Educational Games in Geriatric Medicine Education: A Systematic Review

OBJECTIVE: To systematically review the medical literature to assess the effect of geriatric educational games on the satisfaction, knowledge, beliefs, attitudes and behaviors of health care professionals. METHODS: We conducted a systematic review following the Cochrane Collaboration methodology including an electronic search of 10 electronic databases. We included randomized controlled trials (RCT) and controlled clinical trials (CCT) and excluded single arm studies. Population of interests included members (practitioners or students) of the health care professions. Outcomes of interests were participants' satisfaction, knowledge, beliefs, attitude, and behaviors. RESULTS: We included 8 studies evaluating 5 geriatric role playing games, all conducted in United States. All studies suffered from one or more methodological limitations but the overall quality of evidence was acceptable. None of the studies assessed the effects of the games on beliefs or behaviors. None of the 8 studies reported a statistically significant difference between the 2 groups in terms of change in attitude. One study assessed the impact on knowledge and found non-statistically significant difference between the 2 groups. Two studies found levels of satisfaction among participants to be high. We did not conduct a planned meta-analysis because the included studies either reported no statistical data or reported different summary statistics. CONCLUSION: The available evidence does not support the use of role playing interventions in geriatric medical education with the aim of improving the attitudes towards the elderly.Society of General Internal Medicin

Improving the use of research evidence in guideline development: 2. Priority setting

BACKGROUND: The World Health Organization (WHO), like many other organisations around the world, has recognised the need to use more rigorous processes to ensure that health care recommendations are informed by the best available research evidence. This is the second of a series of 16 reviews that have been prepared as background for advice from the WHO Advisory Committee on Health Research to WHO on how to achieve this. OBJECTIVES: We reviewed the literature on priority setting for health care guidelines, recommendations and technology assessments. METHODS: We searched PubMed and three databases of methodological studies for existing systematic reviews and relevant methodological research. We did not conduct systematic reviews ourselves. Our conclusions are based on the available evidence, consideration of what WHO and other organisations are doing and logical arguments. KEY QUESTIONS AND ANSWERS: There is little empirical evidence to guide the choice of criteria and processes for establishing priorities, but there are broad similarities in the criteria that are used by various organisations and practical arguments for setting priorities explicitly rather than implicitly, WHAT CRITERIA SHOULD BE USED TO ESTABLISH PRIORITIES? • WHO has limited resources and capacity to develop recommendations. It should use these resources where it has the greatest chance of improving health, equity, and efficient use of healthcare resources. • We suggest the following criteria for establishing priorities for developing recommendations based on WHO's aims and strategic advantages: • Problems associated with a high burden of illness in low and middle-income countries, or new and emerging diseases. • No existing recommendations of good quality. • The feasibility of developing recommendations that will improve health outcomes, reduce inequities or reduce unnecessary costs if they are implemented. • Implementation is feasible, will not exhaustively use available resources, and barriers to change are not likely to be so high that they cannot be overcome. • Additional priorities for WHO include interventions that will likely require system changes and interventions where there might be a conflict in choices between individual and societal perspectives. WHAT PROCESSES SHOULD BE USED TO AGREE ON PRIORITIES? • The allocation of resources to the development of recommendations should be part of the routine budgeting process rather than a separate exercise. • Criteria for establishing priorities should be applied using a systematic and transparent process. • Because data to inform judgements are often lacking, unmeasured factors should also be considered – explicitly and transparently. • The process should include consultation with potential end users and other stakeholders, including the public, using well-constructed questions, and possibly using Delphi-like procedures. • Groups that include stakeholders and people with relevant types of expertise should make decisions. Group processes should ensure full participation by all members of the group. • The process used to select topics should be documented and open to inspection. SHOULD WHO HAVE A CENTRALISED OR DECENTRALISED PROCESS? • Both centralised and decentralised processes should be used. Decentralised processes can be considered as separate "tracks". • Separate tracks should be used for considering issues for specific areas, populations, conditions or concerns. The rationales for designating special tracks should be defined clearly; i.e. why they warrant special consideration. • Updating of guidelines could also be considered as a separate "track", taking account of issues such as the need for corrections and the availability of new evidence

Improving the use of research evidence in guideline development: 6. Determining which outcomes are important

BACKGROUND: The World Health Organization (WHO), like many other organisations around the world, has recognised the need to use more rigorous processes to ensure that health care recommendations are informed by the best available research evidence. This is the sixth of a series of 16 reviews that have been prepared as background for advice from the WHO Advisory Committee on Health Research to WHO on how to achieve this. OBJECTIVES: We reviewed the literature on determining which outcomes are important for the development of guidelines. METHODS: We searched five databases of methodological studies for existing systematic reviews and relevant methodological research. We did not conduct a complete systematic review ourselves. Our conclusions are based on the available evidence, consideration of what WHO and other organisations are doing and logical arguments. KEY QUESTIONS AND ANSWERS: We did not find a systematic review that addresses any of the following key questions and we found limited relevant research evidence. What methods should WHO use to identify important outcomes? • Methods of outcome identification should be transparent and explicit. • The consultation process should start with identification of all relevant outcomes associated with an intervention. • Those affected, including consumers, should be involved in the selection of outcomes. • A question driven approach (what is important?) is preferable to a data driven approach (what data are at hand?) to identify important outcomes. What type of outcomes should WHO consider and how should cultural diversity be taken account of in the selection of outcomes? • Desirable (benefits, less burden and savings) and undesirable effects should be considered in all guidelines. • Undesirable effects include harms (including the possibility of unanticipated adverse effects), greater burden (e.g. having to go to the doctor) and costs (including opportunity costs). • Important outcomes (e.g. mortality, morbidity, quality of life) should be preferred over surrogate, indirect outcomes (e.g. cholesterol levels, lung function) that may or may not correlate with patient important outcomes. • Ethical considerations should be part of the evaluation of important outcomes (e.g. impacts on autonomy). • If the importance of outcomes is likely to vary across cultures, stakeholders from diverse cultures should be consulted and involved in the selection of outcomes. How should the importance of outcomes be ranked? • Outcomes should be ranked by relative importance, separated into benefits and downsides. • Information from research on values and preferences should inform the ranking of outcomes whenever possible. • If the importance of outcomes is likely to vary across cultures, ranking of outcomes should be done in specific settings. • If evidence is lacking for an important outcome, this should be acknowledged, rather than ignoring the outcome

Assessing and presenting summaries of evidence in Cochrane Reviews

Cochrane Reviews are intended to help providers, practitioners and patients make informed decisions about health care. The goal of the Cochrane Applicability and Recommendation Methods Group (ARMG) is to develop approaches, strategies and guidance that facilitate the uptake of information from Cochrane Reviews and their use by a wide audience with specific focus on developers of recommendations and on healthcare decision makers. This paper is part of a series highlighting developments in systematic review methodology in the 20 years since the establishment of The Cochrane Collaboration, and its aim is to present current work and highlight future developments in assessing and presenting summaries of evidence, with special focus on Summary of Findings (SoF) tables and Plain Language Summaries. A SoF table provides a concise and transparent summary of the key findings of a review in a tabular format. Several studies have shown that SoF tables improve accessibility and understanding of Cochrane Reviews. The ARMG and GRADE Working Group are working on further development of the SoF tables, for example by evaluating the degree of acceptable flexibility beyond standard presentation of SoF tables, developing SoF tables for diagnostic test accuracy reviews and interactive SoF tables (iSoF). The plain language summary (PLS) is the other main building block for dissemination of review results to end-users. The PLS aims to summarize the results of a review in such a way that health care consumers can readily understand them. Current efforts include the development of a standardized language to describe statistical results, based on effect size and quality of supporting evidence. Producing high quality PLS and SoF tables and making them compatible and linked would make it easier to produce dissemination products targeting different audiences (for example, providers, health policy makers, guideline developers). Current issues of debate include optimal presentation formats of SoF tables, the training required to produce SoF tables, and the extent to which the authors of Cochrane Reviews should provide explicit guidance to target audiences of patients, clinicians and policy-makers

The minimal important difference of the hospital anxiety and depression scale in patients with chronic obstructive pulmonary disease

BACKGROUND: Interpretation of the Hospital Anxiety and Depression Scale (HADS), commonly used to assess anxiety and depression in COPD patients, is unclear. Since its minimal important difference has never been established, our aim was to determine it using several approaches. METHODS: 88 COPD patients with FEV1 /= 0.5 we performed linear regression analyses to predict the minimal important difference from the anchors. As distribution-based approach we used the Effect Size approach. RESULTS: Based on CRQ emotional function and mastery domain as well as on total scores, the minimal important difference was 1.41 (95% CI 1.18-1.63) and 1.57 (1.37-1.76) for the HADS anxiety score and 1.68 (1.48-1.87) and 1.60 (1.38-1.82) for the HADS total score. Correlations of the HADS depression score and CRQ domain and Feeling Thermometer scores were < 0.5. Based on the Effect Size approach the MID of the HADS anxiety and depression score was 1.32 and 1.40, respectively. CONCLUSION: The minimal important difference of the HADS is around 1.5 in COPD patients corresponding to a change from baseline of around 20%. It can be used for the planning and interpretation of trials

Certainty ranges facilitated explicit and transparent judgments regarding evidence credibility

Objectives: The Grading of Recommendations Assessment, Development and Evaluation approach to rating certainty of evidence includes five domains of reasons for rating down certainty. Only one of these, precision, is easily amenable through the confidence interval to quantitation. The other four (risk of bias, inconsistency, indirectness, and publication bias) are not. Nevertheless, conceptually, one could consider a quantified "certainty range" within which the true effect lies. The certainty range would be at least as wide as the confidence interval and would expand with each additional reason for uncertainty. Study Design and Setting: We have applied this concept to rating the certainty of evidence in the baseline risk of venous thromboembolism (VTE) and bleeding in patients undergoing urological surgery. We considered rating up moderate or low quality evidence when the net benefit of VTE prophylaxis was unequivocally positive, that is, when the smallest plausible value of VTE reduction was greater than the largest plausible value of increased bleeding. To establish whether the net benefit was unequivocally positive, we expanded the range of plausible values by 20% for each of the four nonquantitative domains in which there were serious limitations. Results: We present how we applied these methods to examples of open radical cystectomy and laparoscopic partial nephrectomy. In high-VTE risk laparoscopic partial nephrectomy patients and high-and medium-VTE risk open radical cystectomy patients, results proved robust to expanded certainty intervals, justifying rating up quality of evidence. In low -risk patients, the results were not robust, and rating up was therefore not appropriate. Conclusion: This work represents the first empirical application in a decision -making context of the previously suggested concept of certainty ranges and should stimulate further exploration of the associated theoretical and practical issues. (C) 2018 Elsevier Inc. All rights reserved.Peer reviewe

Developing clinical practice guidelines: target audiences, identifying topics for guidelines, guideline group composition and functioning and conflicts of interest

Clinical practice guidelines are one of the foundations of efforts to improve health care. In 1999, we authored a paper about methods to develop guidelines. Since it was published, the methods of guideline development have progressed both in terms of methods and necessary procedures and the context for guideline development has changed with the emergence of guideline clearing houses and large scale guideline production organisations (such as the UK National Institute for Health and Clinical Excellence). It therefore seems timely to, in a series of three articles, update and extend our earlier paper. In this first paper we discuss: the target audience(s) for guidelines and their use of guidelines; identifying topics for guidelines; guideline group composition (including consumer involvement) and the processes by which guideline groups function and the important procedural issue of managing conflicts of interest in guideline development

Developing clinical practice guidelines: types of evidence and outcomes; values and economics, synthesis, grading, and presentation and deriving recommendations

Clinical practice guidelines are one of the foundations of efforts to improve healthcare. In 1999, we authored a paper about methods to develop guidelines. Since it was published, the methods of guideline development have progressed both in terms of methods and necessary procedures and the context for guideline development has changed with the emergence of guideline clearinghouses and large scale guideline production organisations (such as the UK National Institute for Health and Clinical Excellence). It therefore seems timely to, in a series of three articles, update and extend our earlier paper. In this second paper, we discuss issues of identifying and synthesizing evidence: deciding what type of evidence and outcomes to include in guidelines; integrating values into a guideline; incorporating economic considerations; synthesis, grading, and presentation of evidence; and moving from evidence to recommendations

Internal consistency reliability is a poor predictor of responsiveness

BACKGROUND: Whether responsiveness represents a measurement property of health-related quality of life (HRQL) instruments that is distinct from reliability and validity is an issue of debate. We addressed the claims of a recent study, which suggested that investigators could rely on internal consistency to reflect instrument responsiveness. METHODS: 516 patients with chronic obstructive pulmonary disease or knee injury participating in four longitudinal studies completed generic and disease-specific HRQL questionnaires before and after an intervention that impacted on HRQL. We used Pearson correlation coefficients and linear regression to assess the relationship between internal consistency reliability (expressed as Cronbach's alpha), instrument type (generic and disease-specific) and responsiveness (expressed as the standardised response mean, SRM). RESULTS: Mean Cronbach's alpha was 0.83 (SD 0.08) and mean SRM was 0.59 (SD 0.33). The correlation between Cronbach's alpha and SRMs was 0.10 (95% CI -0.12 to 0.32) across all studies. Cronbach's alpha alone did not explain variability in SRMs (p = 0.59, r(2 )= 0.01) whereas the type of instrument was a strong predictor of the SRM (p = 0.012, r(2 )= 0.37). In multivariable models applied to individual studies Cronbach's alpha consistently failed to predict SRMs (regression coefficients between -0.45 and 1.58, p-values between 0.15 and 0.98) whereas the type of instrument did predict SRMs (regression coefficients between -0.25 to -0.59, p-values between <0.01 and 0.05). CONCLUSION: Investigators must look to data other than internal consistency reliability to select a responsive instrument for use as an outcome in clinical trials

“AI’s gonna have an impact on everything in society, so it has to have an impact on public health”: a fundamental qualitative descriptive study of the implications of artificial intelligence for public health

Background: Our objective was to determine the impacts of artificial intelligence (AI) on public health practice. Methods: We used a fundamental qualitative descriptive study design, enrolling 15 experts in public health and AI from June 2018 until July 2019 who worked in North America and Asia. We conducted in-depth semi-structured interviews, iteratively coded the resulting transcripts, and analyzed the results thematically. Results: We developed 137 codes, from which nine themes emerged. The themes included opportunities such as leveraging big data and improving interventions; barriers to adoption such as confusion regarding AI’s applicability, limited capacity, and poor data quality; and risks such as propagation of bias, exacerbation of inequity, hype, and poor regulation. Conclusions: Experts are cautiously optimistic about AI’s impacts on public health practice, particularly for improving disease surveillance. However, they perceived substantial barriers, such as a lack of available expertise, and risks, including inadequate regulation. Therefore, investment and research into AI for public health practice would likely be beneficial. However, increased access to high-quality data, research and education regarding the limitations of AI, and development of rigorous regulation are necessary to realize these benefits