Showing papers by "Gordon H. Guyatt published in 2000"
TL;DR: Level 1 CDRs have the potential to inform clinical judgment, to change clinical behavior, and to reduce unnecessary costs, while maintaining quality of care and patient satisfaction.
Abstract: Clinical experience provides clinicians with an intuitive sense of which findings on history, physical examination, and investigation are critical in making an accurate diagnosis, or an accurate assessment of a patient’s fate. A clinical decision rule (CDR) is a clinical tool that quantifies the individual contributions that various components of the history, physical examination, and basic laboratory results make toward the diagnosis, prognosis, or likely response to treatment in a patient. Clinical decision rules attempt to formally test, simplify, and increase the accuracy of clinicians’ diagnostic and prognostic assessments. Existing CDRs guide clinicians, establish pretest probability, provide screening tests for common problems, and estimate risk. Three steps are involved in the development and testing of a CDR: creation of the rule, testing or validating the rule, and assessing the impact of the rule on clinical behavior. Clinicians evaluating CDRs for possible clinical use should assess the following components: the method of derivation; the validation of the CDR to ensure that its repeated use leads to the same results; and its predictive power. We consider CDRs that have been validated in a new clinical setting to be level 1 CDRs and most appropriate for implementation. Level 1 CDRs have the potential to inform clinical judgment, to change clinical behavior, and to reduce unnecessary costs, while maintaining quality of care and patient satisfaction. JAMA. 2000;284:79-84 www.jama.com
997 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: In this paper, the authors examined the short and long-term effects of an outpatient pulmonary rehabilitation program for COPD patients on dyspnea, exercise, health-related quality of life, and hospitalization rate.
392 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: Percutaneous transluminal coronary angioplasty may lead to a greater reduction in angina in patients with coronary heart disease than medical treatment but at the cost of more coronary artery bypass grafting.
Abstract: Objective: To determine whether percutaneous transluminal coronary angioplasty (angioplasty) is superior to medical treatment in non-acute coronary artery disease. Design: Meta-analysis of randomised controlled trials. Setting: Randomised controlled trials conducted worldwide and published between 1979 and 1998. Participants: 953 patients treated with angioplasty and 951 with medical treatment from six randomised controlled trials, three of which included patients with multivessel disease and pre-existing myocardial infarction. Main outcome measures: Angina, fatal and non-fatal myocardial infarction, death, repeated angioplasty, and coronary artery bypass grafting. Results: In patients treated with angioplasty compared with medical treatment the risk ratios were 0.70 (95% confidence interval 0.50 to 0.98; heterogeneity P Conclusions: Percutaneous transluminal coronary angioplasty may lead to a greater reduction in angina in patients with coronary heart disease than medical treatment but at the cost of more coronary artery bypass grafting. Trials have not included enough patients for informative estimates of the effect of angioplasty on myocardial infarction, death, or subsequent revascularisation, though trends so far do not favour angioplasty.
264 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: Clinicians must consider a patient's risk of adverse events from any intervention and incorporate the patient's values in clinical decision making by using information about the risks and benefits of therapeutic alternatives.
Abstract: Clinicians can use research results to determine optimal care for an individual patient by using a patient’s baseline risk estimate, clinical prediction guidelines that quantitate an individual patient’s potential for benefit, and published articles. We propose that when clinicians are determining the likelihood that treatment will prevent the target event (at the expense of adverse events) in a patient that they also incorporate the patient’s values. The 3 main elements to joint clinical decision making are disclosure of information about the risks and benefits of therapeutic alternatives, exploration of the patient’s values about both the therapy and potential outcomes, and the actual decision. In addressing the patient’s risk of adverse events without treatment and risk of harm with therapy, clinicians must recognize that patients are rarely identical to the average study patient. Differences between study participants and patients in real-world practice tend to be quantitative (differences in degree of risk of the outcome or responsiveness to therapy) rather than qualitative (no risk or adverse response to therapy). The number needed to treat and number needed to harm can be used to generate patientspecific estimates relative to the risk of the outcome event. Clinicians must consider a patient’s risk of adverse events from any intervention and incorporate the patient’s values in clinical decision making by using information about the risks and benefits of therapeutic alternatives.
247 citations
TL;DR: There is evidence from a pooled analysis of randomized trials that reamed IM nailing of lower extremity long bone fractures significantly reduces rates of nonunion and implant failure in comparison with nonreamed nailing.
Abstract: Objective:To determine the effect of reamed versus nonreamed intramedullary (IM) nailing of lower extremity long bone fractures on the rates of nonunion, implant failure, malunion, compartment syndrome, pulmonary embolus, and infection.Design:Quantitative systematic review of prospective, randomized
241 citations
TL;DR: Patients with cholestatic liver disease showed substantial impairment of HRQL, which is further affected by worsening disease severity, and patients who experienced severe itching showed profound HRQL impairment.
151 citations
01 Dec 2000
TL;DR: In this article, the authors define publication bias and how it affects the results of systematic reviews, how it can be detected and minimized, and how to prevent it from occurring in systematic reviews.
Abstract: Systematic reviews and mata-analyses provide the highest level of evidence to guide clinical decisions and inform practice guidelines. Publication bias results from the selective publication of studies based on the direction and magnitude of their results-studies without statistical significance (negative studies) are less likely to be published. Bias results from pooling the results from published studies alone leading to overestimation of the effectiveness of the intervention. In this review we define publication bias, how it affects the results of systematic reviews, how it can be detected and minimized, and how it can be prevented.
133 citations
TL;DR: Health‐related quality‐of‐life scores for patients awaiting liver transplants were significantly lower than those for patients with COPD and CHF and those in the general population, but some residual dysfunction persisted.
TL;DR: Observational studies yield systematically greater estimates of treatment effects than randomized trials of adolescent pregnancy prevention interventions and public policy or individual patient treatment decisions should be based on observational studies only when randomized trials are unavailable.
TL;DR: Current procedures for administration and reimbursement of home oxygen result in a large proportion of recipients not meeting criteria, as well as the prescription of excessive oxygen flow rates.
TL;DR: There are three requirements for an interpretation of the results of a target health-related quality-of-life (HRQOL) measurement instrument: (1) availability of an independent standard or standards, (2) standards that are interpretable (i.e., we must have an intuitive sense of the value we place on different scores or levels in that standard), and (3) standard that are moderately to highly correlated with the target instrument.
Abstract: There are 3 requirements for an interpretation of the results of a target health-related quality-oflife (HRQOL) (or any other) measurement instrument: (1) availability of an independent standard or standards, (2) standards that are interpretable (ie, we must have an intuitive sense of the value we place on different scores or levels in that standard), and (3) standards that are moderately to highly correlated with the target instrument.
TL;DR: The results suggest the appropriateness of a moratorium on these expensive interventions pending demonstration of clear positive effects determined from further study.
Abstract: Background. Older adults who receive training for functional skills in contextually appropriate environments may show greater functional improvement than persons trained in a traditional environment. Functionally limited older adults receiving training in contextually appropriate environments (simulated home and community settings) may show greater improvement in activities of daily living (ADL) than persons trained in a traditional manner. Methods. Eighty-eight patients from a day hospital, aged 65 years or older, were randomized to either receive rehabilitation in a simulated environment (Easy Street) or in a gymnasium setting. Rehabilitation focused on retraining functional skills in a contextually appropriate environment (Easy Street) or in a traditional setting (gymnasium) using motor learning principles for a period of 16 weeks. Outcome measures included the Structured Assessment of Instrumental Living Skills (SAILS), a performance measure with criterion and timed components; a self-report health status questionnaire, the Short Form-36 (SF-36); and the patient-orientated goal-directed Canadian Occupational Performance Measure (COPM). Results. There were no group differences on any of the outcome measures: SAILS ( p 5 .3); the SF-36 physical ( p 5 .83) and mental ( p 5 .51); and the COPM performance scale ( p 5 .94) and satisfaction scale ( p 5 .40). Conclusions. Although we have not excluded benefits of contextually appropriate rehabilitation environments with different intervention approaches, at different stages of rehabilitation or with patients at higher functional levels, our results suggest the appropriateness of a moratorium on these expensive interventions pending demonstration of clear positive effects determined from further study.
TL;DR: The clinician and the medical literature: when can the authors take a shortcut?
TL;DR: The results of the questionnaires indicated moderate health-related quality of life at baseline, with only small changes in scores at the end of the observation period, and future research in this area should include a combination of rehabilitative approaches to improvequality of life for women with spinal fractures due to osteoporosis.
Abstract: Vertebral osteoporotic fractures can cause severe pain and can impair function and reduce quality of life. The purpose of this research was to test the efficacy of an intervention to improve health-related quality of life of women with spinal fractures secondary to osteoporosis. The intervention for this study was an 8-week educational support group, along with weekly telephone calls. A convenience sample of 25 women with spinal fractures was recruited and matched with a control group of 25 subjects. Study questionnaires were administered at the beginning and end of the 8-week session to all 50 subjects. The results of the questionnaires indicated moderate health-related quality of life at baseline, with only small changes in scores at the end of the observation period. Future research in this area should include a combination of rehabilitative approaches to improve quality of life for women with spinal fractures due to osteoporosis.
01 Jan 2000
TL;DR: The clinician and the medical literature: when can the authors take a shortcut?
Abstract: [Wyer PC, Rowe BH, Guyatt GH, Cordell WH. The clinician and the medical literature: when can we take a shortcut? Ann Emerg Med. August 2000;36:149-155.].