Alessandro Liberati

Bio: Alessandro Liberati is an academic researcher from University of Modena and Reggio Emilia. The author has contributed to research in topics: Breast cancer & Systematic review. The author has an hindex of 46, co-authored 144 publications receiving 167184 citations. Previous affiliations of Alessandro Liberati include Mario Negri Institute for Pharmacological Research & Cochrane Collaboration.

What doctors tell patients with breast cancer about diagnosis and treatment: Findings from a study in general hospitals

Abstract: In a study aimed at assessing whether and how patients with breast cancer are informed on their diagnosis and treatment a large group of physicians participating in a quality of care evaluation program were asked to report what they told patients about diagnosis and treatment. The completeness of such communication was then assessed using an explicit protocol designed to measure precision and lack of ambiguity of reported phrases. By this measure 39% patients received 'thorough' information on diagnosis and 11% 'detailed' information on surgery. These proportions become 48% and 14%, respectively, when only cases for whom answers were available are considered. Physicians, however, considered this communication 'thorough' for 69% of patients. Among patient-related characteristics, age, education and stage of disease were independent predictors of quality of information. Setting-dependent features more than individual provider attitudes seemed to account for at least part of the quality of information sharing behaviour as both hospital size (comparing centres larger than 500 beds and smaller ones) and degree of hospital organization (comparing centres adhering to the Italian Breast Cancer Task Force, FONCaM and those not) were - simultaneously - significant predictors of quality of communication, independently from patients' case-mix. Physicians' judgement - measured assuming the explicit protocol as standard - proved to be of acceptable sensitivity only when information was 'Thorough' by the protocol. However, its specificity and predictive values were consistently low in all three categories defined by the protocol, leading to high misclassification rates. The implications of these findings for studies aimed at assessing the quality of patients-providers communication are discussed.

Adjuvant Chemotherapy for Breast Cancer: A Pooled Estimate Based on Published Randomized Control Trials

Abstract: The use of adjuvant chemotherapy for treating patients with operable breast cancer remains a worldwide controversy. Using the data from published randomized control trials with a minimum two-year follow-up, pooled estimates of relapse-free survival rates and overall survival rates were calculated. Relapse-free survival rates were improved by 12.5% (95% confidence interval [CI] ±4.5%) at three years and by 8% (CI ±6%) at five years, with studies using multiple agents showing a greater effect. A significant advantage was also present in overall survival rates at three years, but only for studies involving multiple agents (4% ±3.5%). Results from combining data for other types of trials were inconclusive. The use of this method is presented to illustrate its value as an explicit and systematic one for combining data from several randomized control trials in assessing a therapeutic controversy. ( JAMA 1986;256:1148-1159)

A EUROPEAN VERSION OF THE APPROPRIATENESS EVALUATION PROTOCOL Goals and Presentation

Abstract: This paper describes the development and testing of a European version of the Appropriateness Evaulation Protocol (AEP). It stemmed from the original U.S. version and the multiple adaptations and modifications made previously and separately by researchers in European countries. The group was particularly concerned with developing a common list of reasons for inappropriate admissions and days of stay, since the principal goal was to enable an understanding of inappropriate hospital use and potential solutions within local health and social care systems. Developing a common EU-AEP included several steps. First, each national instrument was translated from the national language to English. These back translations were compared with each other and with the US-AEP. A working group analyzed the content of the lists of reasons published in the literature and proposed a novel conceptual approach. On the basis of workshop discussions, a draft of a common European version was circulated to each participant for agreement. In the EU-AEP, the clinical criteria for the appropriateness of admission include 10 related to patient condition and five to clinical services. The criteria for the appropriateness of days of care include 10 covering medical services, six for life support/nursing services, and eight related to patient condition. The proposed core list of reasons of inappropriateness distinguish clearly between two concepts: a) the level of care required by the patient; and b) the reason why this level of care was not used. The first list would thus refer to the nature of resources and facilities required, while the second would focus more on the efficient organization of those resources. A validated European tool to assess inappropriate hospital admissions and hospital days of stay and their causes might be used to assess the need for resources for inpatient care as well as for outpatient care. Assessing the reasons for inadequacies might lead also to the examination of organizational questions. Finally, a common tool allows comparisons between countries concerning the frequency of inappropriate admissions and days of stay and their reasons in relation to the different organizations of health care across Europe.

Risk factors for pathologically confirmed benign breast disease

Abstract: Between November 1981 and March 1983, data were collected to evaluate risk factors for benign breast lesions in a case-control study based on 288 women with histologically proven benign breast disease, admitted for biopsy to the Tumor Institute of Milan, and 285 age-matched controls. Questions were asked about menstrual and reproductive characteristics, marital status, education, history of various diseases, and lifetime use of oral contraceptives and other hormonal treatments. Nulliparity or low parity, late age at first birth, and late menopause were associated with an increased risk of benign breast disease. The elevated risk associated with late age at first birth was not accounted for by parity. Early age at menarche was associated with an increased risk, but the estimate was not statistically significant. The data do not suggest that the use of oral contraceptives or other female hormones (such as estrogen replacement therapy) is related to the risk of benign breast disease. Risk was apparently lower, however, among current and long-term oral contraceptive users. There was no evidence of a trend with reference to body mass index. The present data indicate a substantial agreement between the risk factors for (pathologically confirmed) benign and malignant breast disease, not only directly, by showing a relationship with parity, age at first birth, and age at menopause, but also indirectly, by failing to produce evidence that greater weight or the use of oral contraceptives has a protective effect.

Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement

Abstract: David Moher and colleagues introduce PRISMA, an update of the QUOROM guidelines for reporting systematic reviews and meta-analyses

Preferred reporting items for systematic reviews and meta-analyses: the PRISMA Statement.

Abstract: Systematic reviews and meta-analyses have become increasingly important in health care. Clinicians read them to keep up to date with their field,1,2 and they are often used as a starting point for developing clinical practice guidelines. Granting agencies may require a systematic review to ensure there is justification for further research,3 and some health care journals are moving in this direction.4 As with all research, the value of a systematic review depends on what was done, what was found, and the clarity of reporting. As with other publications, the reporting quality of systematic reviews varies, limiting readers' ability to assess the strengths and weaknesses of those reviews. Several early studies evaluated the quality of review reports. In 1987, Mulrow examined 50 review articles published in 4 leading medical journals in 1985 and 1986 and found that none met all 8 explicit scientific criteria, such as a quality assessment of included studies.5 In 1987, Sacks and colleagues6 evaluated the adequacy of reporting of 83 meta-analyses on 23 characteristics in 6 domains. Reporting was generally poor; between 1 and 14 characteristics were adequately reported (mean = 7.7; standard deviation = 2.7). A 1996 update of this study found little improvement.7 In 1996, to address the suboptimal reporting of meta-analyses, an international group developed a guidance called the QUOROM Statement (QUality Of Reporting Of Meta-analyses), which focused on the reporting of meta-analyses of randomized controlled trials.8 In this article, we summarize a revision of these guidelines, renamed PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses), which have been updated to address several conceptual and practical advances in the science of systematic reviews (Box 1). Box 1 Conceptual issues in the evolution from QUOROM to PRISMA

Measuring inconsistency in meta-analyses

Abstract: Cochrane Reviews have recently started including the quantity I 2 to help readers assess the consistency of the results of studies in meta-analyses. What does this new quantity mean, and why is assessment of heterogeneity so important to clinical practice? Systematic reviews and meta-analyses can provide convincing and reliable evidence relevant to many aspects of medicine and health care.1 Their value is especially clear when the results of the studies they include show clinically important effects of similar magnitude. However, the conclusions are less clear when the included studies have differing results. In an attempt to establish whether studies are consistent, reports of meta-analyses commonly present a statistical test of heterogeneity. The test seeks to determine whether there are genuine differences underlying the results of the studies (heterogeneity), or whether the variation in findings is compatible with chance alone (homogeneity). However, the test is susceptible to the number of trials included in the meta-analysis. We have developed a new quantity, I 2, which we believe gives a better measure of the consistency between trials in a meta-analysis. Assessment of the consistency of effects across studies is an essential part of meta-analysis. Unless we know how consistent the results of studies are, we cannot determine the generalisability of the findings of the meta-analysis. Indeed, several hierarchical systems for grading evidence state that the results of studies must be consistent or homogeneous to obtain the highest grading.2–4 Tests for heterogeneity are commonly used to decide on methods for combining studies and for concluding consistency or inconsistency of findings.5 6 But what does the test achieve in practice, and how should the resulting P values be interpreted? A test for heterogeneity examines the null hypothesis that all studies are evaluating the same effect. The usual test statistic …