Vivian Coates

Prevention of pneumonia in elderly stroke patients by systematic diagnosis and treatment of dysphagia: an evidence-based comprehensive analysis of the literature.

We conducted a systematic literature review and analysis of programs for evaluating swallowing in order to prevent aspiration pneumonia. This article derives from an evidence report on diagnosis and treatment of swallowing disorders (dysphagia) in acute-car stroke patients prepared by us as an Evidence-based Practice Center (EPC) under contract to the U.S. Agency for Healthcare Research and Quality (AHRQ). Available evidence on the diagnosis and treatment of dysphagia for preventing pneumonia is limited. We found reported pneumonia rates in one historical controlled study of a program using bedside exams (BSE) for acute stroke patients; one uncontrolled case series study of acute stroke patient- reporting of swallowing difficulty; one controlled case series study of videofluoroscopic study of swallowing (VFSS) for acute stroke patients; and one historical controlled study of fiberoptic endoscopic examination of swallowing (FEES) for patients referred for swallowing evaluation in rehabilitation centers. Comparing these results with historical controls indicates that implementation of dysphagia programs is accompanied by substantial reductions in pneumonia rates. While all these methods appeared effective, the small sizes of available studies did not allow determination of the relative efficacy of BSE, VFSS, or FEES.

Poor outcome for neural surgery (epineurotomy or neurolysis) for carpal tunnel syndrome compared with carpal tunnel release alone: a meta-analysis of global outcomes.

A meta-analysis was performed on the results of eight studies that compared the global outcomes of patients who received carpal tunnel release with the global outcomes of patients who received carpal tunnel release and neurolysis or epineurotomy. The meta-analysis suggests that patients who received such neural surgery tended to have poorer global outcomes than those who did not (odds ratio, 0.54; 95 percent confidence interval, 0.32 to 0.90). The data are homogenous, and linear-regression analysis indicates that patient attrition did not influence the outcome of the meta-analysis. The results of this meta-analysis indicate that neural surgery is potentially harmful for most patients with carpal tunnel syndrome. The possibility remains that neural surgery may be helpful in special cases, such as in the presence of marked scarring or neural adhesion, but no available evidence specifically documents the benefits and harms of surgery among such patients.

Disability under Social Security for patients with ESRD: an evidence-based review

Purpose : In the United States, all individuals with end-stage renal (ESRD) disease are automatically eligible for disability benefits under the Social Security Act. Recently, there have been questions about whether the diagnosis of ESRD alone is an appropriate criterion for determining disability under Social Security. Methods : We conducted a systematic review of the published literature and de novo analysis of data from the United States Renal Data System (USRDS) in an attempt to identify the best predictors of inability to work that might be useful during the disability determination process. Results : The published literature yielded little relevant evidence. The USRDS provided a prospectively-collected set of data on 4026 incident dialysis patients over their first year on dialysis, a time period particularly applicable to the key questions. However, data from over half of the patients were missing for the most important variables to this project, and only 42% of patients completed the one-year follow-up questionnaire. These limitations rendered de novo analyses unreliable. However, summary statistics did reveal a decreasing number of working individuals over time, from 41.9% before the initiation of dialysis, to 21.1% at initiation, and 6.6% a year later.PURPOSE In the United States, all individuals with end-stage renal (ESRD) disease are automatically eligible for disability benefits under the Social Security Act. Recently, there have been questions about whether the diagnosis of ESRD alone is an appropriate criterion for determining disability under Social Security. METHODS We conducted a systematic review of the published literature and de novo analysis of data from the United States Renal Data System (USRDS) in an attempt to identify the best predictors of inability to work that might be useful during the disability determination process. RESULTS The published literature yielded little relevant evidence. The USRDS provided a prospectively-collected set of data on 4,026 incident dialysis patients over their first year on dialysis, a time period particularly applicable to the key questions. However. data from over half of the patients were missing for the most important variables to this project, and only 42% of patients completed the one-year follow-up questionnaire. These limitations rendered de novo analyses unreliable. However, summary statistics did reveal a decreasing number of working individuals over time, from 41.9% before the initiation of dialysis. to 21.1% at initiation, and 6.6% a year later.

How Electronic Clinical Data Can Improve Health Technology Assessment

Health technology assessments represent comprehensive summaries of available evidence and information on a technology. They are used by medical decision makers in a variety of ways, including diagnostic testing, treatment selection, care management, patient perspectives, patient safety, insurance coverage, pharmaceutical innovation, equipment planning, device purchasing, and total cost-of-care. Electronic clinical data, which are captured routinely by clinicians and hospitals, are only rarely incorporated into formal health technology assessments. This disconnect reveals a key opportunity. In this paper, we discuss current uses of electronic clinical data, several benefits of including it in health technology assessments, potential pitfalls of that inclusion, and the implications for better medical decisions.

Assessing the utility of genetic tests.

Genetic testing is a rapidly expanding area with many clinical applications. While the introduction of new genetic tests creates tremendous potential for improving patient care, it is essential to adequately evaluate these tests to ensure their accuracy and utility for clinical practice. This article describes a general approach to the evaluation of genetic tests and discusses common challenges that evaluators face. This articles goal was to provide a starting point for those who are concerned with the safety and utility of genetic tests to develop an overall strategy to perform the assessment.

P150 Translating Recommendations Into Clinical Decision Support: Cancerlinq Prototype Experience

Background The Guideline Elements Model (GEM) has been widely used to translate natural language clinical practice guidelines (CPGs) into clinical decision support (CDS) using a highly replicable, guideline-centric approach. A CPG recommendation-to-CDS translation process, which uses GEM-processed content to support an oncology rapid learning system (RLS) prototype, is examined here. Objectives To develop rules for a breast cancer-specific CDS prototype using GEM-processed guideline content. Methods We created five breast cancer patient scenarios with expert input from oncologists based on nine published CPGs. Using the Yale Center for Medical Informatics-developed GEM Cutter III editor, we parsed the narrative CPG recommendations into an XML-based, machine-readable format. GEM-processed content was then encoded into a Drools business rule management system to develop an integrated platform prototype for rules, workflow, and event processing. We used meta-tags to create value sets for key components of each recommendation by selecting terms from UMLS vocabularies, including SNOMED CT and LOINC. Results Forty-five recommendations spanning nine CPGs were processed and converted into Drools rules. We identified 138 decision variables and 91 actions within the selected recommendations. From these, we encoded 148 concepts associated with value set meta-tags and 238 decision rules. Discussion The level of difficulty required to encode the recommendations was directly related to the specificity, complexity, and decidability of each recommendation; there was significant variability among the recommendations. Implications for Guideline Developers/Users CPG developers may need new processes in order to optimise recommendations for incorporation into CDS systems.

039 Guideline Developers’ Self-Perceptions of Adherence to and Intentions to Adhere to the IOM Standards

Background The 2011 IOM report called for more rigorous and transparent development of guidelines. Compliance with the IOM Standards may be challenging for developers. Developer perception of their current adherence to the Standards gives insight into their understanding of them and the likelihood of adhering to them in the future. Objectives (1) Assess developers’ self-perceptions of adherence to the IOM standards (2) Assess developers’ intentions to adhere to the IOM standards. Methods This AHRQ funded work used a mixed-methods approach. We performed semi-structured telephone interviews and surveys to query developers about impressions of and intentions to implement the IOM standards in their CPGs. We also performed our own assessments of guidelines and compared them with developer self-ratings. Results Of 14 developers, 43% utilised a systematic review to underpin their guidelines, and 57% felt they would in the future. Funding sources were not disclosed by 46% of the developers. While 80% utilised an evidence rating scheme, fewer rated the recommendations. Notable differences between developer self-ratings and researcher assessments of adherence occurred in several areas. Discussion While some developers intend to improve processes to meet the Standards, others acknowledged they will not. Yet still others felt they already met the standards, but our assessment suggested a different estimation, revealing varying understanding among developers of the Standards. Implications for Guideline Developers/Users The IOM standards will help identify rigorous and transparent evidence-based guidelines, but will pose implementation challenges. Education of developers on the Standards and expectations around them will be critical.

091 If we Build It, Will you Search for It? Finding Multiple Chronic Condition Guidelines in the National Guideline Clearinghouse

Background In the US, it is estimated more than 25% of Americans have multiple chronic conditions (MCCs) and their care accounts for approximately 66% of total health care spending. Few clinical practice guidelines address MCCs. Objectives Determine the number and scope of guidelines represented in the National Guideline Clearinghouse (NGC), funded by the Agency for Healthcare Research and Quality, addressing MCCs and provide strategies to identify these guidelines and facilitate quick retrieval by NGC users. Methods We searched for guidelines within NGC to identify those that address MCCs. We characterised these guidelines defining the number and type of MCCs addressed, the number of recommendations addressing MCCs, whether they addressed treatment, diagnosis, prevention or counselling, whether they graded the level of evidence, and whether the MCCs were concordant/discordant with the guideline’s primary disease/condition. Results Final analysis of information collected and recommendations and strategies for facilitating retrieval of this content in NGC will be completed by June 2013. Discussion Traditionally, guidelines focus on individual diseases so their application to the growing MCC population is limited. At the same time, evidence supporting recommendations for MCCs is lacking. Although our preliminary findings indicate that there are some guidelines addressing MCCs, there has been no obvious way to locate them on NGC. Implications for Guideline Developers/Users Guideline developers need to create guidelines addressing MCCs. NGC aims to create ways to highlight MCC guidelines and make them easier to find and use.