BMJ Evidenced-Based Medicine最新文献

{"title":"110 External validity of thromboprophylaxis guidelines in hip fracture patients: a retrospective analysis","authors":"Geneviève Courteau Godmaire, Madeleine Durand, M. Laskine","doi":"10.1136/bmjebm-2018-111070.110","DOIUrl":"https://doi.org/10.1136/bmjebm-2018-111070.110","url":null,"abstract":"Objectives Major orthopedic surgeries are recognized risk factors for thrombo-embolic events. Thromboprophylaxis following orthopedic surgery is widely recommended. Yet randomized controlled trials (RCT) evaluating efficacy and safety of thromboprophylaxis in the population with traumatic hip fracture have enrolled a selected group of patients. Patients with traumatic hip fracture often present with multiple comorbidities making them likely to be underrepresented in thromboprophylaxis studies. We hypothesize that randomized controlled trials in support of the CHEST guidelines for thromboprophylaxis following hip surgery for traumatic fracture have a low external validity. We designed a study to measure the prevalence of exclusion criteria from thromboprophylaxis trials in the population that underwent surgery for a traumatic hip fracture at the Centre Hospitalier de l’Université de Montréal (CHUM). We also aimed to quantify the number of transfusions received, number of bleeding events and deaths according to the presence or not of exclusion criteria to randomized controlled trials. Method We identified all original studies supporting the CHEST thromboprophylaxis guidelines for patients suffering a traumatic hip fracture (n=3). We extracted all inclusion and exclusion criteria reported by authors. Then, we conducted a retrospective cohort study on a random selection of all was patients who underwent an urgent traumatic hip fracture surgery at the CHUM from January 1 st 2012 to December 31 2016 Patients (n=250) were randomly selected from the medical archives list (50 patients/year). Data was collected through chart review of the electronic medical charts. For each participant, data on the presence of exclusion criteria, number of transfusions received post-operatively during hospital stay, significant bleeding events, thrombotic events and death were extracted. We used appropriate descriptive statistics, binomial exact confidence intervals and kruskall wallis and fisher’s exact tests to analyze results. Analysis was done using Stata 13. Results We included 250 patients, (172 (68.8%) women, mean age 78.7 SD (13.1)yo). Overall, 164 (66% 95%CI [59% to 71%]) subjects presented at least one exclusion criteria for one of the 3 RCT, and 57 (23%) [95% CI 18% to 29%] presented an exclusion criterion to all trials. No thrombotic event was reported (0%, 95% CI [0% to 1.4%]. There were 114 (46%, 95% CI [39% to 52%]) patients receiving at least one transfusion during the postoperative period. The median number (IQR) of transfusions according to the number of exclusion criteria were: no criteria, 0 (0–1) transfusion; 1 criterion, 0 (0–2); 2 criteria, 0 (0–2); 3 or more criteria, 2 (0–4) (p=0,011). The same trend was observed with significant bleeding events (p<0.001) and mortality (p=0.001), with an increasing proportion of patients experiencing these complications when presenting more exclusion criteria. Conclusions Our results suggest that patients who would","PeriodicalId":298595,"journal":{"name":"BMJ Evidenced-Based Medicine","volume":"243 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2018-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"114540909","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"15 Shared decision making in goals-of-care conversations with elderly patients: concerns and limitations","authors":"A. Plaisance, Annie LeBlanc, P. Archambault","doi":"10.1136/bmjebm-2018-111070.15","DOIUrl":"https://doi.org/10.1136/bmjebm-2018-111070.15","url":null,"abstract":"Background In goals-of-care conversations, patients’ prognosis, level of functional autonomy, values and life goals are discussed in order to inform decisions regarding the use of life-sustaining interventions. Without such discussions, interventions that prolong life at the cost of decreasing its quality may be used without appropriate guidance from patients. Shared decision making (SDM) is recommended to support these goals-of-care conversations. Decision aids (DA), providing unbiased, evidence-based information to patients, can help clinicians engage in SDM. We developed a DA adapted to the context of an Intensive Care Unit (ICU) and a training program that could support these goals-of-care conversations. Objectives We aimed to: (i) determine to which extent DA use and training increase intensivists’ SDM related skills, (ii) identify elderly patients’ concerns regarding goals-of-care and whether and how they are addressed during the conversation, and (iii) identify opportunities for intensivists to improve their SDM skills. Methods We conducted a three-phase study using mixed-methods analysis, in a single ICU (Lévis, Canada), recruiting intensivists to participate in the training program and use the DA during real life goals-of-care conversations. We recruited elderly patients (>65 years) with whom intensivists intended to engage in a goals-of-care conversation. We videotaped goals-of-care conversations in three phases: (i) prior to the training session and DA availability, (ii) with the DA available for use, (iii) after the training session (and DA availability). We conducted a videographic analysis to assessed the degree of SDM related behaviour displayed (12-item OPTION scale, min-max scores: 0–48) and a retrospective qualitative content analysis to address goals-of-care elements addressed during conversations. Results We recruited 7 dyads per phase for a total of 21 patients (71% male; mean age 76 years) and 5 intensivists (80% male). None of the 21 conversations were supported by the DA. Median OPTION score were 12 (interquartile range [IQR]: 10–14), 10 (IQR: 7–12) and 9 (IQR: 8–14) for the three phases respectively. Content analysis showed that intensivists tended to focus on medical interventions rather than talking about death/dying and avoided addressing options of not attempting cardiopulmonary/mechanical ventilation. When intensivists talked about death and dying, they used euphemisms and metaphors referring to the human body as a machine. Conclusion Our results show that the intensivists never used the DA and avoided discussing death and dying and the option of not attempting cardiopulmonary/mechanical ventilation in the case of a cardiac arrest/respiratory failure during the three study phases.","PeriodicalId":298595,"journal":{"name":"BMJ Evidenced-Based Medicine","volume":"4 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2018-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"124087192","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"85 Implementing tools for reduction of overdiagnosis and overtreatment in clinical practice – position papers","authors":"Ronen Bareket, A. Gaver, E. Lavon, I. Miskin","doi":"10.1136/BMJEBM-2018-111070.85","DOIUrl":"https://doi.org/10.1136/BMJEBM-2018-111070.85","url":null,"abstract":"Objectives The Institute for Quality in Medicine (IQM) is one of the arms of the IMA (Israeli Medical Association, representing professionally physicians in Israel). The institute publishes position papers and guidelines written by professional societies of the IMA. These documents are part of the curriculum for specialization qualification and considered as guidelines for common practice by the courts. The Israel Society for the Reduction of Overdiagnosis and Overtreatment (ISROD) was founded in 2016 under the auspices of the IMA. A position paper, written by a multidisciplinary team, was recently published by ISROD and IQM. The paper addresses all professional societies and guideline writing panels; detailing rationale and need to address overdiagnosis and overtreatment (OdX), elaborating mechanisms which lead to OdX and giving recommendations aimed at implementation of methods for reducing OdX in new clinical guidelines. We aimed to write a new position paper for the clinicians. Method A new multidisciplinary team was established……. In order to understand and relate to the different clinical contexts in which overdiagnosis happens. (as many types of clinical settings and dilemmas:) The team members come from various fields of medicine: internal medicine, emergency medicine, hematology, orthopedic, urology, general surgery, family medicine, pediatrics. Results Key points that will be included in the position paper are: Use of time as a diagnostic tool and as a strategy to prevent overdiagnosis, engaging patients in shared decision making, asking themselves and encouraging patients to ask the ‘4 questions’ about offered test and treatments (natural history, benefits, harms, alternatives), next step consideration, keeping some healthy skepticism relating to benefits of medical interventions, looking for opportunities for Quaternary Prevention in each interaction with patients, offering deprescribing and ‘undiagnosing’ when appropriate, coping with mistakes, CME, and role of the medical director. Conclusions The target of ISROD’s first position paper was guideline’s writing panels within the scientific societies. The target of the second position paper is actually each Israeli physician. We hope to provide individual doctors across medical specialties with tools to reduce overdiagnosis on a daily basis.","PeriodicalId":298595,"journal":{"name":"BMJ Evidenced-Based Medicine","volume":"15 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2018-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"131327365","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"97 Innovative approaches to proactively identify members with special medical needs","authors":"Milan Mrekaj, Alvertos Fiorantis, J. Kaariainen, M. Carolan, E. Sourlas","doi":"10.1136/bmjebm-2018-111070.97","DOIUrl":"https://doi.org/10.1136/bmjebm-2018-111070.97","url":null,"abstract":"Objectives Bupa’s purpose is longer, healthier, happier lives. We do this by providing a broad range of healthcare services, support and advice to people throughout their lives. Bupa is commited to becoming the most customer centered health and wellbeing organisation in the world. Meeting a patient’s individual care needs is right at the heart of this comittment. The objective is to develop a predictive model which accurately identifies patients whose claiming behaviour is likely to escalate in the near future. This allows for timely referral to specialist support nurses, medical directors/forums for discussion and input and case coordination to help the most vulnerable patients at their time of need, potentially avoiding unnecessary treatment at the same time. Method The modelling dataset is a sample of a half a million patients with Bupa PMI cover who claimed or were due to claim on their policy in last 15 months and more than 650 indicators. The indictors included member demographics and claims-based variables with severity (claimed amount), frequency (number of care episodes), and timing (months since last treatment) aspects. Taking into consideration the business needs, we wanted to create a model that generates both accurate predictions and meaningful ‘insights’, which could be converted into triggers for patients’ case management. We considered several traditional statistical methods (logistic regression) and more innovative machine-learning techniques (mainly tree based models). The latter can capture very complex relationships and therefore be more accurate but often lack insights. Results Compared to the traditional method we ran, tree based algorithms, in particular xgboost, provided the highest accuracy, with 2 out of 3 patients correctly classified. Despite the general belief that machine-learning models are considered ‘black boxes’, we were able to generate 3 levels of insights: • A list of the most important factors at a population level (age, previous cancer claim, etc.). • Insights at individual indicator level. For example, we found that once over 55, a patients’ likelihood of their care escalating increases dramatically. • The contribution each indicator has on patient level to their individual probability. Conclusions This talk demonstrates the value and potential applications of predictive modelling in the UK private medical settings. Such an application enables us to create triggers for case management, pathways tailored for an individual patient, and potentially avoiding unnecessary treatment.","PeriodicalId":298595,"journal":{"name":"BMJ Evidenced-Based Medicine","volume":"795 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2018-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"123908287","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"62 A randomised on-line survey to explore how disease labels, psychological traits and illness risk perceptions affect behavioural intentions","authors":"Rae Thomas, Mark T. Spence, Rajat Roy, E. Beller","doi":"10.1136/bmjebm-2018-111070.62","DOIUrl":"https://doi.org/10.1136/bmjebm-2018-111070.62","url":null,"abstract":"Objectives Negative consequences of medical labelling have been reported in research literature1 and differences in an individual’s intention to undertake further testing have been shown in studies that randomly assigned participants to labelled and unlabeled hypothetical medical scenarios.2 When given information about overdiagnosis of polycystic ovary syndrome after medical scenarios, all groups (irrespective of whether the medical label was used) reduced their intention to have follow-up tests3. What is unknown, is how an individual’s psychological traits such the predisposition to seek medical care, emotional stability, extraversion, and locus of control and their perceptions of risk and stigma toward the health condition might impact a person’s decision to undertake further tests when exposed to either a labelled or unlabeled medical scenario. Method A randomised controlled online survey was distributed to 256 participants aged 45–70 years in three countries (Australia, Ireland and Canada). Participants completed trait-based measures including health locus of control, regulatory focus (promotion/prevention), self-perceptions of medical usage, and health risk orientation. Participants were then randomised to receive two scenarios (stratified for age, gender and country). Scenarios described the outcome of a recent health test using either medical terms (‘labelled’) or condition descriptions (‘descriptive’). There were ‘labelled’ and ‘descriptive’ scenarios for four health conditions known for controversies over threshold changes (pre-diabetes, mild hypertension, mild hyperlipidaemia, and chronic kidney disease stage 3a). Each scenario informed participants they were close to the threshold and gave participants information about overdiagnosis. Post-scenario, participants rated their perception of illness risk and stigma. Between group differences for intentions to pursue a follow-up test was the primary outcome. We also assess what traits may have impacted their decision. Results Preliminary analyses suggest that after adjusting for two scenarios per person, there was no significant difference between the ‘labelled’ (n=129) and ‘descriptive’ (n=127) groups in their intention to have follow-up tests (95% CI −0.77 to 0.33 points). In a multivariable regression model, there was a significant increase in intentions to pursue further tests when participants were: high users of medical interventions (p Conclusions Previous research has consistently found a labelling effect, but the cause of the effect is unclear. Our findings both contrast and expand upon previous research. We analyzed four different health conditions with controversies around the threshold. All scenarios were ‘close to the cut-off’. It is unclear why our ‘labelled’ and ‘description’ scenarios did not produce significant differences in intentions to undertake further tests, as has been found in previous studies. It may be that by first eliciting psychological trait measures related ","PeriodicalId":298595,"journal":{"name":"BMJ Evidenced-Based Medicine","volume":"47 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2018-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"124335392","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"115 Running around the swimming pool: behavioural symptoms versus akathisia as a side effect of risperidone in an 84 years old woman cognitively impaired","authors":"M. Congedo","doi":"10.1136/BMJEBM-2018-111070.115","DOIUrl":"https://doi.org/10.1136/BMJEBM-2018-111070.115","url":null,"abstract":"Objectives In cognitive impaired elderly with behavioural symptoms the use of antipsychotic drugs is critical because of side effects whose nature often is not correctly recognized (Marston L, Nazareth I, Petersen I, et al. Prescribing of antipsychotics in UK primary care: a cohort study. BMJ Open 2014;4:e006135. doi:10.1136/bmjopen-2014–006135). For physicians the common reaction is to increase drug dosage to obtain sedation but with the result of movement or behavioural symptoms worsening. The opposite decision, to lower drug dosage, if taken by physicians, can be difficult to share with caregivers because of fear to find more difficulties in managing the patient, and with other health professionals that consider sedation a priority and are trained to use drugs as the main resource. Which is the best interest of the patient who cannot give direct information about personal feelings and perceptions? Method A cognitively impaired 84 years old woman was referred to the psychiatrist because of behavioural symptoms as wandering and refusal of help in dressing or showering. For the psychiatrist suggestion, risperidone was administered at increasing dosage. No change in behaviour was noticed but wandering increased. After a few weeks of treatment the psychiatrist suggested to reach the dosage of 10 mg daily. The old lady was on holiday in a residence to the sea: as the need to move increased, she began to use to run breathlessly around the swimming pool in the garden. To the protests of her caregiver, she answered she was forced to run because of agitation. In a few days she was referred to emergency in the nearby hospital where she met a neurologist who decided to taper off the treatment and refer the patient to the dementia service for follow up. Results After risperidone withdrawing, in the neurological surgery the old lady appeared as a demented patient with clinical, neuropsychological tests and neuroimaging suggesting Alzheimer dementia; she needed sedation because of wandering and quetiapine 25 mg twice was administered daily with good results also in the caregiver management. After 2 years, behaviour symptoms were mild and easy to contrast by conversation and food or drink offer, the wandering gradually changed in daily promenades in the countryside with the caregiver or alone in the large home garden. No special needs were reported and everyday life help for showering and dressing was well accepted. The caregiver asked for a small increase in quetiapina dosage to help in sleeping and the option of quetiapine 25 mg three times a day is still in use. The patient son met her mother 3 or 4 times a week for leisure promenades and quiet, short conversation with her. Conclusions Akathisia is an example of ambiguous symptom that can be read as part of behavioural syndrome in demented patients instead of a side effect of treatment with psychotropic drugs as antipsychotics or antidepressants (Gøtzsche P. Deadly Psychiatry and Organized Denial. People’s","PeriodicalId":298595,"journal":{"name":"BMJ Evidenced-Based Medicine","volume":"98 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2018-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"122604801","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"5 The difficult art of un-doing","authors":"J. Brodersen, I. Heath, G. Roksund, H. Sundby, E. Swensen","doi":"10.1136/bmjebm-2018-111070.5","DOIUrl":"https://doi.org/10.1136/bmjebm-2018-111070.5","url":null,"abstract":"The evidence for overdiagnosis and overtreatment within medicine is growing: across disciplines and across the globe. Clinicians and their patients must now face the challenge of integrating this new knowledge into the realities of their everyday practice and the numerous decisions about investigation, labelling and treatment that have to be taken. While patients seek more involvement and more balanced information, professionals too often struggle with lack of confidence and lack of political and legal support in proceeding slowly and carefully. While winding back the harms of too much medicine is a noble cause, the very real fear of making mistakes continues to push doctors, and perhaps especially younger colleagues, towards acting precipitately and unthinkingly. This symposium will offer a theoretical framework for the ‘de-implementation’ of both screening and treatments that cause harm or do not improve outcomes for patients. We will present new thinking and a new vocabulary for a new practice. We will then describe clinical examples from everyday general practice to demonstrate how new knowledge on overdiagnosis/overtreatment can be integrated within shared decision-making in the consultation. Finally there will be an interactive role play on overdiagnosis/overtreatment, based on experiences from teaching and training medical students at the University of Trondheim, Norway. Objectives The symposium will offer a theoretical framework and demonstrate practical clinical examples for the ‘de-implementation’ of diagnostic processes and treatments that cause harm or do not improve outcomes for patients. Method In the symposium the presenters will share new thinking and a new vocabulary for a new practice. We will then describe clinical examples from everyday general practice to demonstrate how new knowledge on overdiagnosis/overtreatment can be integrated within shared decision-making in the consultation. Finally there will be an interactive role play on overdiagnosis/overtreatment, based on experiences from teaching and training medical students. Results Interactive session aimed at sharing theoretical reflections and clinical GP experience from. Conclusions Interactive session aimed at sharing theoretical reflections and clinical GP experience.","PeriodicalId":298595,"journal":{"name":"BMJ Evidenced-Based Medicine","volume":"22 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2018-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"115353686","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"45 Decision support and knowledge translation tools to highlight the benefits and harms of screening: an analysis of online access and dissemination of the canadian task force for preventive healthcare resources","authors":"E. Lang, Danielle Kasperavicius, D. Buckland, Rossella Scoleri, Julia E. Moore, B. Thombs, S. Straus","doi":"10.1136/bmjebm-2018-111070.45","DOIUrl":"https://doi.org/10.1136/bmjebm-2018-111070.45","url":null,"abstract":"Objectives The Canadian Task Force for Preventive Healthcare (CTFPHC) has developed a bilingual library of fifteen tools to support clinical and shared decision-making for screening in primary care. https://canadiantaskforce.ca/tools-resources/. These include clinical algorithms and frequently asked questions as well as infographics that are designed to facilitate Knowledge Translation (KT). We report the proportion of guidelines in the CTFPHC library which recommend against screening based on harms such as overdiagnosis. We also set out to describe the access and dissemination metrics for these resources from both language and geographical perspectives as well as in terms of inter-resource comparisons. Method Resources include clinical and patient algorithms, clinician and patient FAQs and infographics that are designed to communicate harms and benefits including over-diagnosis and false positive estimates. Resources were developed with input from clinicians and patients. We examined website access and report on dissemination strategies for CTFPHC KT tools using website analytics as well as data on from the Canadian Medical Association Journal (CMAJ). Results are reported descriptively for the years 2016 and 2017 inclusively. Results Most CTFPHC guidelines (11/15) recommend against screening. The most widely viewed were the clinical algorithm for Hypertension and the ‘1000 person tool’ for prostate cancer which highlights harms and benefits. English versions were viewed approximately 7000 times each in 2016 and 2017 with the French version accessed at 10% of that. Childhood obesity, developmental delay and cognitive impairment screening were among the least viewed with approximately 700 total views in English (2016/2017). In 2017, 70 000 hard copies of KT tools for abdominal aortic aneurysm, Hepatitis C screening and tobacco smoking in children and adolescents were distributed with the CMAJ. City-based analysis of access in Canada is in keeping with population levels with the exception of Ottawa where the CTFPHC is based and was ranked third. Both in 2016 and 2017, Brazil logged the third most sessions with the CTFPHC website after Canada and the US. Conclusions The CTFPHC guidelines highlight the harms of screening by demonstrating rates of overdiagnosis and have recommended against screening in controversial areas such as breast cancer screening for women aged 40–49 and colon cancer screening for men aged greater than 75; colonoscopy is also recommended against as a screening tool. The CTFPHC resources to support decision-making receive modest online traffic. The screening scenario for which the harms likely outweigh the benefits i.e. prostate cancer screening are among the most widely seen. These resources are accessed beyond the intended Canadian audience.","PeriodicalId":298595,"journal":{"name":"BMJ Evidenced-Based Medicine","volume":"13 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2018-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"116674087","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"113 An exploration of physician perspectives on mammography screening for average-risk women","authors":"Sophia Siedlikowski, G. Bartlett, R. Grad, C. Ells","doi":"10.1136/bmjebm-2018-111070.113","DOIUrl":"https://doi.org/10.1136/bmjebm-2018-111070.113","url":null,"abstract":"Objectives Although the influence of practice guidelines on physicians’ ordering of mammography screening is well established, conflicts exist in the recommended mammography screening initiation ages and screening frequency among different mammography guidelines. Furthermore, growing evidence nuancing the benefits and harms of screening has put systematic screening into question. Understanding physician perspectives on the evidence that affects patient care will be important for informing future best practices as guidelines evolve. A large amount of data exists on these perspectives from thousands of physicians who read and react to clinical research synopses (Patient Oriented Evidence that Matter: POEMs) through an ongoing continuing medical education program. The purpose of this study is to explore physicians’ perspectives on clinical research regarding mammography screening for average-risk women and the extent to which they use this POEM information in their clinical practice. Method The Essential Evidence Plus database was searched from 2012 to 2017 with the term ‘breast neoplasm’ to identify relevant POEMs on mammography screening, screening decision-making, and overdiagnosis. Using the Information Assessment Method (IAM), physician ratings and comments about mammography evidence were extracted from reflections on clinical research summarized as POEMs. The items of interest in the IAM were those calling on physicians to reflect on the value of the information and its applicability. Quantitative data were assessed with descriptive statistics. Using an iterative approach, the qualitative data were subjected to both an inductive and deductive analysis. These data were coded thematically into sub-themes, which were grouped into major themes. Connections were sought between both quantitative and qualitative data. Results Four relevant POEMs were identified. The number of quantitative POEM ratings ranged from 1243 to 1351. Across all POEMs, among the physician ratings about using the information for a patient, over 50% were about using it in a discussion with a patient or other healthcare provider. Three major themes emerged from the analysis of 310 qualitative comments across all POEMs: 1) Perspectives on information presented in POEMs, 2) Applying this information in practice, and 3) Confronting clinical and cultural realities. Physicians held diverse perspectives on the value of the POEMs. Some physicians continued to support screening while others condemned harms such as overdiagnosis. Although physicians noted the potential of the POEM to improve patient counseling, access to this information did not necessarily diminish perceived challenges in screening discussions. Physicians advocated for the personalization of screening decision-making and patient-centered approaches to respect each patient’s values and preferences. Conclusions This study of POEMs data reveals important divergences in the ways physicians value clinical evidence on mammog","PeriodicalId":298595,"journal":{"name":"BMJ Evidenced-Based Medicine","volume":"168 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2018-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"127004931","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"41 Will the use of high sensitivity troponin result in overdiagnosis of myocardial infarction?","authors":"J. Doust, P. Glasziou","doi":"10.1136/bmjebm-2018-111070.41","DOIUrl":"https://doi.org/10.1136/bmjebm-2018-111070.41","url":null,"abstract":"Objectives The introduction of high sensitivity troponin (hs-Tn) redefines who is diagnosed with myocardial infarction (MI) and may increase the incidence of MI. The Preventing Overdiagnosis Working Group of the Guidelines International Network recently published a checklist for groups seeking to modify a disease definition in 2017. We used the checklist to determine if this clarifies the harms and benefits of the new test in the diagnosis of MI. Method We assessed the evidence for hs-Tn against each of the questions in the 8-item checklist:Differences between the previous and the new definitionChanges to the incidence and prevalence of the diseaseTrigger for considering the modificationDoes it predict clinically important outcomes compared with the previous definition?What is the repeatability, reproducibility, and accuracy of the new disease definition?Benefit: What is the incremental benefit for patients?Harm: What is the incremental harm for patients?What is the net benefit and harm for patients? Results hs-Tn has higher analytical sensitivity, which allows myocardial infarction to be diagnosed earlier and treatment commenced. Patients with low levels at 4 hours can be safely discharged. hs-Tn also is predictive of clinically important outcomes and has higher precision than earlier forms of the troponin. Maintaining the 99th centile as the threshold for diagnosis of myocardial infarction and the methods used in studies to determine the reference limit leads to an increase in the numbers of people diagnosed with myocardial infarction, with significant differences between studies depending on the types of patients being tested. The evidence for assessing the benefits and harms of hs-Tn is limited, limited to a before-after study showing an improvement in health outcomes. The introduction of hs-Tn in Australia earlier than in the US may explain the divergence in the incidence of non-ST elevation myocardial infarction in the two countries. Conclusions The example of hs-Tn illustrates that rigorous evaluations of disease definitions cannot be isolated from the tests used to diagnose that disease. Despite the significant consequences from the introduction of the test and the potential for overdiagnosis, it has been introduced because of improvements in analytical performance rather than on a thorough evaluation of potential harms and benefits.","PeriodicalId":298595,"journal":{"name":"BMJ Evidenced-Based Medicine","volume":"58 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2018-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"115286230","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}