Showing papers by "Gordon H. Guyatt published in 1986"
Journal Article•
TL;DR: This article describes a pragmatic approach to questionnaire construction that yields consistently satisfactory disease-specific measures of quality of life and outlines a more efficient, less costly strategy that leaves reproducibility, responsiveness and validity untested.
Abstract: While measurement of quality of life is a vital part of assessing the effect of treatment in many clinical trials, a measure that is responsive to clinically important change is often unavailable. Investigators are therefore faced with the challenge of constructing an index for a specific condition or even for a single trial. There are several stages in the development and testing of a quality-of-life measure: selecting an initial item pool, choosing the "best" items from that pool, deciding on questionnaire format, pretesting the instrument, and demonstrating the responsiveness and validity of the instrument. At each stage the investigator must choose between a rigorous, time-consuming approach to questionnaire construction that will establish the clinical relevance, responsiveness and validity of the instrument and a more efficient, less costly strategy that leaves reproducibility, responsiveness and validity untested. This article describes these options and outlines a pragmatic approach that yields consistently satisfactory disease-specific measures of quality of life.
718 citations
TL;DR: Double-blind randomized trials are used in which a single patient undergoes a series of pairs of treatments, consisting of one active and one placebo or alternative treatment per pair, with the order determined by random allocation.
Abstract: Although the treatment of an individual patient in routine clinical practice has been likened to an experiment, the method is so susceptible to bias that we have come to demand multi-patient, double-blind, randomized controlled trials on matters of efficacy. Unfortunately, such trials have not or cannot be carried out for many clinical disorders; even when they have been executed their results may be difficult to extrapolate to individual patients. To resolve this problem, we have begun to use double-blind randomized trials in which a single patient undergoes a series of pairs of treatments, consisting of one active and one placebo or alternative treatment per pair, with the order determined by random allocation. Appropriate treatment targets (signs, symptoms, or laboratory tests) are used as the measure of efficacy, and the trial is continued until efficacy is established or disproved. We describe such a trial, which resulted in a dramatically beneficial modification of treatment in a patient with partially reversible airflow limitation. We have established a clinical service that facilitates the widespread use of the method in our community.
495 citations
Journal Article•
TL;DR: Diagnostic technologies should be disseminated only if they are less expensive, produce fewer untoward effects and are at least as accurate as existing methods, if they eliminate the need for other investigations without loss of accuracy, or if they lead to institution of effective therapy.
Abstract: Most new diagnostic technologies have not been adequately assessed to determine whether their application improves health. Comprehensive evaluation of diagnostic technologies includes establishing technologic capability and determining the range of possible uses, diagnostic accuracy, impact on the health care provider, therapeutic impact and impact on patient outcome. Guidelines to determine whether each of these criteria have been met adequately are presented. Diagnostic technologies should be disseminated only if they are less expensive, produce fewer untoward effects and are at least as accurate as existing methods, if they eliminate the need for other investigations without loss of accuracy, or if they lead to institution of effective therapy. Establishing patient benefit often requires a randomized controlled trial in which patients receive the new test or an alternative diagnostic strategy. Other study designs are logistically less difficult but may not provide accurate assessment of benefit. Rigorous assessment of diagnostic technologies is needed for efficient use of health care resources.
214 citations
TL;DR: It is argued that decision making can be improved by striving towards a more rational approach to the adoption and utilization of health technology and a comprehensive set of guidelines for both clinical and economic evaluation is proposed.
143 citations
TL;DR: In this article, the authors describe three strategies to enhance the efficiency and effectiveness of journal reading: priority should be given to reading original articles concerning reports of planned investigations because only these articles provide sufficient details to assess the relevance, validity, and clinical application of new knowledge.
Abstract: Patient care is often outmoded because physicians lack awareness about important advances in medical knowledge. According to physicians, reading journals is the most popular method for staying informed, but the great volume of journal literature precludes clinicians' from reading all of it. In this first of six articles on keeping up with the medical literature, we describe three strategies to enhance the efficiency and effectiveness of journal reading. First, priority should be given to reading original articles concerning reports of planned investigations because only these articles provide sufficient details to assess the relevance, validity, and clinical application of new knowledge. Second, reading should be restricted to articles of direct pertinence to one's clinical practice. Third, the methods section of articles should be quickly screened first to select studies that have used sufficiently high standards to warrant clinical action based on study results.
102 citations
TL;DR: Before-after designs of therapeutic impact studies will be most useful in primary investigations which, if positive, should be followed by more rigorous studies to establish patient benefit.
81 citations
TL;DR: Many of the options available to clinicians who wish to do their own computer searching of MEDLINE, the largest of the electronic services for the biomedical literature, are described.
Abstract: Access to the medical literature through personal computers is now readily available and can greatly reduce logistical barriers to using recently published journal articles to support clin...
81 citations
TL;DR: A preemptive strategy for clinicians to determine which journals to read on a regular basis is described, selected initially on the basis of circulation or citation impact, and then consecutive issues surveyed to determine the journals' yields of articles that are both directly relevant and of high quality.
Abstract: For practitioners, one of the major objectives for reading the medical literature is to maintain clinical competence. Ideally, this task is accomplished through efficiently extracting from...
50 citations
TL;DR: The results support a clinical policy of initial treatment with diuretics and addition of either captopril or enalapril for patients who remain symptomatic on optimal diuretic therapy.
Abstract: In this article literature concerning the major drugs used in the treatment of heart failure is reviewed. Because of major discrepancies in results from short term and uncontrolled studies versus long term randomised control trials, only the latter group of studies are addressed in detail. Of 3 randomised control trials of digoxin, 1 has been positive, and 2 negative. Digoxin is probably of benefit to a minority of heart failure patients. Four randomised control trials of oral nitrates have shown a reduction in left ventricular filling pressure, and trends favouring active treatment for the indices of exercise capacity and functional status. Of 2 randomised control trials of hydralazine one is totally negative, the other difficult to interpret because of major loss of patients to followup. Of 5 trials of quinazolone derivatives (prazosin and trimazosin), 2 have been positive, 2 showed non-statistically significant trends favouring active treatment, and 1 was completely negative. These results are consistent with a modest benefit of prazosin and trimazosin in some heart failure patients. Five trials of angiotensin-converting enzyme inhibitors (captopril and enalapril) have shown dramatic and consistent benefit in exercise capacity and functional status. These results support a clinical policy of initial treatment with diuretics and addition of either captopril or enalapril for patients who remain symptomatic on optimal diuretic therapy. A trial of digoxin is warranted in patients whose functional capacity remains reduced on this regimen.
47 citations
TL;DR: Using the problem of understanding and controlling the risk for the acquired immunodeficiency syndrome among personnel of a community hospital, the Index Medicus and MEDLINE were the best sources of up-to-date articles, but MEDLINE was three times as fast.
Abstract: Ideally, searches for published articles to solve clinical problems should lead to the best evidence on a given topic quickly and at reasonable expense. This goal can be achieved with modern information skills, sources, and services. In this article, we describe and compare various means, from textbooks to computers, that provide access to information of potential value in addressing clinical problems as they arise. Using the problem of understanding and controlling the risk for the acquired immunodeficiency syndrome among personnel of a community hospital, we examined the following sources for their utility in locating journal literature: general and specialty medical texts, personal reprint collections, expert clinicians, recent journal issues, library textbook collections, the Index Medicus "Bibliography of Reviews" and subject index, and MEDLINE computer searching. For this problem, Index Medicus and MEDLINE were the best sources of up-to-date articles, but MEDLINE was three times as fast.
40 citations
TL;DR: Tactics for formulating a personalized journal-reading list and ensuring access to the key articles in one's field at a reasonable cost are described and deleted from regular reading and added to journals more relevant to one's interests.
Abstract: Clinicians can derive immense satisfaction from keeping abreast of new developments in patient care by regularly scanning the medical journal literature. Combined with good reading habits and self-discipline, this scanning generally can be accomplished within the time that most practitioners allot to attempting to keep up to date. We describe tactics for formulating a personalized journal-reading list and ensuring access to the key articles in one's field at a reasonable cost. These tactics begin with deleting low-yield journals from regular reading and adding journals more relevant to one's interests. The cost of multiple journal subscriptions can be reduced by circulating different journals among colleagues or by regular visits to the library. These tactics can be supplemented or replaced by using Current Contents or the Selective Dissemination of Information service of the National Library of Medicine and other database vendors.
TL;DR: This article assists the reader in the development of a tailor-made system that is based on making key decisions that strike a balance between filing needs and the lack of enthusiasm that most of us have for filing.
Abstract: The human mind is not well suited to storing and retrieving large amounts of infrequently used information. An effective personal filing system is needed if good articles that we encounter...
Journal Article•
TL;DR: To assess the need for a multidisciplinary geriatric unit in the treatment of elderly patients with hip fractures, all patients aged 60 years or older who were treated for hip fractures in five hospitals in Hamilton, Ont., between August 1982 and September 1983 were reviewed.
Abstract: To assess the need for a multidisciplinary geriatric unit in the treatment of elderly patients with hip fractures, we reviewed the charts of all patients aged 60 years or older who were treated for hip fractures in five hospitals in Hamilton, Ont., between August 1982 and September 1983. We hypothesized that discharge to a different location from that before admission would indicate reduced functional status and classified the reasons for a change in residence as poor patient motivation, need for rehabilitation, compromised ambulation, postoperative complications and inevitable deterioration. We believed that geriatric care would be most beneficial to those in the first three groups. Of the 327 patients with hip fractures 40 (12%) died before discharge. Of the 287 surviving patients 149 (52%) had been discharged by 4 weeks, and only 29 (10%) remained in hospital by 12 weeks. Of the 287, 44 (15%) were discharged to a different location from that before admission: in 75% the cause appeared to be inevitable deterioration (57%) or postoperative complications (18%). The remaining 25% needed rehabilitation and were all sent to appropriate facilities. None of the patients with ambulation problems or poor motivation required an increased level of care. We could not show a need for geriatric care in our population; possible explanations are discussed.