Jane M. Young

Meta-analysis of short-term outcomes after laparoscopic resection for colorectal cancer.

The safety and efficacy of laparoscopic resection (LR) for colorectal cancer remains to be established.

What are the unmet supportive care needs of people with cancer? A systematic review

Goals of workThe identification and management of unmet supportive care needs is an essential component of health care for people with cancer. Information about the prevalence of unmet need can inform service planning/redesign.Materials and methodsA systematic review of electronic databases was conducted to determine the prevalence of unmet supportive care needs at difference time points of the cancer experience.ResultsOf 94 articles or reports identified, 57 quantified the prevalence of unmet need. Prevalence of unmet need, their trends and predictors were highly variable in all domains at all time points. The most frequently reported unmet needs were those in the activities of daily living domain (1–73%), followed by psychological (12–85%), information (6–93%), psychosocial (1–89%) and physical (7–89%). Needs within the spiritual (14–51%), communication (2–57%) and sexuality (33–63%) domains were least frequently investigated. Unmet needs appear to be highest and most varied during treatment, however a greater number of individuals were likely to express unmet need post-treatment compared to any other time. Tumour-specific unmet needs were difficult to distinguish. Variations in the classification of unmet need, differences in reporting methods and the diverse samples from which patients were drawn inhibit comparisons of studies.ConclusionThe diversity of methods used in studies hinders analysis of patterns and predictors of unmet need among people with cancer and precludes generalisation. Well-designed, context-specific, prospective studies, using validated instruments and standard methods of analysis and reporting, are needed to benefit future interventional research to identify how best to address the unmet supportive care needs of people with cancer.

Does telling people what they have been doing change what they do? A systematic review of the effects of audit and feedback

Background: Many people advocate audit and feedback as a strategy for improving professional practice. The main results of an update of a Cochrane review on the effects of audit and feedback are reported. Data sources: The Cochrane Effective Practice and Organisation of Care Group’s register up to January 2004 was searched. Randomised trials of audit and feedback that reported objectively measured professional practice in a healthcare setting or healthcare outcomes were included. Review methods: Data were independently extracted and the quality of studies were assessed by two reviewers. Quantitative, visual and qualitative analyses were undertaken. Main results: 118 trials are included in the review. In the primary analysis, 88 comparisons from 72 studies were included that compared any intervention in which audit and feedback was a component to no intervention. For dichotomous outcomes, the median-adjusted risk difference of compliance with desired practice was 5% (interquartile range 3–11). For continuous outcomes, the median-adjusted percentage change relative to control was 16% (interquartile range 5–37). Low baseline compliance with recommended practice and higher intensity of audit and feedback appeared to predict the effectiveness of audit and feedback. Conclusions: Audit and feedback can be effective in improving professional practice. The effects are generally small to moderate. The absolute effects of audit and feedback are likely to be larger when baseline adherence to recommended practice is low and intensity of audit and feedback is high.

What do we know about how to do audit and feedback? Pitfalls in applying evidence from a systematic review

BackgroundImproving the quality of health care requires a range of evidence-based activities. Audit and feedback is commonly used as a quality improvement tool in the UK National Health Service [NHS]. We set out to assess whether current guidance and systematic review evidence can sufficiently inform practical decisions about how to use audit and feedback to improve quality of care.MethodsWe selected an important chronic disease encountered in primary care: diabetes mellitus. We identified recommendations from National Institute for Clinical Excellence (NICE) guidance on conducting audit and generated questions which would be relevant to any attempt to operationalise audit and feedback in a healthcare service setting. We explored the extent to which a systematic review of audit and feedback could provide practical guidance about whether audit and feedback should be used to improve quality of diabetes care and, if so, how audit and feedback could be optimised.ResultsNational guidance suggests the importance of securing the right organisational conditions and processes. Review evidence suggests that audit and feedback can be effective in changing healthcare professional practice. However, the available evidence says relatively little about the detail of how to use audit and feedback most efficiently.ConclusionAudit and feedback will continue to be an unreliable approach to quality improvement until we learn how and when it works best. Conceptualising audit and feedback within a theoretical framework offers a way forward.

Evidence‐based medicine in general practice: beliefs and barriers among Australian GPs

If implemented, evidence-based medicine (EBM) in general practice will improve health outcomes for patients. This paper examines the views of 60 Australian general practitioners about EBM. While 57% of respondents had a computer in their surgery, 15% had Internet access and only 3% had access to the Cochrane Library at work. The most commonly cited barrier to EBM was ‘patient demand for treatment despite lack of evidence for effectiveness’ (45%). The next three most highly rated barriers related to lack of time. For each of three tasks of EBM, namely searching for evidence, appraising evidence and discussing the implications of evidence with patients, lack of time was rated as a ‘very important barrier’ by significantly more participants than lack of skills (McNemar’s tests: χ21 = 7.1, P = 0.008, χ21 = 14.0, P = 0.001 and χ21 = 9.0, P = 0.003, respectively). Preferred resources for EBM included clinical practice guidelines (rated as ‘very useful’ by 55%) and journals that summarize research evidence, for example Evidence-based Medicine (52%). Systematic reviews were considered ‘very useful’ by only 15% of respondents, consistent with our finding that 30% did not understand the term ‘systematic review’. Furthermore, 43% did not understand ‘meta-analysis’. A minority indicated they understood the terms ‘relative risk’ (23%), ‘absolute risk’ (28%) and ‘number needed to treat’ (15%) sufficiently to explain to others. Skills development is crucial to achieve EBM in general practice.

META-ANALYSIS OF NON-RANDOMIZED COMPARATIVE STUDIES OF THE SHORT-TERM OUTCOMES OF LAPAROSCOPIC RESECTION FOR COLORECTAL CANCER

Laparoscopic resection remains to be established as the procedure of first choice for operable colorectal cancer. The aim of the study was to conduct a systematic review of non‐randomized comparative studies of laparoscopic resection for colorectal cancer. Published work in English was searched for relevant articles published by the end of 2003. The MOOSE statement was used to conduct the meta‐analysis. Study quality was assessed by two investigators using the MINORS tool and the analysis was conducted using Comprehensive Meta‐analysis software (Biostat, Englewood, NJ, USA) and Microsoft Excel (Microsoft, Redmond, WA, USA). One thousand two hundred and twenty abstracts were reviewed and 398 articles examined in detail. Out of 108 articles reporting the results of relevant studies, 75 were reports of 64 non‐randomized comparative studies. Fifteen studies were excluded. Analysis of the outcomes of 6438 resections showed that the conversion rate was 13.3% with a statistically significant difference between studies with more than 50 versus those with 50 or less attempted resections (11.7 vs 16.5%; P < 0.001). Laparoscopic resection took 27.6% (41 min) longer to carry out than open resection. There was no significant difference between the two groups in early mortality rates (1.2 vs 1.1%; P = 0.787) or likelihood of re‐operation (2.3 vs 1.5%; P = 0.319). Laparoscopic resection was associated with a lower morbidity rate (24.05 vs 30.80%, odds ratio (95% confidence interval) = 0.77 (0.63–0.95); P = 0.014, n = 4111, random‐effects model). Time until passage of first flatus, passage of a bowel motion, tolerating oral fluids and a solid diet was 1.2–1.6 days (26 to 37%) shorter, measurements of pain and narcotic analgesic requirements were 16–35% lower and hospital stay was 3.5 days (18.8%) shorter following laparoscopic resection compared with open resection. The two approaches were 99% similar in terms of adequacy of oncological clearance. Meta‐analysis of non‐randomized comparative studies favours laparoscopic over open resection for colorectal cancer. The results were remarkably similar to those of a contemporaneous meta‐analysis of randomized controlled trials published by the end of 2002.

Growing Literature, Stagnant Science? Systematic Review, Meta-Regression and Cumulative Analysis of Audit and Feedback Interventions in Health Care

ABSTRACTBACKGROUNDThis paper extends the findings of the Cochrane systematic review of audit and feedback on professional practice to explore the estimate of effect over time and examine whether new trials have added to knowledge regarding how optimize the effectiveness of audit and feedback.METHODSWe searched the Cochrane Central Register of Controlled Trials, MEDLINE, and EMBASE for randomized trials of audit and feedback compared to usual care, with objectively measured outcomes assessing compliance with intended professional practice. Two reviewers independently screened articles and abstracted variables related to the intervention, the context, and trial methodology. The median absolute risk difference in compliance with intended professional practice was determined for each study, and adjusted for baseline performance. The effect size across studies was recalculated as studies were added to the cumulative analysis. Meta-regressions were conducted for studies published up to 2002, 2006, and 2010 in which characteristics of the intervention, the recipients, and trial risk of bias were tested as predictors of effect size.RESULTSOf the 140 randomized clinical trials (RCTs) included in the Cochrane review, 98 comparisons from 62 studies met the criteria for inclusion. The cumulative analysis indicated that the effect size became stable in 2003 after 51 comparisons from 30 trials. Cumulative meta-regressions suggested new trials are contributing little further information regarding the impact of common effect modifiers. Feedback appears most effective when: delivered by a supervisor or respected colleague; presented frequently; featuring both specific goals and action-plans; aiming to decrease the targeted behavior; baseline performance is lower; and recipients are non-physicians.DISCUSSIONThere is substantial evidence that audit and feedback can effectively improve quality of care, but little evidence of progress in the field. There are opportunity costs for patients, providers, and health care systems when investigators test quality improvement interventions that do not build upon, or contribute toward, extant knowledge.

Systematic review of randomized controlled trials of the effectiveness of biofeedback for pelvic floor dysfunction

Pelvic floor dysfunction (PFD) is a type of functional constipation. The effectiveness of biofeedback as a treatment remains unclear.

How to critically appraise an article

Critical appraisal is a systematic process used to identify the strengths and weaknesses of a research article in order to assess the usefulness and validity of research findings. The most important components of a critical appraisal are an evaluation of the appropriateness of the study design for the research question and a careful assessment of the key methodological features of this design. Other factors that also should be considered include the suitability of the statistical methods used and their subsequent interpretation, potential conflicts of interest and the relevance of the research to ones own practice. This Review presents a 10-step guide to critical appraisal that aims to assist clinicians to identify the most relevant high-quality studies available to guide their clinical practice.

Predictors of General Health After Major Trauma

BACKGROUND Traumatic injury is a leading contributor to the global burden of disease, yet there has been little research on possible predictors of general health after major trauma. This study aims to explore possible predictors of general health after major physical trauma. METHODS A survey was performed of 731 surviving consecutive adult patients presenting to a major trauma center with accidental major trauma, between 1 year and 5 years postinjury. Data pertaining to general patient factors, injury severity factors, socioeconomic factors, and claim-related factors were abstracted from the hospital trauma database and the questionnaire. Multiple linear regression was used to develop a predictive model for the main outcome, the physical and mental component summaries of the SF-36 General Health Survey. RESULTS One hundred and forty nine patients were excluded, 93 refused to participate, and 134 did not respond, leaving 355 participants. On multivariate analysis, better physical health was significantly associated with increasing time since the injury and lower Injury Severity Scores (p = 0.03 and 0.02, respectively). Having a settled compensation claim, having an unsettled compensation claim, and using a lawyer were independently associated with poor physical health (p = 0.02, 0.006, and <0.0001, respectively). Measures of injury severity or socioeconomic status were not associated with mental health. However, having an unsettled compensation claim was strongly associated with poor mental health (p < 0.0001). CONCLUSION General health after major physical trauma is more strongly associated with factors relating to compensation than with the severity of the injury. Processes involved with claiming compensation after major trauma may contribute to poor patient outcomes.