Development and use of health outcome descriptors: a guideline development case study.

BACKGROUND: During healthcare guideline development, panel members often have implicit, different definitions of health outcomes that can lead to misunderstandings about how important these outcomes are and how to balance benefits and harms. McMaster GRADE Centre researchers developed 'health outcome descriptors' for standardizing descriptions of health outcomes and overcoming these problems to support the European Commission Initiative on Breast Cancer (ECIBC) Guideline Development Group (GDG). We aimed to determine which aspects of the development, content, and use of health outcome descriptors were valuable to guideline developers. METHODS: We developed 24 health outcome descriptors related to breast cancer screening and diagnosis for the European Commission Breast Guideline Development Group (GDG). Eighteen GDG members provided feedback in written format or in interviews. We then evaluated the process and conducted two health utility rating surveys. RESULTS: Feedback from GDG members revealed that health outcome descriptors are probably useful for developing recommendations and improving transparency of guideline methods. Time commitment, methodology training, and need for multidisciplinary expertise throughout development were considered important determinants of the process. Comparison of the two health utility surveys showed a decrease in standard deviation in the second survey across 21 (88%) of the outcomes. CONCLUSIONS: Health outcome descriptors are feasible and should be developed prior to the outcome prioritization step in the guideline development process. Guideline developers should involve a subgroup of multidisciplinary experts in all stages of development and ensure all guideline panel members are trained in guideline methodology that includes understanding the importance of defining and understanding the outcomes of interest.

A head injury teaching module for prehospital assessment.

The purpose of this project was to create a teaching module and evaluation tool for the prehospital assessment of patients with head injuries using the Full Outline of UnResponsiveness (FOUR) Score scale. The teaching module consisted of an overview of brain injury scales, general characteristics of the Glasgow Coma Scale (GCS) and the FOUR Score, demonstrations of the FOUR Score, and evaluation of the teaching module by participants. Participants determined that the FOUR Score is a viable alternative to the GCS, but took longer time to assess patients. Development of a more rapidly obtained FOUR Score, called the EMBR, is one option that may make this a viable alternative to the GCS.

When are hypotheses useful in ecology and evolution?

Research hypotheses have been a cornerstone of science since before Galileo. Many have argued that hypotheses (1) encourage discovery of mechanisms, and (2) reduce bias-both features that should increase transferability and reproducibility. However, we are entering a new era of big data and highly predictive models where some argue the hypothesis is outmoded. We hypothesized that hypothesis use has declined in ecology and evolution since the 1990s, given the substantial advancement of tools further facilitating descriptive, correlative research. Alternatively, hypothesis use may have become more frequent due to the strong recommendation by some journals and funding agencies that submissions have hypothesis statements. Using a detailed literature analysis (N = 268 articles), we found prevalence of hypotheses in eco-evo research is very low (6.7%-26%) and static from 1990-2015, a pattern mirrored in an extensive literature search (N = 302,558 articles). Our literature review also indicates that neither grant success nor citation rates were related to the inclusion of hypotheses, which may provide disincentive for hypothesis formulation. Here, we review common justifications for avoiding hypotheses and present new arguments based on benefits to the individual researcher. We argue that stating multiple alternative hypotheses increases research clarity and precision, and is more likely to address the mechanisms for observed patterns in nature. Although hypotheses are not always necessary, we expect their continued and increased use will help our fields move toward greater understanding, reproducibility, prediction, and effective conservation of nature.

Further validation of the FOUR score coma scale by intensive care nurses.

OBJECTIVE: The FOUR (Full Outline of UnResponsiveness) score is a new coma scale that consists of 4 components (eye, motor, brainstem, and respiration). The scale was recently validated, but variability among nursing staff has been documented. PATIENTS AND METHODS: We prospectively studied the FOUR score in 80 patients with acute neurologic disease in an intensive care unit (ICU) and compared it with the Glasgow Coma Scale (GCS) using 20 experienced and inexperienced neuroscience ICU nurses and nonneuroscience ICU nurses. Each nurse was trained with the use of video examples and instruction cards. Each patient was rated by 2 nurses, with the order randomly assigned. RESULTS: The rater agreement was good to excellent with the FOUR score (weighted kappa: eye, 0.84; respiration, 0.92; brainstem, 0.89; and motor, 0.73) and similar to that for the GCS (weighted kappa: eye, 0.85; verbal, 0.89; and motor, 0.74). Greater average experience in years was associated with less disagreement, but the difference was not statistically significant. CONCLUSION: The FOUR score provides more neurologic information than the GCS. The FOUR score can be used by any ICU nurses, even those with minimal experience.

Mammographic screening programmes in Europe: organization, coverage and participation.

OBJECTIVES: To summarize participation and coverage rates in population mammographic screening programmes for breast cancer in Europe. METHODS: We used the European Network for Information on Cancer (EUNICE), a web-based data warehouse (EUNICE Breast Cancer Screening Monitoring, EBCSM) for breast cancer screening, to obtain information on programme characteristics, coverage and participation from its initial application in 10 national and 16 regional programmes in 18 European countries. RESULTS: The total population targeted by the screening programme services covered in the report comprised 26.9 million women predominantly aged 50-69. Most of the collected data relates to 2005, 2006 and/or 2007. The average participation rate across all programmes was 53.4% (range 19.4-88.9% of personally invited); or 66.4% excluding Poland, a large programme that initiated personal invitations in 2007. Thirteen of the 26 programmes achieved the European Union benchmark of acceptable participation (>70%), nine achieved the desirable level (>75%). Despite considerable invitation coverage across all programmes (79.3%, range 50.9-115.2%) only 48.2% (range 28.4-92.1%) of the target population were actually screened. The overall invitation and examination coverage excluding Poland was 70.9% and 50.3%, respectively. CONCLUSIONS: The results demonstrate the feasibility of European-wide screening monitoring using the EBCSM data warehouse, although further efforts to refine the system and to harmonize standards and data collection practices will be required, to fully integrate all European countries. The more than three-fold difference in the examination coverage should be taken into account in the evaluation of service screening programmes.

How effective are breast cancer screening programmes by mammography? Review of the current evidence.

Randomised controlled trials showed that breast cancer screening by mammography reduces breast cancer mortality in women over age 50 by 25-30%. However, it was not clear if this effect would persist outside the controlled trial environment or even could be enhanced. We review the current evidence of the impact of long-standing breast cancer screening programmes (Australia, Canada, Denmark, Finland, Iceland, Italy, the Netherlands, Spain, Sweden and the United Kingdom) on breast cancer mortality. The decrease observed in women invited to screening ranges from 16% to 36%. Breast cancer mortality reductions range from 24% to 48% in women having attended at least one screen after correcting for selection bias. Although evaluation design, time period studied, participation rates achieved differ, the trend in mortality reduction is consistent. Adjuvant therapy is estimated to contribute about one third to this decrease. We conclude that mammography screening programmes implemented for at least 10 years achieve a similar, but not greater mortality reduction as the randomised controlled trials. However, it may take some more years before the full impact of these mammography screening programmes can be assessed.

Cost-effectiveness of opportunistic versus organised mammography screening in Switzerland.

BACKGROUND: Various centralised mammography screening programmes have shown to reduce breast cancer mortality at reasonable costs. However, mammography screening is not necessarily cost-effective in every situation. Opportunistic screening, the predominant screening modality in several European countries, may under certain circumstances be a cost-effective alternative. In this study, we compared the cost-effectiveness of both screening modalities in Switzerland. METHODS: Using micro-simulation modelling, we predicted the effects and costs of biennial mammography screening for 50-69 years old women between 1999 and 2020, in the Swiss female population aged 30-70 in 1999. A sensitivity analysis on the test sensitivity of opportunistic screening was performed. RESULTS: Organised mammography screening with an 80% participation rate yielded a breast cancer mortality reduction of 13%. Twenty years after the start of screening, the predicted annual breast cancer mortality was 25% lower than in a situation without screening. The 3% discounted cost-effectiveness ratio of organised mammography screening was euro11,512 per life year gained. Opportunistic screening with a similar participation rate was comparably effective, but at twice the costs: euro22,671-24,707 per life year gained. This was mainly related to the high costs of opportunistic mammography and frequent use of imaging diagnostics in combination with an opportunistic mammogram. CONCLUSION: Although data on the performance of opportunistic screening are limited, both opportunistic and organised mammography screening seem effective in reducing breast cancer mortality in Switzerland. However, for opportunistic screening to become equally cost-effective as organised screening, costs and use of additional diagnostics should be reduced.