Alun L. Cameron

Rapid reviews versus full systematic reviews: An inventory of current methods and practice in health technology assessment

OBJECTIVES This review assessed current practice in the preparation of rapid reviews by health technology assessment (HTA) organizations, both internationally and in the Australian context, and evaluated the available peer-reviewed literature pertaining to the methodology used in the preparation of these reviews. METHODS A survey tool was developed and distributed to a total of fifty International Network of Agencies for Health Technology Assessment (INAHTA) members and other selected HTA organizations. Data on a broad range of themes related to the conduct of rapid reviews were collated, discussed narratively, and subjected to simple statistical analysis where appropriate. Systematic searches of the Cochrane Library, EMBASE, MEDLINE, and the Australian Medical Index were undertaken in March 2007 to identify literature pertaining to rapid review methodology. Comparative studies, guidelines, program evaluations, methods studies, commentaries, and surveys were considered for inclusion. RESULTS Twenty-three surveys were returned (46 percent), with eighteen agencies reporting on thirty-six rapid review products. Axiomatic trends were identified, but there was little cohesion between organizations regarding the contents, methods, and definition of a rapid review. The twelve studies identified by the systematic literature search did not specifically address the methodology underpinning rapid review; rather, many highlighted the complexity of the area. Authors suggested restricted research questions and truncated search strategies as methods to limit the time taken to complete a review. CONCLUSIONS Rather than developing a formalized methodology by which to conduct rapid reviews, agencies should work toward increasing the transparency of the methods used for each review. It is perhaps the appropriate use, not the appropriate methodology, of a rapid review that requires future consideration.

Deep brain stimulation for essential tremor: A systematic review

Deep brain stimulation (DBS) is a neurosurgical treatment, which has proven useful in treating Parkinsons disease. This systematic review assessed the safety and effectiveness of DBS for another movement disorder, essential tremor. All studies concerning the use of DBS in patients with essential tremor were identified through searching of electronic databases and hand searching of reference lists. Studies were categorized as before/after DBS or DBS stimulation on/off to allow the effect of the stimulation to be analyzed separately to that of the surgery itself. A total of 430 patients who had received DBS for essential tremor were identified. Most of the reported adverse events were mild and could be treated through changing the stimulation settings. Generally, in all studies, there was a significant improvement in outcomes after DBS compared with baseline scores. In addition, DBS was significantly better in testing when the stimulation was turned on, compared with stimulation turned off or baseline. Based on Level IV evidence, DBS is possibly a safe and effective therapy for essential tremor.

Rapid versus full systematic reviews: Validity in clinical practice?

Introduction:  Rapid reviews are being produced with greater frequency by health technology assessment (HTA) agencies in response to increased pressure from end‐user clinicians and policy‐makers for rapid, evidence‐based advice on health‐care technologies. This comparative study examines the differences in methodologies and essential conclusions between rapid and full reviews on the same topic, with the aim of determining the validity of rapid reviews in the clinical context and making recommendations for their future application.

Does patient volume affect clinical outcomes in adult intensive care units

PurposeThis systematic review assessed if outcomes in adult intensive care units (ICUs) are related to hospital and ICU patient volume.MethodsA systematic search strategy was used to identify studies reporting on volume–outcome relationship in adult ICU patients till November 2010. Inclusion of articles was established through a predetermined protocol. Two reviewers assessed studies independently and data extraction was performed using standardized data extraction forms.ResultsA total of 254 articles were screened. Of these 25 were relevant to this study. After further evaluation a total of 13 studies including 596,259 patients across 1,068 ICUs met the inclusion criteria and were reviewed. All were observational cohort studies. Four of the studies included all admissions to ICU, five included mechanically ventilated patients, two reported on patients admitted with sepsis and one study each reported on patients admitted with medical diagnoses and post cardiac arrest patients admitted to ICU, respectively. There was a wide variability in the quantitative definition of volume and classification of hospitals and ICUs on this basis. Methodological heterogeneity amongst the studies precluded a formal meta-analysis. A trend towards favourable outcomes for high volume centres was observed in all studies. Risk-adjusted mortality rates revealed a survival advantage for a specific group of patients in high volume centres in ten studies but no significant difference in outcomes was evident in three studies.ConclusionsThe results indicate that outcomes of certain subsets of ICU patients—especially those on mechanical ventilation, high-risk patients, and patients with severe sepsis—are better in high volume centres within the constraints of risk adjustments.

Systematic Review of Endovenous Laser Therapy Versus Surgery for the Treatment of Saphenous Varicose Veins

This systematic review compares the safety and efficacy of endovenous laser therapy (ELT) and surgery involving saphenous ligation and stripping as treatments for varicose veins. Systematic searches of medical bibliographic databases, the Internet and lists of references were conducted in August 2007 and April 2008 to identify relevant primary studies. Inclusion of papers was resolved through application of a predetermined protocol. Information on the safety and effectiveness of ELT and surgery was analyzed. Fifty-nine studies were included, with seven studies directly comparing ELT with surgery. Serious adverse events after ELT or surgery were rare. While occurrence rates of some minor adverse events appeared higher after ELT in collated data, comparative studies commonly favored ELT over surgery. Few differences were apparent between treatments with respect to clinical effectiveness outcomes, although long-term follow-up was lacking. Nonclinical effectiveness outcomes generally favored ELT over surgery in the first 2 months after treatment. ELT appears to be at least as safe as surgery. While ELT offers short-term benefits and appears to be as clinically effective as surgery up to 12 months after treatment, clinical trials with a minimum of 3 years of follow-up are required to establish the enduring effectiveness of ELT.

Involvement of consumers in health technology assessment activities by inahta agencies

OBJECTIVES To obtain further information from members of the International Network of Agencies for Health Technology Assessment (INAHTA) on the involvement of consumers in their programs. METHODS A questionnaire for a survey was developed and sent to member agencies in November 2010. Survey responses were compared with those from an earlier survey conducted in 2005. RESULTS Of the thirty-three agencies that provided responses, 67 percent involve consumers in some aspects of their health technology assessment (HTA) programs, compared with 57 percent in 2005. As in the earlier survey, most agencies reporting involvement have contact with consumer or patient organizations and a large minority also involve individual consumers. Summaries of HTA reports that are intended to be easily understood by consumers are prepared by 84 percent of the agencies, and 42 percent involve consumers in dissemination of HTA material. In both areas, there was some increase from the levels previously reported. CONCLUSIONS The survey results suggest that there is a trend to increased involvement of consumers by the INAHTA agencies in their programs but that the level of involvement remains relatively limited. The manner of consumer participation varies between agencies.

Systematic review of computer-navigated total knee arthroplasty.

Conventional total knee arthroplasty (TKA) and the more recently available computer‐navigated total knee arthroplasty (CNTKA) use alternative methods to achieve correct limb alignment. This systematic review was undertaken to assess the safety and effectiveness of CNTKA compared with conventional TKA.

Systematic review of hyperbaric oxygen therapy for the treatment of non-neurological soft tissue radiation-related injuries

PurposeThe purpose of this paper was to provide an evidence-based evaluation of the safety and effectiveness of hyperbaric oxygen therapy (HBOT) for the treatment of non-neurological soft tissue radiation-related injuries (STRI).MethodsSystematic searches of medical bibliographic databases, the Internet, and lists of references were conducted in December 2010 and April 2013 to identify relevant primary studies. Inclusion and classification of papers was resolved through the application of a predetermined protocol. Information on both the safety and effectiveness of HBOT was analyzed.ResultsForty-one articles were included, with 11 comparing HBOT to a regimen without HBOT. Comparative evidence varied considerably in methodological quality, and numerous limitations were identified. Absolute data showed that serious adverse events after HBOT were rare, while more common adverse events were minor and self-limiting. Compared to observation, conventional, or sham therapies, evidence of benefit in clinical outcomes was shown for HBOT for radiation proctitis and wounds in irradiated soft tissue of the head and neck, but not for postirradiation soft tissue edema or radiation cystitis. Clinical outcomes differed little between HBOT and argon plasma coagulation for radiation proctitis and between HBOT and hyaluronic acid for radiation cystitis.ConclusionsHBOT is a safe intervention which may offer clinical benefits to patients suffering from radiation proctitis and non-neurological STRI of the head and neck. However, differing clinical responses across STRI demonstrate a need for further well-designed clinical trials to validate the use of HBOT for individual STRI, both as an adjunct to conventional treatments and relative to definitive treatments.

Systematic review of a patient care bundle in reducing staphylococcal infections in cardiac and orthopaedic surgery

Surgical site infections (SSIs) are serious adverse events hindering surgical patients’ recovery. In Australia and New Zealand, SSIs are a huge burden to patients and healthcare systems. A bundled approach, including pre‐theatre nasal and/or skin decolonization has been used to reduce the risk of staphylococcal infection. The aim of this review is to assess the effectiveness of the bundle in preventing SSIs for cardiac and orthopaedic surgeries. The review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses statement. Published literature was searched in PubMed, Embase and Cochrane Library of Systematic reviews. Identified articles were selected and extracted based on a priori defined Population‐Intervention‐Comparator‐Outcome and eligibility criteria. Data of randomized controlled trials (RCTs) and comparative observational studies were synthesized by meta‐analyses. Quality appraisal tools were used to assess the evidence quality. The review included six RCTs and 19 observational studies. The bundled treatment regimens varied substantially across all studies. RCTs showed a trend of Staphylococcus aureus SSIs reduction due to the bundle (relative risk = 0.59, 95% confidence interval (CI) = 0.33, 1.06) with moderate heterogeneity. Observational studies showed statistically significant reduction in all‐cause and S. aureus SSIs, with 51% (95% CI = 0.41, 0.59) and 47% (95% CI = 0.35, 0.65), respectively. No publication biases were detected. SSIs in major cardiac and orthopaedic surgeries can be effectively reduced by approximately 50% with a pre‐theatre patient care bundle approach.

Continuous paravertebral block for post-cardiothoracic surgery analgesia: a systematic review and meta-analysis

A continuous paravertebral block is used when pain relief is required beyond the duration of a single-injection paravertebral block. Surgical procedures requiring an incision into the pleural cavity are some of the most painful procedures postoperatively and, if not managed appropriately, can lead to chronic pain. The current gold standard for post-cardiothoracic surgery pain management is epidural analgesia, which has contraindications, a failure rate of up to 12% and risk of complications such as epidural abscess and spinal haematoma. This systematic review and meta-analysis aimed to investigate the use of a continuous paravertebral block for post-cardiothoracic surgery analgesia. Randomized controlled trials evaluating the continuous paravertebral block against epidural analgesia, wound infiltration, placebo or standard care (intravenous opioids) for post-cardiothoracic surgery analgesia were considered for inclusion in the systematic review. PubMed, EMBASE, The Cochrane Library and the University of York Centre for Reviews and Dissemination databases were searched from inception to 15 September 2014. Risk of bias and generalizability were assessed using a modified Downs and Black checklist. A meta-analysis was conducted on suitable studies comparing the continuous paravertebral nerve block with epidural anaesthesia, with fixed-effects models being used to pool the effects. Twenty-three randomized controlled trials with 1120 participants were included. The continuous paravertebral block was associated with a significant improvement in incidence of nausea and vomiting (odds ratio = 0.29, 95% confidence interval = [0.16, 0.56]), hypotension (odds ratio = 0.16, 95% confidence interval = [0.06, 0.41]) and urinary retention (odds ratio = 0.22, 95% confidence interval = [0.09, 0.52]) compared with the epidural block. No statistically significant difference in pain relief was reported. The continuous paravertebral block has equivalent analgesic effects to epidural analgesia, wound infiltration and standard care, but is associated with a lower incidence of nausea and vomiting, hypotension and urinary retention than epidural analgesia.