Showing papers by "Alessandro Liberati published in 2007"

PartecipaSalute, an Italian project to involve lay people, patients' associations and scientific-medical representatives in the health debate.

Abstract: Consumers and patients are increasingly demanding an active role in health-care access and quality, and associations and pressure groups are interacting directly with national health services and with researchers, doctors and scientific or professional societies. This article describes an Italian project aimed at creating a partnership among lay people, patients associations and the scientific/medical community. In Italy, consumers are generally passive recipients of health information from various sources: doctors and health-care professionals, the health system, media, web and parents or peers. This information is often contradictory and non-evidence-based, leading to misunderstandings and confusion. The Di Bella case, the outcry about an alleged new cure for autism, and the increasing number of health awareness campaigns are all clear examples of the lack of an evidence-based culture among Italian consumers and patients associations (see Box 1). To cope with this, lay people must learn how to develop their scientific literacy, becoming familiar with clinical and epidemiological research and acquiring instruments to critically appraise and understand health information. Although these activities are in their infancy in Italy, there are some good examples of empowerment efforts (see Box 2). The number of consumer and patients associations is steadily growing: a survey in 2003 by the Italian National Statistical Institute identified about 21 000 non-profit organizations across the country, a 50% increase compared with a 1997 survey. These organizations cover a wide spectrum of activities corresponding to a broad definition of health, including psychosocial support and direct services, and the findings confirm the deeply rooted Italian tradition of mutual aid in the health-care field. In the last 10 years, consumers and patients associations have extended their interventions from self-help and care to advocacy, including important efforts to convey more information to the public, and organize awareness raising campaigns. In common with other European and American countries, patients federations are emerging in Italy to boost the impact of individual organizations. Some now lobby at local, national and international level, drawing health authorities attention to the need for improvement in a given area. This has led to the introduction of patients charters and the mandatory presence of lay representatives on local ethics committees, yet the medical and scientific community still fails to see patients and consumer groups as partners with equal rights and weight . Consumers, patients and their associations, on the other hand, often lack doi: 10.1111/j.1369-7625.2007.00444.x

Using Clinical Evidence in a national continuing medical education program in Italy.

Abstract: Interest in evidence-based medicine (EBM) is growing in Italy, although its impact upon health policies and clinical practice is unclear. Rather than getting health information from unbiased evidence-based sources, doctors in Italy still rely heavily upon the pharmaceutical industry for their information needs. For example, a recent survey showed that general practitioners receive 11 visits per week by pharmaceutical sales representatives [1]. The study suggested that this information is considered complete and sufficiently reliable by many doctors. In an effort to ensure that all physicians have access to valid and reliable evidence on drug effectiveness and safety, the Italian Drug Agency (AIFA) launched a program to disseminate independent and unbiased information. The agency did this by translating Clinical Evidence, a compendium of the best available evidence on treating a wide range of common conditions (Box 1), into Italian and distributing it freely. By 2006, the fourth Italian edition (based on Clinical Evidence volume 14) had been published. The online Italian version of Clinical Evidence is freely available to all 248,000 doctors in practice in Italy. Box 1. Clinical Evidence Clinical Evidence (http://www.clinicalevidence.com) has specific features that make it different from both traditional textbooks and practice guidelines [19]: Its contents are driven by practical questions rather than by the availability of evidence. It aims not to make recommendations but to inform based on the best available evidence. It highlights rather than hides gaps in research evidence. It is continuously updated. According to its Web site, Clinical Evidence “describes the best available evidence from systematic reviews, RCTs [randomised controlled trials], and observational studies where appropriate, and if there is no good evidence it says so.” In 1999, the first free distribution of 50,000 copies of Clinical Evidence was assessed through a survey exploring doctors' judgement of its validity, relevance, and usability. Results showed that the compendium had been well received, and confirmed doctors' preference for problem-driven information and the key role of a strong endorsement from health authorities for its implementation [2]. A compulsory system of continuing medical education (CME) for all health professionals was introduced in Italy in 1998, based on credits awarded for time spent on educational activities. The more traditional form of acquiring CME is to attend lectures and conferences; it is much more rare for doctors to be exposed to small group interactive events. In order to maximise the effectiveness of the financial commitment for disseminating Clinical Evidence, and to speed up the diffusion of EBM, AIFA sponsored a free-access e-learning system, based on Clinical Evidence, called ECCE (the Italian acronym for Continuing Education Clinical Evidence).

Understanding systematic reviews: the meta-analysis graph (also called 'forest plot').

Abstract: Mammographic screening for breast cancer is controversial, as reflected in greatly varying national policies. The objective was to assess the effect of screening for breast cancer with mammography on mortality and morbidity. MEDLINE (16 May 2000), The Cochrane Breast Cancer Group’s trial register (24 Jan 2000) and reference lists. Letters, abstracts and unpublished trials. Authors were contacted. Randomised trials comparing mammographic screening with no mammographic screening. Data were extracted by both authors independently. Seven completed and eligible trials involving half a million women were identified. The two best trials provided medium-quality data and, when combined, yield a relative risk for overall mortality of 1.00 (95% CI 0.96–1.05) after 13 years. However, the trials are underpowered for all-cause mortality, and confidence intervals include a possible worthwhile effect as well as a possible detrimental effect. If data from all eligible trials (excluding flawed studies) are considered then the relative risk for overall mortality after 13 years is 1.01 (95% CI 0.99–1.03). The best trials failed to show a significant reduction in breast cancer mortality with a relative risk of 0.97 (95% CI 0.82–1.14). If data from all eligible trials (excluding flawed studies) are considered then the relative risk for breast cancer mortality after 13 years is 0.80 (95% CI 0.71–0.89). However, breast cancer mortality is considered to be an unreliable outcome and biased in favour of screening. Flaws are due to differential exclusion of women with breast cancer from analysis and differential misclassification of cause of death. The currently available reliable evidence does not show a survival benefit of mass screening for breast cancer (and the evidence is inconclusive for breast cancer mortality). Women, clinicians and policy makers should consider these findings carefully when they decide whether or not to attend or support screening programs.

Scales to climb borderline personalities: when science goes nowhere.

Abstract: Although these psychosocial scales are increasingly used, scepticism and confusion remain regarding the ability of many scales to summarise composite indices and if they are meaningful in orienting a conclusive clinical decision. We explore some of the limitations regarding scales use and misuse in science. The purpose of the review by Binks et al. [1] is to evaluate the evidence for the efficacy of psychological intervention for people with BPD. This review is extremely important from a policy standpoint given the prevalence of the problem (2%), the association with deliberate selfharm and suicide, and the long-term cost to the healthcare system due to chronicity and intense health service demands by people with BPD. The Authors expected that outcomes would not have been consistently reported across the included trials and that different measures of disease and scales had been used (e.g., quality of life, mental state, behaviour, etc.). In order not to miss useful observations, the Authors included data from any rating scale as long as these instruments had been described in a peer-reviewed journal. This broad approach resulted in 15 outcome categories, each of which has several measures, totalling 82 outcomes. There are six primary outcomes, placed in five different categories. For example, the category mental state is articulated in: (1) general mental state; (2) not clinically important change in general mental state (a primary outcome); (3) not any change in general mental state; and ... etc. Death is the only outcome with no subcategories. The advantage of the choice made by the Authors is that the whole body of research on this topic is covered, but at what price? The disadvantage is that a general reader will not go through this review as he will find himself lost trying to understand the essence of the trial results. Even a psychologist using a methodological approach will be puzzled by the question: Which is an effective treatment for borderline personality disorders? This is not easy to answer given the multitude and fragmentation of the instruments and outcomes presented in the review.