José Ignacio Emparanza

Harmonising evidence-based medicine teaching : a study of the outcomes of e-learning in five European countries

BackgroundWe developed and evaluated the outcomes of an e-learning course for evidence based medicine (EBM) training in postgraduate medical education in different languages and settings across five European countries.MethodsWe measured changes in knowledge and attitudes with well-developed assessment tools before and after administration of the course. The course consisted of five e-learning modules covering acquisition (formulating a question and search of the literature), appraisal, application and implementation of findings from systematic reviews of therapeutic interventions, each with interactive audio-visual learning materials of 15 to 20 minutes duration. The modules were prepared in English, Spanish, German and Hungarian. The course was delivered to 101 students from different specialties in Germany (psychiatrists), Hungary (mixture of specialties), Spain (general medical practitioners), Switzerland (obstetricians-gynaecologists) and the UK (obstetricians-gynaecologists). We analysed changes in scores across modules and countries.ResultsOn average across all countries, knowledge scores significantly improved from pre- to post-course for all five modules (p < 0.001). The improvements in scores were on average 1.87 points (14% of total score) for module 1, 1.81 points (26% of total score) for module 2, 1.9 points (11% of total score) for module 3, 1.9 points (12% of total score) for module 4 and 1.14 points (14% of total score) for module 5. In the country specific analysis, knowledge gain was not significant for module 4 in Spain, Switzerland and the UK, for module 3 in Spain and Switzerland and for module 2 in Spain. Compared to pre-course assessment, after completing the course participants felt more confident that they can assess research evidence and that the healthcare system in their country should have its own programme of research about clinical effectiveness.ConclusionE-learning in EBM can be harmonised for effective teaching and learning in different languages, educational settings and clinical specialties, paving the way for development of an international e-EBM course.

Effectiveness of an e-learning course in evidence-based medicine for foundation (internship) training

Summary Aim To evaluate the educational effectiveness of a clinically integrated e-learning course for teaching basic evidence-based medicine (EBM) among postgraduate medical trainees compared to a traditional lecture-based course of equivalent content. Methods We conducted a cluster randomized controlled trial to compare a clinically integrated e-learning EBM course (intervention) to a lecture-based course (control) among postgraduate trainees at foundation or internship level in seven teaching hospitals in the UK West Midlands region. Knowledge gain among participants was measured with a validated instrument using multiple choice questions. Change in knowledge was compared between groups taking into account the cluster design and adjusted for covariates at baseline using generalized estimating equations (GEE) model. Results There were seven clusters involving teaching of 237 trainees (122 in the intervention and 115 in the control group). The total number of postgraduate trainees who completed the course was 88 in the intervention group and 72 in the control group. After adjusting for baseline knowledge, there was no difference in the amount of improvement in knowledge of EBM between the two groups. The adjusted post course difference between the intervention group and the control group was only 0.1 scoring points (95% CI −1.2–1.4). Conclusion An e-learning course in EBM was as effective in improving knowledge as a standard lecture-based course. The benefits of an e-learning approach need to be considered when planning EBM curricula as it allows standardization of teaching materials and is a potential cost-effective alternative to standard lecture-based teaching.

The effectiveness of a clinically integrated e-learning course in evidence-based medicine: A cluster randomised controlled trial

BackgroundTo evaluate the educational effects of a clinically integrated e-learning course for teaching basic evidence-based medicine (EBM) among postgraduates compared to a traditional lecture-based course of equivalent content.MethodsWe conducted a cluster randomised controlled trial in the Netherlands and the UK involving postgraduate trainees in six obstetrics and gynaecology departments. Outcomes (knowledge gain and change in attitude towards EBM) were compared between the clinically integrated e-learning course (intervention) and the traditional lecture based course (control). We measured change from pre- to post-intervention scores using a validated questionnaire assessing knowledge (primary outcome) and attitudes (secondary outcome).ResultsThere were six clusters involving teaching of 61 postgraduate trainees (28 in the intervention and 33 in the control group). The intervention group achieved slightly higher scores for knowledge gain compared to the control, but these results were not statistically significant (difference in knowledge gain: 3.5 points, 95% CI -2.7 to 9.8, p = 0.27). The attitudinal changes were similar for both groups.ConclusionA clinically integrated e-learning course was at least as effective as a traditional lecture based course and was well accepted. Being less costly than traditional teaching and allowing for more independent learning through materials that can be easily updated, there is a place for incorporating e-learning into postgraduate EBM curricula that offer on-the-job training for just-in-time learning.Trial registrationTrial registration number: ACTRN12609000022268.

Quantification of iron concentration in the liver by MRI

ObjectiveMeasurement of liver iron concentration is a key parameter for the management of patients with primary and secondary haemochromatosis. Magnetic resonance imaging (MRI) has already demonstrated high accuracy to quantify liver iron content. To be able to improve the current management of patients that are found to have iron overload, we need a reproducible, standardised method that is, or can easily be made, widely available.MethodsThis article discusses the different MRI techniques and models to quantify liver iron concentration that are currently available and envisaged for the near future from a realistic perspective.ResultsT2 relaxometry methods are more accurate than signal intensity ratio (SIR) methods and they are reproducible but are not yet standardised or widely available. SIR methods, on the other hand, are very specific for all levels of iron overload and, what is more, they are also reproducible, standardised and already widely available.ConclusionsFor these reasons, today, both methods remain necessary while progress is made towards universal standardisation of the relaxometry technique.

Oxygen use in acute myocardial infarction: an online survey of health professionals' practice and beliefs

Introduction There is growing interest in the safety of oxygen therapy in emergency patients. A Cochrane review of oxygen versus air for patients with acute myocardial infarction (AMI) showed a potentially important, but statistically non-significant, increase in mortality (RR 3.03 (95% CI 0.93 to 9.83)) and concluded a definitive randomised controlled trial (RCT) was needed. Objective To explore the feasibility of conducting an RCT of oxygen versus air in AMI, by exploring the beliefs of UK professionals who treat patients with AMI about oxygens benefits, and to establish a baseline of reported practice by asking about their use of oxygen. Method A cross-sectional online survey of UK emergency department, cardiology and ambulance staff. Result 524 responses were received. All specialities had over 100 respondents. 98.3% said they always or usually use oxygen. 80% reported having local guidelines that recommended the routine use of oxygen. 55% believed oxygen definitely or probably significantly reduces the risk of death, while only 1.3% reported that they thought ‘it may even increase the risk of death.’ There were only minor differences across specialities and grades. Conclusion Widespread belief in the benefit of oxygen in AMI may make it difficult to persuade funders of the importance of this issue and health professionals to participate in enrolling patients into a trial in which oxygen would be withheld from half their patients.

Prognostic score in acute meningococcemia

A prognostic score for children with acute meningococcemia is proposed. We reviewed 176 consecutive patients with acute meningococcemia with ten fatalities admitted to our pediatric ICU in the last 3 yr. The score was obtained from patients in shock, using a stepwise linear discriminant analysis of 18 clinical and laboratory variables on admission. Nine variables showed a significant discriminant power in predicting survival and death: coma, base excess, platelets, glucose, temperature, WBC, sex, purpura, and CSF. The score predicted survival in 100% and death in 91%. The predictive values were significantly better than evaluation by the frequencies of the usual clinical and laboratory variables.

Derivation and validation of a clinical prediction rule for delirium in patients admitted to a medical ward: an observational study.

Objectives To develop and validate a simple clinical prediction rule, based on variables easily measurable at admission, to identify patients at high risk of developing delirium during their hospital stay on an internal medicine ward. Design Prospective study of two cohorts of patients admitted between 1 May and 30 June 2008 (derivation cohort), and between 1 May and 30 June 2009 (validation cohort). Setting A tertiary hospital in Donostia-Gipuzkoa (Spain). Participants In total 397 patients participated in the study. The mean age and incidence of delirium were 75.9 years and 13%, respectively, in the derivation cohort, and 75.8 years and 25% in the validation cohort. Main outcome measures The predictive variables analysed and finally included in the rule were: being aged 85 years old or older, being dependent in five or more activities of daily living, and taking two or more psychotropic drugs (antipsychotics, benzodiazepines, antidepressants, anticonvulsant and/or antidementia drugs). The variable of interest was delirium as defined by the short Confusion Assessment Method, which assesses four characteristics: acute onset and fluctuating course, inattention, disorganised thinking and altered level of consciousness. Results We developed a rule in which the individual risk of delirium is obtained by adding one point for each criterion met (age≥85, high level of dependence, and being on psychotropic medication). The result is considered positive if the score is ≥1. The rule accuracy was: sensitivity=93.4% (95% CI 85.5% to 97.2%), specificity=60.6% (95% CI 54.1% to 66.8%), positive predictive value=44.4% (95% CI 36.9% to 52.1%) and negative predictive value=96.5% (95% CI: 92% to 98.5%). The area under the receiver operator characteristic (ROC) curve was 0.85 for the validation cohort. Conclusions The presence or absence of any of the three predictive factors (age≥85, high level of dependence and psychotropic medication) allowed us to classify patients on internal medicine wards according to the risk of developing delirium. The simplicity of the variables in our clinical prediction rule means that the data collection required is feasible in busy medicine units.

Percutaneous aspiration versus tube drainage for spontaneous pneumothorax: systematic review and meta-analysis

Spontaneous pneumothorax is an extremely frequent pathology. Despite this, there is still no clear consensus on managing these patients. Therefore, we perform a systematic review and meta-analysis of the effectiveness of percutaneous aspiration compared with tube drainage for treating idiopathic spontaneous pneumothorax. Controlled, randomised clinical trials were selected, in which the effectiveness of percutaneous aspiration is compared with that of chest tube drainage, in terms of resolution of the pneumothorax and rates of relapse and hospital admission. Relevant articles were identified by searching electronic databases (e.g., Medline, EMBASE, CENTRAL, mRCT and Pascal), as well as the references of the papers found in this manner, with a cut-off date of April 2009. Quality was assessed by two independent evaluators, using the CASPe appraisal tool. Effectiveness of percutaneous aspiration is compared with that of chest tube drainage, in terms of resolution of the pneumothorax and rates of relapse and hospital admission.

Quality of life in patients with non-muscle-invasive bladder cancer: One-year results of a multicentre prospective cohort study

OBJECTIVE Few studies describe the effect of non-muscle-invasive bladder cancer (NMIBC) on health-related quality of life (HRQL), although patients are mostly diagnosed at this stage of the disease. Taking into account this current evidence gap and the high incidence rates in Spain, we aimed to describe the evolution over time of HRQL in Spanish patients with NMIBC and to examine the clinical and treatment-related factors associated with HRQL change during the first year of management. METHODS AND MATERIALS Observational multicenter prospective inception cohort study conducted in urology departments of 7 Spanish hospitals. A consecutive sample of 244 patients with anatomopathologically confirmed NMIBC, recruited from October 2010 to September 2011, was followed during the diagnostic process, and 6 and 12 months later. HRQL was assessed by generic and disease-specific instruments: the Short Form-36 (covering physical and mental health) and the Bladder Cancer Index, measuring urinary, bowel, and sexual domains (summary scores: 0-100). Bivariate analysis was performed and generalized estimating equation models were constructed to assess HRQL score change. RESULTS Almost 52% of the patients were diagnosed at stage I, and 84% were men. The number of patients treated only with transurethral resection (TUR) was 144, and 82 also received intravesical therapy with bacillus Calmette-Guérin (BCG) or mitomycin C. Mental health was significantly worse than Short Form-36 reference norms at diagnosis (mean of 49.7 vs. 53.3, 95% CI: 52.5-54.2). Urinary domain improved significantly from diagnosis (85.2, 95% CI: 82.9-87.4) to 12-month evaluation (90.2, 95% CI: 87.7-92.8), whereas sexual domain showed deterioration from 56.4 (95% CI: 52.8-59.9) to 53.7 (95% CI: 50.0-57.4). Adjusted HRQL score changes from baseline to 12-month follow-up estimated with generalized estimating equation models showed improvement on the following parameters: urinary domain after TUR with or without intravesical therapy (+3.9, 95% CI: 0.1-7.7), bowel domain among patients treated with TUR and BCG (+7.0, 95% CI: 2.4-11.5), and sexual domain among those treated with TUR and mitomycin C (+13.1, 95% CI: 5.9-20.2). CONCLUSIONS For the first time, a distinctive HRQL pattern of bladder cancer treatment benefits emerges for TUR alone, and in combination with BCG or mitomycin C, which deserves further research. Treatment differences cannot be interpreted in terms of efficacy but can be useful to generate hypotheses to test in future studies.

How far did we get? : How far to go? : A European survey on postgraduate courses in evidence-based medicine

BACKGROUND Over the past decade, evidence-based medicine (EBM) has gained recognition as a means to improve the quality of health care provision. However, little is known about learning opportunities to acquire EBM-associated skills. The EUebm-Unity partnership explored current educational activities for EBM practice for doctors across Europe. METHODS We surveyed organizations offering postgraduate EBM courses across Europe inquiring about their course programme, teaching content and strategies, and interest in a Europe-wide curriculum in EBM. RESULTS One hundred and fifty-six organizers in eight European countries reported 403 courses that had started first-time from 1996 to 2006. Despite a steady increase, in absolute terms, the frequency of courses was low and varied from 1 first-time offering of a course per 640 doctors (Spain) to 1 first-time offering per 5600 doctors (Austria) over 10 years. Most adopted the McMaster EBM teaching concept of small group, problem-based learning focussing on interventions, diagnostic tests and guidelines, and included efforts to link EBM to patient care. Teaching staff consisted of doctors from academic and non-academic settings, supported by methodologists. Efforts to formally integrate EBM in postgraduate activities were only partially successful. Most organizations welcomed a standardized European qualification in EBM. A limitation of the survey is the lack of follow-up information about the continuation of courses following the first-time offering. CONCLUSIONS All countries offer some EBM courses with varying teaching intensity. Learning opportunities are insufficient to ensure widespread dissemination of knowledge and skills. Most countries welcome more efforts to develop inexpensive and feasible educational activities at a postgraduate level.