Stephen Blamey

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.

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.

Diagnosis of appendicitis in adults by ultrasonography or computed tomography: A systematic review and meta-analysis

OBJECTIVES The use of ultrasonography and computed tomography (CT) in the diagnosis of appendicitis in adult patients was compared. METHODS Systematic review and meta-analysis of current evidence in two clinical situations: unselected nonpregnant, adult patients with symptoms of appendicitis, and more selective use in only those patients who still have an equivocal diagnosis subsequent to routine clinical investigations. RESULTS Meta-analysis of eligible studies shows CT to have better sensitivity and specificity than ultrasound in both clinical situations. CONCLUSIONS Application of these findings in clinical practice and/or policy would need to evaluate the better diagnostic performance of CT against its cost and availability. In addition, it is imperative that future studies be conducted in patient populations that are well-defined with respect to prior investigations. Sequelae of false-negative and false-positive diagnoses should also be evaluated.

A norovirus gastroenteritis epidemic in a long-term-care facility.

BACKGROUND In Victoria, Australia, from July to December 2002, 126 outbreaks of viral and suspected viral gastroenteritis were reported in healthcare institutions. Norovirus was found to account for at least 77 of the 126 outbreaks. METHODS In October 2002, the infection control unit investigated an outbreak of acute gastroenteritis on three wards in a 500-bed, long-term-care facility in Melbourne, Victoria, Australia. Cohorting and other infection control measures were initiated. RESULTS The outbreak was controlled 32 days after the first symptoms of acute gastroenteritis were identified. Fifty-two patients and 11 staff members were affected. Norovirus genotype 2 was detected on two of the three wards. Norovirus was not isolated in the third ward but was suspected to be the causative organism. CONCLUSIONS Outbreaks of viral gastroenteritis can cause significant morbidity in a long-term-care facility, affecting both patients and staff. In addition, the transmission of viral pathogens can be well established before there is recognition of an outbreak.

Technical developments and a team approach leads to an improved outcome: lessons learnt implementing laparoscopic splenectomy.

Background:  To document the technical aspects, outcome and lessons learnt during the learning curve phase of implementing laparoscopic splenectomy, by comparing the results before and after the introduction of a standardized technique.

Systematic review of the impact of endoscopic ultrasound on the management of patients with esophageal cancer

OBJECTIVES Although endoscopic ultrasound (EUS) staging of esophageal cancer is established in clinical practice, high-quality evidence about its impact on patient outcomes is not available. This study aims to determine the impact of EUS for esophageal cancer staging on patient management and survival. METHODS A systematic review was conducted using Medline, PreMedline, Embase, and The Cochrane Library. Included studies were (i) comparative studies reporting survival following EUS esophageal cancer staging, (ii) therapeutic impact studies reporting change in patient management following EUS. The quality of included studies was critically appraised. RESULTS One systematic review, five studies reporting therapeutic impact, and two studies reporting patient survival were identified. The design and quality of the therapeutic impact studies varied widely. Management changed in 24-29 percent of patients following EUS staging of esophageal cancer (two studies). No studies provided data on the avoidance of surgery for this indication. One retrospective cohort study with historical control found EUS staging of esophageal cancer improved patient survival; a second study with similar design limitations did not find a survival benefit for EUS staging in patients undergoing resection. These studies had a high potential for bias, limiting the value of these findings. CONCLUSIONS Two studies provided evidence of a change in patient management following EUS for staging esophageal cancer, a higher level of evidence for a clinical benefit than can be obtained from accuracy studies alone. This evidence contributed to a recommendation for public funding of EUS in staging esophageal cancer in Australia.

Using recombinant human thyroid‐stimulating hormone for the diagnosis of recurrent thyroid cancer

Background:  Recombinant human thyroid‐stimulating hormone (rhTSH) has been suggested as a diagnostic agent in the diagnosis of recurrent thyroid cancer, instead of the current practice of thyroid hormone (THT) withdrawal.

Improving standards, improving surgery

For many years, cardiac and vascular implantable items have been purchased pre-sterilized and the batch or lot number has been recorded at the time of surgery using labels provided by the manufacturer. More recently, general surgical prostheses such as mesh for hernia repair have also been purchased in pre-sterilized packs. Australian Standard 4187-2003 Cleaning, disinfecting and sterilizing reusable medical and surgical instruments and equipment, and maintenance of associated environments in health care facilities 1 makes two recommendations with regard to implantable items. First, implantable items should be purchased in sterilized packs; and second, identification of the manufacturer’s batch or lot number in the patient record is recommended. Incorporating the manufacturer’s batch or lot number of any unsterile, commercially prepared implantable materials into the unit pack is also recommended. This enables appropriate tracking of manufacturing or sterilization issues from production to patient. Historically, orthopaedic surgery has involved the use of screws and plates that have been unsterile at time of purchase. A selection of (single use/implantable) plates and screws are processed together (small or large fragment set) and unused items are reprocessed as reusable items. A small or large fragment set is a tray of plates and screws with specialist instruments to assist with insertion, such as retractors, screw driver and depth gauge. Implantable items may be cleaned and reprocessed many times prior to use. Linking the manufacturer’s batch or lot number and the sterilization record to the patient record is difficult and seldom achieved in this model of practice. To comply with the recommendations for batch control labels, manufacturers provide implantable items which have been sterilized, individually packaged and labelled. ‘Peel off’ batch control labels are provided for the patient record so that tracking is simple if a recall is needed. We report an incident in which visible prior contamination of a small fragment set was identified during a procedure. In keeping with best practice, the patient was informed that an infection control breach had occurred. Despite the very small risk to the patient, counselling was offered and follow-up testing for blood-borne viruses, over a 6-month period, was recommended. Compliance with the recommendations of AS4187-2003 to purchase implantable items sterile and routinely document the manufacturers’ batch or lot number in the patient record will reduce the risk of this type of incident and simplify follow-up management. It is appropriate to embrace improvement and changes that reduce the risk of adverse events and maximize patient safety.

Re: Liquid-based cytology for cervical screening

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