Showing papers by "Deborah J. Cook published in 2000"
TL;DR: Quantitative research is designed to test well-specified hypotheses, determine whether an intervention did more harm than good, and find out how much a risk factor predisposes persons to disease.
Abstract: Quantitative research is designed to test well-specified hypotheses, determine whether an intervention did more harm than good, and find out how much a risk factor predisposes persons to disease. Equally important, qualitative research offers insight into emotional and experiential phenomena in health care to determine what, how, and why. There are 4 essential aspects of qualitative analysis. First, the participant selection must be well reasoned and their inclusion must be relevant to the research question. Second, the data collection methods must be appropriate for the research objectives and setting. Third, the data collection process, which includes field observation, interviews, and document analysis, must be comprehensive enough to support rich and robust descriptions of the observed events. Fourth, the data must be appropriately analyzed and the findings adequately corroborated by using multiple sources of information, more than 1 investigator to collect and analyze the raw data, member checking to establish whether the participants' viewpoints were adequately interpreted, or by comparison with existing social science theories. Qualitative studies offer an alternative when insight into the research is not well established or when conventional theories seem inadequate. JAMA. 2000;284:357-362
888 citations
TL;DR: This series provides clinicians with strategies and tools to interpret and integrate evidence from published research in their care of patients to relate to the value-laden nature of clinical decisions and to the hierarchy of evidence postulated by evidence-based medicine.
Abstract: This series provides clinicians with strategies and tools to interpret and integrate evidence from published research in their care of patients. The 2 key principles for applying all the articles in this series to patient care relate to the value-laden nature of clinical decisions and to the hierarchy of evidence postulated by evidence-based medicine. Clinicians need to be able to distinguish high from low quality in primary studies, systematic reviews, practice guidelines, and other integrative research focused on management recommendations. An evidence-based practitioner must also understand the patient's circumstances or predicament; identify knowledge gaps and frame questions to fill those gaps; conduct an efficient literature search; critically appraise the research evidence; and apply that evidence to patient care. However, treatment judgments often reflect clinician or societal values concerning whether intervention benefits are worth the cost. Many unanswered questions concerning how to elicit preferences and how to incorporate them in clinical encounters constitute an enormously challenging frontier for evidence-based medicine. Time limitation remains the biggest obstacle to evidence-based practice but clinicians should seek evidence from as high in the appropriate hierarchy of evidence as possible, and every clinical decision should be geared toward the particular circumstances of the patient.
704 citations
TL;DR: The second part of this 2-part series on how to interpret qualitative research addresses, "what are the results," and, "how do they help me care for my patients?"
Abstract: The second part of this 2-part series on how to interpret qualitative
research addresses, "what are the results," and, "how do they help me care
for my patients?" Qualitative analysis is a process of summarizing and interpreting
data to develop theoretical insights that describe and explain social phenomena
such as interactions, experiences, roles, perspectives, symbols, and organizations.
Key results are often illustrated with excerpts from interview transcripts,
field notes, or documents. The results of a qualitative research report are
best understood as an empirically based contribution to ongoing dialogue and
exploration. Empirically based theory evolves from a process of exploration,
discovery, analysis, and synthesis. Each concept should be defined carefully
in a way that is meaningful to the reader. Concepts should be adequately developed
and illustrated when theoretical conclusions are drawn. Arguments should be
explained and justified. The qualitative research report ideally should address
how the findings relate to other theories in the field. The qualitative study
can provide a useful road map for understanding and navigating similar social
settings interactions, or relationships.
451 citations
TL;DR: Results of several cohort studies suggest that smoking cessation after myocardial infarction is associated with a significant decrease in mortality.
Abstract: Objective To determine the effect of smoking cessation on mortality after myocardial infarction Data Sources English- and non–English-language articles published from 1966 through 1996 retrieved using keyword searches of MEDLINE and EMBASE supplemented by letters to authors and searching bibliographies of reviews Study Selection Selection of relevant abstracts and articles was performed by 2 independent reviewers Articles were chosen that reported the results of cohort studies examining mortality in patients who quit vs continued smoking after myocardial infarction Data Extraction Mortality data were extracted from the selected articles by 2 independent reviewers Data Synthesis Twelve studies were included containing data on 5878 patients The studies took place in 6 countries between 1949 and 1988 Duration of follow-up ranged from 2 to 10 years All studies showed a mortality benefit associated with smoking cessation The combined odds ratio based on a random effects model for death after myocardial infarction in those who quit smoking was 054 (95% confidence interval, 046-062) Relative risk reductions across studies ranged from 15% to 61% The number needed to quit smoking to save 1 life is 13 assuming a mortality rate of 20% in continuing smokers The mortality benefit was consistent regardless of sex, duration of follow-up, study site, and time period Conclusion Results of several cohort studies suggest that smoking cessation after myocardial infarction is associated with a significant decrease in mortality
412 citations
TL;DR: To help clinicians assess sedation at the bedside, to aid readers critically appraise the growing number of sedation studies in the ICU literature, and to inform the design of future investigations, additional information about the measurement properties of Sedation effectiveness instruments is needed.
Abstract: Objective: To systematically review instruments for measuring the level and effectiveness of sedation in adult and pediatric ICU patients.¶Study identification: We searched MEDLINE, EMBASE, the Cochrane Library and reference lists of the relevant articles. We selected studies if the sedation instrument reported items related to consciousness and one or more additional items related to the effectiveness or side effects of sedation.¶Data abstraction: We extracted data on the description of the instrument and on their measurement properties (internal consistency, reliability, validity and responsiveness).¶Results: We identified 25 studies describing relevant sedation instruments. In addition to the level of consciousness, agitation and synchrony with the ventilator were the most frequently assessed aspects of sedation. Among the 25 instruments, one developed in pediatric ICU patients (the Comfort Scale), and 3 developed in adult ICU patients (the Ramsay scale, the Sedation-Agitation-Scale and the Motor Activity Assessment Scale), were tested for both reliability and validity. None of these instruments were tested for their ability to detect change in sedation status over time (responsiveness).¶Conclusion: Many instruments have been used to measure sedation effectiveness in ICU patients. However, few of them exhibit satisfactory clinimetric properties. To help clinicians assess sedation at the bedside, to aid readers critically appraise the growing number of sedation studies in the ICU literature, and to inform the design of future investigations, additional information about the measurement properties of sedation effectiveness instruments is needed.
361 citations
TL;DR: After a decade of unsystematic observation of an internal medicine residency programme committed to systematic training of evidence based practitioners, the limitations of this strategy are highlighted and two complementary alternatives are suggested.
Abstract: High quality health care implies practice that is consistent with the best evidence. An intuitively appealing way to achieve such evidence based practice is to train clinicians who can independently find, appraise, and apply the best evidence (whom we call evidence based practitioners). Indeed, we ourselves have advocated this approach.1 Now, however, we want to highlight the limitations of this strategy and suggest two complementary alternatives.
The skills needed to provide an evidence based solution to a clinical dilemma include defining the problem; constructing and conducting an efficient search to locate the best evidence; critically appraising the evidence; and considering that evidence, and its implications, in the context of patients' circumstances and values. Attaining these skills requires intensive study and frequent, time consuming, application.
After a decade of unsystematic observation of an internal medicine residency programme committed to systematic training of evidence based practitioners,1 we have concluded—consistent …
321 citations
TL;DR: This report hopes this report will generate further thought about ways to improve the quality of reports of meta-analyses of RCTs and that interested readers, reviewers, researchers, and editors will use the QUOROM statement and generate ideas for its improvement.
Abstract: Background: The Quality of Reporting of Meta-analyses (QUOROM) conference was convened to address standards for improving the quality of reporting of meta-analyses of clinical rand
319 citations
TL;DR: An observer agreement study in which two of eight intensivists and a radiologist, blinded to one another's interpretation, reviewed 778 radiographs from 99 critically ill patients concludes that intensivist without formal consensus training can achieve moderate levels of agreement.
Abstract: To measure the reliability of chest radiographic diagnosis of acute respiratory distress syndrome (ARDS) we conducted an observer agreement study in which two of eight intensivists and a radiologist, blinded to one another's interpretation, reviewed 778 radiographs from 99 critically ill patients. One intensivist and a radiologist participated in pilot training. Raters made a global rating of the presence of ARDS on the basis of diffuse bilateral infiltrates. We assessed interobserver agreement in a pairwise fashion. For rater pairings in which one rater had not participated in the consensus process we found moderate levels of raw (0.68 to 0.80), chance-corrected ( κ 0.38 to 0.55), and chance-independent ( Φ 0.53 to 0.75) agreement. The pair of raters who participated in consensus training achieved excellent to almost perfect raw (0.88 to 0.94), chance-corrected ( κ 0.72 to 0.88), and chance-independent ( Φ 0.74 to 0.89) agreement. We conclude that intensivists without formal consensus training can achiev...
259 citations
TL;DR: The Conferencia sobre Calidad de Elaboracion de the Informes of the Metaanalisis (QUOROM) as discussed by the authors was organized by 30 personas, entre epidemiologos clinicos, estadisticos, editores e investigadores.
Abstract: La Conferencia sobre Calidad de Elaboracion de los Informes de los Metaanalisis (QUOROM) se convoco con el fin de abordar la mejora de la calidad de la elaboracion de los informes de los metaanalisis de los ensayos clinicos controlados (ECC). El Grupo QUOROM estuvo integrado por 30 personas, entre epidemiologos clinicos, estadisticos, editores e investigadores. Durante la conferencia se pidio al grupo que identificase aquellos elementos que, en su opinion, se deberian incluir en un protocolo de control de calidad por niveles. En la medida de lo posible, la eleccion de los elementos de dicho protocolo se guio por la evidencia cientifica, que sugeria que el incumplimiento del elemento propuesto se podria traducir en resultados sesgados. Se utilizo una tecnica Delphi modificada para valorar los elementos seleccionados a priori como parte del protocolo. La conferencia se tradujo en la declaracion QUOROM, un protocolo de control de calidad y un diagrama de flujo. El protocolo de control de calidad describe la que creemos es la mejor forma de presentar el resumen, la introduccion, los metodos, los resultados y la discusion del informe de un metaanalisis. Esta organizada en 21 categorias y subcategorias relativas a busquedas, seleccion, evaluacion de la validez, analisis de los datos, caracteristicas del estudio y sintesis de los datos cuantitativos, y en los resultados de "flujo de pruebas"; se identifico la documentacion de la investigacion con 18 elementos. El diagrama de flujo proporciona informacion tanto sobre el numero de ensayos clinicos controlados identificados, incluidos y excluidos, como sobre las razones de su exclusion. Esperamos que este trabajo genere un mayor grado de reflexion sobre como mejorar la calidad de los informes de los metaanalisis de los ensayos clinicos controlados, y que los lectores, revisores, investigadores y editores utilicen la declaracion QUOROM y generen ideas destinadas a su mejora.
217 citations
TL;DR: It is concluded that from a hospital’s perspective, NPPV and standard therapy for carefully selected patients with acute, severe exacerbations of COPD are more effective and less expensive than standard therapy alone.
Abstract: ObjectiveThe use of noninvasive ventilation for patients with acute respiratory failure has become increasingly popular over the last decade. Although the literature provides good evidence for the effectiveness of noninvasive ventilation in addition to standard therapy compared with standard therapy
149 citations
TL;DR: This section focuses on clinical studies evaluating diagnostic procedures using endotracheal specimens (ie, cytologic examination, antibody coating, elastin fibers, Gram’s stain, and culture) in immunocompetent adults with suspected VAP.
TL;DR: VTE prophylaxis was underprescribed, and VTE diagnostic tests were infrequent, but several ICU-acquired risk factors for VTE were documented in this medical-surgical ICU.
TL;DR: VAP is associated with approximately a 4 day increase in length of ICU stay and an attributable mortality of approximately 20–30 %, and Ventilator-associated pneumonia is a major morbid outcome among critically ill patients.
Abstract: Objective: The objective of this narrative review is to summarize selected current concepts and clinical evidence regarding the burden of illness of VAP, including its epidemiology, diagnosis, attributable mortality and risk factors.¶Data Sources & Selection: Studies were identified through MEDLINE, EMBASE, bibliographies of primary and review articles and personal files.¶Results: While cross sectional studies inform us about VAP prevalence, longitudinal studies inform us of the cumulative risk and conditional risk of developing VAP. Reported VAP rates are modulated by factors related to case mix, causative micro-organisms, interventions that influence risk over time, and VAP definitions employed. Population-specific and organism-specific VAP rates are needed to avoid misleading benchmarking between different ICUs, and to minimize inappropriate between-study comparisons. Observational studies have shown that invasive sampling techniques versus non-invasive approaches to diagnose VAP facilitates more targeted antibiotic treatment; however, the influence of the diagnostic method on endpoints such as mortality is less clear. VAP is associated with approximately a 4 day increase in length of ICU stay and an attributable mortality of approximately 20–30 %. Fixed VAP risk factors include underlying cardiorespiratory disease, neurologic injury and trauma. Modifiable VAP risk factors include supine body position, witnessed aspiration, paralytic agents and antibiotic exposure. If modifiable risk factors tested in randomized trials lower VAP rates, such as semirecumbency versus supine positioning, these represent effective VAP prevention strategies.¶Conclusions: Ventilator-associated pneumonia is a major morbid outcome among critically ill patients. Studies evaluating more effective prevention and treatment strategies are needed.
TL;DR: Based on the use of more frequent ventilator circuit changes, closed suctioning systems, heated humidifiers, and respiratory therapists, ventilATOR circuit and secretion management practice appears more costly in Canada than in France.
Abstract: Objective To determine the use of ventilator circuit and secretion management strategies in France and Canada. Design Binational cross-sectional survey. Population Intensive care unit (ICU) directors in French and Canadian university hospitals. Measurements We compared responses between countries regarding the use of seven circuit and secretion strategies, the rationales against their use, decisional responsibility for these strategies, whether ventilator-associated pneumonia (VAP) practice was audited, and whether VAP prevention guidelines addressing these strategies were used. Results The response rate was 72/84 (85.7%) for French and 31/32 (96.9%) for Canadian ICUs. Endotracheal intubation was predominantly oral in both countries. Changing the ventilator circuits only for every new patient was more frequent in France than in Canada (p Conclusions Our study does not support the notion that published recommendations substantially impact reported use of several ventilator circuit and secretion management strategies. Based on the use of more frequent ventilator circuit changes, closed suctioning systems, heated humidifiers, and respiratory therapists, ventilator circuit and secretion management practice appears more costly in Canada than in France.
Journal Article•
TL;DR: The significance of gay or lesbian identity on the experiences of medical training using naturalistic methods of inquiry and the domains explored included career choice, "coming out," becoming a doctor, the environment and career implications.
Abstract: Background: Gay and lesbian physicians in training face considerable challenges as they become professionalized. Qualitative research is necessary to understand the social and cultural factors that influence their medical training. In this study we explored the significance of gay or lesbian identity on the experiences of medical training using naturalistic methods of inquiry. Methods: Semi-structured interviews, focus groups and an email listserv were used to explore professional and personal issues of importance to 29 gay and lesbian medical students and residents in 4 Canadian cities. Data, time, method and investigator triangulation were used to identify and corroborate emerging themes. The domains explored included career choice, “coming out,” becoming a doctor, the environment and career implications. Results: Gay or lesbian medical students and residents experienced significant challenges. For all participants, sexual orientation had an effect on their decisions to enter and remain in medicine. Once in training, the safety of a variety of learning environments was of paramount importance, and it affected subsequent decisions about identity disclosure, residency and career path. Respondents’ assessment of professional and personal risk was influenced by the presence of identifiable supports, curricula inclusive of gay and lesbian sexuality and health issues and effective policies censuring discrimination based on sexual orientation. The need for training programs to be proactive in acknowledging and supporting diversity was identified. Interpretation: Considerable energy and emotion are spent by gay and lesbian medical students and residents navigating training programs, which may be, at best, indifferent and, at worst, hostile.
TL;DR: The dialogue between ICU teammembers and families regarding limitation of treatment as a therapeutic narrative is examined, that is, as a story which frames therapeutic events as well as the critically ill patient's experience in a meaningful and psychological comforting way for families and health care providers.
Abstract: End-of-life decisions regarding the withdrawal and withholding of lifesupporting technology have become commonplace within intensive careunits (ICUs). In this paper, we examine the dialogue between ICU teammembers and families regarding limitation of treatment as a therapeuticnarrative – that is, as a story which frames therapeutic events aswell as the critically ill patient's experience in a meaningful andpsychologically comforting way for families and health care providersalike. The key themes of these end-of-life narratives are discussed, aswell as the qualities that the stories share with other narratives ofthe same genre.
Journal Article•
TL;DR: NIPPV was used for ARF of diverse causes in many hospital settings and was started and managed by physicians with various levels of training and experience and may be optimized by a multidisciplinary educational practice guideline.
Abstract: Background: The use of noninvasive positive-pressure ventilation (NIPPV) for acute respiratory failure (ARF) has become more widespread over the past decade, but its prescription, use and outcomes in the clinical setting remain uncertain. The objective of this study was to review the use of NIPPV for ARF with respect to clinical indications, physician ordering, monitoring strategies and patient outcomes.
01 Jan 2000
TL;DR: A fundamental question is posed to the group for discussion the following week: Could life support preference forms unduly routinize and constrain dialog between clinicians and patients or family members?
Abstract: At a Monday morning meeting of your hospital's Continuous Quality Improvement Committee, the last agenda item is an initiative "to enhance patient-clinician communication." The Chair proposes that all medical charts include a form to record patient wishes about cardiopulmonary resuscitation and end-of-life care. The Committee members agree in principle on the goals of enhanced communication and more accurate documentation of patient preferences. However, you raise potential concerns about how these forms might change the nature of end-of-life decision-making, and even impair communication. As the meeting draws to a close, you pose a fundamental question to the group for discussion the following week: Could life support preference forms unduly routinize and constrain dialog between clinicians and patients or family members?
01 Jun 2000
TL;DR: The authors examined reference lists, handsearched Respiratory Care (from 1997 to 1999), and searched their personal files for unpublished studies.
Abstract: Searching The following databases were searched from 1971 to 1998 (the search strategies used were provided in the report): MEDLINE, EMBASE, HealthSTAR, CINAHL, the Cochrane Controlled Trials Register and the Cochrane Database of Systematic Reviews. The authors also examined reference lists, handsearched Respiratory Care (from 1997 to 1999), and searched their personal files. The authors did not search for unpublished studies.
TL;DR: In this article, the authors examine the structure of allocative reasoning found in clinical guidelines, identify the ethical principles implied and compare how guidelines enact these principles with how explicit systems-level rationing exercises and health policy analyses have approached them, and offer some preliminary suggestions for how these ethical issues might be addressed in the process of guideline development.
Abstract: Clinical practice guidelines are expanding their scope of authority from clinical decision making to collective policy making, and promise to gain ground as resource allocation tools in coming years. A close examination of how guidelines approach patient selection criteria offers insight into their ethical implications when used as resource allocation or rationing instruments. The purposes of this paper are: a) to examine the structure of allocative reasoning found in clinical guidelines; b) to identify the ethical principles implied and compare how guidelines enact these principles with how explicit systems-level rationing exercises and health policy analyses have approached them; and c) to offer some preliminary suggestions for how these ethical issues might be addressed in the process of guideline development. The resulting framework can be used by guideline developers and users to understand and address some of the ethical issues raised by guidelines for the use of scarce technologies.
TL;DR: The screen log became a communication tool that fostered research‐oriented continuous quality improvement initiatives for the management of concurrently conducted randomized trials in the ICU and was used as an instrument to monitor trial execution.
Abstract: Objective:To develop and evaluate a screen log for monitoring enrollment in multiple randomized clinical trials conducted in a single center.Setting:University-affiliated 20-bed tertiary care medical-surgical intensive care unit (ICU).Patients:Consecutive ICU patients admitted between April 1995 and
Journal Article•
TL;DR: This multidisciplinary, multimethod oxygen pathway led to changes in oxygen-prescribing behaviour, consumed more resources than standard management and was not associated with changes in patient outcome.
Abstract: BACKGROUND: Oxygen is commonly administered to patients in hospital, but prescribing and monitoring of such therapy may be suboptimal. The objective of this study was to develop, disseminate, implement and evaluate a multidisciplinary clinical pathway for the administration of oxygen. METHODS: The authors developed a clinical pathway for the ordering, titration and discontinuation of oxygen, which was disseminated through teaching sessions, in-service training sessions and information posters in a medical clinical teaching unit (CTU). Implementation of the pathway was ensured by means of reminders and patient-centred audit and feedback to CTU nurses and house staff. During a 3-month intervention phase, consecutive patients requiring supplemental oxygen were treated according to the pathway. During a 1-month "wash-out" phase followed by a 3-month non-intervention phase, patients were treated at the discretion of the CTU team. Clinical and economic data were collected in both phases. RESULTS: In the 2 phases, patient characteristics, the concentration and duration of oxygen prescribed, the frequency of oxygen saturation monitoring, the frequency of arterial blood gas testing and the clinical outcomes were similar. However, there were more discontinuation orders in the intervention phase (p < 0.001). In the intervention phase, costs were higher for monitoring of oxygen saturation ($44.95/patient v. $36.17/patient, p = 0.048) and for order transcription ($2.71/patient v. $1.28/patient, p < 0.001); total costs, including those for personnel, were also higher in the intervention phase ($76.93/patient v. $56.67/patient, p = 0.02). The cost of education about the oxygen pathway was $45.71/patient. When the education cost was included, the total cost of oxygen therapy during the intervention phase was $122.64/patient; this was significantly higher than the total cost of oxygen therapy during the non-intervention phase ($56.67/patient) (p < 0.001). INTERPRETATION: This multidisciplinary, multimethod oxygen pathway led to changes in oxygen-prescribing behaviour, consumed more resources than standard management and was not associated with changes in patient outcome. Appropriate management of oxygen prescribing and monitoring by physicians and nurses take time and costs money.
TL;DR: Source Citation Drakulovic MB, Torres A, Bauer TT, et al.
Abstract: Source Citation Drakulovic MB, Torres A, Bauer TT, et al. Supine body position as a risk factor for nosocomial pneumonia in mechanically ventilated patients: a randomised trial. Lancet. 1999;354:18...
TL;DR: Several excellent microbiological, clinical, and methodological points regarding the randomized trial by Valles and colleagues are made, many of which are more appropriately addressed to the investigators of this trial.
Abstract: van Saene et al. make several excellent microbiological, clinical, and methodological points regarding the randomized trial by Valles and colleagues (1), many of which are more appropriately addressed to the investigators of this trial. As regards their rhetorical question, although critical appraisal of research necessarily converges on study design and results, responsible interpretation cannot proceed without understanding of pathophysiology and grounding with clinical expertise (2). Since publication of the Valles trial (1) and our article, 3 and 5 yrs have passed, respectively. Two additional randomized trials have evaluated subglottic secretion drainage, further advancing our understanding of the influence of this mechanical approach to nosocomial pneumonia prevention.