Background Audit and feedback continues to be widely used as a strategy to improve professional practice. It appears logical that healthcare professionals would be prompted to modify their practice if given feedback that their clinical practice was inconsistent with that of their peers or accepted guidelines. Yet, audit and feedback has not been found to be consistently effective. Objectives To assess the effects of audit and feedback on the practice of healthcare professionals and patient outcomes. Search strategy We searched the Cochrane Effective Practice and Organisation of Care Group's register up to January 2001. This was supplemented with searches of MEDLINE and reference lists, which did not yield additional relevant studies. Selection criteria Randomised trials of audit and feedback (defined as any summary of clinical performance over a specified period of time) that reported objectively measured professional practice in a healthcare setting or healthcare outcomes. Data collection and analysis Two reviewers independently extracted data and assessed study quality. Quantitative (meta-regression), visual and qualitative analyses were undertaken. Main results We included 85 studies, 48 of which have been added to the previous version of this review. There were 52 comparisons of dichotomous outcomes from 47 trials with over 3500 health professionals that compared audit and feedback to no intervention. The adjusted RDs of non-compliance with desired practice varied from 0.09 (a 9% absolute increase in non-compliance) to 0.71 (a 71% decrease in non-compliance) (median = 0.07, inter-quartile range = 0.02 to 0.11). The one factor that appeared to predict the effectiveness of audit and feedback across studies was baseline non-compliance with recommended practice. Reviewer's conclusions Audit and feedback can be effective in improving professional practice. When it is effective, the effects are generally small to moderate. The absolute effects of audit and feedback are more likely to be larger when baseline adherence to recommended practice is low.

Audit and feedback: effects on professional practice and healthcare outcomes

We have produced a draft sequence of the rice genome for the most widely cultivated subspecies in China, Oryza sativa L. ssp. indica, by whole-genome shotgun sequencing. The genome was 466 megabases in size, with an estimated 46,022 to 55,615 genes. Functional coverage in the assembled sequences was 92.0%. About 42.2% of the genome was in exact 20-nucleotide oligomer repeats, and most of the transposons were in the intergenic regions between genes. Although 80.6% of predicted Arabidopsis thaliana genes had a homolog in rice, only 49.4% of predicted rice genes had a homolog in A. thaliana. The large proportion of rice genes with no recognizable homologs is due to a gradient in the GC-content of rice coding sequences.

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A draft sequence of the rice genome (Oryza sativa L. ssp indica)

This study describes and validates a new method for metagenomic biomarker discovery by way of class comparison, tests of biological consistency and effect size estimation. This addresses the challenge of finding organisms, genes, or pathways that consistently explain the differences between two or more microbial communities, which is a central problem to the study of metagenomics. We extensively validate our method on several microbiomes and a convenient online interface for the method is provided at http://huttenhower.sph.harvard.edu/lefse/.

Metagenomic biomarker discovery and explanation

The discovery of a series of genetic and serological markers associated with disease susceptibility and phenotype in inflammatory bowel disease has led to the prospect of an integrated classification system involving clinical, serological and genetic parameters. The Working Party has reviewed current clinical classification systems in Crohn's disease, ulcerative colitis and indeterminate colitis, and provided recommendations for clinical classification in practice. Progress with respect to integrating serological and genetic markers has been examined in detail, and the implications are discussed. While an integrated system is not proposed for clinical use at present, the introduction of a widely acceptable clinical subclassification is strongly advocated, which would allow detailed correlations among serotype, genotype and clinical phenotype to be examined and confirmed in independent cohorts of patients and, thereby, provide a vital foundation for future work.

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Toward an Integrated Clinical, Molecular and Serological Classification of Inflammatory Bowel Disease: Report of a Working Party of the 2005 Montreal World Congress of Gastroenterology

OBJECTIVES: To consider methods and related evidence for evaluating bias in non-randomised intervention studies. DATA SOURCES: Systematic reviews and methodological papers were identified from a search of electronic databases; handsearches of key medical journals and contact with experts working in the field. New empirical studies were conducted using data from two large randomised clinical trials. METHODS: Three systematic reviews and new empirical investigations were conducted. The reviews considered, in regard to non-randomised studies, (1) the existing evidence of bias, (2) the content of quality assessment tools, (3) the ways that study quality has been assessed and addressed. (4) The empirical investigations were conducted generating non-randomised studies from two large, multicentre randomised controlled trials (RCTs) and selectively resampling trial participants according to allocated treatment, centre and period. RESULTS: In the systematic reviews, eight studies compared results of randomised and non-randomised studies across multiple interventions using meta-epidemiological techniques. A total of 194 tools were identified that could be or had been used to assess non-randomised studies. Sixty tools covered at least five of six pre-specified internal validity domains. Fourteen tools covered three of four core items of particular importance for non-randomised studies. Six tools were thought suitable for use in systematic reviews. Of 511 systematic reviews that included non-randomised studies, only 169 (33%) assessed study quality. Sixty-nine reviews investigated the impact of quality on study results in a quantitative manner. The new empirical studies estimated the bias associated with non-random allocation and found that the bias could lead to consistent over- or underestimations of treatment effects, also the bias increased variation in results for both historical and concurrent controls, owing to haphazard differences in case-mix between groups. The biases were large enough to lead studies falsely to conclude significant findings of benefit or harm. Four strategies for case-mix adjustment were evaluated: none adequately adjusted for bias in historically and concurrently controlled studies. Logistic regression on average increased bias. Propensity score methods performed better, but were not satisfactory in most situations. Detailed investigation revealed that adequate adjustment can only be achieved in the unrealistic situation when selection depends on a single factor. CONCLUSIONS: Results of non-randomised studies sometimes, but not always, differ from results of randomised studies of the same intervention. Non-randomised studies may still give seriously misleading results when treated and control groups appear similar in key prognostic factors. Standard methods of case-mix adjustment do not guarantee removal of bias. Residual confounding may be high even when good prognostic data are available, and in some situations adjusted results may appear more biased than unadjusted results. Although many quality assessment tools exist and have been used for appraising non-randomised studies, most omit key quality domains. Healthcare policies based upon non-randomised studies or systematic reviews of non-randomised studies may need re-evaluation if the uncertainty in the true evidence base was not fully appreciated when policies were made. The inability of case-mix adjustment methods to compensate for selection bias and our inability to identify non-randomised studies that are free of selection bias indicate that non-randomised studies should only be undertaken when RCTs are infeasible or unethical. Recommendations for further research include: applying the resampling methodology in other clinical areas to ascertain whether the biases described are typical; developing or refining existing quality assessment tools for non-randomised studies; investigating how quality assessments of non-randomised studies can be incorporated into reviews and the implications of individual quality features for interpretation of a review's results; examination of the reasons for the apparent failure of case-mix adjustment methods; and further evaluation of the role of the propensity score.

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Evaluating non-randomised intervention studies.

BACKGROUND
The objective of this study was, first to determine what proportion of clinical treatment evaluation questions involving surgical operations could be answered by a randomized controlled trial (RCT). Second, for those questions not amenable to a RCT, to determine the problems that potentially preclude the initiation of RCT in an ideal clinical research setting.


METHODS
A sample of treatment evaluation questions involving a surgical procedure was obtained by a computerized search of the surgical literature. Problems precluding a RCT were defined. Their face validity and interobserver and intraobserver reliability were assessed. By use of these criteria, the sample questions were evaluated to determine whether a RCT could be performed and, if not, the predominant reasons precluding RCT of surgical procedures.


RESULTS
Only 38.8% of treatment evaluation questions could have been answered by a RCT in an ideal clinical research setting. Patient preference was the most common precluding problem encountered (40% of all problems). The principal precluding problem was patient preference in 23.1%, an uncommon condition in 24.2%, and lack of community (clinical) equipoise in 10%. Methodologic issues (1.2%) and surgical preference (2.3%) were infrequent precluding problems. Questions evaluating therapy for malignant disease, comparing surgical with nonsurgical therapies, and where survival was the primary outcome were more likely to have problems precluding RCT.


CONCLUSIONS
In the ideal situation RCT can be performed to evaluate only 40% of treatment questions involving surgical procedures. Patient preferences, uncommon conditions, and lack of surgical community equipoise appear to be the most common reasons precluding the of RCT of surgical operations.

Original communications Should we be performing more randomized controlled trials evaluating surgical operations

Appendicitis is the most common acute surgical condition of the abdomen1 The rate of acute appendicitis varies among countries Declining rates of acute appendicitis have been reported in the United States and Europe2,3,4 However, the frequency appears to be increasing in the developing countries5,6 Age, sex and seasonal variations of acute appendicitis have been observed in many studies, but the reasons for these variations are not clear

Although acute appendicitis is a common surgical condition, little is known about its epidemiology in Canada Therefore, this study was conducted to explore the demographic characteristics, incidence, seasonal variation and trends of acute appendicitis in the Province of Ontario from 1991 to 1998

http://canjsurg.ca/wp-content/uploads/2014/03/46-4-263.pdf

Epidemiologic features of acute appendicitis in Ontario, Canada.

Objective
To determine the incidence of small bowel obstruction (SBO), to identify risk factors for its development, and to determine the most common sites of adhesions causing SBO in patients undergoing ileal pouch–anal anastomosis (IPAA).

Risk of small bowel obstruction after the ileal pouch-anal anastomosis.

OBJECTIVE: To determine if any significant differences exist between laparoscopic appendectomy (LA) and open appendectomy (OA). DESIGN: A meta-analysis of randomized controlled trials (RCTs) comparing LA to OA. DATA SOURCES: An extensive literature search was conducted for appropriate articles published between January 1990 and March 1997. Articles were initially retrieved through MEDLINE with MeSH terms "appendicitis" or "appendectomy" and "laparoscopy". Additional methods included cross-referencing bibliographics of retrieved articles, hand searching abstracts from relevant meetings and consultation with a content expert. STUDY SELECTION: Only RCTs published in English in which patients had a preoperative diagnosis of acute appendicitis were included. DATA EXTRACTION: The outcomes of interest included operating time, hospital stay, readmission rates, return to normal activity and complications. The Cochrane Collaboration Review Manager 3.0 was used to calculate odds ratios (OR), weighted mean differences (WMD) and 95% confidence intervals (CI). The random-effects model was used for statistical analysis. DATA SYNTHESIS: Twelve trials met the inclusion criteria. Because there were insufficient data in some trials, operating time, hospitalization and return to work were assessed in only 8 trials. Mean operating time was significantly longer with LA (WMD 18.10 minutes, 95% CI 12.87 to 23.15 minutes). There were fewer wound infections in LA (OR 0.40, 95% CI 0.24 to 0.69), but no significant differences in intra-abdominal abscess rates (OR 1.94, 95% CI 0.68 to 5.58). There was no significant difference in the mean length of hospital stay (WMD -0.16 days, 95% CI -0.44 to 0.15 days) or readmission rates (OR 1.16, 95% CI 0.54 to 2.48). However, the return to normal activity was significantly earlier with LA (WMD -5.79 days, 95% CI -7.38 to -4.21 days). Sensitivity analyses did not affect the results. CONCLUSION: This meta-analysis suggests that operating room time is significantly longer, hospital stay is unchanged but return to normal activities is significantly earlier with LA.

A meta-analysis of laparoscopic versus open appendectomy in patients suspected of having acute appendicitis.

Question: Is there a difference in cancer-related survival between laparoscopic assisted colectomy (LAC) and open colectomy (OC)? Design: Randomized controlled trial. Setting: Single-centre trial, Barcelona, Spain. Patients: Two hundred and nineteen of 442 eligible patients with adenocarcinoma of the colon were included. Patients were excluded if the tumour was below 15 cm from the anal verge or was in the transverse colon; if there were distant metastases, adjacent organ involvement or obstruction; or the patient had previous colonic surgery. One hundred and eleven were randomized to the LAC group and 108 to the OC. Interventions: Randomization was done the day before surgery. Patients were stratified into 2 groups according to tumour location (right or left side with respect to the splenic flexure) and assigned to the LAC or OC group by means of sealed opaque envelopes containing computer-generated random numbers. Patients in both groups had surgery by a single gastrointestinal surgical team. Pre- and postoperative care was standardized for bowel prep and perioperative antibiotics. Patients received either LAC or OC using a no-touch technique and initial vascular ligation. Main outcome measure: Overall survival. Results: The Cox model showed that LAC was independently associated with reduced risk of tumour relapse (hazard ratio 0.39, 95% CI 0.19 – 0.82), death from any cause (0.48, 0.23 –1.01) and death from a cancer-related cause (0.38, 0.16– 0.91) compared with OC. This superiority of LAC was due to differences in patients with stage III tumours (freedom from recurrence p = 0.04, overall survival p = 0.02, and cancer- related survival p = 0.006). Conclusion: LAC is more effective than OC for treatment in terms of morbidity, hospital stay, tumour recurrence and cancer-related survival.

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Canadian Association of General Surgeons Evidence Based Reviews in Surgery. 10. Laparoscopy-assisted colectomy versus open colectomy for treatment of non-metastatic colon cancer: a randomized trial.

Robin S. McLeod

Papers

Original communications Should we be performing more randomized controlled trials evaluating surgical operations

Epidemiologic features of acute appendicitis in Ontario, Canada.

Risk of small bowel obstruction after the ileal pouch-anal anastomosis.

A meta-analysis of laparoscopic versus open appendectomy in patients suspected of having acute appendicitis.

Canadian Association of General Surgeons Evidence Based Reviews in Surgery. 10. Laparoscopy-assisted colectomy versus open colectomy for treatment of non-metastatic colon cancer: a randomized trial.