A Comparison of AGREE and RIGHT: which Clinical Practice Guideline Reporting Checklist Should Be Followed by Guideline Developers?

BACKGROUND: A clinical practice guideline (CPG) reporting checklist is used to assist CPG developers in recording what content should be provided in a CPG report. Recently, two checklists have become available on the Enhancing the QUAlity and Transparency Of health Research Network website: AGREE (Appraisal of Guidelines, Research and Evaluation) published in 2016 and RIGHT (Reporting Items for practice Guidelines in HealThcare) published in 2017. The objective of this study was to describe the advantages and disadvantages of these two CPG reporting checklists. METHODS: Two epidemiologists who lacked experience using both AGREE and RIGHT but were familiar with evidence-based medicine methodology independently compared AGREE with RIGHT on an item-by-item basis. Their assessments were compiled on a pre-designed data form and any disagreements were resolved through discussion. Three other co-authors independently compared AGREE with RIGHT and decided if they agreed with the results of comparison of the two CPG reporting checklists from the first two co-authors. Finally, another co-author reviewed the comparison results to ensure that the description was clear and understandable. RESULTS: The following six relationships between the two checklists were observed: (1) 11 items from AGREE completely matched with 12 items from RIGHT; (2) four items were listed in AGREE only; (3) 12 items were listed in RIGHT only; (4) three items in AGREE were partially covered by three items in RIGHT; (5) six items in RIGHT were partially covered by three items in AGREE; and (6) two items intersected across AGREE and RIGHT. Based on the comparison results, the potential impact analysis of selecting either checklist is described. DISCUSSION: We recommend that CPG developers use either AGREE plus items unique to RIGHT or RIGHT plus items unique to AGREE.

Multivariate Outliers: A Conceptual and Practical Overview for the Nurse and Health Researcher.

The presence of statistical outliers is a shared concern in research. If ignored or improperly handled, outliers have the potential to distort parameter estimates and possibly compromise the validity of research findings. The purpose of this paper is to provide a conceptual and practical overview of multivariate outliers with a focus on common techniques used to identify and manage multivariate outliers. Specifically, this paper discusses the use of Mahalanobis distance and residual statistics as common multivariate outlier identification techniques. It also discusses the use of leverage and Cook's distance as two common techniques to determine the influence that multivariate outliers may have on statistical models. Finally, this paper discusses techniques that are commonly used to handle influential multivariate outlier cases.

Functional limitations in people with multimorbidity and the association with mental health conditions: Baseline data from the Canadian Longitudinal Study on Aging (CLSA).

INTRODUCTION: Increasing multimorbidity is often associated with declining physical functioning, with some studies showing a disproportionate impact on functioning when mental health conditions are present. More research is needed because most multimorbidity studies exclude mental health conditions. OBJECTIVES: This study aims to improve our understanding of the association between functional limitation and multimorbidity, including a comparison of those with multimorbidity that includes versus excludes mental health conditions. METHODS: This is a population-based, cross-sectional analysis of data from The Canadian Longitudinal Study on Aging. Functional limitation was defined as the presence of any of 14 activities of daily living (ADLs) or instrumental activities of daily living (IADLs). Multimorbidity, measured by the number of chronic conditions, included mood and anxiety disorders. Logistic regression explored the association between multimorbidity (with and without mental health conditions) and functional limitation. Factor analysis identified common condition clusters to help understand clinical complexity in those with mood/anxiety disorders and the potential influences on functional limitation. RESULTS: There were 51,338 participants, with a similar proportion of men and women (49% versus 51%) and 42% age 65 years or older. Fifteen percent (15%) had no chronic conditions and 17% had 5+. Ten percent (10%) reported at least one ADL or IADL limitation. Odds ratios (ORs) for functional limitation increased with multimorbidity and were generally higher for those with versus without mental health conditions (e.g., ORs from 1 to 5+ chronic conditions increased 1.9 to 15.8 for those with mood/anxiety disorders versus 1.8 to 10.2 for those without). Factor analysis showed that mood/anxiety conditions clustered with somatic conditions (e.g., migraines, bowel/gastrointestinal disorders). CONCLUSION: This study found higher odds of functional limitation for those with multimorbidity that included versus excluded mental health conditions, at all levels of multimorbidity. It highlights the need for concurrent management of mental and physical comorbidities to prevent functional limitations and future decline. This approach is aligned with the NICE clinical assessment and management guidelines for people with multimorbidity.

Frailty differences across population characteristics associated with health inequality: a cross-sectional analysis of baseline data from the Canadian Longitudinal Study on Aging (CLSA).

OBJECTIVE: To evaluate the pattern of frailty across several of social stratifiers associated with health inequalities. DESIGN, SETTING AND PARTICIPANTS: Cross-sectional baseline data on 51 338 community-living women and men aged 45-85 years from the population-based Canadian Longitudinal Study on Aging (collected from September 2011 to May 2015) were used in this study. PRIMARY OUTCOMES AND MEASURES: A Frailty Index (FI) was constructed using self-reported chronic conditions, psychological function and cognitive status and physical functioning variables. Social stratifiers were chosen based on the Pan-Canadian Health Inequalities Reporting Initiative, reflecting key health inequalities in Canada. Unadjusted and adjusted FIs and domain-specific FIs (based on chronic conditions, physical function, psychological/cognitive deficits) were examined across population strata. RESULTS: The overall mean FI was 0.13±0.08. It increased with age and was higher in women than men. Higher mean FIs were found among study participants with low income (0.20±0.10), who did not complete secondary education (0.17±0.09) or had low perceived social standing (0.18±0.10). Values did not differ by Canadian province of residence or urban/rural status. After simultaneously adjusting for population characteristics and other covariates, income explained the most heterogeneity in frailty, especially in younger age groups; similar patterns were found for men and women. The average frailty for people aged 45-54 in the lowest income group was greater than that for those aged 75-85 years. The heterogeneity in the FI among income groups was greatest for the psychological/cognitive domain. CONCLUSIONS: Our results suggest that especially in the younger age groups, psychological/cognitive deficits are most highly associated with both overall frailty levels and the gradient in frailty associated with income. If this is predictive of later increases in the other two domains (and overall frailty), it raises the question whether targeting mental health factors earlier in life might be an effective approach to mitigating frailty.

Oral Health, Diet, and Frailty at Baseline of the Canadian Longitudinal Study on Aging.

OBJECTIVES: Poor diet due to poor oral health was proposed as a potential mediator of the association between poor oral health and frailty. This study explores the cross-sectional associations between poor oral health, poor diet, and frailty in Canadian adults, aged 45 to 85 years, and then tests whether the expected oral health-frailty association is changed by taking into account the pathway through poor diet. DESIGN: Cross-sectional study. SETTING: The baseline wave of the Canadian Longitudinal Study on Aging, a nationally representative population study. PARTICIPANTS: Data from 28 738 community-dwelling participants, aged 45 to 85 years. MEASUREMENTS: We characterized poor oral health (cumulative count of 24 items of oral health problems), poor diet (scale of poor food consumption from 7 healthy foods groups), and frailty (cumulative frailty index of 76 items). Regression-based path analyses were used to investigate associations between poor oral health, poor diet, and frailty, adjusted for age group, sex, income, smoking, living alone, education, physical activity, social support, and dental visit. RESULTS: Poorer oral health was associated with low income, smoking, low physical activity, low social support, and no dental visit. There were associations between poorer oral health and poorer diet (effect size ß adjusted = .40; 95% confidence interval [CI] = .20-.61) and between poorer oral health and increased frailty (ß adjusted = .85; 95% CI = .68-1.02). The indirect effect through the path of poor diet was approximately 0.01 (95% CI = 0.01-0.02) (ie, explaining ∼1% of the effect of poor oral health on frailty). CONCLUSIONS: Poor oral health was associated with poor diet and frailty. Each additional oral health problem was associated with an increase of approximately 1 frailty index point, even after full adjustment for poor diet. The indirect effect of poor oral health through poor diet was modest. Though poor oral health was associated with poorer diet quality, a more direct effect of poor oral health on increasing frailty may be indicated. J Am Geriatr Soc 68:959-966, 2020.

Assessing the measurement properties of a Frailty Index across the age spectrum in the Canadian Longitudinal Study on Aging.

BACKGROUND: Frailty is a way to appreciate the variable vulnerability to declining health status of people as they age. No consensus for measuring frailty has been established. This study aimed to adapt a Frailty Index (FI) to the Canadian Longitudinal Study on Aging (CLSA) and evaluate its applicability in both younger and older adults. METHODS: An FI was created based on 90 potential health deficits collected from adults aged 45-85 years at recruitment (N=21 241, 49.0% male). The construct validity of this instrument and the factor structure of the health deficits were evaluated. RESULTS: The direction of associations between the FI and other variables were consistent with a priori hypotheses for construct validity. FI values were significantly associated with age (r=0.17; p<0.001), falls (r=0.12; p<0.001), injuries (r=0.12; p<0.001), formal home care (r =0.30; p<0.001), informal home care (r=0.32; p<0.001) and use of assistive devices (r=0.40; p<0.001). Values were negatively associated with male sex (r=-0.12; p<0.001), income (r=-0.34; p<0.001) and education (r=-0.17; p<0.001). Key factors among the health indicators were physical functioning, satisfaction with life and depressive symptoms. Results did not change when the sample was stratified by age and sex. CONCLUSION: The FI is a feasible method to evaluate frailty and capture frailty-related heterogeneity in populations aged 45-85 years. In this study, the FI had good construct validity in middle-aged and older adults, showing expected correlations with sociodemographic factors consistently across age groups. This method can be easily reproduced in similar datasets, making the FI a generalisable instrument.

Procedural skills training for Canadian medical students participating in international electives.

BACKGROUND: International medical electives (IMEs) are unique learning opportunities; however, trainees can risk patient safety. Returning medical students often express concern about doing procedures beyond their level of training. The Canadian Federation of Medical Students has developed guidelines for pre-departure training (PDT), which do not address procedural skills. The purpose of this research is to determine which procedural skills to include in future PDT. METHODS: Twenty-six medical students who returned from IMEs completed surveys to assess PDT. Using a Likert scale, we compared procedures performed by students before departing on IME to those performed while abroad. We used a similar scale to assess which procedures students feel ought to be included in future PDT. RESULTS: There was no significant increase in number of procedures performed while on IME. Skills deemed most important to include in future PDT were intravenous line insertion, suturing of lacerations, surgical assisting and post-operative wound care. CONCLUSIONS: Pre-departure training is new and lacks instruction in procedural skills. Over half the students rated several procedural skills such as IV line insertion, suturing, assisting in surgery, post operative wound management and foley catheterization as important assets for future PDT.

The level of evidence keeps improving: An updated analysis of the scientific program at the Canadian Association of Paediatric Surgeons Annual Meeting.

INTRODUCTION: The purpose of this study is to examine the scientific program of the Canadian Association of Pediatric Surgeons (CAPS) to determine if the quality of research has improved. METHODS: CAPS abstracts from 2010 to 2013 were reviewed by two independent researchers. Presentation type, study design, and level of evidence (LOE) were recorded. All differences were adjudicated by an epidemiologist. Fisher's exact test compared results to a previous study that assessed LOE in CAPS abstracts from 2005 to 2009. RESULTS: 291 abstracts were reviewed with 53 excluded and 238 included in final analysis. Reviewers demonstrated high agreement for study design (ICC=0.767 95%CI 0.715-0.810) and LOE (ICC=0.914 95%CI 0.892-0.931). Out of 238 studies, 117 (49%) were podium and 122 (51%) posters. Number of high-quality studies increased in 2010-2013 versus 2005-2009 (n=253), specifically systematic reviews (n=15 (6%) vs. n=3 (1%) p<0.01), randomized controlled trials (n=4 (2%) vs. n=0 (0%), p=0.05), and prospective cohort studies (n=41 (17%) vs. n=26 (10%), p<0.001). Retrospective cohort is still the most common. However, the number of studies has significantly decreased (n=121 (51%) vs. n=171 (68%), p<0.001). The proportion of high-level studies (LOE 2 or better) also improved (48 (20%) vs. 24 (10%) p<0.001). CONCLUSION: The quality of research presented at CAPS has greatly improved, especially in the past five years.

Quality of reporting of the literature on gastrointestinal reflux after repair of esophageal atresia-tracheoesophageal fistula.

OBJECTIVES: There is variation in the management of postoperative gastroesophageal reflux (GER) in esophageal atresia-tracheoesophageal fistula (EA-TEF). Well-reported literature is important for clinical decision-making. We assessed the quality of reporting (QOR) of postoperative GER management in EA-TEF. METHODS: A comprehensive search of MEDLINE, EMBASE, CINHAL, CENTRAL databases and gray literature was conducted. Included articles reported a primary diagnosis of EA-TEF, a secondary diagnosis of postoperative GER, and primary treatment of GER with antireflux medications. The QOR was assessed using the STrengthening the Reporting of OBservational studies in Epidemiology (STROBE) checklist. RESULTS: Retrieval of 2910 articles resulted in 48 relevant articles (N=2592 patients) with an overall quality percentage score of 48%-95% (median=65%). The best reported items were "participants" and "outcome data" (93.8% each), "generalisability" (91.7%) and "background/rationale" (89.6%). Less than 20% of studies provided detailed "main results"; less than 5% of studies reported adequately on "bias" or "funding." Sample size calculation and study limitations were included in 17 (35.4%) and 16 (33.3%) studies respectively. Follow-up time was inconsistently reported. CONCLUSIONS: Although the overall QOR is moderate using STROBE, important areas are underreported. Inadequate methodological reporting may lead to inappropriate clinical decisions. Awareness of STROBE, emphasizing proper reporting is needed.