Research activity and the association with mortality.

INTRODUCTION: The aims of this study were to describe the key features of acute NHS Trusts with different levels of research activity and to investigate associations between research activity and clinical outcomes. METHODS: National Institute for Health Research (NIHR) Comprehensive Clinical Research Network (CCRN) funding and number of patients recruited to NIHR Clinical Research Network (CRN) portfolio studies for each NHS Trusts were used as markers of research activity. Patient-level data for adult non-elective admissions were extracted from the English Hospital Episode Statistics (2005-10). Risk-adjusted mortality associations between Trust structures, research activity and, clinical outcomes were investigated. RESULTS: Low mortality Trusts received greater levels of funding and recruited more patients adjusted for size of Trust (n = 35, 2,349 £/bed [95% CI 1,855-2,843], 5.9 patients/bed [2.7-9.0]) than Trusts with expected (n = 63, 1,110 £/bed, [864-1,357] p<0.0001, 2.6 patients/bed [1.7-3.5] p<0.0169) or, high (n = 42, 930 £/bed [683-1,177] p = 0.0001, 1.8 patients/bed [1.4-2.1] p<0.0005) mortality rates. The most research active Trusts were those with more doctors, nurses, critical care beds, operating theatres and, made greater use of radiology. Multifactorial analysis demonstrated better survival in the top funding and patient recruitment tertiles (lowest vs. highest (odds ratio & 95% CI: funding 1.050 [1.033-1.068] p<0.0001, recruitment 1.069 [1.052-1.086] p<0.0001), middle vs. highest (funding 1.040 [1.024-1.055] p<0.0001, recruitment 1.085 [1.070-1.100] p<0.0001). CONCLUSIONS: Research active Trusts appear to have key differences in composition than less research active Trusts. Research active Trusts had lower risk-adjusted mortality for acute admissions, which persisted after adjustment for staffing and other structural factors

Are antifibrinolytic drugs equivalent in reducing blood loss and transfusion in cardiac surgery? A meta-analysis of randomized head-to-head trials

BACKGROUND: Aprotinin has been shown to be effective in reducing peri-operative blood loss and the need for re-operation due to continued bleeding in cardiac surgery. The lysine analogues tranexamic acid (TXA) and epsilon aminocaproic acid (EACA) are cheaper, but it is not known if they are as effective as aprotinin. METHODS: Studies were identified by searching electronic databases and bibliographies of published articles. Data from head-to-head trials were pooled using a conventional (Cochrane) meta-analytic approach and a Bayesian approach which estimated the posterior probability of TXA and EACA being equivalent to aprotinin; we used as a non-inferiority boundary a 20% increase in the rates of transfusion or re-operation because of bleeding. RESULTS: Peri-operative blood loss was significantly greater with TXA and EACA than with aprotinin: weighted mean differences were 106 mls (95% CI 37 to 227 mls) and 185 mls (95% CI 134 to 235 mls) respectively. The pooled relative risks (RR) of receiving an allogeneic red blood cell (RBC) transfusion with TXA and EACA, compared with aprotinin, were 1.08 (95% CI 0.88 to 1.32) and 1.14 (95% CI 0.84 to 1.55) respectively. The equivalent Bayesian posterior mean relative risks were 1.15 (95% Bayesian Credible Interval [BCI] 0.90 to 1.68) and 1.21 (95% BCI 0.79 to 1.82) respectively. For transfusion, using a 20% non-inferiority boundary, the posterior probabilities of TXA and EACA being non-inferior to aprotinin were 0.82 and 0.76 respectively. For re-operation the Cochrane RR for TXA vs. aprotinin was 0.98 (95% CI 0.51 to 1.88), compared with a posterior mean Bayesian RR of 0.63 (95% BCI 0.16 to 1.46). The posterior probability of TXA being non-inferior to aprotinin was 0.92, but this was sensitive to the inclusion of one small trial. CONCLUSION: The available data are conflicting regarding the equivalence of lysine analogues and aprotinin in reducing peri-operative bleeding, transfusion and the need for re-operation. Decisions are sensitive to the choice of clinical outcome and non-inferiority boundary. The data are an uncertain basis for replacing aprotinin with the cheaper lysine analogues in clinical practice. Progress has been hampered by small trials and failure to study clinically relevant outcomes

Do computerised clinical decision support systems for prescribing change practice? A systematic review of the literature (1990-2007)

Computerised clinical decision support systems (CDSSs) are used widely to improve quality of care and patient outcomes. This systematic review evaluated the impact of CDSSs in targeting specific aspects of prescribing, namely initiating, monitoring and stopping therapy. We also examined the influence of clinical setting (institutional vs ambulatory care), system- or user-initiation of CDSS, multi-faceted vs stand alone CDSS interventions and clinical target on practice changes in line with the intent of the CDSS. We searched Medline, Embase and PsychINFO for publications from 1990-2007 detailing CDSS prescribing interventions. Pairs of independent reviewers extracted the key features and prescribing outcomes of methodologically adequate studies (experiments and strong quasi-experiments). 56 studies met our inclusion criteria, 38 addressing initiating, 23 monitoring and three stopping therapy. At the time of initiating therapy, CDSSs appear to be somewhat more effective after, rather than before, drug selection has occurred (7/12 versus 12/26 studies reporting statistically significant improvements in favour of CDSSs on = 50% of prescribing outcomes reported). CDSSs also appeared to be effective for monitoring therapy, particularly using laboratory test reminders (4/7 studies reporting significant improvements in favour of CDSSs on the majority of prescribing outcomes). None of the studies addressing stopping therapy demonstrated impacts in favour of CDSSs over comparators. The most consistently effective approaches used system-initiated advice to fine-tune existing therapy by making recommendations to improve patient safety, adjust the dose, duration or form of prescribed drugs or increase the laboratory testing rates for patients on long-term therapy. CDSSs appeared to perform better in institutional compared to ambulatory settings and when decision support was initiated automatically by the system as opposed to user initiation. CDSSs implemented with other strategies such as education were no more successful in improving prescribing than stand alone interventions. Cardiovascular disease was the most studied clinical target but few studies demonstrated significant improvements on the majority of prescribing outcomes. Our understanding of CDSS impacts on specific aspects of the prescribing process remains relatively limited. Future implementation should build on effective approaches including the use of system-initiated advice to address safety issues and improve the monitoring of therapy

Evidence-based patient decision making: the development of a decision aid on blood transfusion

Research Doctorate - Doctor of Philosophy (PhD)Background: Decision aids are structures education packages designed to foster shared decision making between patient physician. They are often used when there is confusion or disagreement associated with the values patients assigned to, and the evidence on, the various outcomes of the intervention in question. Blood transfusion relation to elective surgery is an area that requires both physicians and patients to carefully consider different treatment options. The issues of variation in transfusion practices, different personal values in regards to receiving blood, and the uncertainty as to whether the benefits of technologies aimed at minimising allogeneic blood use (e.g. pre-operative autologous donation or PAD) outweigh the potential harms justify attempts to design a patient decision aid in this area. Aims: The overall aim of the thesis was to develop and pilot test a decision aid describing blood transfusion options to patients planning any type of major elective surgery (such as hip replacement or heart bypass). A series of studies and reviews were necessary to adequately inform the development of the decision aid. Hence, additional aims of the thesis were: to investigate whether the manner in which treatment effects are presented influence the healthcare decisions made by patients (information framing). ; To systematically review the evidence on the benefits and harms of PAD (e.g. need for allogeneic/autologous blood, other clinical outcomes). ; To examine the attitudes, beliefs, understanding and possible misconceptions of the general public, patients, special interest group members (e.g. Hepatitis C Council), and physicians regarding blood transfusion. Methods: The following studies were undertaken to inform the development of the decision aid: a systematic review and meta-analysis exploring the impact of information framing on patient treatment decision making; a systematic review and meta-analysis of controlled observational studies on PAD; and a survey (administered as a computer assisted telephone interview) of the views and opinions of physicians, patients, patients, and the public about blood transfusion. Decision aid development was guided by the Ottawa Decision Support Framework. The initial evaluation stages involved drafting and re-drafting the decision content by a group of experts in the fields of haematology, internal medicine, epidemiology, and health psychology. The final draft of the decision aid was reviewed by health professionals and patients who were about to have or had recently undergone major elective surgery. Participants provided feedback on its acceptability and identified areas for improvement during a semi-structures telephone interview. The decision aid was also quality assessed using the CREDIBLE criteria. Results: The results of a systematic review on information framing indicated that numerical data should be presented in more than one way to ensure patients form an accurate perception of treatment worth. In general, surgical and medical treatments tended to be preferred when information was expressed in a survival (positive) frame compared to a mortality (negative) frame, or when expressed as relative risk reduction (RRR) as opposed to absolute risk reduction (ARR) or number needed to treat (NNT) frames. The systematic review of controlled observational studies on PAD produced similar results to those from randomised controlled trials: PAD statistically significantly decreased the need for allogeneic blood yet increased the likelihood of receiving any transfusion (allogeneic/autologous) compared to usual care. Most studies (75%) did not use a transfusion protocol and seven studies reported using a more liberal protocol for the transfusion of autologous blood compared to allogeneic blood. Due to the paucity of research examining other clinical outcomes such as infection and thrombosis, there is insufficient data to determine the impact PAD may have on these outcomes. In surveys with patients, special interest group members and the public, one-third of respondents voiced concern with receiving an allogeneic blood transfusion, and most respondents overestimated the probability of contracting HIV and HCV through a blood transfusion when compared to other events of equal risk (e.g. being struck by lightning). Approximately 80% of respondents preferred PAD due to the perception that it eliminated all risks associated with a blood transfusion, is 100% compatible, and that it helps others through contributing to the blood supply. Although approximately half of the physicians interviewed used a transfusion trigger or protocol, individual patient characteristics were the main factor driving the decision of whether to transfuse. However, some respondents were critical of those who either did (or did not) use protocols, while others modified the "science of the guidelines" according to the needs of the individual. The final draft of the decision aid asked patients to consider the point at which they would prefer to receive a blood transfusion after major elective surgery (using haemoglobin values or transfusion "triggers" as a guide) and to decide whether or not to use PAD. The decision aid, "Blood Transfusion Options for Planned Surgery: A Decision Aid for Patients", consisted of a 32-page A5 size booklet and 28-minute audio tape or CD. The decision aid included the following sections: information about blood and blood loss; facts about blood transfusions; blood transfusions an you; your transfusion preference after surgery; approaches to replacing blood less; the differences between volunteer-donated and self-donated blood; adverse effects of blood transfusion; frequently asked questions; steps in decision making; and scientific references. A decision slip was included at the back of the booklet for patients to complete and return to their surgeon. Patients felt that the decision aid removed fears and common misconceptions associated with blood transfusion by providing them with more knowledge and realistic expectations of transfusion risks. Importantly, health professionals and patients felt that the information in the decision aid was presented in a balanced way and that it did not coerce patients to choose one particular option over another. Pilot data revealed that although the decision aid was generally well received, a number of revisions will be required before successful implementation. Important changes include; updating all information for recency; providing better explanations of numerical data; reducing the amount of information where appropriate; tailoring the decision aid for use in orthapaedic surgery (due to reduced utilisation rates of PAD); and clarifying the role of transfusion triggers in the decision aid, including whether it is appropriate to involved patients in that stage of the decision making process. The format of the decision aid also needs to be reconsidered (i.e. computer-based or continue with print and audio material) as costs and time restraints were highlighted as potential barriers to its use in practice. Based on the CREDIBLE criteria, the decision aid requires an updating policy, accessible documentation of the development process, and formal evaluation using a before-after pilot-study/randomised controlled trial. Conclusion: The task of developing and evaluating a decision aid on blood transfusion was found to be very complex and demanding. For instance, a number of in-depth studies were needed to adequately inform decision aid development and the decision aid still requires formal evaluation. However, the findings from the research undertaken in the thesis also reinforced the need for a decision aid on blood transfusion - the evidence on the benefits and harms of blood transfusion and PAD is controversial, practice variation exists, and personal values influenced patient and physician views of blood transfusion and PAD. Despite receiving positive feedback from health professionals and patients, the decision aid requires some significant modifications. Reduced utilisation rates of PAD indicate that a generic decision aid for procedures other than major orthopaedic surgery may not be relevant in practice. Although the issues surrounding blood transfusion justify the need for a decision aid, the desire for both patients and physicians for limited patient involvement regarding the decision of when to give a blood transfusion (using transfusion triggers as a guide) suggests that the aims of the decision aid in this area need to be reconsidered. However, as the number of older Australians undergoing major elective surgery rises due to population ageing, the availability of decision aids that adequately inform patients of the benefits and harms of blood transfusion and the option of PAD will be imperative. With further revision and evaluation, this decision aid should fulfill its promise as an effective tool for education patients about blood transfusion

Mid-age women's consultations with acupuncturists: A longitudinal analysis of 11,200 women, 2001-2007

Objectives: The objectives of this study were to chart the patterns and determine the factors associated with acupuncture consultations among a large cohort of mid-aged women in Australia over a 6-year period. Design: A longitudinal analysis of questionnaires completed in 2001, 2004, and 2007 as part of the Australian Longitudinal Study on Women's Health. Statistical analyses included Generalized Estimating Equations. Subjects: Mid-aged women (n=11,200) were randomly selected from the Australian Medicare database, with oversampling of women from rural and remote areas. Outcome measure: The outcome measure was consultation with an acupuncturist in the 12 months prior to each survey. Results: The percentage of women who consulted an acupuncturist in the years 2001, 2004, and 2007 were 4.2%, 4.3%, and 5.9%, respectively. Only 0.5% of women consulted with an acupuncturist at all survey periods, 2.0% at two survey periods, and 7.4% at only one survey period. Acupuncture consultations significantly increased if the women had back problems (odds ratio [OR]=1.5), arthritis (OR=1.3), had higher levels of education (OR=1.9), were high users of general practitioners/family practitioners (OR=2.6), and high users of biomedical specialists (OR=1.4). Conclusions: Use of acupuncturists among mid-age women appears to be strongly influenced by poor physical health. The percentage of women in the community who use acupuncture remained relatively consistent over the study period. Women do not tend to consistently use acupuncture over time, but instead appear to use acupuncture as a one-off treatment or at selected time points

Spirituality, religion, social support and health among older Australian adults

AIM: To examine the impact of perceived importance of spirituality or religion (ISR) and religious service attendance (RSA) on health and well-being in older Australians. METHODS: A cross-sectional survey of 752 community-dwelling men and women aged 55-85 years from the Hunter Region, New South Wales. RESULTS: Overall, 51% of participants felt spirituality or religion was important in their lives and 24% attended religious services at least 2-3 times a month. In univariate regression analyses, ISR and RSA were associated with increased levels of social support (P &lt; 0.001). However, ISR was also associated with more comorbidities (incidence-rate ratio= 1.2, 95% confidence interval 1.08-1.33). There were no statistically significant associations between ISR or RSA and other measures such as mental and physical health. CONCLUSION: Spirituality and religious involvement have a beneficial impact on older Australians\u27 perceptions of social support, and may enable individuals to better cope with the presence of multiple comorbidities later in life

The efficacy of zinc supplementation in depression: systematic review of randomised controlled trials

BACKGROUND: Depression is a significant public health problem. Pre-clinical studies suggest a potential role of zinc in reducing or preventing depressive symptoms. Many epidemiological studies have examined the association of low zinc status with depression; however, clinical trials on the effect of zinc supplementation in depression are limited. This review aimed to synthesise results from all published randomised controlled trials on the efficacy of zinc supplementation for reducing or preventing depressive symptoms. METHODS: Six databases were searched over all years of records until March 2011. All randomised controlled trials with a comparison group, that examined zinc supplementation as the intervention and depressive symptoms as the primary outcome were included. Pairs of reviewers extracted key information of study characteristics and outcomes, and assessed the quality of each study. RESULTS: Four randomised controlled trials met inclusion criteria. In studies that examined the effects of zinc supplementation as an adjunct to antidepressants drug treatment, zinc significantly lowered depressive symptom scores of depressed patients. There is less clear evidence on the effectiveness of zinc supplementation alone on depressive symptoms of non-depressed healthy subjects. The overall study quality was rated 'moderate'. LIMITATIONS: There are limited trials examining the effects of zinc supplementation on depressive symptoms. An overall pooled estimate of effect for all included studies could not be calculated and evidence was difficult to summarise because of substantial heterogeneity. CONCLUSION: Evidence suggests potential benefits of zinc supplementation as a stand-alone intervention or as an adjunct to conventional antidepressant drug therapy for depression. However, there are methodological limitations in existing studies and so further well-designed, adequately powered research is required

Computerized clinical decision support for prescribing: provision does not guarantee uptake

There is wide variability in the use and adoption of recommendations generated by computerized clinical decision support systems (CDSSs) despite the benefits they may bring to clinical practice. We conducted a systematic review to explore the barriers to, and facilitators of, CDSS uptake by physicians to guide prescribing decisions. We identified 58 studies by searching electronic databases (1990–2007). Factors impacting on CDSS use included: the availability of hardware, technical support and training; integration of the system into workflows; and the relevance and timeliness of the clinical messages. Further, systems that were endorsed by colleagues, minimized perceived threats to professional autonomy, and did not compromise doctor-patient interactions were accepted by users. Despite advances in technology and CDSS sophistication, most factors were consistently reported over time and across ambulatory and institutional settings. Such factors must be addressed when deploying CDSSs so that improvements in uptake, practice and patient outcomes may be achieved

Breastfeeding for oral health in preschool children

This is the protocol for a review and there is no abstract. The objectives are as follows: Primary Primary * To compare the rates of dental caries in children who were bottle fed as infants to children who were breastfed up to six months, between 6 and 12 months, or longer Secondary Secondary * To compare the rates of dental caries in children who were: demand breastfed, non-demand breastfed * To compare the rates of dental caries in children who were: breastfed via direct nursing, breastfed via a bottle, bottle fed with infant formula * To compare the rates of dental caries in children who were: exclusively breastfed, partially breastfed, exclusively bottle fed with infant formula * To compare the rates of dental caries in children who were: breastfed during day and night time, breastfed during the day only This review examines the hypotheses that breastfed children would have lower rates of dental caries than bottle fed infants