Participatory methods used in the evaluation of medical devices: a comparison of focus groups, interviews, and a survey

BACKGROUND

Stakeholder engagement in evaluation of medical devices is crucial for aligning devices with stakeholders' views, needs, and values. Methods for these engagements have however not been compared to analyse their relative merits for medical device evaluation. Therefore, we systematically compared these three methods in terms of themes, interaction, and time-investment.

METHODS

We compared focus groups, interviews, and an online survey in a case-study on minimally invasive endoscopy-guided surgery for patients with intracerebral haemorrhage. The focus groups and interviews featured two rounds, one explorative focussing on individual perspectives, and one interactive focussing on the exchange of perspectives between participants. The comparison between methods was made in terms of number and content of themes, how participants interact, and hours invested by all researchers.

RESULTS

The focus groups generated 34 themes, the interviews 58, and the survey 42. Various improvements for the assessment of the surgical procedure were only discussed in the interviews. In focus groups, participants were inclined to emphasise agreement and support, whereas the interviews consisted of questions and answers. The total time investment for researchers of focus groups was 95 h, of interviews 315 h, and survey 81 h.

CONCLUSIONS

Within the context of medical device evaluation, interviews appeared to be the most appropriate method for understanding stakeholder views since they provide a scope and depth of information that is not generated by other methods. Focus groups were useful to rapidly bring views together. Surveys enabled a quick exploration. Researchers should account for these methodological differences and select the method that is suitable for their research aim.

Early technology review: towards an expedited pathway

OBJECTIVES

Evidence development for medical devices is often focused on satisfying regulatory requirements with the result that health professional and payer expectations may not be met, despite considerable investment in clinical trials. Early engagement with payers and health professionals could allow companies to understand these expectations and reflect them in clinical study design, increasing chances of positive coverage determination and adoption into clinical practice.

METHODS

An example of early engagement through the EXCITE International model using an early technology review (ETR) is described which includes engagement with payers and health professionals to better inform companies to develop data that meet their expectations. ETR is based on an early evidence review, a framework of expectations that guides the process and identified gaps in evidence. The first fourteen ETRs were reviewed for examples of advice to companies that provided additional information from payers and health professionals that was thought likely to impact on downstream outcomes or strategic direction. Given that limitations were imposed by confidentiality, examples were genericized.

RESULTS

Advice through early engagement can inform evidence development that coincides with expectations of payers and health professionals through a structured, objective, evidence-based approach. This could reduce the risk of business-related adverse outcomes such as failure to secure a positive coverage determination and/or acceptance by expert health professionals.

CONCLUSIONS

Early engagement with key stakeholders exemplified by the ETR approach offers an alternative to the current approach of focusing on regulatory expectations. This could reduce the time to reimbursement and clinical adoption and benefit patient outcomes and/or health system efficiencies.

The IDEAL framework for surgical robotics: development, comparative evaluation and long-term monitoring

The next generation of surgical robotics is poised to disrupt healthcare systems worldwide, requiring new frameworks for evaluation. However, evaluation during a surgical robot's development is challenging due to their complex evolving nature, potential for wider system disruption and integration with complementary technologies like artificial intelligence. Comparative clinical studies require attention to intervention context, learning curves and standardized outcomes. Long-term monitoring needs to transition toward collaborative, transparent and inclusive consortiums for real-world data collection. Here, the Idea, Development, Exploration, Assessment and Long-term monitoring (IDEAL) Robotics Colloquium proposes recommendations for evaluation during development, comparative study and clinical monitoring of surgical robots-providing practical recommendations for developers, clinicians, patients and healthcare systems. Multiple perspectives are considered, including economics, surgical training, human factors, ethics, patient perspectives and sustainability. Further work is needed on standardized metrics, health economic assessment models and global applicability of recommendations.

Usage and parental knowledge of antibiotics in children undergoing (adeno) tonsillectomy in northern Tanzania

Introduction

Antimicrobial Resistance (AMR) is a growing concern globally, mostly being contributed by a limited understanding of antibiotic utilization as a result of inappropriate acquisition and prescription. Parental awareness is essential in optimizing their usage and preserving the effectiveness of these crucial medications. The current study investigates the usage and parental knowledge of antibiotics in children undergoing (adeno) tonsillectomy ((A)TE) in Northern Tanzania.

Methods

a cross-sectional survey was conducted among parents/caregivers of children who underwent (A)TE in Northern Tanzania. A modified and well-structured questionnaire, which was adapted from a World Health Organization (WHO) questionnaire and used to assess the parents´ knowledge of antibiotics and antibiotic use.

Results

the study included 157 participants. About 54% of the children under the age of 5 years. As of 88% of children had already received antibiotics prior to surgery, 92% of the used antibiotics were prescribed by a clinician, and 5% of parents to used leftovers antibiotics for their children. While 88% of the parents reported adhering to prescriptions, 8% of reported buying the same antibiotic (as prescribed before) without consulting a clinician again when their children are sick.

Conclusion

the use of antibiotics, including broad-spectrum antibiotics, was found to be high in our study group. Parents demonstrate a relatively good understanding of antibiotic usage. It is plausible to speculate that a higher prevalence of non-insured, unemployed, and less educated parents may lead to an increased incidence of misuse and misinterpretation of antibiotics.

Prophylactic Mesh Placement During Formation of an End-colostomy: Long-term Randomized Controlled Trial on Effectiveness and Safety

OBJECTIVE

The aim of this study was to determine if prophylactic mesh placement is an effective, safe, and cost-effective procedure to prevent parastomal hernia (PSH) formation in the long term.

BACKGROUND

A PSH is the most frequent complication after stoma formation. Prophylactic placement of a mesh has been suggested to prevent PSH, but long-term evidence to support this approach is scarce.

METHODS

In this multicentre superiority trial patients undergoing the formation of a permanent colostomy were randomly assigned to either retromuscular polypropylene mesh reinforcement or conventional colostomy formation. Primary endpoint was the incidence of a PSH after 5 years. Secondary endpoints were morbidity, mortality, quality of life, and cost-effectiveness.

RESULTS

A total of 150 patients were randomly assigned to the mesh group (n = 72) or nonmesh group (n = 78). For the long-term follow-up, 113 patients were analyzed, and 37 patients were lost to follow-up. After a median follow-up of 60 months (interquartile range: 48.6-64.4), 49 patients developed a PSH, 20 (27.8%) in the mesh group and 29 (37.2%) in the nonmesh group ( P = 0.22; RD: -9.4%; 95% CI: -24, 5.5). The cost related to the meshing strategy was € 2.239 lower than the nonmesh strategy (95% CI: 491.18, 3985.49), and quality-adjusted life years did not differ significantly between groups ( P = 0.959; 95% CI: -0.066, 0.070).

CONCLUSIONS

Prophylactic mesh placement during the formation of an end-colostomy is a safe procedure but does not reduce the incidence of PSH after 5 years of follow-up. It does, however, delay the onset of PSH without a significant difference in morbidity, mortality, or quality of life, and seems to be cost-effective.

An Overview of Stakeholders, Methods, Topics, and Challenges in Participatory Approaches Used in the Development of Medical Devices: A Scoping Review

BACKGROUND

There is a wide variety of participatory approaches to involve stakeholders in the development of medical devices, but there is no comprehensive overview of these approaches. We therefore studied what participatory approaches are used in the development of medical devices as well as the most important characteristics and challenges of these approaches.

METHODS

We conducted a scoping review and searched PubMed, Embase and Web of Science for articles published between July 2014 and July 2019. Papers were included if they presented original research featuring any form of stakeholder participation in the development of medical devices. We used The Spectrum of Public Participation to categorise the approach of each paper. Subsequently, we described the characteristics of each approach: the stakeholders involved, data collection methods, and topics addressed. We also identified challenges of the approaches as reported by researchers.

RESULTS

277 papers were included, which could be categorised into three levels of participation: collaboration, involvement, and consultation. Patients and healthcare professionals are frequently engaged in all approaches. The most often used methods are workshops in the collaboration approach papers, and interviews in the involvement and consultation approach papers. Topics addressed in all approaches are: the problem, device requirements, design choices, testing, and procedural aspects of involvement. Reported challenges entail issues related to sampling, analysis, social dynamics, feasibility, and the limited number of topics that can be addressed.

CONCLUSION

Participatory approaches reported in literature can be categorised in three overarching approaches that have comparable methodological characteristics. This suggests that if researchers want to apply a participatory approach it is not necessary to adopt a pre-determined approach, such as 'participatory action research' (PAR). Instead, they can independently determine the degree of participation, stakeholders, methods, topics, and strategies to account for challenges, making sure the participatory approach fits their research question and context.

Beyond the RCT: When are Randomized Trials Unnecessary for New Therapeutic Devices, and What Should We Do Instead?

OBJECTIVE

The aim of this study was to develop an evidence-based framework for evaluation of therapeutic devices, based on ethical principles and clinical evidence considerations.

SUMMARY BACKGROUND DATA

Nearly all medical products which do not work solely through chemical action are regulated as medical devices. Their huge range of purposes, mechanisms of action and risks pose challenges for regulation. High-profile implantable device failures have fuelled concerns about the level of clinical evidence needed for market approval. Calls for more rigorous evaluation lack clarity about what kind of evaluation is appropriate, and are commonly interpreted as meaning more randomized controlled trials (RCTs). These are valuable where devices are genuinely new and claim to offer measurable therapeutic benefits. Where this is not the case, RCTs may be inappropriate and wasteful.

METHODS

Starting with a set of ethical principles and basic precepts of clinical epidemiology, we developed a sequential decision-making algorithm for identifying when an RCT should be performed to evaluate new therapeutic devices, and when other methods, such as observational study designs and registry-based approaches, are acceptable.

RESULTS

The algorithm clearly defines a group of devices where an RCT is deemed necessary, and the associated framework indicates that an IDEAL 2b study should be the default clinical evaluation method where it is not.

CONCLUSIONS

The algorithm and recommendations are based on the principles of the IDEAL-D framework for medical device evaluation and appear eminently practicable. Their use would create a safer system for monitoring innovation, and facilitate more rapid detection of potential hazards to patients and the public.

IDEAL-D Framework for Device Innovation: A Consensus Statement on the Preclinical Stage

OBJECTIVE

To extend the IDEAL framework for device innovation, IDEAL-D, to include the preclinical stage of development (stage 0).

BACKGROUND

In previous work, the IDEAL collaboration has proposed frameworks for new surgical techniques and complex therapeutic technologies, the central tenet being that development and evaluation can and should proceed together in an ordered and logical manner that balances innovation and safety.

METHODS

Following agreement at the IDEAL Collaboration Council, a multidisciplinary working group was formed comprising 12 representatives from healthcare, academia, industry, and a patient advocate. The group conducted a series of discussions following the principles used in the development of the original IDEAL framework. Importantly, IDEAL aims for maximal transparency, optimal validity in the evaluation of primary effects, and minimization of potential risk to patients or others. The proposals were subjected to further review and editing by members of the IDEAL Council before a final consensus version was adopted.

RESULTS

In considering which studies are required before a first-in-human study, we have: (1) classified devices according to what they do and the risks they carry, (2) classified studies according to what they show about the device, and (3) made recommendations based on the principle that the more invasive and high risk a device is, the greater proof required of their safety and effectiveness before progression to clinical studies (stage 1).

CONCLUSIONS

The proposed recommendations for preclinical evaluation of medical devices represent a proportionate and pragmatic approach that balances the de-risking of first-in-human translational studies against the benefits of rapid translation of new devices into clinical practice.

O01 PROPHYLACTIC MESH PLACEMENT DURING FORMATION OF AN END-COLOSTOMY LONG TERM RCT ON EFFECTIVENESS AND SAFETY

Aim

To determine if prophylactic mesh placement is an effective, safe, and cost-effective procedure to prevent parastomal hernia (PSH) formation in the long term.

Material and Methods

In this multicenter superiority trial patients undergoing formation of a permanent colostomy were randomly assigned to either retromuscular mesh reinforcement or conventional colostomy formation. The primary endpoint was the incidence of a PSH after 5 years. Secondary endpoints were morbidity, mortality, quality of life and cost-effectiveness.

Results

A total of 150 patients were randomly assigned to the mesh group (n = 72) or non-mesh group (n = 78). For the long term follow up, we could analyse 113 patients since 37 patients were lost to follow-up. After a median follow-up of 60 months (IQR 48.6 – 64.4), 49 patients developed a PSH, 20 (27.8%) in the mesh group and 29 (37.2%) in the non-mesh group (p = 0.22; 95% CI -24 – 5.5). A total of 25 patients developed an incisional hernia, seven in the mesh group (10.4%) versus 18 in the non-mesh group (27.2%) (p = 0.013, 95% CI 3.5 – 30.0). No relevant differences were found in quality of life or cost-effectiveness between both study group.

Conclusions

Use of a prophylactic retromuscular mesh at the ostomy site delays but not reduces the incidence of PSH after 5 years of follow-up. It leads to less severe PSH according to the EHS and MM classification with fewer repairs needed. Furthermore it causes patients to have fewer stoma related complications necessitating change of appliances and it is safe without any adverse events or increase in morbidity.

Development of a diagnostic model to identify patients at high risk for cerebellopontine angle lesions

Purpose

To develop a diagnostic model to identify patients at high risk of a CPA lesion.

Methods

A consecutive cohort of patients with AAD referred by a general practitioner, who underwent their first MRI examination of the CPA between 2005 and 2015 was included. Demographics, symptoms, findings during physical examination, and pure-tone audiometry were used as potential predictors. The presence of a CPA lesion was used as outcome.

Results

We analyzed data of 2,214 patients, detecting 73 CPA lesions in 69 (3.1%) patients. The final model contained eleven variables, namely gender [male] [OR 1.055 (95% CI 0.885–1.905)], sudden onset of hearing loss [OR 0.768 (95% CI 0.318–0.992)], gradual onset of hearing loss [OR 1.069 (95% CI 0.500–1.450)], unilateral tinnitus [OR 0.682 (95% CI 0.374–0.999)], complaints of unilateral aural fullness [OR 1.006 (95% CI 0.783–2.155)], instability [OR 1.006 (95% CI 0.580–2.121)], headache [OR 0.959 (95% CI 0.059–1.090)], facial numbness [OR 2.746 (95% CI 0.548–11.085)], facial nerve dysfunction during physical examination [OR 1.024 (95% CI 0.280–3.702)], and asymmetry in BC at 1 kHz [OR 1.013 (95% CI 1.000–1.027)] and 4 kHz [OR 1.008 (95% CI 1.000–1.026)].

Conclusion

The proposed diagnostic model is a first step in selecting patients with a high risk of a CPA lesion among those with AAD. It needs to be externally validated prior to its implementation in clinical practice.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00405-021-06778-6.

Front-of-Package Food Labeling to Reduce Caries: Economic Evaluation

Front-of-package food labeling (FoPFL) is increasingly advocated as an effective intervention to facilitate behavior changes toward healthier food purchasing and consumption, particularly in relation to products with added sugar. The present study assessed the potential caries-related impacts of FoPFL, using Germany as an example. The outcomes of interest were caries lesions prevented, dental treatment costs avoided, productivity loss reductions, and disability-adjusted life years (DALYs) averted. The baseline consumption of added sugar was derived from the German National Nutrition Survey. The reduction in sugar intake due to FoPFL was modeled according to estimates from a recent meta-analysis. Microsimulations were performed for 500,000 individuals and over a time horizon of 10 y. Deterministic and probabilistic sensitivity analyses were performed to check the robustness of results. For the period from 2017 to 2027, FoPFL was identified to prevent 2,370,715 (95% confidence interval [CI], 2,062,730-2,678,700) caries lesions and avert 677.62 (95% CI, 589.59-765.65) DALYs. Treatment cost savings amounted to €175.67 million (95% CI, €152.85-€198.49), and productivity losses reduced by €27.33 million (95% CI, €23.78-€30.88). Sensitivity analyses showed that the magnitude of the effects is highly dependent on consumers' response to FoPFL. Our findings suggest that FoPFL has the potential to substantially reduce caries increment, caries-related morbidity, and economic burden. In addition, our study allows for the inclusion of oral health estimates in overall health estimates for sugar-related food labeling. Before prioritizing a strategy to tackle sugar consumption, decision makers should carefully consider all relevant context-specific factors and implementation costs.

Forecasting future dental health expenditures: Development of a framework using data from 32 OECD countries

Objective

To (1) develop a framework for forecasting future dental expenditures, using currently available information, and (2) identify relevant research and data gaps such that dental expenditure predictions can continuously be improved in the future.

Methods

Our analyses focused on 32 OECD countries. Dependent on the number of predictors, we employed dynamic univariate and multivariate modelling approaches with various model specifications. For univariate modelling, an auto‐regressive (AR) dynamic model was employed to incorporate historical trends in dental expenditures. Multivariate modelling took account of historical trends, as well as of relationships between dental expenditures, dental morbidity, economic growth in terms of gross domestic product and demographic changes.

Results

Estimates of dental expenditures varied substantially across different model specifications. Models relying on dental morbidity as one of the predictors performed worst regardless of their specification. Using the best‐fitted model specification, that is the univariate second‐order autoregression [AR(2)], the forecasted dental expenditures across 32 OECD countries amounted to US$316bn (95% forecasted interval, FI: 258‐387) in 2020, US$434bn (95%FI: 354‐532) in 2030 and US$594bn (95%FI: 485‐728) in 2040. Per capita spending in 2040 was forecasted to be highest in Germany (US$889, 95%FI: 726‐1090) and lowest in Mexico (US$52, 95%FI: 42‐64).

Conclusions

The present study demonstrates the feasibility and challenges in predicting dental expenditures and can serve as a basis for improvement towards more sustainable and resilient health policy and resource planning. Within the limitations of available data sources, our findings suggest that dental expenditures in OECD countries could increase substantially over the next two decades and vary considerably across countries. For more accurate estimation and a better understanding of determinants of dental expenditures, more comprehensive data on dental spending and dental morbidity are urgently needed.

Intrathoracic versus cervical anastomosis after minimally invasive esophagectomy for esophageal cancer: A randomized controlled trial

4509

Background: Robust evidence is lacking whether Ivor Lewis minimally invasive esophagectomy (MIE) or McKeown MIE should be preferred for patients with mid to distal esophageal or gastro-esophageal junction Siewert I-II (GEJ) cancer. Methods: In this multicenter randomized controlled trial, patients with esophageal (below the level of the carina) or GEJ cancer planned for curative resection were recruited. Eligible patients were randomly assigned (1:1) to either Ivor Lewis MIE or McKeown MIE. The primary endpoint was anastomotic leakage (AL) requiring endoscopic, radiologic or surgical intervention. Secondary outcome parameters were overall AL rate, postoperative complications, length of stay and mortality. Results: A total of 262 patients were randomly assigned to Ivor Lewis MIE (n = 130) or McKeown MIE (n = 132). Seventeen patients were excluded from the trial due to not meeting inclusion criteria (n = 2), physical unfitness for surgery (n = 3), patients’ choice (n = 3), interval metastases (n = 5) or peroperative metastases (n = 4). AL necessitating reintervention occurred in 15 (12.3%) of 122 patients after Ivor Lewis MIE and in 39 (31.7%) of 123 patients after McKeown MIE (relative risk 0.39, 95% CI 0.22-0.65; risk difference 19.4%, 95% CI 7.9%-31.8%). Overall AL rate was 12.3% after Ivor Lewis MIE and 34.1% after McKeown MIE. Severe complications (Clavien-Dindo ≥ 3b) were observed in 10.7% after Ivor Lewis MIE and in 22.0% after McKeown MIE. Pleural effusion requiring drainage occurred in 9.8% of patients after Ivor Lewis MIE and 21.1% of patients after McKeown MIE. RLN palsy rate was 0% after Ivor Lewis MIE and 7.3% after McKeown MIE. Median length of hospital stay was 10 days (IQR 8 – 15 days) after Ivor Lewis MIE and 12 days (IQR 9 – 18 days) after McKeown MIE. ICU length of stay and mortality rates were comparable between groups. Conclusions: These findings provide evidence for a lower rate of AL requiring reintervention after Ivor Lewis MIE compared to McKeown MIE for patients with mid to distal esophageal or GEJ cancer. Clinical trial information: NTR4333 .

Safety and effectiveness of aspirin and enoxaparin for venous thromboembolism prophylaxis after total hip and knee arthroplasty: a systematic review

BACKGROUND

Patients undergoing total hip arthroplasty (THA) or total knee arthroplasty (TKA) are at risk of venous thromboembolism (VTE). Australian orthopaedic guidelines recommend aspirin and low-molecular-weight heparin (e.g. enoxaparin) for VTE prophylaxis; however, there is debate in the international literature around the use of aspirin as VTE prophylaxis. This review assesses the risks and benefits of aspirin compared to enoxaparin as VTE prophylaxis for patients undergoing THA or TKA.

METHODS

A systematic review was conducted to identify relevant randomized controlled trials. Studies comparing enoxaparin, aspirin and/or placebo for VTE prophylaxis in THA or TKA patients were included. Network meta-analysis (NMA) was performed to calculate risk ratios (RRs) and confidence intervals (CIs). Quality appraisal was conducted by assessing risk of bias and the strength of the evidence.

RESULTS

Nine randomized controlled trials were eligible for inclusion. The NMA found no statistically significant differences for the investigated outcomes: total DVT rates (RR = 1.21, 95% CI 0.86, 1.72), symptomatic pulmonary embolism (PE) rates (RR = 1.02, 95% CI 0.02, 50.86), major haemorrhage (RR = 0.97, 95% CI 0.02, 50.99) and wound complication (RR = 0.73, 95% CI 0.17, 3.20). The occurrence of PE was rare. Due to limited data, sub-group analysis was not possible. The overall quality of evidence in the NMA is considered to be very low.

CONCLUSION

This review did not find statistically significant differences between aspirin and enoxaparin. Future studies should identify more evidence, particularly for rare outcomes such as PE, as this might help decision-makers to get consensus on the use of aspirin as VTE prophylaxis.

Management of intrathoracic and cervical anastomotic leakage after esophagectomy for esophageal cancer: a systematic review

Background

Anastomotic leakage (0-30%) after esophagectomy is a severe complication and is associated with considerable morbidity and mortality. The aim of this study was to determine which treatment for anastomotic leakage after esophagectomy have the best clinical outcome, based on the currently available literature.

Methods

A systematic literature search was performed in Medline, Embase, and Web of Science until April 2017. All studies reporting on the specific treatment of cervical or intrathoracic anastomotic leakage following esophagectomy with gastric tube reconstruction for esophageal or cardia cancer were included. The primary outcome parameter was postoperative mortality. Methodological quality was assessed by the Newcastle-Ottawa Quality Assessment Scale.

Results

Nineteen retrospective cohort studies including 273 patients were identified. Methodological quality of all studies was poor to moderate. Mortality rates of intrathoracic anastomotic leakages in the treatment groups were as follows: conservative (14%), endoscopic stent (8%), endoscopic drainage (8%), endoscopic vacuum-assisted closure system (0%), and surgery treatment group (50%). Mortality rates of cervical anastomotic leakages in the treatment groups were as follows: conservative (8%), endoscopic stent (29%), and endoscopic dilatation (0%).

Discussion

Due to small cohorts, heterogeneity between studies, and lack of data regarding leakage characteristics, no evidence supporting a specific treatment for anastomotic leakage after esophagectomy was found. A severity score based on leakage characteristics instead of treatment given is essential for determining the optimal treatment of anastomotic leakage. In the absence of robust evidence-based treatment guidelines, we suggest customized treatment depending on sequelae of the leak and clinical condition of the patient. PrDepartment of Surgery, Radboudumc, P.O.B. 9101/618 NLactical advices are provided.

Trial registration

Registration number PROSPERO: CRD42016032374.

The caries-related cost and effects of a tax on sugar-sweetened beverages

OBJECTIVES

While taxes on sugar-sweetened beverages (SSBs) have frequently been proposed to reduce non-communicable diseases like obesity and type 2 diabetes, relatively little is known about the caries-related impacts of SSB taxation. We assessed the effect of a 20% ad valorem tax on SSBs on dental caries and related treatment costs, specifically taking into account that consumers may switch from SSBs to other (non-taxed) sugar-containing drinks.

STUDY DESIGN

Cost-effectiveness analysis.

METHODS

A tooth-level Markov model was developed to evaluate the cost and effects of SSB taxation. Tax-related changes in sugar consumption were calculated using available evidence on SSBs price and cross-price elasticities, thereby taking changes in drinks consumption behaviors into account. The model was used to establish lifetime disease-free tooth years, caries lesions prevented, caries-related treatment costs avoided, tax revenues, and administrative costs (reference case: the Netherlands). Deterministic and probabilistic sensitivity analyses were performed to address uncertainties.

RESULTS

A 20% SSB taxation would result in an average of 2.13 (95% uncertainty interval [UI] 2.12-2.13) caries-free tooth years per person and, on population level, prevention of 1,030,163 (95% UI 1,027,903-1,032,423) caries lesions. The intervention was found to save an aggregate total of € 159.01 (95% UI 158.67-159.35) million in terms of dental care expenditures. The estimated lifetime tax revenues (€3.49billion) were larger than the administrative costs for taxation (€37.3 million).

CONCLUSIONS

Our results show that SSB taxation may substantially improve oral health and reduce the caries-related economic burden. Benefits would be the greatest for younger age groups.

An international comparison of diagnostic and management strategies for vestibular schwannoma

Objective

To compare international diagnostic and management strategies for vestibular schwannoma (VS).

Methods

A web-based questionnaire was sent to 130 otolaryngologists, mainly identified through the European Skull Base Society. It contained questions on general information including guideline usage as well as questions on diagnosis (focussing on selection of patients for MRI) and management of VS, including case scenarios. Descriptive statistics were reported.

Results

Thirty-six otolaryngologists working in 11 different countries completed the questionnaire (response rate: 28%). Guidelines for diagnosis and management of VS are used by 44% and 42% of respondents, respectively. In the diagnostic strategy for VS, different types and combinations of audiovestibular function tests are used when deciding whether a patient should undergo an MRI. Respondents apply 18 different definitions of asymmetrical hearing loss. Variation was also apparent from reported considerations on management of VS. Most respondents (84%) prefer a wait-and-scan strategy in case of a small intrameatal VS (Koos 1). Variety in management strategies increases for patients with a medium to large sized VS (Koos 2, 3 and 4). The details of each management strategy (wait-and-scan, microsurgery, stereotactic radiosurgery and fractionated radiotherapy) also differ among respondents.

Conclusions

A large variation in diagnostic and management strategies for VS was identified between respondents. More evidence and/or consensus seem warranted to reduce uncertainties for patients, and differences in outcome and costs that might result from the variety of strategies currently being applied.

Electronic supplementary material

The online version of this article (10.1007/s00405-018-5199-6) contains supplementary material, which is available to authorized users.

Importance and Presence of High-Quality Evidence for Clinical Decisions in Neurosurgery: International Survey of Neurosurgeons

BACKGROUND

The publication rate of neurosurgical guidelines has increased tremendously over the past decade; however, only a small proportion of clinical decisions appear to be based on high-quality evidence.

OBJECTIVE

The aim was to evaluate the evidence available within neurosurgery and its value within clinical practice according to neurosurgeons.

METHODS

A Web-based survey was sent to 2552 neurosurgeons, who were members of the European Association of Neurosurgical Societies.

RESULTS

The response rate to the survey was 6.78% (173/2552). According to 48.6% (84/173) of the respondents, neurosurgery clinical practices are based on less evidence than other medical specialties and not enough high-quality evidence is available; however, 84.4% (146/173) of the respondents believed neurosurgery is amenable to evidence. Of the respondents, 59.0% (102/173) considered the neurosurgical guidelines in their hospital to be based on high-quality evidence, most of whom considered their own treatments to be based on high-quality (level I and/or level II) data (84.3%, 86/102; significantly more than for the neurosurgeons who did not consider the hospital guidelines to be based on high-quality evidence: 55%, 12/22; P<.001). Also, more neurosurgeons with formal training believed they could understand, criticize, and interpret statistical outcomes presented in journals than those without formal training (93%, 56/60 and 68%, 57/84 respectively; P<.001).

CONCLUSIONS

According to the respondents, neurosurgery is based on high-quality evidence less often than other medical specialties. The results of the survey indicate that formal training in evidence-based medicine would enable neurosurgeons to better understand, criticize, and interpret statistical outcomes presented in journals.

Instrument completion and validation of the patient-reported apnea questionnaire (PRAQ)

Background

We previously developed the preliminary version of the Patient-Reported Apnea Questionnaire (PRAQ), a questionnaire measuring health-related quality of life in patients with (suspected) obstructive sleep apnea (OSA). This questionnaire was developed for clinical practice, where it can potentially serve two goals: use on an individual patient level to improve patient care, and use on an aggregate level to measure outcomes for quality improvement at a sleep center. In this study we aim to finalize the PRAQ, make a subselection of items and domains specifically for outcome measurement, and assess the validity, reliability and responsiveness of the PRAQ.

Methods

Patients with suspected OSA were included and asked to complete the PRAQ and additional questionnaires one or more times. The collected data was used to perform the final item selection for clinical practice and for outcome measurement, create the domains for outcome measurement, and assess the measurement properties internal consistency, test-retest reliability, convergent validity and responsiveness.

Results

180 patients were included in the study. The final version of the PRAQ for use in clinical practice contains 40 items and 10 domains. A subselection of 33 items in 5 domains was selected for optimal outcome measurement with the PRAQ. The results for the outcome measurement domains were: Cronbach’s alpha 0.88–0.95, ICC 0.81–0.88, and > 75% of hypotheses correct for convergent validity and responsiveness.

Conclusions

The PRAQ shows good measurement properties in patients with (suspected) OSA.

Electronic supplementary material

The online version of this article (10.1186/s12955-018-0988-6) contains supplementary material, which is available to authorized users.

Minimally invasive and endoscopic versus open necrosectomy for necrotising pancreatitis: a pooled analysis of individual data for 1980 patients

OBJECTIVE

Minimally invasive surgical necrosectomy and endoscopic necrosectomy, compared with open necrosectomy, might improve outcomes in necrotising pancreatitis, especially in critically ill patients. Evidence from large comparative studies is lacking.

DESIGN

We combined original and newly collected data from 15 published and unpublished patient cohorts (51 hospitals; 8 countries) on pancreatic necrosectomy for necrotising pancreatitis. Death rates were compared in patients undergoing open necrosectomy versus minimally invasive surgical or endoscopic necrosectomy. To adjust for confounding and to study effect modification by clinical severity, we performed two types of analyses: logistic multivariable regression and propensity score matching with stratification according to predicted risk of death at baseline (low: <5%; intermediate: ≥5% to <15%; high: ≥15% to <35%; and very high: ≥35%).

RESULTS

Among 1980 patients with necrotising pancreatitis, 1167 underwent open necrosectomy and 813 underwent minimally invasive surgical (n=467) or endoscopic (n=346) necrosectomy. There was a lower risk of death for minimally invasive surgical necrosectomy (OR, 0.53; 95% CI 0.34 to 0.84; p=0.006) and endoscopic necrosectomy (OR, 0.20; 95% CI 0.06 to 0.63; p=0.006). After propensity score matching with risk stratification, minimally invasive surgical necrosectomy remained associated with a lower risk of death than open necrosectomy in the very high-risk group (42/111 vs 59/111; risk ratio, 0.70; 95% CI 0.52 to 0.95; p=0.02). Endoscopic necrosectomy was associated with a lower risk of death than open necrosectomy in the high-risk group (3/40 vs 12/40; risk ratio, 0.27; 95% CI 0.08 to 0.88; p=0.03) and in the very high-risk group (12/57 vs 28/57; risk ratio, 0.43; 95% CI 0.24 to 0.77; p=0.005).

CONCLUSION

In high-risk patients with necrotising pancreatitis, minimally invasive surgical and endoscopic necrosectomy are associated with reduced death rates compared with open necrosectomy.

The development of a patient-reported outcome measure for patients with obstructive sleep apnea: the Patient-Reported Apnea Questionnaire (PRAQ)

BACKGROUND

Obstructive sleep apnea (OSA) is a chronic condition that can have a wide range of consequences for a patient's health-related quality of life. Monitoring aspects of quality of life in clinical practice has the potential to improve the patient-centeredness of care for patients with OSA. The aim of this article is to describe the development of the Patient-Reported Apnea Questionnaire (PRAQ), a patient-reported outcome measure (PROM) that is designed for use in clinical practice on an individual patient level, as well as subsequent outcome measurement on an aggregate level.

METHODS

We used the items of available PROMs for OSA to create a new PROM with focus on its applicability in clinical practice. We used a tailored development process to come to a selection of domains and items. Patients and healthcare professionals were intensively involved in the development of the PRAQ via membership of the development team, online surveys and focus groups, as well as two rounds of cognitive validation.

RESULTS

This first version of the PRAQ consists of 43 items and 10 preliminary domains, and covers the aspects of quality of life that healthcare professionals and patients wish to discuss in clinical practice. Patients indicate that PRAQ is comprehensive and that its length is acceptable. Comprehensive patient involvement has ensured good content validity for the PRAQ.

CONCLUSIONS

This article shows how a PROM can be developed with a specific focus on its applicability in clinical practice.

Appraising convergent validity of patient-reported outcome measures in systematic reviews: constructing hypotheses and interpreting outcomes

Purpose

Convergent validity is one type of validity that is commonly assessed for patient-reported outcome measures (PROMs). It is assessed by means of “hypothesis testing”: determining whether the scores of the instrument under study correlate with other instruments in the way that one would expect. Authors of systematic reviews on measurement properties for PROMs may encounter validation articles which do not state hypotheses by which convergent validity can be tested. The information in these articles can therefore not be readily used to determine the adequacy of convergent validity. We suggest that in these cases, reviewers construct their own hypotheses. However, constructing hypotheses and interpreting outcomes is not always straightforward, and we wish to aid reviewers based on our own recent experiences with a systematic review on measurement properties.

Recommendations

We have the following recommendations for authors of a systematic review on measurement properties who wish to construct hypotheses for convergent validity: take an active role in judging the suitability of the comparator instruments of validation articles; be transparent about which hypotheses were constructed, the underlying assumptions on which they are based, and whether they were constructed by the authors of the validation article or by the reviewer; discuss unmet hypotheses, especially if convergent validity is judged to be inadequate; and when synthesizing data, add up the results of all hypotheses for one instrument, rather than judging convergent validity per study.

Measurement properties of patient-reported outcome measures (PROMs) in adults with obstructive sleep apnea (OSA): A systematic review

This systematic review summarizes the evidence regarding the quality of patient-reported outcome measures (PROMs) validated in patients with obstructive sleep apnea (OSA). We performed a systematic literature search of all PROMs validated in patients with OSA, and found 22 measures meeting our inclusion criteria. The quality of the studies was assessed using the consensus-based standards for the selection of health status measurement instruments (COSMIN) checklist. The results showed that most of the measurement properties of the PROMs were not, or not adequately, assessed. For many identified PROMs there was no involvement of patients with OSA during their development or before the PROM was tested in patients with OSA. Positive exceptions and the best current candidates for assessing health status in patients with OSA are the sleep apnea quality of life index (SAQLI), Maugeri obstructive sleep apnea syndrome (MOSAS) questionnaire, Quebec sleep questionnaire (QSQ) and the obstructive sleep apnea patient-oriented severity index (OSAPOSI). Even though there is not enough evidence to fully judge the quality of these PROMs as outcome measure, when interpreted with caution, they have the potential to add value to clinical research and clinical practice in evaluating aspects of health status that are important to patients.

Preferred Reporting Items for Systematic Review and Meta-Analyses of individual participant data: the PRISMA-IPD Statement

IMPORTANCE

Systematic reviews and meta-analyses of individual participant data (IPD) aim to collect, check, and reanalyze individual-level data from all studies addressing a particular research question and are therefore considered a gold standard approach to evidence synthesis. They are likely to be used with increasing frequency as current initiatives to share clinical trial data gain momentum and may be particularly important in reviewing controversial therapeutic areas.

OBJECTIVE

To develop PRISMA-IPD as a stand-alone extension to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) Statement, tailored to the specific requirements of reporting systematic reviews and meta-analyses of IPD. Although developed primarily for reviews of randomized trials, many items will apply in other contexts, including reviews of diagnosis and prognosis.

DESIGN

Development of PRISMA-IPD followed the EQUATOR Network framework guidance and used the existing standard PRISMA Statement as a starting point to draft additional relevant material. A web-based survey informed discussion at an international workshop that included researchers, clinicians, methodologists experienced in conducting systematic reviews and meta-analyses of IPD, and journal editors. The statement was drafted and iterative refinements were made by the project, advisory, and development groups. The PRISMA-IPD Development Group reached agreement on the PRISMA-IPD checklist and flow diagram by consensus.

FINDINGS

Compared with standard PRISMA, the PRISMA-IPD checklist includes 3 new items that address (1) methods of checking the integrity of the IPD (such as pattern of randomization, data consistency, baseline imbalance, and missing data), (2) reporting any important issues that emerge, and (3) exploring variation (such as whether certain types of individual benefit more from the intervention than others). A further additional item was created by reorganization of standard PRISMA items relating to interpreting results. Wording was modified in 23 items to reflect the IPD approach.

CONCLUSIONS AND RELEVANCE

PRISMA-IPD provides guidelines for reporting systematic reviews and meta-analyses of IPD.

Cost-effectiveness of selective neck dissection versus modified radical neck dissection for treating metastases in patients with oral cavity cancer: A modelling study

BACKGROUND

Choosing between a more or less extensive neck dissection implies a tradeoff between survival, quality of life, and costs. The purpose of this study was to determine if selective neck dissection (level I-III or I-IV) is cost-effective compared with modified radical neck dissection (level I-V) in patients with cT1-2 oral squamous cell carcinoma (OSCC) with singular nodal disease confined to level I or II.

METHODS

A decision-analytic model was developed to model quality-adjusted life years (QALYs) and costs over a lifetime horizon, based on literature.

RESULTS

The selective neck dissection strategy resulted in an expected health loss of 0.06 QALY and savings of €1351 per patient compared to modified radical neck dissection. The results were sensitive to differences in regional failure probabilities between the strategies.

CONCLUSION

With the evidence used in this model, selective neck dissection was not cost-effective compared to modified radical neck dissection. Prospective research on regional failure is needed to provide optimal treatment for patients with OSCC.

Ethical considerations and rationale of the MAKI trial: a multicenter double-blind randomized placebo-controlled trial into the preventive effect of palivizumab on recurrent wheezing associated with respiratory syncytial virus infection in children with a gestational age of 33-35 weeks

BACKGROUND

Respiratory syncytial virus (RSV) lower respiratory tract infection (LRTI) is the most frequent cause of bronchiolitis during infancy. Long-term airway morbidity with recurrent post bronchiolitis wheezing (PBW) episodes, which are probably associated with respiratory infections, occurs in 30 to 70% of infants that were hospitalised with RSV LRTI.

METHODS

We set up a multicenter, placebo-controlled double-blind randomized clinical trial in healthy preterm infants born between 33 and 35 weeks gestational age (WGA). The children received either one-monthly intramuscular palivizumab or placebo injection during the RSV season with a minimum of 2 injections.

RESULTS

The primary objective was to determine the preventive effect of RSV immunoprophylaxis (palivizumab) on the development of recurrent wheezing during the first year of life. The primary outcome measure was the number of wheezing days during the first year of life as obtained by daily logs. As a secondary outcome nasal swabs were taken for viral analysis in case of respiratory symptoms. We will also examine wheezing at age 1, 3 and 6 years both reported by the parents and the general practitioner and quality of life as secondary outcomes. This trial is possible because RSV immunoprophylaxis, although effective in this population, is not completely used in the Netherlands due to its high costs.

CONCLUSION

The Institutional review board (IRB) concluded the study has high clinical relevance because the benefit of 50% chance of protection by palivizumab outweighs the risk of side adverse events due to intramuscular administration of placebo.

Breastfeeding modulates neonatal innate immune responses: a prospective birth cohort study

BACKGROUND

Neonatal Toll-like receptor (TLR) responses are biased toward Th2-polarizing responses at birth and rapidly mature toward more balanced responses during the first month of life. Postnatal TLR maturation may be guided by environmental exposure.

AIMS

To determine the environmental determinants of neonatal TLR function.

MATERIALS AND METHODS

A prospective birth cohort study was performed in 291 healthy term neonates. Mode of delivery, breastfeeding, birth month, siblings, pets and parental smoking were analyzed in relation to neonatal innate immune parameters at the age of 1 month. Whole blood concentrations of innate immune cells were measured by flow cytometry. In vitro TLR-mediated cytokine production was determined by ELISA.

RESULTS

Breastfeeding was the major determinant of neonatal innate immunity, associated with 5 (31%) of neonatal innate immune parameters, of which the association with TLR7-mediated IL-10 production was most significant (76 pg/ml in breastfed neonates vs. 293 pg/ml in formula-fed neonates, p = 0.001). Of innate immune variables, TLR3-mediated IL-12p70 production was highly associated with environmental exposures (pets, breastfeeding and mode of delivery), whereas TLR9-mediated cytokine responses were not associated with any environmental factor.

CONCLUSION

Neonatal innate immune responses are differentially modulated by environmental exposure in the first month of life. The protective effect of breastfeeding against subsequent infections and atopy might be explained by its innate immune modulatory effects in the first month of life.

Cord blood vitamin D deficiency is associated with respiratory syncytial virus bronchiolitis

BACKGROUND

Respiratory syncytial virus (RSV) is the most important pathogen causing severe lower respiratory tract infection (LRTI) in infants. Epidemiologic and basic studies suggest that vitamin D may protect against RSV LRTI.

OBJECTIVE

To determine the association between plasma vitamin D concentrations at birth and the subsequent risk of RSV LRTI.

DESIGN

A prospective birth cohort study was performed in healthy term neonates. Concentrations of 25-hydroxyvitamin D (25-OHD) in cord blood plasma were related to RSV LRTI in the first year of life, defined as parent-reported LRTI symptoms in a daily log and simultaneous presence of RSV RNA in a nose-throat specimen.

RESULTS

The study population included 156 neonates. Eighteen (12%) developed RSV LRTI. The mean plasma 25-OHD concentration was 82 nmol/L. Overall, 27% of neonates had 25-OHD concentrations < 50 nmol/L, 27% had 50-74 nmol/L and only 46% had 25-OHD 75 nmol/L. Cord blood 25-OHD concentrations were strongly associated with maternal vitamin D3 supplementation during pregnancy. Concentrations of 25-OHD were lower in neonates who subsequently developed RSV LRTI compared with those who did not (65 nmol/L versus 84 nmol/L, P = .009). Neonates born with 25-OHD concentrations <50 nmol/L had a sixfold (95% confidence interval: 1.6-24.9; P = .01) increased risk of RSV LRTI in the first year of life compared with those with 25-OHD concentrations ≥ 75 nmol/L.

CONCLUSIONS

Vitamin D deficiency in healthy neonates is associated with increased risk of RSV LRTI in the first year of life. Intensified routine vitamin D supplementation during pregnancy may be a useful strategy to prevent RSV LRTI during infancy.

Neonatal total IgE and respiratory tract infections in children with intrauterine smoke exposure

BACKGROUND

Exposure to environmental tobacco smoke (ETS) is known to increase the risk of respiratory tract infections (RTI). Some children, however, may be more susceptible to the harmful effects of ETS than others. We examined whether early atopic status (defined by elevated neonatal total IgE (tIgE) or symptoms of atopic dermatitis) modified the association between ETS exposure and RTI.

METHODS

The data of 2863 children from the Prevention and Incidence of Asthma and Mite Allergy birth cohort were collected to the age of 4 years. Neonatal tIgE was collected from a subset of 914 children, and clinical information by yearly parental questionnaires. The effect of pre- and/or postnatal ETS exposure, early atopic status and interaction between these factors was studied for various RTI.

RESULTS

Children with elevated tIgE or atopic dermatitis and prenatal ETS exposure have a strongly increased risk of frequent RTI (aOR 6.18 (95% CI 1.45 to 26.34) and 5.69 (2.01 to 16.04), respectively; interaction p=0.006 and p=0.14, respectively) compared to non-atopic children without prenatal ETS exposure. Similar results were seen for lower RTI and otitis. This effect was less evident for postnatal ETS.

CONCLUSION

Early atopic status enhances the risk of RTI in children with prenatal ETS exposure. This suggests that host factors modify the association between ETS and RTI.