How can we improve the interpretation of systematic reviews?

A study conducted by Lai and colleagues, published this week in BMC Medicine, suggests that more guidance might be required for interpreting systematic review (SR) results. In the study by Lai and colleagues, positive (or favorable) results were influential in changing participants' prior beliefs about the interventions presented in the systematic review. Other studies have examined the relationship between favorable systematic review results and the publication of systematic reviews. An international registry may decrease the number of unpublished systematic reviews and will hopefully decrease redundancy, increase transparency, and increase collaboration within the SR community. In addition, using guidance from the Preferred Items for Systematic Reviews and Meta-analyses (PRISMA: http://www.prisma-statement.org/) Statement and the Grading of Recommendations Assessment, Development, and Evaluation (GRADE: http://www.gradeworkinggroup.org/) approach can also be used to improve the interpretation of systematic reviews. In this commentary, we highlight important methodological issues related to the conduct and reporting of systematic reviews and also present our own guidance on interpreting systematic reviews

Factors associated with the subspecialty choices of internal medicine residents in Canada

<p>Abstract</p> <p>Background</p> <p>Currently, there are more residents enrolled in cardiology training programs in Canada than in immunology, pharmacology, rheumatology, infectious diseases, geriatrics and endocrinology combined. There is no published data regarding the proportion of Canadian internal medicine residents applying to the various subspecialties, or the factors that residents consider important when deciding which subspecialty to pursue. To address the concern about physician imbalances in internal medicine subspecialties, we need to examine the factors that motivate residents when making career decisions.</p> <p>Methods</p> <p>In this two-phase study, Canadian internal medicine residents participating in the post graduate year 4 (PGY4) subspecialty match were invited to participate in a web-based survey and focus group discussions. The focus group discussions were based on issues identified from the survey results. Analysis of focus group transcripts grew on grounded theory.</p> <p>Results</p> <p>110 PGY3 residents participating in the PGY4 subspecialty match from 10 participating Canadian universities participated in the web-based survey (54% response rate). 22 residents from 3 different training programs participated in 4 focus groups held across Canada. Our study found that residents are choosing careers that provide intellectual stimulation, are consistent with their personality, and that provide a challenge in diagnosis. From our focus group discussions it appears that lifestyle, role models, mentorship and the experience of the resident with the specialty appear to be equally important in career decisions. Males are more likely to choose procedure based specialties and are more concerned with the reputation of the specialty as well as the anticipated salary. In contrast, residents choosing non-procedure based specialties are more concerned with issues related to lifestyle, including work-related stress, work hours and time for leisure as well as the patient populations they are treating.</p> <p>Conclusion</p> <p>This study suggests that internal medicine trainees, and particularly males, are increasingly choosing procedure-based specialties while non-procedure based specialties, and in particular general internal medicine, are losing appeal. We need to implement strategies to ensure positive rotation experiences, exposure to role models, improved lifestyle and job satisfaction as well as payment schedules that are equitable between disciplines in order to attract residents to less popular career choices.</p

A systematic review of cost-effectiveness analyses of complex wound interventions reveals optimal treatments for specific wound types.

BackgroundComplex wounds present a substantial economic burden on healthcare systems, costing billions of dollars annually in North America alone. The prevalence of complex wounds is a significant patient and societal healthcare concern and cost-effective wound care management remains unclear. This article summarizes the cost-effectiveness of interventions for complex wound care through a systematic review of the evidence base.MethodsWe searched multiple databases (MEDLINE, EMBASE, Cochrane Library) for cost-effectiveness studies that examined adults treated for complex wounds. Two reviewers independently screened the literature, abstracted data from full-text articles, and assessed methodological quality using the Drummond 10-item methodological quality tool. Incremental cost-effectiveness ratios were reported, or, if not reported, calculated and converted to United States Dollars for the year 2013.ResultsOverall, 59 cost-effectiveness analyses were included; 71% (42 out of 59) of the included studies scored 8 or more points on the Drummond 10-item checklist tool. Based on these, 22 interventions were found to be more effective and less costly (i.e., dominant) compared to the study comparators: 9 for diabetic ulcers, 8 for venous ulcers, 3 for pressure ulcers, 1 for mixed venous and venous/arterial ulcers, and 1 for mixed complex wound types.ConclusionsOur results can be used by decision-makers in maximizing the deployment of clinically effective and resource efficient wound care interventions. Our analysis also highlights specific treatments that are not cost-effective, thereby indicating areas of resource savings. Please see related article: http://dx.doi.org/10.1186/s12916-015-0288-5

Besieged : Malta 1565

The sixteenth century Mediterranean has often been described as ‘a battleground’ between the two great empires of Catholic Spain in the West and the Muslim Ottomans in the East. It was a century during which the two great empires gave evidence of their formidable might. Before the rise of the Habsburg kings, Charles V and Philip II, the Catholic Kings of Spain, Ferdinand and Isabella, who were responsible for the unification of Spain, played as vital a part in creating the Spanish Empire as did the Ottoman sultans before the fall of Constantinople in 1453.peer-reviewe

Clinical Trials and Novel Pathogens: Lessons Learned from SARS

During the recent global outbreak of severe acute respiratory syndrome (SARS), thousands of patients received treatments of uncertain efficacy and known toxicity such as ribavirin and corticosteroids. Despite this, no controlled clinical trials assessing the efficacy of these agents were conducted. If a second global SARS outbreak occurred, clinicians would not have controlled data on which to base therapeutic decisions. We discuss the unique methodologic and logistical challenges faced by researchers who attempt to conduct controlled trials of therapeutic agents during an outbreak of a novel or unknown infectious pathogen. We draw upon our own experience in attempting to conduct a randomized controlled trial (trial) of ribavirin therapy for SARS and discuss the lessons learned. Strategies to facilitate future clinical trials during outbreaks of unknown or novel pathogens are also presented

Assessing Organizational Readiness for Change Comment on “Development and Content Validation of a Transcultural Instrument to Assess Organizational Readiness for Knowledge Translation in Healthcare Organizations: The OR4KT”

Abstract This commentary provides an overview of the organizational readiness for change (ORC) literature over the last decade, with respect to prevailing definitions, theories, and tools to guide assessment of ORC in preparation for implementation. The development of the OR4KT by Gagnon et al is an important contribution to this body of work. This commentary highlights the strengths of the OR4KT including development based on two systematic reviews conducted by the authors to synthesize OR theory and measurement tools, and applicability to a wider range of high-income country healthcare settings through inclusion of input from a diverse group of international experts and transcultural adaptation of the tool, in the context of the literature to date. Limitations and future directions for further development of the tool are also discussed and include application of quantitative psychometric approaches and evaluation of the tool in a broader range of healthcare settings

Knowledge translation is the use of knowledge in health care decision making

Abstract Objective: To provide an overview of the science and practice of knowledge translation. Study Design: Narrative review outlining what knowledge translation is and a framework for its use. Results: Knowledge translation is defined as the use of knowledge in practice and decision making by the public, patients, health care professionals, managers, and policy makers. Failures to use research evidence to inform decision making are apparent across all these key decision maker groups. There are several proposed theories and frameworks for achieving knowledge translation. A conceptual framework developed by Graham et al., termed the knowledge-to-action cycle, provides an approach that builds on the commonalities found in an assessment of planned action theories. Conclusions: Review of the evidence base for the science and practice of knowledge translation has identified several gaps including the need to develop valid strategies for assessing the determinants of knowledge use and for evaluating sustainability of knowledge translation interventions.

Understanding the relationship between the perceived characteristics of clinical practice guidelines and their uptake: protocol for a realist review

<p>Abstract</p> <p>Background</p> <p>Clinical practice guidelines have the potential to facilitate the implementation of evidence into practice, support clinical decision making, specify beneficial therapeutic approaches, and influence public policy. However, these potential benefits have not been consistently achieved. The limited impact of guidelines can be attributed to organisational constraints, the complexity of the guidelines, and the lack of usability testing or end-user involvement in their development. Implementability has been referred to as the perceived characteristics of guidelines that predict the relative ease of their implementation at the clinical level, but this concept is as yet poorly defined. The objective of our study is to identify guideline attributes that affect uptake in practice by considering evidence from four disciplines (medicine, psychology, management, human factors engineering) to determine the relationship between the perceived characteristics of recommendations and their uptake and to develop a framework of implementability.</p> <p>Methods</p> <p>A realist-review approach to knowledge synthesis will be used to understand attributes of guidelines (<it>e.g</it>., its text and content) and how changing these elements might impact clinical practice and clinical decision making. It also allows for the exploration of 'what works for whom, in what circumstances, and in what respects'. The realist review will be structured according to Pawson's five practical steps in realist reviews: (1) clarifying the scope of the review, (2) determining the search strategy, (3) ensuring proper article selection and study quality assessment, (4) extracting and organising data, and (5) synthesising the evidence and drawing conclusions. Data will be synthesised according to a two-stage analysis: (1) we will extract and define all relevant guideline attributes from the different disciplines, then create a shortlist of unique attributes and investigate their relationships with uptake, and (2) we will compare and contrast the attributes and guideline uptake within each and between the four disciplines to create a robust framework of implementability.</p> <p>Discussion</p> <p>Creating guidelines that are designed to maximise uptake may be a potentially effective and inexpensive way of increasing their impact. However, this is best achieved by a comprehensive framework to inform the design of guidelines drawing on a range of disciplines that study behaviour change. This study will use a customised realist-review approach to synthesising the literature to better understand and operationalise a complex and under-theorised concept.</p