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Setting an agenda for comparative effectiveness systematic reviews in CKD care.

ABSTRACT: Systematic reviews comparing the effectiveness of strategies to prevent, detect, and treat chronic kidney disease are needed to inform patient care. We engaged stakeholders in the chronic kidney disease community to prioritize topics for future comparative effectiveness research systematic reviews. We developed a preliminary list of suggested topics and stakeholders refined and ranked topics based on their importance. Among 46 topics identified, stakeholders nominated 18 as 'high' priority. Most pertained to strategies to slow disease progression, including: (a) treat proteinuria, (b) improve access to care, (c) treat hypertension, (d) use health information technology, and (e) implement dietary strategies. Most (15 of 18) topics had been previously studied with two or more randomized controlled trials, indicating feasibility of rigorous systematic reviews. Chronic kidney disease topics rated by stakeholders as 'high priority' are varied in scope and may lead to quality systematic reviews impacting practice and policy.

SUBMITTER: Crews DC

PROVIDER: S-EPMC3472164 | biostudies-literature | 2012 Aug

REPOSITORIES: biostudies-literature

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Setting an agenda for comparative effectiveness systematic reviews in CKD care.

Crews Deidra C DC Greer Raquel C RC Fadrowski Jeffrey J JJ Choi Michael J MJ Doggett David D Segal Jodi B JB Fawole Kemi A KA Crawford Pammie R PR Boulware L Ebony LE

BMC nephrology 20120801

Systematic reviews comparing the effectiveness of strategies to prevent, detect, and treat chronic kidney disease are needed to inform patient care. We engaged stakeholders in the chronic kidney disease community to prioritize topics for future comparative effectiveness research systematic reviews. We developed a preliminary list of suggested topics and stakeholders refined and ranked topics based on their importance. Among 46 topics identified, stakeholders nominated 18 as 'high' priority. Most ...[more]

PMID: 22853705

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Project description:Collider bias, or stratifying data by a covariate consequence rather than cause (confounder) of treatment and outcome, plagues randomised and observational trauma research. Of the seven trials of prehospital hypertonic saline in dextran (HSD) that have been evaluated in systematic reviews, none found an overall between-group difference in survival, but four reported significant subgroup effects. We hypothesised that an avoidable type of collider bias often introduced inadvertently into trauma comparative effectiveness research could explain the incongruous findings.The two most recent HSD trials, a single-site pilot and a multi-site pivotal study, provided data for a secondary analysis to more closely examine the potential for collider bias. The two trials had followed the a priori statistical analysis plan to subgroup patients by a post-randomisation covariate and well-established surrogate for bleeding severity, massive transfusion (MT), ? 10 unit of red blood cells within 24h of admission. Despite favourable HSD effects in the MT subgroup, opposite effects in the non-transfused subgroup halted the pivotal trial early. In addition to analyzing the data from the two trials, we constructed causal diagrams and performed a meta-analysis of the results from all seven trials to assess the extent to which collider bias could explain null overall effects with subgroup heterogeneity.As in previous trials, HSD induced significantly greater increases in systolic blood pressure (SBP) from prehospital to admission than control crystalloid (p=0.003). Proportionately more HSD than control decedents accrued in the non-transfused subgroup, but with paradoxically longer survival. Despite different study populations and a span of over 20 years across the seven trials, the reported mortality effects were consistently null, summary RR=0.99 (p=0.864, homogeneity p=0.709).HSD delayed blood transfusion by modifying standard triggers like SBP with no detectable effect on survival. The reported heterogeneous HSD effects in subgroups can be explained by collider bias that trauma researchers can avoid by improved covariate selection and data capture strategies.

Project description:Little is known about the barriers, facilitators and interventions that impact on systematic review uptake. The objective of this study was to identify how uptake of systematic reviews can be improved.Studies were included if they addressed interventions enhancing the uptake of systematic reviews. Reports in any language were included. All decisionmakers were eligible. Studies could be randomised trials, cluster-randomised trials, controlled-clinical trials and before-and-after studies.We searched 19 databases including PubMed, EMBASE and The Cochrane Library, covering the full range of publication years from inception to December 2010. Two reviewers independently extracted data and assessed quality according to the Effective Practice and Organisation of Care criteria.10 studies from 11 countries, containing 12 interventions met our criteria. Settings included a hospital, a government department and a medical school. Doctors, nurses, mid-wives, patients and programme managers were targeted. Six of the studies were geared to improving knowledge and attitudes while four targeted clinical practice.Three studies of low-to-moderate risk of bias, identified interventions that showed a statistically significant improvement: educational visits, short summaries of systematic reviews and targeted messaging. Promising interventions include e-learning, computer-based learning, inactive workshops, use of knowledge brokers and an e-registry of reviews. Juxtaposing barriers and facilitators alongside the identified interventions, it was clear that the three effective approaches addressed a wide range of barriers and facilitators.A limited number of studies were found for inclusion. However, the extensive literature search is one of the strengths of this review.Targeted messaging, educational visits and summaries are recommended to enhance systematic review uptake. Identified promising approaches need to be developed further. New strategies are required to encompass neglected barriers and facilitators. This review addressed effectiveness and also appropriateness of knowledge uptake strategies.

Project description:BackgroundEstablishing priorities for discussion during time-limited primary care visits is challenging in the care of patients with cognitive impairment. These patients commonly attend primary care visits with a family companion.ObjectiveTo examine whether a patient-family agenda setting intervention improves primary care visit communication for patients with cognitive impairment DESIGN: Two-group pilot randomized controlled study PARTICIPANTS: Patients aged 65 + with cognitive impairment and family companions (n = 93 dyads) and clinicians (n = 14) from two general and one geriatrics primary care clinic INTERVENTION: A self-administered paper-pencil checklist to clarify the role of the companion and establish a shared visit agenda MEASUREMENTS: Patient-centered communication (primary); verbal activity, information disclosure including discussion of memory, and visit duration (secondary), from audio recordings of visit discussion RESULTS: Dyads were randomized to usual care (n = 44) or intervention (n = 49). Intervention participants endorsed an active communication role for companions to help patients understand what the clinician says or means (90% of dyads), remind patients to ask questions or ask clinicians questions directly (84% of dyads), or listen and take notes (82% of dyads). Intervention dyads identified 4.4 health issues for the agenda on average: patients more often identified memory (59.2 versus 38.8%; p = 0.012) and mood (42.9 versus 24.5%; p = 0.013) whereas companions more often identified safety (36.7 versus 18.4%; p = 0.039) and personality/behavior change (32.7 versus 16.3%; p = 0.011). Communication was significantly more patient-centered in intervention than in control visits at general clinics (p < 0.001) and in pooled analyses (ratio of 0.86 versus 0.68; p = 0.046). At general clinics, intervention (versus control) dyads contributed more lifestyle and psychosocial talk (p < 0.001) and less biomedical talk (p < 0.001) and companions were more verbally active (p < 0.005). No intervention effects were found at the geriatrics clinic. No effect on memory discussions or visit duration was observed.ConclusionPatient-family agenda setting may improve primary care visit communication for patients with cognitive impairment.Trial registrationClinicalTrials.gov : NCT02986958.

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Setting an agenda for comparative effectiveness systematic reviews in CKD care.

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Setting an agenda for comparative effectiveness systematic reviews in CKD care.

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