Indirectness (transferability) is critical when considering existing economic evaluations for GRADE clinical practice guidelines: a systematic review.

OBJECTIVES: Grading of Recommendations Assessment, Development and Evaluation (GRADE) practice guideline developers often perform systematic reviews of potential economic evaluations to inform recommendation decision-making. We aimed to identify indirectness characteristics of economic evaluations, related to GRADE evidence-to-decision (EtD) theoretical frameworks, that influence selection of these articles. STUDY DESIGN AND SETTING: MEDLINE, EMBASE, CINAHL, and EconLit were systematically searched to May 2020 to identify indirectness characteristics relevant for economic evaluation transferability to GRADE EtD theoretical frameworks. Four reviewers screened citations to identify articles of any type that explored study characteristics most important or relevant to economic evaluation transferability, restricted to English language we generated frequencies of article features, used thematic analysis to summarize study characteristics, and assessed certainty in the evidence using GRADE-CERQual. RESULTS: We included 57 articles, with a dearth of empirical literature-some may have been missed. We identified eight general themes and 28 subthemes most important to transferability from 41% of articles. Moderate-to-high confidence evidence suggested that GRADE EtD domains of population, intervention and comparison research question elements, resource use estimation and methodology, and provider and decision maker acceptability are most important indirectness study characteristics that economists consider when choosing economic evaluation outcomes for use in recommendation decision-making. CONCLUSION: We have identified factors important for guideline developers to consider when selecting economic evaluations as research evidence. An economic competency on the development team facilitates these endeavors. This supports the GRADE Working Group's tenant of transparent reporting or availability of sufficient information elsewhere to assess indirectness.

Guidelines that use the GRADE approach often fail to provide complete economic information for recommendations: A systematic survey.

OBJECTIVE: Little is known about how developers and panel members report cost and cost effectiveness considerations in GRADE guideline Evidence-to-Decision (EtD) frameworks. A systematic survey was conducted to explore approaches and factors contributing to variability in economic information reporting. STUDY DESIGN AND SETTING: Guideline organization websites were systematically searched to create a convenience sample of guidelines. Reviewers screened published EtD frameworks and generated frequencies of reporting approaches. We used thematic analysis to summarize factors related to variability of economic information reporting. RESULTS: We included 142 guidelines. The overall rate of reporting economic information was high (91%); however, there was variability across completion of predefined EtD Likert-type judgments (70%), noting information as not identified across EtD framework domains (57%), and providing remarks to justify recommendations (38%). Six themes contributing to variability emerged, related to: intervention, population, payor, provider, healthcare resource use, and economic model building factors. Only 2 guidelines performed a GRADE certainty appraisal of economic outcomes. CONCLUSION: Completing predefined EtD Likert-type judgments, specifically reporting a literature review approach, study selection criteria and economic model building limitations, as well as linking these to recommendation justification remarks are potential areas for improved use, adoption and adaptation of recommendation, and transparency of GRADE EtD frameworks.

GRADE Guidelines 30: the GRADE approach to assessing the certainty of modeled evidence-An overview in the context of health decision-making.

OBJECTIVES: The objective of the study is to present the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) conceptual approach to the assessment of certainty of evidence from modeling studies (i.e., certainty associated with model outputs). STUDY DESIGN AND SETTING: Expert consultations and an international multidisciplinary workshop informed development of a conceptual approach to assessing the certainty of evidence from models within the context of systematic reviews, health technology assessments, and health care decisions. The discussions also clarified selected concepts and terminology used in the GRADE approach and by the modeling community. Feedback from experts in a broad range of modeling and health care disciplines addressed the content validity of the approach. RESULTS: Workshop participants agreed that the domains determining the certainty of evidence previously identified in the GRADE approach (risk of bias, indirectness, inconsistency, imprecision, reporting bias, magnitude of an effect, dose-response relation, and the direction of residual confounding) also apply when assessing the certainty of evidence from models. The assessment depends on the nature of model inputs and the model itself and on whether one is evaluating evidence from a single model or multiple models. We propose a framework for selecting the best available evidence from models: 1) developing de novo, a model specific to the situation of interest, 2) identifying an existing model, the outputs of which provide the highest certainty evidence for the situation of interest, either "off-the-shelf" or after adaptation, and 3) using outputs from multiple models. We also present a summary of preferred terminology to facilitate communication among modeling and health care disciplines. CONCLUSION: This conceptual GRADE approach provides a framework for using evidence from models in health decision-making and the assessment of certainty of evidence from a model or models. The GRADE Working Group and the modeling community are currently developing the detailed methods and related guidance for assessing specific domains determining the certainty of evidence from models across health care-related disciplines (e.g., therapeutic decision-making, toxicology, environmental health, and health economics).

Patients' Attitudes Toward Nonphysician Screening of Low Back and Low Back Related Leg Pain Complaints Referred for Surgical Assessment.

STUDY DESIGN: A questionnaire survey. OBJECTIVE: The aim of this study was to explore patient attitudes toward screening to assess suitability for low back surgery by nonphysician health care providers. SUMMARY OF BACKGROUND DATA: Canadian spine surgeons have shown support for nonphysician screening to assess and triage patients with low back pain and low back related leg pain. However, patients' attitudes toward this proposed model are largely unknown. METHODS: We administered a 19-item cross-sectional survey to adults with low back and/or low back related leg pain who were referred for elective surgical assessment at one of five spine surgeons' clinics in Hamilton, Ontario, Canada. The survey inquired about demographics, expectations regarding wait time for surgical consultation, as well as willingness to pay, travel, and be screened by nonphysician health care providers. RESULTS: Eighty low back patients completed our survey, for a response rate of 86.0% (80 of 93). Most respondents (72.5%; 58 of 80) expected to be seen by a surgeon within 3 months of referral, and 88.8% (71 of 80) indicated willingness to undergo screening with a nonphysician health care provider to establish whether they were potentially a surgical candidate. Half of respondents (40 of 80) were willing to travel >50 km for assessment by a nonphysician health care provider, and 46.2% were willing to pay out-of-pocket (25.6% were unsure). However, most respondents (70.0%; 56 of 80) would still want to see a surgeon if they were ruled out as a surgical candidate, and written comments from respondents revealed concern regarding agreement between surgeons' and nonphysicians' determination of surgical candidates. CONCLUSION: Patients referred for surgical consultation for low back or low back related leg pain are largely willing to accept screening by nonphysician health care providers. Future research should explore the concordance of screening results between surgeon and nonphysician health care providers. LEVEL OF EVIDENCE: 3.

Lone workers attitudes towards their health: views of Ontario truck drivers and their managers.

BACKGROUND: Truck driving is the second most common occupation among Canadian men. Transportation of goods via roads is of crucial importance for the Canadian economy. The industry is responsible annually for $17 billion in GDP and is projected to increase by 28% over the next 10 years. Recruitment is an issue with 20% of drivers projected to retire or leave the profession in the next 10 years. Despite the reliance on transport truck drivers for the delivery of goods which affects Canada's economy and daily living of residents, little is known about the health care needs of this large cohort of primarily male lone workers from a drivers' perspective. Transport truck drivers are independent workers whose non traditional workplace is their tractor, the truck stops and the journey on the road.The objective of this study was to obtain a contextually informed description of lifestyle issues, health and disease risk factors experienced by drivers and perceived by their managers in the truck driving occupation. METHODS: Using a grounded theory approach, 4 focus groups were conducted with drivers (n = 16) and managers (n = 10) from two trucking companies in Southwestern Ontario to identify the lived experience of the drivers as it relates to preventable risks to health and wellness. A semi structured guided interview was used to explore the lifestyle context of transport truck driving and organizational aspects of the occupation (workplace culture, working conditions and health and wellness promotion). RESULTS: The predominant themes described stress, workplace, communication, lifestyle, driving culture, family, and fatigue concerns. In terms of the transportation work environment, drivers and managers were aware of the profession's potential to foster lifestyle related chronic diseases but described challenges in making the profession more amenable to a healthy lifestyle. CONCLUSIONS: Workplace environmental determinants are significant in shaping health behaviours. Chronic disease health risks were the main health concerns identified. Health risks were exacerbated by working conditions (job demands, work hours, financial pressure and the sedentary nature of the job). Workplace health strategies will need to take into account the unique challenges of the occupation.

Primary health care needs for a priority population: a survey of professional truck drivers.

BACKGROUND: There are no Canadian data regarding health and wellness of transport truck drivers. OBJECTIVES: We pilot-tested a survey instrument to examine the risk factors and health needs of Canadian truck drivers. METHODS: A self-administered survey was completed by truck drivers employed in 13 companies in-and-near Hamilton, Ontario, Canada. The survey was developed using published tools with input from focus groups and included demographics, health issues, health service utilization, and awareness of workplace health programs. Descriptive statistics were used to estimate prevalence of health issues and risk factors. RESULTS: 822 surveys were distributed and 406 drivers (49.4%) responded; 48.5% were 50 years and older, 96.0% were male. Diabetes, heart disease, stroke, arthritis, and lung problems were reported by 7%, 4.1%, 0.6%, 10.8% and 2.8% respectively. 96% had salt intake above the recommended daily intake, 31.5% smoked daily and the prevalence of being overweight and with poor diet was 53.2% and 48.4%. CONCLUSIONS: Prevalence of current disease was low; however, prevalence of risk factors for chronic disease was substantial. The survey was feasible to administer and provided benchmark data regarding truck drivers' perceived health. A national survey of Canadian drivers is suggested to improve generalizability and facilitate analysis for associations to poorer driver health.

Systematic review and network meta-analysis of interventions for fibromyalgia: a protocol.

BACKGROUND: Fibromyalgia is associated with substantial socioeconomic loss and, despite considerable research including numerous randomized controlled trials (RCTs) and systematic reviews, there exists uncertainty regarding what treatments are effective. No review has evaluated all interventional studies for fibromyalgia, which limits attempts to make inferences regarding the relative effectiveness of treatments. METHODS/DESIGN: We will conduct a network meta-analysis of all RCTs evaluating therapies for fibromyalgia to determine which therapies show evidence of effectiveness, and the relative effectiveness of these treatments. We will acquire eligible studies through a systematic search of CINAHL, EMBASE, MEDLINE, AMED, HealthSTAR, PsychINFO, PapersFirst, ProceedingsFirst, and the Cochrane Central Registry of Controlled Trials. Eligible studies will randomly allocate patients presenting with fibromyalgia or a related condition to an intervention or a control. Teams of reviewers will, independently and in duplicate, screen titles and abstracts and complete full text reviews to determine eligibility, and subsequently perform data abstraction and assess risk of bias of eligible trials. We will conduct meta-analyses to establish the effect of all reported therapies on patient-important outcomes when possible. To assess relative effects of treatments, we will construct a random effects model within the Bayesian framework using Markov chain Monte Carlo methods. DISCUSSION: Our review will be the first to evaluate all treatments for fibromyalgia, provide relative effectiveness of treatments, and prioritize patient-important outcomes with a focus on functional gains. Our review will facilitate evidence-based management of patients with fibromyalgia, identify key areas for future research, and provide a framework for conducting large systematic reviews involving indirect comparisons.

Surgeon attitudes toward nonphysician screening of low back or low back-related leg pain patients referred for surgical assessment: a survey of Canadian spine surgeons.

STUDY DESIGN: Questionnaire survey. OBJECTIVE: To explore spine surgeons' attitudes toward the involvement of nonphysician clinicians (NPCs) to screen patients with low back or low back-related leg pain referred for surgical assessment. SUMMARY OF BACKGROUND DATA: Although the utilization of physician assistants is common in several healthcare systems, the attitude of spine surgeons toward the independent assessment of patients by NPCs remains uncertain. METHODS: We administered a 28-item survey to all 101 surgeon members of the Canadian Spine Society, which inquired about demographic variables, patient screening efficiency, typical wait times for both assessment and surgery, important components of low back-related complaints history and examination, indicators for assessment by a surgeon, and attitudes toward the use of NPCs to screen patients with low back and leg pain referred for elective surgical assessment. RESULTS: Eighty-five spine surgeons completed our survey, for a response rate of 84.1%. Most respondents (77.6%) were interested in working with an NPC to screen patients with low back-related complaints referred for elective surgical assessment. Perception of suboptimal wait time for consultation and poor screening efficiency for surgical candidates were associated with greater surgeon interest in an NPC model of care. We achieved majority consensus regarding the core components for a low back-related complaints history and examination, and findings that would support surgical assessment. A majority of respondents (75.3%) agreed that they would be comfortable not assessing patients with low back-related complaints referred to their practice if indications for surgery were ruled out by an NPC. CONCLUSION: The majority of Canadian spine surgeons were open to an NPC model of care to assess and triage nonurgent or emergent low back-related complaints. Clinical trials to establish the effectiveness and acceptance of an NPC model of care by all stakeholders are urgently needed.

Interprofessional and integrated care of the elderly in a family health team.

PROBLEM ADDRESSED: Family physicians provide most of the care for the frail elderly population, but many challenges and barriers can lead to difficulties with fragmented, ineffective, and inefficient services. OBJECTIVE OF PROGRAM: To improve the quality, efficiency, and coordination of care for the frail elderly living in the community and to enhance geriatric and interprofessional skills for providers and learners. PROGRAM DESCRIPTION: The Seniors Collaborative Care Program used an interprofessional, shared-care, geriatric model. The feasibility of the program was evaluated through a pilot study conducted between November 2008 and June 2009 at Stonechurch Family Health Centre, part of the McMaster Family Health Team. The core team comprised a nurse practitioner, an FP, and a registered practical nurse. Additional team members included a pharmacist, a dietitian, a social worker, and a visiting geriatrician. Twenty-five seniors were evaluated through the pilot program. Patients were assessed within 5 weeks of initial contact. Patients and practitioners valued timely, accessible, preventive, and multidisciplinary aspects of care. The nurse practitioner's role was prominent in the program, while the geriatrician's clinical role was focused efficiently. CONCLUSION: The family health team is ideally positioned to deliver shared care for the frail elderly. Our model allowed for a short referral time and easy access, which might allow seniors to remain in their environment of choice.