness, primarily attributable to inpatient costs. In addition to severity of bleeding, Child's class, endoscopic findings, and the timing of pharmacological therapy seem to influence the overall cost of managing esophageal varices.

Evidence of case management effect on traumatic-brain-injured adults in rehabilitation

The purpose of this study was to evaluate the evidence for effectiveness of case management during recovery from traumatic brain injury (TBI) in adults. After an overview of TBI incidence, prevalence, and problems, and a brief explanation of case management, the study methods are described, the findings are discussed and recommendations are made for future research. Medline, HealthSTAR, CINAHL, PsychINFO, and the Cochrane Library databases were searched and 83 articles met the criteria for review. The strongest studies (n = 3) were critically appraised and their design features and data were placed in two evidence tables. Due to methodological limitations, there was neither clear evidence of effectiveness nor of ineffectiveness. For future research, we recommend controlled research designs, standardization of measures, adequate statistical analysis and specification of health outcomes of importance to persons with TBI and their families.

Patterns of endoscopy use in the United States

BACKGROUND & AIMS

The aim of this study was to use a large national endoscopic database to determine why routine endoscopy is performed in diverse practice settings.

METHODS

A computerized endoscopic report generator was developed and disseminated to gastrointestinal (GI) specialists in diverse practice settings. After reports were generated, a data file was transmitted electronically to a central databank, where data were merged from multiple sites for analysis.

RESULTS

From April 1, 1997, to October 28, 1998, 276 physicians in 31 practice sites in 21 states provided 18,444 esophagogastroduodenoscopy (EGD) reports, 20,748 colonoscopy reports, and 9767 flexible sigmoidoscopy reports to the central databank. EGD was most commonly performed to evaluate dyspepsia and/or abdominal pain (23.7%), dysphagia (20%), symptoms of gastroesophageal reflux without dysphagia (17%), and suspected upper GI bleeding (16.3%). Colonoscopy was most often performed for surveillance of prior neoplasia (24%) and evaluation of hematochezia (19%) or positive fecal occult blood test (15%). Flexible sigmoidoscopy was most commonly performed for routine screening (40%) and evaluation of hematochezia (22%). There were significant differences between academic and nonacademic sites.

CONCLUSIONS

The endoscopic database can be an important resource for future research in endoscopy by documenting current practice patterns and changes in practice over time.

Effectiveness of Helicobacter pylori therapies in a clinical practice setting

BACKGROUND

Whether eradication rates for Helicobacter pylori treatment regimens obtained in controlled clinical trials (efficacy) can also be obtained in clinical practice (effectiveness) is unknown because no such trials have been reported in the United States.

OBJECTIVES

To determine the eradication rates of H pylori in a community practice setting and the effects of practice variation in the choice of treatment regimen on patient outcome (H pylori infection cure) and cost.

METHODS

Between February 1 and December 30, 1996, 38 community-based gastroenterologists in the Portland, Ore, metropolitan area enrolled a total of 250 patients infected with H pylori, as determined by endoscopic or noninvasive methods. Various therapeutic regimens aimed at eradicating H pylori were used by the gastroenterologists, and a posttreatment urea breath test was used to determine H pylori infection cure. Compliance and incidental effects were also measured and decision analysis was used to estimate the cost of treatment.

RESULTS

The regimens used varied considerably. Patients receiving a 2- or 3-times-a-day treatment regimen were significantly more compliant (P=.01) than those receiving a 4-times-a-day regimen. Proton pump inhibitor-based triple-therapy regimens were significantly more effective than all other treatment regimens combined (87% vs 70%; P = .001) in eradicating H pylori. These proton pump inhibitor-based triple-therapy regimens were also more cost-effective by decision analysis for a hypothetical cohort of patients with duodenal ulcer disease.

CONCLUSIONS

The considerable variation in the choice of treatment regimens affects the clinical and economic outcomes of patients undergoing therapy for H pylori infection. Whether these data reflect the outcome in other communities is unknown but should be determined. It will be necessary to determine if the dissemination of these data results in a reduction of practice variation and improvement in clinical and economic outcomes of patients being treated for H pylori infection in clinical practice.

Effect of cognitive rehabilitation on outcomes for persons with traumatic brain injury: A systematic review

We evaluated evidence for the effectiveness of cognitive rehabilitation methods to improve outcomes for persons with traumatic brain injury (TBI). A search of MEDLINE, HealthSTAR, CINAHL, PsycINFO, and the Cochrane Library produced 600 potential references. Thirty-two studies met predetermined inclusion criteria and were abstracted; data from 24 were placed into evidence tables. Two randomized controlled trials and one observational study provided evidence that specific forms of cognitive rehabilitation reduce memory failures and anxiety, and improve self-concept and interpersonal relationships for persons with TBI. The durability and clinical relevance of these findings is not established. Future research utilizing control groups and multivariate analysis must incorporate subject variability and must include standard definitions of the intervention and relevant outcome measures that reflect health and function.

Summary report: evidence for the effectiveness of rehabilitation for persons with traumatic brain injury

We evaluated the evidence for effectiveness of rehabilitation methods throughout the phases of recovery from traumatic brain injury (TBI) in adults. MEDLINE, HealthSTAR, CINAHL, PsycINFO, and the Cochrane Library were searched, and a total of 3,098 abstracts were reviewed. The strongest studies were critically appraised and their data placed in evidence tables. Results showed that to determine the effectiveness of rehabilitation interventions for persons with TBI, a commitment must be made to population-based studies, strong controlled research design, standardization of measures, adequate statistical analysis, and specification of health outcomes of importance to persons with TBI and their families.

Clinical guideline, part 2. Screening for thyroid disease: an update. American College of Physicians

PURPOSE

To review information on the benefits of screening with a sensitive thyroid-stimulating hormone (TSH) test for thyroid dysfunction in asymptomatic patients seeking primary care for other reasons. This paper focuses on whether screening should be aimed at detection of subclinical thyroid dysfunction and whether persons with mildly abnormal TSH levels can benefit.

DATA SOURCES

A MEDLINE search for studies of screening for thyroid dysfunction and of treatment for complications of subclinical thyroid dysfunction.

STUDY SELECTION

Studies of screening with thyroid function tests in the general adult population or in patients seen in the general office setting were selected (n=33). All controlled studies of treatment in patients with subclinical hypothyroidism or subclinical hyperthyroidism were also included (n=23).

DATA EXTRACTION

The prevalence of overt and subclinical thyroid dysfunction, the evidence for the efficacy of treatment, and the incidence of complications in defined age and sex groups were extracted from each study.

DATA SYNTHESIS

Screening can detect symptomatic but unsuspected overt thyroid dysfunction. The yield is highest for women older than 50 years of age: In this group, 1 in 71 women screened could benefit from relief of symptoms. Evidence of the efficacy of treatment for subclinical thyroid dysfunction is inconclusive.

CONCLUSIONS

Even though treatment for subclinical thyroid dysfunction is controversial, office-based screening to detect overt thyroid dysfunction may be indicated in women older than 50 years of age. Large randomized trials are needed to determine the likelihood that treatment will improve quality of life in otherwise healthy patients who have mildly elevated TSH levels.

Adequacy of hospital discharge status as a measure of outcome among injured patients

CONTEXT

Crude mortality rates at the time of hospital discharge are commonly used to assess the quality of care provided to patients hospitalized following trauma.

OBJECTIVES

To evaluate the adequacy of hospital death rates as an outcome measure following trauma and to determine the influence of noninjury illness as a cause of hospital death and the frequency of postdischarge death.

DESIGN

Retrospective cohort analyses using hospital discharge data for injured patients cross-linked to death certificate data that provided 1 year of follow-up for all patients discharged alive.

PATIENTS

A total of 90048 injured patients admitted to all acute care hospitals in the state of Washington from 1991 through 1993 and discharged with at least 1 diagnosis coded in the International Classification of Diseases, Ninth Revision, Clinical Modification to indicate trauma.

MAIN OUTCOME MEASURES

Death in the hospital and death within 30 days of hospital discharge.

RESULTS

Among 1912 injured patients with in-hospital deaths, 825 death certificates (43%) listed a noninjury cause of death. The overall mortality rate at hospital discharge was 21.2 per 100000 hospitalized injured patients, and was 12.1 per 100000 for trauma deaths and 9.1 per 100000 for those designated as nontrauma deaths. Patients with trauma-related death designations were younger (mean age, 51.5 years vs 77.9 years), had shorter lengths of stay (median stay, 2 days vs 5 days), and sustained more severe injures (P<.001). Including the 1273 deaths that occurred within 30 days of hospital discharge increased rates for trauma-designated deaths to 14.1 per 100000 and increased rates for nontrauma-designated deaths to 21.3 per 100000.

CONCLUSIONS

Hospital discharge death rates are incomplete measures of death frequency for injured patients. Designation of the cause of death, especially among older, hospitalized, injured patients often reflects preexisting medical conditions. Adequate assessment of mortality following trauma requires measurement of the frequency of death following hospital discharge.

Management of symptoms of gastroesophageal reflux disease: does endoscopy influence medical management?

OBJECTIVES

The purpose of this study was to examine the theories that underlie the clinical decision to perform endoscopy in patients with symptoms of gastroesophageal reflux disease (GERD). Physicians reported that they use endoscopic findings to modify medical treatment of GERD. This study was undertaken to test this hypothesis in clinical practice.

METHODS

A consortium of community specialists in gastrointestinal disease was formed. Physicians completed a database on patients undergoing elective endoscopy for symptoms of GERD, which includes symptom severity, endoscopic findings, and medical treatment before and after endoscopy. An increase in medical treatment was defined as an increase in acid suppression therapy, and/or the addition of a promotility drug, and/or referral for surgery.

RESULTS

Data were collected prospectively over 6 months on 664 patients with symptoms of GERD, and complete data were available on 598 patients. Barrett's esophagus or active esophagitis (erythema, erosions, or ulceration) was present in 374 patients. Of these patients, 74% had an increase in therapy after endoscopy; for only 5% did therapy decrease. In contrast, among 224 patients with a normal-appearing esophagus, 35% had an increase in treatment and 65% had either a decrease in treatment or no change. In most cases, the increase in treatment was due to persistence of symptoms or because of endoscopic findings in the stomach or duodenum. The differences in treatment changes between the two groups was highly significant (p < 0.0001).

CONCLUSION

The results support the theory that physicians often use endoscopic results to tailor medical therapy in patients with symptoms of GERD.

Rural hospital transfer patterns before and after implementation of a statewide trauma system. OHSU Rural Trauma Research Group

OBJECTIVE

To evaluate trauma transfer practices in rural Oregon before and after implementation of a statewide trauma system.

METHODS

A pre- vs post-system implementation (historical control) analysis of trauma transfer practices was performed using a sample of rural ED trauma patients from 4 Level-3 and 5 Level-4 trauma hospitals. Medical records of patients with specific index injury diagnoses in 4 anatomic regions (head, chest, liver/ spleen, and femur/open-tibia) were reviewed for a 3-year period before statewide trauma system implementation and 3 years after hospital trauma designation.

RESULTS

Of 1,057 patients entered into the database, 532 were evaluated during the pre-system period and 525 were evaluated during the post-system period. Overall, 47% had head injuries, 34% had chest injuries, 23% had femur/open-tibia injuries, and 12% had spleen/liver injuries. There were 142 (13%) patients with an injury in > 1 index area. After trauma system implementation, there was a significant increase in the proportion of ED trauma patients transferred from Level-4 trauma hospitals (32% vs 68%, p < 0.001), with a corresponding decrease in the number of hospital admissions to these facilities (63% to 29%, p < 0.001). Significant increases in the proportion transferred from Level-4 trauma hospital EDs were noted for all index injury categories (p < 0.001). Trauma patients presenting to Level-4 EDs were significantly more likely to be transferred to Level-2 facilities (66% vs 82%, p = 0.030), while patients at Level-3 facilities were significantly more likely to be transferred to Level-1 centers (2% vs 14%, p = 0.002) following trauma system implementation. Multiple logistic regression modeling indicated that implementation of the statewide trauma system was an independent predictor of rural trauma patient transfer from Level-4 hospitals, while transfers from Level-3 facilities were dependent on type of injury.

CONCLUSION

Implementation of the Oregon statewide trauma system was associated with a redistribution of rural trauma patients to trauma hospitals with greater therapeutic resources.

Risk factors for Barrett's esophagus in community-based practice. GORGE consortium. Gastroenterology Outcomes Research Group in Endoscopy

OBJECTIVES

Endoscopy is often performed in patients with gastroesophageal reflux (GER) disease because of concern about the presence of Barrett's esophagus (BE). The purpose of this study was to determine whether the duration of GER symptoms and/or a history of esophagitis was associated with an increased risk of BE.

METHODS

This was an observational, prospective, community-based study. Consecutive patients undergoing elective endoscopy because of GER symptoms were enrolled. Endoscopy reports and pathological findings were reviewed to classify patients as having no esophagitis, esophagitis, or probable BE. Correlations with duration of symptoms and a history of esophagitis were analyzed.

RESULTS

In all, 701 of 2641 patients (27%) undergoing elective endoscopy had GER symptoms, and 77 of these patients had probable BE. Compared with patients with GER symptoms for less than 1 yr, the odds ratio for BE in patients with GER symptoms for 1-5 years was 3.0 and increased to 6.4 in patients with symptoms for more than 10 yr (p < 0.001). A history of esophagitis was not an independent risk factor for BE (p = 0.17).

CONCLUSIONS

Prevalence of BE is strongly associated with duration of GER symptoms.

Community-based research--a framework for problem formulation: the case of upper endoscopy for gastroesophageal reflux disease

OBJECTIVE

To identify clinical hypotheses and information gaps underlying disagreement about the use of upper gastrointestinal endoscopy (EGD) for the diagnosis of gastroesophageal reflux disease (GERD), and to design a registry study to test these hypotheses.

DESIGN AND SETTING

Structured group discussions with community-based practicing gastroenterologists.

RESULTS

Thirty-three gastroenterologists from 17 sites discussed a set of clinical scenarios concerning the use of EGD in GERD patients with different clinical histories. Clinicians identified patient characteristics and outcome variables missing from the original problem formulation. Using decision tables, the combinations of patient characteristics that provoked disagreement among clinicians were determined. The resulting decision tables specified which characteristics and outcome variables should be measured to test competing clinical theories of when to use EGD in patients with GERD. Subsequently, the clinicians conducted a practice-based study measuring uncertain variables associated with disagreement about the need for EGD in specific clinical situations.

CONCLUSION

A structured, but flexible, approach to group discussion may help identify factors that are important in decision making and the hypotheses that should be addressed in resolving variations in practice styles. Technology assessors can use these methods to identify variables underlying clinicians' concerns about the clinical validity of recommendations about practice. This experience with eliciting patient characteristics and uncertain variables underscores the importance of involving practicing clinicians in the process and could be a useful model for problem formulation in guideline development and in community-based research.

History of visible rectal bleeding in a primary care population. Initial assessment and 10-year follow-up

OBJECTIVE

To determine whether a complaint of visible rectal bleeding that is elicited by a screening review of systems merits investigation and to assess the accuracy of a defined protocol to evaluate bleeding.

DESIGN

Prospective cohort study.

SETTING

Primary care clinics in a veterans medical center.

PATIENTS

We used an 8-item review of systems to identify 297 individuals with visible rectal bleeding; 201 (68%) of these individuals completed a specified protocol consisting of double-contrast barium enema (DCBE) examination, rigid sigmoidoscopy, and follow-up visit after 6 to 12 months. Ten years later we verified the diagnosis in 131 (93%) of 141 patients whose initial evaluation suggested no cause, or a benign anorectal cause, of bleeding.

MAIN OUTCOME MEASURES

Final diagnoses after 2 and 10 years; sensitivity and specificity of symptoms, DCBE, and rigid sigmoidoscopy.

RESULTS

We diagnosed serious disease in 48 (24%) of the 201 patients; 26 had polyps, 9 had inflammatory bowel disease, and 13 (6.5%) had colon cancer. Symptoms did not predict the diagnosis. Neither DCBE nor rigid sigmoidoscopy alone was sufficiently sensitive to be used alone, but the combination of DCBE and rigid sigmoidoscopy had a sensitivity of 0.96 and a specificity of 0.76 for the diagnosis of polyps, cancer, or inflammatory bowel disease.

CONCLUSIONS

Self-reported rectal bleeding detected by means of a review of systems was associated with a high likelihood of important pathology. Physicians should ask all adults about visible rectal bleeding and should visualize the entire colon in those who report bleeding.

Practice variation and the risk of low birth weight in a public prenatal care program

OBJECTIVES

Use of antepartum tests of fetal well-being is widespread even though effectiveness in preventing fetal damage or stillbirth has not been established. The study objective was to examine whether aggressive use of these tests might contribute to increased rates of other birth outcomes, including low birth weight (LBW).

METHODS

A total of 3,235 low-income women receiving care from 28 clinic sites were studied. All women were eligible for Medi-Cal benefits. Clinic sites were classified as aggressive, moderate, or low users of antepartum tests. The relations between patient risk factors, clinic testing style, LBW, and other pregnancy outcomes were examined using multiple logistic regression.

RESULTS

After adjustment for risk factors, patients seen by aggressive testers had a risk of LBW higher than patients receiving care from moderate testers (odds ratio = 1.65; P < 0.01). Rates of LBW within patients receiving care from moderate and low testers did not differ (P = 0.22). Patients seen by aggressive testers also had higher rates of preterm delivery, cesarean delivery, and provided more expensive care.

CONCLUSIONS

Although antepartum testing is intended to prevent fetal distress, extremely aggressive use of antepartum testing may have unfavorable effects on LBW and other pregnancy outcomes. More attention should be paid to variation in obstetric practices in evaluations of the costs and effectiveness of public prenatal care programs.

Low birthweight in a public prenatal care program: behavioral and psychosocial risk factors and psychosocial intervention

A retrospective, observational study of 3073 low income African American, Latina, and White women receiving comprehensive prenatal care at 26 provider sites was completed. The purpose of the study was to test three hypotheses. First, after adjustment for biomedical complications, the presence of maternal behavioral and psychosocial factors would be associated with an increased rate of low birthweight infants. Second, increased time spent in psychosocial services would negate the relationship between maternal psychosocial factors and low birthweight. Third, after adjusting for biomedical, behavioral, and psychosocial factors, rates of low birthweight would no longer differ by race. Maternal smoking (over five cigarettes per week), maternal low weight for height and/or weight gain, negative mood (depression, anxiety, and/or hostility) and rejection of the pregnancy were found to be related to an increased rate of low birthweight birth (< 2500 g). Receiving more than 45 min of psychosocial services was related to a reduced rate of low birthweight birth for all women regardless of risk profile. The rate of low birthweight remained higher in African American women after adjusting for all significant maternal biomedical, behavioral, and psychosocial risk and intervention factors. Further analyses revealed that the strength and direction of the relationship between time spent in psychosocial services and low birthweight remained after controlling for the number of prenatal care visits, the time spent in nutrition or health educational services, and gestational age. Also, the time spent in psychosocial services was related to a reduced rate of low birthweight even after excluding time spent in psychosocial services in the third trimester of pregnancy or excluding women who received their first psychosocial assessment in the third trimester from the analysis. Although definitive evidence from randomized trials of psychosocial services is lacking, receiving over 45 min of psychosocial services was related to a reduced risk of low birthweight for all women in this study. Therefore, general psychosocial services appears to be an important component of prenatal care for all low income women.

Influence of a statewide trauma system on location of hospitalization and outcome of injured patients

OBJECTIVE

Evaluate the influence of implementing the Oregon statewide trauma system on admission distribution and risk of death.

DESIGN

Retrospective pre- and posttrauma system analyses of hospital discharge data regarding injured patients with one or more of the following injuries: head, chest, spleen/liver, pelvic fracture, and femur/tibia fracture.

MATERIALS AND METHODS

Risk-adjusted odds ratio of admission to Level I or II (tertiary care) trauma centers, and odds ratio of death were determined using hospital discharge abstract data on 27,633 patients. Patients treated in 1985-1987, before trauma system establishment, were compared to patients treated in 1991-1993 after the trauma system was functioning.

MEASUREMENTS AND MAIN RESULTS

After trauma system implementation, the odds ratio of admission to Level I or II trauma centers increased (odds ratio 2.36, 95% confidence interval 2.24-2.49). In addition, the odds ratio of death for injured patients declined after trauma system establishment (odds ratio 0.82, confidence interval 0.73-0.92).

CONCLUSIONS

The Oregon trauma system was successfully implemented with more patients with index injuries admitted to hospitals judged most capable of managing trauma patients. The Oregon trauma system also appears beneficial since trauma system establishment is associated with a statewide reduction in risk of death.

An analysis of Hospital Discharge Index as a trauma data base

STUDY OBJECTIVE

To document the validity of a Hospital Discharge Index (HDI) as a data base on injured patients.

DESIGN

Patient information in trauma registries was compared with information in HDI.

POPULATION

Injured patients admitted to trauma centers.

METHODS

Patients in HDI were crossmatched with individuals in one or two trauma registries using deterministic matching techniques. Agreement regarding the presence and severity of injury was assessed.

RESULTS

A comprehensive trauma registry from a level I trauma center and HDI agreed on the presence of an injury in each of 6 body regions over a range of kappa values from 0.17 to 0.71. The severity of injury score assigned by the two data bases demonstrated agreement over a range of intraclass correlation values from 0.12 to 0.82.

CONCLUSION

HDI provides adequate information concerning injury for the majority of hospitalized patients, but was primarily limited by incomplete information. Efforts to improve HDI should focus on guidelines for data abstraction.

Information seeking in primary care: how physicians choose which clinical questions to pursue and which to leave unanswered

Primary care physicians have many questions about optimal care while they are seeing patients, but they pursue only about 30% of their questions. The authors designed a study to determine the factors that motivate physicians to pursue answers to some of their questions, while leaving the majority of their questions unanswered. They interviewed 49 non-academic primary care physicians during office hours to record clinical questions as they arose in the course of patient care. The physicians then recorded their perceptions of each question with respect to 12 factors expected to motivate information seeking. Two to five days after the interview, each physician was telephoned to determine which questions had been pursued. In a multiple logistic-regression model only two factors were significant predictors of pursuit of new information: the physician's belief that a definitive answer existed, and the urgency of the patient's problem. Other factors, including the difficulty of finding the answer, potential malpractice liability, potential help or harm to the patient, and self-perceived knowledge of the problem, were not significant in the model. Primary care physicians are significantly more likely to pursue answers to their clinical questions when they believe that definitive answers to those questions exist, and when they perceive the patient's problem to be urgent. Medical information systems must be shown to have direct and immediate benefits to solving the problems of patient care if they are to be more widely used by practitioners.

Outcome of hospitalized injured patients after institution of a trauma system in an urban area

OBJECTIVE

To determine if risk of death for hospitalized injured patients changes when an urban trauma system is implemented.

DESIGN

An analysis of the risk of death in hospitalized injured patients in 1984 and 1985 (pretrauma system), 1986 and 1987 (early trauma system), and 1990 and 1991 (established trauma system) using hospital discharge abstract data.

SETTING

A total of 18 acute care hospitals in the four-county area encompassing Portland, Ore.

PATIENTS

A cohort of 70,350 hospitalized patients with at least one discharge diagnosis indicating injury.

MAIN OUTCOME MEASURE

Death during hospitalization.

RESULTS

After the trauma system was established, 77% of patients in the region with an Injury Severity Score (ISS) of 16 or greater were admitted to level I trauma centers. More than 72% of patients with an ISS less than 16 were hospitalized in nontrauma centers. Risk of death for injured patients hospitalized at level I trauma centers declined after the trauma system was established (odds ratio, 0.65; 95% confidence interval, 0.51 to 0.81). Patients who died in trauma centers after institution of the trauma system were younger and had more severe injuries, and the majority died within 1 day of admission, whereas patients who died in nontrauma centers died a median of 5 days after admission.

CONCLUSION

Establishment of a trauma system shifted the more seriously injured patients to level I trauma centers, where there was a significant reduction in the adjusted death rate.

Oregon trauma system: change in initial admission site and post- admission transfer of injured patients

OBJECTIVE

Associate statewide trauma system development with a change in the percentage of injured patients initially hospitalized at Levels I and II categorized trauma hospitals and a change in the length of stay (LOS) prior to arrival at a Level I or II hospital (PRE-LOS) and total LOS (T-LOS) for post-admission transfer patients.

METHODS

A retrospective analysis was performed using a hospital discharge database of 235,395 discharges with codes for acute injury managed at 74 acute care hospitals in Oregon State from 1983 to 1991. Primary outcome measures were admission site and transfer patient PRE-LOS and T-LOS. Predicator variables included category of initial hospital admission site, injury severity scale (ISS) score, head injury, age, and status of trauma system (pre-system, 1983 to 1987; transitional, 1988 to 1989; and post-system, 1991 to 1992).

RESULTS

There was a significant increase in the percentage of initial admissions to hospitals with Level I and II categorization (17.6%, 26.2%, and 27.6% for the three periods of development, respectively; p < 0.00001). The percentage of patients with ISS scores greater than 15 admitted initially to Level I or II hospitals increased from 33.4% to 52.6% and 57.3%; p < 0.00001). Only 1,059 0.57%) of 185,321 patients initially admitted to Level III, Level IV, or noncategorized hospitals were transferred to a Level I or II hospital. Mean PRE-LOS for 1.059 transferred patients showed a significant decrease with system development (2.3, 1.9, and 1.8 days, respectively; p < 0.02). When adjusted for age, ISS score, and head injury effects, mean T-LOS was significantly reduced for the transitional and post-system periods (p < 0.05).

CONCLUSIONS

In Oregon, development of a statewide trauma system was associated with increased initial admissions to Level I and II trauma hospitals. For those patients transferred to higher levels of care post- admission, hospital LOSs were decreased with trauma system development.

Effect of the Clinical Laboratory Improvement Amendments of 1988 (CLIA '88) on the incidence of invasive cervical cancer

The Clinical Laboratory Improvement Act of 1988 (CLIA '88) mandates strict, new quality-control measures for laboratories that interpret cervical cytology smears. Proposed regulations include proficiency testing of cytotechnologists and remediation for technologists and laboratories that fail to meet proposed proficiency standards. Proponents of the new regulations argue that these measures will reduce deaths from cervical cancer by reducing the false-negative rate of the Papanicolaou (Pap) test, but opponents argue that the regulations will increase the price of processing Pap tests and thereby reduce access to cervical cancer screening for high-risk, vulnerable populations. To examine these claims the authors used David Eddy's published simulation to model the natural history and detection of cervical neoplasia, and developed a new model to examine the health consequences of diminished access to Pap testing. The authors estimated the false-negative rate of the Pap test and the price elasticity of demand for preventive services on the basis of the published literature, and modeled the entire range of published or quoted predictions about the impact of CLIA '88 on accuracy and price. The results show that, if effects on access are ignored, reducing the false-negative rate from 15% to 5% would prevent 66 invasive cancers per 100,000 average risk women screened. However, under moderate assumptions regarding the effect of price on access, the regulations would prevent only 11 (instead of 66) cancers per 100,000 eligible women. The regulatory effect is very sensitive to the degree of improvement in the false-negative rate and increase in price that the regulations cause. Over the range of assumptions and predictions encountered in the literature and tested in our analysis, the proposed regulations could greatly reduce or greatly increase the incidence of invasive cancer, especially among high-risk and uninsured women. The implementation of the regulations should be delayed until new information regarding the actual false-negative rate of the Pap test allow a more precise estimate of the potential impact on the incidence of cervical cancer.

A decision analysis of traumatic splenic injuries

We created a decision analysis model of the nonsurgical management of traumatic splenic injuries to clarify the risk of hospital survival, overwhelming postsplenectomy infection (OPSI) deaths, and transfusion-related deaths. We reviewed 72 cases of splenic injury at our institution to identify our transfusion requirements for successful observation (0.5 units), observation failure (1.0 units), and surgical splenic management (1.6 units). Using our model and baseline probabilities determined from the literature, we compared the nonsurgical management of splenic injuries with immediate laparotomy and found an increase in hospital survival with observation, but an over two-fold increase in the risk of transfusion-related death. The OPSI deaths were not markedly different between the two strategies. Overall, we found decision analysis useful in identifying important variables such as the probability of nontherapeutic laparotomy death or missed injury, and in clarifying the risk of the nonsurgical management of splenic injuries with regard to transfusion-related deaths and OPSI deaths.

Monitoring therapy in patients taking levothyroxine

PURPOSE

To evaluate the use of thyroid function tests to monitor therapy in patients taking levothyroxine.

DATA IDENTIFICATION

Studies published between 1966 and January 1990 were identified through computer searches and references of identified studies.

STUDY SELECTION

Studies that included a careful description of the patients under study, well-defined interventions, and a meaningful criterion standard were emphasized.

DATA EXTRACTION

Data from different studies were combined to estimate the probability of positive and negative test results in well-defined clinical situations. Informal methods of synthesizing evidence were used when combining data from different studies was not justified.

RESULTS

The sensitive thyrotropin (TSH) test is the preferred method to monitor therapy because it agrees with physiologic measures of thyroid hormone effect. Among clinically euthyroid patients who take 100 to 150 micrograms/d of levothyroxine, the probability that the sensitive thyrotropin will be undetectable is close to 50%. These patients are most likely to benefit from testing. Patients who take over 250 micrograms/d are almost certain to have undetectable sensitive thyrotropin levels; in these patients, the dose may be lowered without testing.

CONCLUSIONS

Adequate long-term studies are needed to determine the role of biochemical testing in monitoring therapy. Current evidence suggests that the sensitive thyrotropin test should be used to monitor therapy. Clinically euthyroid patients taking lower dosages of levothyroxine are most likely to benefit from testing.

Screening for thyroid disease

PURPOSE

To evaluate the usefulness of screening for thyroid dysfunction in various clinical settings.

DESIGN

Review and synthesis of the literature.

MAIN RESULTS

Screening in the community detects new overt thyrotoxicosis or hypothyroidism in approximately 0.5% of the general population. The yield is best among women over 40 years of age (1%) and is lowest among young men (0%). Case-finding (testing clinic patients who are seeing a physician for unrelated reasons) has a better yield and is less expensive than screening in the community. Patients hospitalized with acute illnesses do not benefit from routine thyroid function testing. However, patients who are admitted to specialized geriatric units because of general disability, failure to thrive, and other indications may benefit. In various studies, from 2% to 5% of patients admitted to geriatric units have treatable thyroid disease. The serum total thyroxine, free thyroxine index, free thyroxine, and sensitive thyrotropin assay are all effective as initial tests for screening. The sensitive thyrotropin assay is less cost-effective than the other choices.

RECOMMENDATIONS

Case-finding in some women over 40 years of age can be useful. Patients admitted to specialized geriatric units may also benefit from routine testing. Thyroid function tests are not indicated for community screening programs or for patients hospitalized with acute medical or psychiatric illnesses.

Factors involved in the interpretation of fetal monitor tracings

In order to study how physicians choose to use electronic fetal monitoring and interpret tracings, we administered a questionnaire to which 107 practicing obstetricians and 11 experts in electronic fetal monitoring responded. Sixty-one (57%) of the respondents monitored more than half of their deliveries (high users). In comparison to the less frequent users of electronic fetal monitoring (low users), they showed more positive attitudes toward electronic fetal monitoring and were nearly always more likely to perform cesarean sections on hypothetical patients described in the questionnaire. These differences appeared to be due to the high users' higher estimate of danger to the fetus. We also found that most physicians were generally more likely to perform a cesarean section on a high-risk mother than a low-risk mother with the same tracing. The majority of high and low users and nearly all of the experts, however, felt that antepartum risk factors are not of value in deciding what to do about an abnormal tracing. We conclude that there is wide variation in the way in which obstetricians use, interpret, and act on electronic fetal monitoring tracings. Some of these differences may be due to differing attitudes toward electronic fetal monitoring, differences in interpretation of electronic fetal monitoring tracings, and differences in the way obstetricians incorporate maternal risk factors into their decision-making.