787 research outputs found
Evidence for risk of bias in cluster randomised trials: review of recent trials published in three general medical journals
Objective To examine the prevalence of a risk of bias associated with the design and conduct of cluster randomised controlled trials among a sample of recently published studies. Design Retrospective review of cluster randomised trials published in the BMJ, Lancet, and New England Journal of Medicine from January 1997 to October 2002. Main outcome measures Prevalence of secure randomisation of clusters, identification of participants before randomisation (to avoid foreknowledge of allocation), differential recruitment between treatment arms, differential application of inclusion and exclusion criteria, and differential attrition. Results Of the 36 trials identified, 24 were published in the BMJ, I I in the Lancet, and a single trial in the New England journal of Medicine. At the cluster level, 15 (42%) trials provided evidence for secure allocation and 25 (69%) used stratified allocation. Few trials showed evidence of imbalance at the cluster level. However, some evidence of susceptibility to risk of bias at the individual level existed in 14 (39%) studies. Conclusions Some recently published cluster randomised trials may not have taken adequate precautions to guard against threats to the internal validity of their design
Comparative case study investigating sociotechnical processes of change in the context of a national electronic health record implementation
Methodological bias in cluster randomised trials
Background: Cluster randomised trials can be susceptible to a range of methodological problems. These problems are not commonly recognised by many researchers. In this paper we discuss the issues that can lead to bias in cluster trials. Methods: We used a sample of cluster randomised trials from a recent review and from a systematic review of hip protectors. We compared the mean age of participants between intervention groups in a sample of 'good' cluster trials with a sample of potentially biased trials. We also compared the effect sizes, in a funnel plot, between hip protector trials that used individual randomisation compared with those that used cluster randomisation. Results: There is a tendency for cluster trials, with evidence methodological biases, to also show an age imbalance between treatment groups. In a funnel plot we show that all cluster trials show a large positive effect of hip protectors whilst individually randomised trials show a range of positive and negative effects, suggesting that cluster trials may be producing a biased estimate of effect. Conclusion: Methodological biases in the design and execution of cluster randomised trials is frequent. Some of these biases associated with the use of cluster designs can be avoided through careful attention to the design of cluster trials. Firstly, if possible, individual allocation should be used. Secondly, if cluster allocation is required, then ideally participants should be identified before random allocation of the clusters. Third, if prior identification is not possible, then an independent recruiter should be used to recruit participants
Cluster randomised trials in the medical literature: two bibliometric surveys
Background: Several reviews of published cluster randomised trials have reported that about half did not take clustering into account in the analysis, which was thus incorrect and potentially misleading. In this paper I ask whether cluster randomised trials are increasing in both number and quality of reporting. Methods: Computer search for papers on cluster randomised trials since 1980, hand search of trial reports published in selected volumes of the British Medical Journal over 20 years. Results: There has been a large increase in the numbers of methodological papers and of trial reports using the term 'cluster random' in recent years, with about equal numbers of each type of paper. The British Medical Journal contained more such reports than any other journal. In this journal there was a corresponding increase over time in the number of trials where subjects were randomised in clusters. In 2003 all reports showed awareness of the need to allow for clustering in the analysis. In 1993 and before clustering was ignored in most such trials. Conclusion: Cluster trials are becoming more frequent and reporting is of higher quality. Perhaps statistician pressure works
Spatial effects should be allowed for in primary care and other community-based cluster RCTS
<p>Abstract</p> <p>Background</p> <p>Typical advice on the design and analysis of cluster randomized trials (C-RCTs) focuses on allowance for the clustering at the level of the unit of allocation. However often C-RCTs are also organised spatially as may occur in the fields of Public Health and Primary Care where populations may even overlap.</p> <p>Methods</p> <p>We allowed for spatial effects on the error variance by a multiple membership model. These are a form of hierarchical model in which each lower level unit is a member of more than one higher level unit. Membership may be determined through adjacency or through Euclidean distance of centroids or in other ways such as the proportion of overlapping population. Such models may be estimated for Normal, binary and Poisson responses in Stata (v10 or above) as well as in WinBUGS or MLWin. We used this to analyse a dummy trial and two real, previously published cluster-allocated studies (one allocating general practices within one City and the other allocating general practices within one County) to investigate the extent to which ignoring spatial effects affected the estimate of treatment effect, using different methods for defining membership with Akaike's Information Criterion to determine the "best" model.</p> <p>Results</p> <p>The best fitting model included both a fixed North-South gradient and a random cluster effect for the dummy RCT. For one of the real RCTs the best fitting model included both a random practice effect plus a multiple membership spatial term, while for the other RCT the best fitting model ignored the clustering but included a fixed North-South gradient. Alternative models which fitted only slightly less well all included spatial effects in one form or another, with some variation in parameter estimates (greater when less well fitting models were included).</p> <p>Conclusions</p> <p>These particular results are only illustrative. However, we believe when designing C-RCTs in a primary care setting the possibility of spatial effects should be considered in relation to the intervention and response, as well as any explanatory effect of fixed covariates, together with any implications for sample size and methods for planned analyses.</p
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Refining genetic boundaries for Agassiz’s desert tortoise (Gopherus agassizii) in the western Sonoran Desert: the influence of the Coachella Valley on gene flow among populations in southern California
Understanding the influence of geographic features on the evolutionary history and population structure of a species can assist wildlife managers in delimiting genetic units (GUs) for conservation and management. Landscape features including mountains, low elevation depressions, and even roads can influence connectivity and gene flow among Agassiz’s desert tortoise (Gopherus agassizii) populations. Substantial changes in the landscape of the American Southwest occurred during the last six million years (including the formation of the Gulf of California and the lower Colorado River), which shaped the distribution and genetic structuring of tortoise populations. The area northwest of the Gulf of California is occupied by the Salton Trough, including the Coachella Valley at its northern end. Much of this area is below sea level and unsuitable as tortoise habitat, thus forming a potential barrier for gene flow. We assessed genetic relationships among three tortoise populations separated by the Coachella Valley. Two adjacent populations were on the east side of the valley in the foothills of the Cottonwood and Orocopia mountains separated by Interstate 10. The third population, Mesa, was located about 87 km away in the foothills of the San Bernardino Mountains at the far northwestern tip of the valley. The Cottonwood and Orocopia localities showed genetic affiliation with the adjacent Colorado Desert GU immediately to the east, and the Mesa population exhibited affiliation with both the Southern Mojave and Colorado Desert GUs, despite having a greater geographic distance (0.5x–1.5x greater) to the Colorado Desert GU. The genetic affiliation with the Colorado Desert GU suggests that the boundary for that GU needs to be substantially extended to the west to include the desert tortoise populations around the Coachella Valley. Their inclusion in the Colorado Desert GU may benefit these often overlooked populations when recovery actions are considered
Changing Clinical and Therapeutic Trends in Tentorial Dural Arteriovenous Fistulas: A Systematic Review
Changes in Russian managerial values: a test of the convergence hypothesis?
This paper considers how Russian managerial values are developing in the context of the sweeping economic, political and social changes associated with the transition of Russia to a market economy. By replicating earlier research (Holt et al., 1994; Ralston et al., 1997), it was possible to overcome the weaknesses of previous cross-sectional studies by tracking changes in Russian managers' values over time. The paper concludes that some convergence between the values of Russian and US managers can be observed, but that the form of this convergence is not uniform. In addition, the way in which Russian managers act upon these values in the context of their own national context means that considerable divergence in managerial behaviour is still evident. Implications for international human resource management are discussed
Levels and Correlates of Non-Adherence to WHO Recommended Inter-Birth Intervals in Rufiji, Tanzania.
Poorly spaced pregnancies have been documented worldwide to result in adverse maternal and child health outcomes. The World Health Organization (WHO) recommends a minimum inter-birth interval of 33 months between two consecutive live births in order to reduce the risk of adverse maternal and child health outcomes. However, birth spacing practices in many developing countries, including Tanzania, remain scantly addressed. METHODS: Longitudinal data collected in the Rufiji Health and Demographic Surveillance System (HDSS) from January 1999 to December 2010 were analyzed to investigate birth spacing practices among women of childbearing age. The outcome variable, non-adherence to the minimum inter-birth interval, constituted all inter-birth intervals <33 months long. Inter-birth intervals >=33 months long were considered to be adherent to the recommendation. Chi-Square was used as a test of association between non-adherence and each of the explanatory variables. Factors affecting non-adherence were identified using a multilevel logistic model. Data analysis was conducted using STATA (11) statistical software. RESULTS: A total of 15,373 inter-birth intervals were recorded from 8,980 women aged 15--49 years in Rufiji district over the follow-up period of 11 years. The median inter-birth interval was 33.4 months. Of the 15,373 inter-birth intervals, 48.4% were below the WHO recommended minimum length of 33 months between two live births. Non-adherence was associated with younger maternal age, low maternal education, multiple births of the preceding pregnancy, non-health facility delivery of the preceding birth, being an in-migrant resident, multi-parity and being married. CONCLUSION: Generally, one in every two inter-birth intervals among 15--49 year-old women in Rufiji district is poorly spaced, with significant variations by socio-demographic and behavioral characteristics of mothers and newborns. Maternal, newborn and child health services should be improved with a special emphasis on community- and health facility-based optimum birth spacing education in order to enhance health outcomes of mothers and their babies, especially in rural settings
A longitudinal study of perceived health during pregnancy: antecedents and outcomes
Perceived health was studied longitudinally in a sample of 364 nulliparous women. Psychosocial, contextual, and biomedical factors were taken into account to predict medically relevant versus benign symptoms which were then used to predict perceived health over time. The results of structural equation modeling showed that pregnancy adjustment and medically relevant symptoms which were affected by social support, perceived stress, and negative affect predicted later perceived health. The outcomes of perceived health were examined during the third trimester in terms of medical care utilization and emergency room visits. Perceived health solely accounted for medical care utilization, while emergency room visits were accounted by medical care utilization and perceived stress
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