Peter Littlejohns

AGREE II: advancing guideline development, reporting and evaluation in health care

Clinical practice guidelines, which are systematically developed statements aimed at helping people make clinical, policy-related and system-related decisions,[1][1],[2][2] frequently vary widely in quality.[3][3],[4][4] A strategy was needed to differentiate among guidelines and ensure that those

Influence of delay on survival in patients with breast cancer: a systematic review

BACKGROUND Most patients with breast cancer are detected after symptoms occur rather than through screening. The impact on survival of delays between the onset of symptoms and the start of treatment is controversial and cannot be studied in randomised controlled trials. We did a systematic review of observational studies (worldwide) of duration of symptoms and survival. METHODS We identified 87 studies (101,954 patients) with direct data linking delay (including delay by patients) and survival. We classified studies for analysis by type of data in the original reports: category I studies had actual 5-year survival data (38 studies, 53,912 patients); category II used actuarial or multivariate analyses (21 studies, 25,102 patients); and category III was all other types of data (28 studies, 22,940 patients). We tested the main hypothesis that longer delays would be associated with lower survival, and a secondary hypothesis that longer delays were associated with more advanced stage, which would account for lower survival. FINDINGS In category I studies, patients with delays of 3 months or more had 12% lower 5-year survival than those with shorter delays (odds ratio for death 1.47 [95% CI 1.42-1.53]) and those with delays of 3-6 months had 7% lower survival than those with shorter delays (1.24 [1.17-1.30]). In category II, 13 of 14 studies with unrestricted samples showed a significant adverse relation between longer delays and survival, whereas four of five studies of only patients with operable disease showed no significant relation. In category III, all three studies with unrestricted samples supported the primary hypothesis. The 13 informative studies showed that longer delays were associated with more advanced stage. In studies that controlled for stage, longer delay was not associated with shorter survival when the effect of stage on survival was taken into account. INTERPRETATION Delays of 3-6 months are associated with lower survival. These effects cannot be accounted for by lead-time bias. Efforts should be made to keep delays by patients and providers to a minimum.

Factors predicting delayed presentation of symptomatic breast cancer: a systematic review

BACKGROUND Delayed presentation of symptomatic breast cancer is associated with lower survival. Understanding of the factors that influence delay is important for the development of strategies to shorten delays. We did a systematic review to assess the quality and strength of evidence on risk factors for delays by patients and providers. METHODS We generated hypotheses about the relation between each putative risk factor and delay, against which we tested studies. We did searches to identify papers containing original data related to risk factors for delays by patients (n=86) and providers (n=28). We critically appraised the papers for inclusion in the review according to predefined criteria. The small number of studies of adequate quality did not allow formal meta-analysis. We therefore assigned strength of evidence according to a combination of the number and size of studies supporting, not supporting, or refuting the hypotheses. FINDINGS Most studies were deemed to be of poor quality and were excluded. Among 23 studies of adequate quality, however, there was strong evidence for an association between older age and delay by patients, and strong evidence that marital status was unrelated to delays by patients. Younger age and presentation with a breast symptom other than a lump were strong risk factors for delays by providers. Moderate evidence was shown for several other factors. INTERPRETATION The strength of the current evidence is inadequate to inform the development of specific strategies to shorten delays by patients or providers. Clarification of the findings of this review through a major programme of primary research is urgently required.

Implementing Evidence-Based Practice: Factors That Influence the Use of Research Evidence by Occupational Therapists

Developing a professional and organisational culture within National Health Service (NHS) trusts that is supportive of improving evidence-based practice will require both the generation and the use of research evidence. This article reports the findings of a study that explored the factors that inhibit and facilitate the use of research evidence by occupational therapists. The sample of 100 occupational therapists was drawn from across seven acute NHS trusts, in one NHS region, including two teaching hospitals. The postal survey achieved a 78% response rate. The findings illustrate that whilst occupational therapists have a positive attitude towards the use of research and are keen to make use of that evidence in practice, workload pressures are a major inhibiting factor. The challenge for practitioners and managers alike is to create organisational conditions that are supportive of the NHS policy objectives to enhance the use of evidence-based practice.

AGREE II: advancing guideline development, reporting and evaluation in health care.

From McMaster University (Brouwers, Kho, Hanna, Makarski); the Program in Evidence-based Care, Cancer Care Ontario (Brouwers), Hamilton, Ontario; British Columbia Cancer Agency (Browman), Victoria, BC; the Dutch Institute for Healthcare Improvement CBO and IQ Healthcare (Burgers), Radboud University Nijmegen Medical Centre, the Netherlands; St. George’s University of London (Cluzeau), London, UK; the University of Bristol (Feder), Bristol, UK; Unité Cancer et Environement (Fervers), Université de Lyon e Centre Léon Bérard, Université Lyon 1, EA 4129, Lyon, France; the Canadian Institutes of Health Research (Graham), Ottawa, Ontario; the Ottawa Hospital Research Institute (Grimshaw), Ottawa, Ontario; the National Institute for Health and Clinical Excellence (Littlejohns), London, UK; and the Canadian Partnership Against Cancer (Zitzelsberger), Ottawa, Ontario

Disinvestment from low value clinical interventions: NICEly done?

Over the past 10 years NICE has identified over 800 clinical interventions for potential disinvestment. But Sarah Garner and Peter Littlejohns report that although disinvestment will increase efficiency and quality, the opportunity for cash saving is unlikely to meet the necessary targets

A Collaboratively-Derived Science-Policy Research Agenda

The need for policy makers to understand science and for scientists to understand policy processes is widely recognised. However, the science-policy relationship is sometimes difficult and occasionally dysfunctional; it is also increasingly visible, because it must deal with contentious issues, or itself becomes a matter of public controversy, or both. We suggest that identifying key unanswered questions on the relationship between science and policy will catalyse and focus research in this field. To identify these questions, a collaborative procedure was employed with 52 participants selected to cover a wide range of experience in both science and policy, including people from government, non-governmental organisations, academia and industry. These participants consulted with colleagues and submitted 239 questions. An initial round of voting was followed by a workshop in which 40 of the most important questions were identified by further discussion and voting. The resulting list includes questions about the effectiveness of science-based decision-making structures; the nature and legitimacy of expertise; the consequences of changes such as increasing transparency; choices among different sources of evidence; the implications of new means of characterising and representing uncertainties; and ways in which policy and political processes affect what counts as authoritative evidence. We expect this exercise to identify important theoretical questions and to help improve the mutual understanding and effectiveness of those working at the interface of science and policy.

Prevalence and diagnosis of chronic respiratory symptoms in adults.

OBJECTIVE--To investigate the prevalence and diagnosis of chronic respiratory disease in adults. DESIGN--Screening questionnaire was sent to all patients aged 40-70 on the register of a group general practice; those responding positively were sent a detailed questionnaire and invited for assessment of respiratory function by forced expiratory volume in one second, forced vital capacity, peak flow rate, and reversibility studies with a beta adrenergic inhaler. SETTING--Group general practice in south west London. RESULTS--Of 2387 patients aged 40-70, 1444 completed a screening questionnaire. Of the 509 patients who reported cough, phlegm, wheeze, or shortness of breath, 324 responded to a detailed questionnaire, 256 of whom had simple respiratory function assessed. Chronic bronchitis affected 106 (17%) men and 58 (7%) women, and wheeze occurring at least once a week affected 60 (9%) men and 20 (3%) women. Only a half to a third of patients had received a diagnostic label of chronic bronchitis or asthma for their symptoms. There was considerable clinical and physiological similarity (including reversibility of the airways) between patients labelled as having asthma and having chronic bronchitis. A label of asthma was used more often for patients of social classes I and II. CONCLUSIONS--Comparison with prevalence surveys carried out in the 1950s showed that respiratory symptoms are as common now as then, but the risk of disabling chronic bronchitis has fallen, more among men than women, probably because of their reduced smoking. Changes in diagnostic fashion, together with increased detection, may have contributed to the upward trend in reported morbidity from asthma over the past 30 years.

Reallocating resources: how should the National Institute for Health and Clinical Excellence guide disinvestment efforts in the National Health Service?

The recent acute budgetary pressures within the English National Health Service (NHS) have accentuated calls for targeted disinvestment thereby eliminating ineffective or low-value services to provide resources that can be reallocated toward more cost-effective purposes. This challenge extends beyond allocating new resources wisely, a goal that has been, since its inception, the primary focus of the National Institute for Health and Clinical Excellence (NICE). But on 6 September 2006, the Department of Health announced a new mandate for NICE to help the NHS identify interventions that are not effective. This paper discusses current NICE efforts to support value in the NHS and then explores the policy options available to the Institute as it prepares to launch a programme to meet the NHS request for guidance on disinvestment. All of the possible options present challenges. NICE will need to collaborate in new ways with partners inside, and perhaps outside, the NHS. However, the Institute has an established reputation for rigour, transparency and political durability that makes it well qualified to sustain public support in the face of difficult decisions. Disinvestment will provide a stern test of these qualities.

Guidance on priority setting in health care (GPS-Health): the inclusion of equity criteria not captured by cost-effectiveness analysis

This Guidance for Priority Setting in Health Care (GPS-Health), initiated by the World Health Organization, offers a comprehensive map of equity criteria that are relevant to health care priority setting and should be considered in addition to cost-effectiveness analysis. The guidance, in the form of a checklist, is especially targeted at decision makers who set priorities at national and sub-national levels, and those who interpret findings from cost-effectiveness analysis. It is also targeted at researchers conducting cost-effectiveness analysis to improve reporting of their results in the light of these other criteria.The guidance was develop through a series of expert consultation meetings and involved three steps: i) methods and normative concepts were identified through a systematic review; ii) the review findings were critically assessed in the expert consultation meetings which resulted in a draft checklist of normative criteria; iii) the checklist was validated though an extensive hearing process with input from a range of relevant stakeholders.The GPS-Health incorporates criteria related to the disease an intervention targets (severity of disease, capacity to benefit, and past health loss); characteristics of social groups an intervention targets (socioeconomic status, area of living, gender; race, ethnicity, religion and sexual orientation); and non-health consequences of an intervention (financial protection, economic productivity, and care for others).