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Literature update July 2010

Alan M. Jette and Nancy Latham. Improving the Evidence Base for Physical Therapy Disability Interventions. Physical Therapy 2010;90:324-325.



Paul Christopher Webster. Value of medical practice guidelines questioned. CMAJ 2010;182(4):E190.


Kaveh G. Shojania, Alison Jennings, Alain Mayhew, Craig Ramsay, Martin Eccles, and Jeremy Grimshaw. Effect of point-of-care computer reminders on physician behaviour: a systematic review. CMAJ 2010;182(5):E216-E225.

Background: The opportunity to improve care using computer reminders is one of the main incentives for implementing sophisticated clinical information systems. We conducted a systematic review to quantify the expected magnitude of improvements in processes of care from computer reminders delivered to clinicians during their routine activities. Methods: We searched the MEDLINE, Embase and CINAHL databases (to July 2008) and scanned the bibliographies of retrieved articles. We included studies in our review if they used a randomized or quasi-randomized design to evaluate improvements in processes or outcomes of care from computer reminders delivered to physicians during routine electronic ordering or charting activities. Results: Among the 28 trials (reporting 32 comparisons) included in our study, we found that computer reminders improved adherence to processes of care by a median of 4.2% (interquartile range [IQR] 0.8%–18.8%). Using the best outcome from each study, we found that the median improvement was 5.6% (IQR 2.0%–19.2%). A minority of studies reported larger effects; however, no study characteristic or reminder feature significantly predicted the magnitude of effect except in one institution, where a well-developed, "homegrown" clinical information system achieved larger improvements than in all other studies (median 16.8% [IQR 8.7%–26.0%] v. 3.0% [IQR 0.5%–11.5%]; p = 0.04). A trend toward larger improvements was seen for reminders that required users to enter a response (median 12.9% [IQR 2.7%–22.8%] v. 2.7% [IQR 0.6%–5.6%]; p = 0.09). Interpretation: Computer reminders produced much smaller improvements than those generally expected from the implementation of computerized order entry and electronic medical record systems. Further research is required to identify features of reminder systems consistently associated with clinically worthwhile improvements.


Behzad Nadjm, Ben Amos, George Mtove, Jan Ostermann, Semkini Chonya, Hannah Wangai, Juma Kimera, Walii Msuya, Frank Mtei, Denise Dekker, Rajabu Malahiyo, Raimos Olomi, John A Crump, Christopher J M Whitty, Hugh Reyburn. WHO guidelines for antimicrobial treatment in children admitted to hospital in an area of intense Plasmodium falciparum transmission: prospective study. BMJ  2010;340:c1350.


Objectives To assess the performance of WHO’s "Guidelines for care at the first-referral level in developing countries" in an area of intense malaria transmission and identify bacterial infections in children with and without malaria. Design Prospective study. Setting District hospital in Muheza, northeast Tanzania. Participants Children aged 2 months to 13 years admitted to hospital for febrile illness. Main outcome measures Sensitivity and specificity of WHO guidelines in diagnosing invasive bacterial disease; susceptibility of isolated organisms to recommended antimicrobials. Results Over one year, 3639 children were enrolled and 184 (5.1%) died; 2195 (60.3%) were blood slide positive for Plasmodium falciparum, 341 (9.4%) had invasive bacterial disease, and 142 (3.9%) were seropositive for HIV. The prevalence of invasive bacterial disease was lower in slide positive children (100/2195, 4.6%) than in slide negative children (241/1444, 16.7%). Non-typhi Salmonella was the most frequently isolated organism (52/100 (52%) of organisms in slide positive children and 108/241 (45%) in slide negative children). Mortality among children with invasive bacterial disease was significantly higher (58/341, 17%) than in children without invasive bacterial disease (126/3298, 3.8%) (P<0.001), and this was true regardless of the presence of P falciparum parasitaemia. The sensitivity and specificity of WHO criteria in identifying invasive bacterial disease in slide positive children were 60.0% (95% confidence interval 58.0% to 62.1%) and 53.5% (51.4% to 55.6%), compared with 70.5% (68.2% to 72.9%) and 48.1% (45.6% to 50.7%) in slide negative children. In children with WHO criteria for invasive bacterial disease, only 99/211(47%) of isolated organisms were susceptible to the first recommended antimicrobial agent. Conclusions In an area exposed to high transmission of malaria, current WHO guidelines failed to identify almost a third of children with invasive bacterial disease, and more than half of the organisms isolated were not susceptible to currently recommended antimicrobials. Improved diagnosis and treatment of invasive bacterial disease are needed to reduce childhood mortality.




Magne Nylenna, Øystein Eiring, Grete Strand, John-Arne Røttingen. Wiring a nation: putting knowledge into action. The Lancet 2010;375(9719):1048-1051.


Anne Townsend, Susan M. Cox, and Linda C. Li. Qualitative Research Ethics: Enhancing Evidence-Based Practice in Physical Therapy. Physical Therapy 2010;90:615-628.

Background: Increasing challenges to health care systems and the prominence of patient-centered care and evidence-based practice have fostered the application of qualitative approaches in health care settings, prompting discussions of associated ethical issues in a range of disciplines. Objectives: The purposes of this work were to identify and describe the application and value of qualitative health research for physical therapy and to identify ethical considerations in a qualitative research study. Design: This was a qualitative interview study with telephone follow-ups. Methods: Forty-six participants were interviewed about their early experiences with rheumatoid arthritis. They also were asked what motivated them to volunteer for the study. To inform the discussion of ethics in qualitative health research, this study drew on the in-depth interviews, took a descriptive approach to the data, and applied the traditional ethical principles of autonomy, justice, and beneficence to the study process. Results: Ethical issues emerged in this qualitative health research study that were both similar to and different from those that exist in a positivist paradigm (eg, clinical research). With flexibility and latitude, the traditional principle approach can be applied usefully to qualitative health research. Conclusions: These findings build on previous research and discussion in physical therapy and other disciplines that urge a flexible approach to qualitative research ethics and recognize that ethics are embedded in an unfolding research process involving the role of the subjective researcher and an active participant. We suggest reflexivity as a way to recognize ethical moments throughout qualitative research and to help build methodological and ethical rigor in research relevant to physical therapist practice.


Mabotuwana Thusitha, Warren Jim, Elley C Raina, Kennelly John, Paton Chris, Warren Debra, Chang Wai Kuinileti, Wells Stewart. Use of interval based quality indicators in blood pressure management to enhance quality of pay for performance incentives: comparison to two indicators from the Quality and Outcomes Framework. Quality in Primary Care 2010;18(2):93-101.


Background: Pay for performance incentives are becoming increasingly popular, but are typically based on only a single point-in-time measurement as an indicator of chronic condition management. Aims: To determine the association between three time-interval based indicators of suboptimal blood pressure (BP) control and two point-in-time indicators from the UK Quality and Outcomes Framework (QOF): BP5 (the percentage of patients with hypertension in whom the last BP in the previous nine months was ≤150/90) and DM12 (the percentage of patients with diabetes in whom the last BP in the previous 15 months was ≤145/85). Methods: We extracted classification data and BP measurements from four New Zealand general practices with 4260 to 6130 enrolled patients. Data were analysed for three indicators with respect to a nine-month evaluation period for patients with hypertension and a 15-month period for patients with diabetes: (1) two or more consistently high BP measurements spaced over ≥90 days, (2) a high BP measurement followed by a lapse of >120 days in BP measurement and (3) no BP measurement for >180 days. Results: For the four practices, 65-81% of the patients satisfied BP5 and 59-68% of patients satisfied DM12. Of the hypertension patients satisfying BP5, 31% (95% CI: 28-33%) failed at least one of the three interval based indicators; 42% (95% CI: 39-46%) of the diabetes patients satisfying DM12 failed at least one of the three interval based indicators. Conclusion: Considering only a point-in-time controlled BP measurement provides an incomplete view of the quality of BP management in patients with hypertension or diabetes over a period of time.


M. M. Mello and T. H. Gallagher. Malpractice Reform — Opportunities for Leadership by Health Care Institutions and Liability Insurers. NJEM 2010;362(15):1353-1356.

Brouwers MC, Makarski J, Levinson AJ. A randomized trial to evaluate e-learning interventions designed to improve learner's performance, satisfaction, and self-efficacy with the AGREE II. Implementation Science 2010; 5:29.

Background Practice guidelines (PGs) are systematically developed statements intended to assist in patient, practitioner, and policy decisions. The AGREE II is the revised and updated standard tool for guideline development, reporting and evaluation. It is comprised of 23 items and a user's Manual. The AGREE II is ready for use. Objectives To develop, execute, and evaluate the impact of two internet-based educational interventions designed to accelerate the capacity of stakeholders to use the AGREE II: a multimedia didactic tutorial with a virtual coach, and a higher intensity training program including both the didactic tutorial and an interactive practice exercise component. Methods Participants (clinicians, developers, and policy makers) will be randomly assigned to one of three conditions. Condition one, didactic tutorial -- participants will go through the on-line AGREE II tutorial supported by a virtual coach and review of the AGREE II prior to appraising the test PG. Condition two, tutorial + practice -- following the multimedia didactic tutorial with a virtual coach, participants will review the on-line AGREE II independently and use it to appraise a practice PG. Upon entering their AGREE II score for the practice PG, participants will be given immediate feedback on how their score compares to expert norms. If their score falls outside a predefined range, the participant will receive a series of hints to guide the appraisal process. Participants will receive an overall summary of their performance appraising the PG compared to expert norms. Condition three, control arm -- participants will receive a PDF copy of the AGREE II for review and to appraise the test PG on-line. All participants will then rate one of ten test PGs with the AGREE II. The outcomes of interest are learners' performance, satisfaction, self-efficacy, mental effort, and time-on-task; comparisons will be made across each of the test groups. Discussion Our research will test innovative educational interventions of various intensities and instructional design to promote the adoption of AGREE II and to identify those strategies that are most effective for training. The results will facilitate international capacity to apply the AGREE II accurately and with confidence and to enhance the overall guideline enterprise.



With thanks to our colleagues at BMJ publishing we are delighted to announce a collaboration that allows us to provide free access to a featured article in each enGINe.
The toll-free link which wil expire on 31st August.

Rachel E Rowe. Local guidelines for the transfer of women from midwifery unit to obstetric unit during labour in England: a systematic appraisal of their quality. Qual Saf Health Care 2010;19:90-94.


Background A proportion of women planning to give birth in a midwifery unit will experience complications during labour that necessitate transfer to an obstetric unit. Local guidelines for the transfer of women in labour have the potential to impact on quality of care and the safety of the transfer process. Objective To systematically appraise the quality of local NHS guidelines on the transfer of women from midwifery unit to obstetric unit during labour. Methods Guidelines were requested from all 52 NHS hospital trusts in England with midwifery units. The Appraisal of Guidelines for Research and Evaluation Instrument was used to evaluate the quality of the guidelines received. Results Relevant guidelines were received from 34 (65%) trusts. No guidelines scored on the ‘editorial independence’ domain. The mean score on ‘scope and purpose’ (56.2%), concerned with the aims, clinical questions and target patient population of the guideline, was higher than for other domains: ‘clarity and presentation’ (language and format) 45.3%, ‘stakeholder involvement’ (representation of users’ views) 15.3%, ‘rigour of development’ (process used to develop guideline) 15.0%, ‘applicability’ (organisational, behavioural and cost implications of applying guideline) 7.1%. Only three guidelines were recommended for use in clinical practice. Conclusions We believe this to be the first systematic appraisal of the quality of local NHS guidelines. Overall these local guidelines were of poor quality. It is not clear whether the quality of these midwifery guidelines is typical of local guidelines in other clinical areas, but this study raises fundamental questions about the appropriate development of high-quality local clinical guidelines.



Takahiro Higashi, Takeo Nakayama, Shunichi Fukuhara, Hisashi Yamanaka, Tsuneyo Mimori, Junnosuke Ryu, Kazuo Yonenobu, Norikazu Murata, Hiroaki Matsuno, Hajime Ishikawa, and Takahiro Ochi. Opinions of Japanese rheumatology physicians regarding clinical practice guidelines. Int J Qual Health Care 2010; 22:78-85.

Objective. To examine the views of rheumatology physicians concerning clinical practice guidelines in Japan, and changes to them following the dissemination of new guidelines for rheumatoid arthritis (RA) in 2004. Design. Two cross-sectional questionnaire surveys, the first conducted before publication of new evidence-based RA clinical practice guidelines and the second conducted after implementation. Setting. Rheumatology-focused practices in Japan. Participants. A random sample of physicians registered with the Japan Rheumatism Foundation who satisfied the registration criteria with regard to experience with RA care. Results. The percentage of guideline users increased from 48 to 60% following publication of the new RA guidelines in 2004 (P < 0.01). The majority agreed that clinical practice guidelines support decision-making in practice, although the proportion of supportive responses decreased slightly in the second survey, from 83 to 77% (P < 0.01) for decision-making, while concern about restricting physician autonomy increased from 18 to 22% (P = 0.01). While only 39% of physicians felt that clinical practice guidelines would contribute to malpractice litigation, the proportion of physicians who were concerned that clinical practice guidelines would be used to bring legal action against providers was larger than that who expected they would defend providers (58 vs 30%, P < 0.001). Conclusions. Clinical practice guidelines are well accepted among Japanese rheumatology physicians, albeit that the proportion decreased slightly after the introduction of new guidelines. One reason for this may be concern about the use of the guidelines in malpractice litigation. To facilitate implementation, trends in physician support for the guidelines should be closely monitored.


Eric G. Campbell. Public Disclosure of Conflicts of Interest: Moving the Policy Debate Forward. Arch Intern Med 2010;170(8):667.


Nilsson Kajermo K, Bostrom A, Thompson DS, Hutchinson AM, Estabrooks CA, Wallin L.. The BARRIERS scale - the barriers to research utilization scale: A systematic review. Implementation Science  2010;5:32.

Background. A commonly recommended strategy for increasing research use in clinical practice is to identify barriers to change and then tailor interventions to overcome the identified barriers. In nursing, the BARRIERS Scale has been used extensively to identify barriers to research utilization. Aim and Objectives .The aim of this systematic review was to examine the state of knowledge resulting from use of the BARRIERS Scale and to make recommendations about future use of the Scale. The following objectives were addressed: To examine how the Scale has been modified, to examine its psychometric properties, to determine the main barriers (and whether they varied over time and geographic locations), and to identify associations between nurses' reported barriers and reported research use. Methods. Medline (1991 to September 2009) and CINHAL (1991 to September 2009) were searched for published research, and ProQuest(R) digital dissertations were searched for unpublished dissertations using the BARRIERS Scale. Inclusion criteria were: studies using the BARRIERS Scale in its entirety and where the sample was nurses. Two authors independently assessed the study quality and extracted the data. Descriptive and inferential statistics were used. Results. Sixty-three studies were included, with most using a cross-sectional design. Not one study used the Scale for tailoring interventions to overcome identified barriers. The main barriers reported were related to the setting, and the presentation of research findings. Overall, identified barriers were consistent over time and across geographic locations, despite varying sample size, response rate, study setting, and assessment of study quality. Few studies reported associations between reported research use and perceptions of barriers to research utilization. Conclusions. The BARRIERS Scale is a nonspecific tool for identifying general barriers to research utilization. The Scale is reliable as reflected in assessments of internal consistency. The validity of the Scale, however, is doubtful. There is no evidence that it is a useful tool for planning implementation interventions. We recommend that no further descriptive studies using the BARRIERS Scale be undertaken. Barriers need to be measured specific to the particular context of implementation and the intended evidence to be implemented.

Schalk DM, Bijl ML, Halfens RJ, Hollands L, Cummings GG. Interventions aimed at improving the nursing work environment: a systematic review. Implementation Science 2010; 5:34.

Background. Nursing work environments (NWEs) in Canada and other Western countries have increasingly received attention following years of restructuring and reported high workloads, high absenteeism, and shortages of nursing staff. Despite numerous efforts to improve NWEs, little is known about the effectiveness of interventions to improve NWEs. The aim of this study was to review systematically the scientific literature on implemented interventions aimed at improving the NWE and their effectiveness. Methods. An online search of the databases CINAHL, Medline, Scopus, ABI, Academic Search Complete, HEALTHstar, ERIC, Psychinfo, and Embase, and a manual search of Emerald and Longwoods was conducted. (Quasi-) experimental studies with pre/post measures of interventions aimed at improving the NWE, study populations of nurses, and quantitative outcome measures of the nursing work environment were required for inclusion. Each study was assessed for methodological strength using a quality assessment and validity tool for intervention studies. A taxonomy of NWE characteristics was developed that would allow us to identify on which part of the NWE an intervention targeted for improvement, after which the effects of the interventions were examined. Results. Over 9,000 titles and abstracts were screened. Eleven controlled intervention studies met the inclusion criteria, of which eight used a quasi-experimental design and three an experimental design. In total, nine different interventions were reported in the included studies. The most effective interventions at improving the NWE were: primary nursing (two studies), the educational toolbox (one study), the individualized care and clinical supervision (one study), and the violence prevention intervention (one study). Conclusions. Little is known about the effectiveness of interventions aimed at improving the NWE, and published studies on this topic show weaknesses in their design. To advance the field, we recommend that investigators use controlled studies with pre/post measures to evaluate interventions that are aimed at improving the NWE. Thereby, more evidence-based knowledge about the implementation of interventions will become available for healthcare leaders to use in rebuilding nursing work environments.


McCaughey D, Bruning NS. Rationality versus reality: the challenges of evidence-based decision making for health policy makers. Implementation Science 2010; 5:39.

Background Current health care systems have extended the evidence-based medicine (EBM) approach to health policy and delivery decisions, such as access-to-care, health care funding and health program continuance, through attempts to integrate valid and reliable evidence into the decision making process. The nature of these policy decisions have major impacts on society and have high personal and financial costs associated with those decisions. Decision models such as these function under a shared assumption of rational choice and utility maximization in the decision making process. Discussion We contend that health policy decision makers are generally unable to attain the basic goals of evidence-based decision making (EBDM) because humans make decisions with their naturally limited, faulty and biased decision making processes. A cognitive information processing framework is presented to support this argument, and subtle cognitive processing mechanisms are introduced to support the focal thesis: health policy makers' decisions are influenced by the subjective manner in which they individually process decision relevant information rather than on the objective merits of the evidence alone. Subsequent health policy decisions do not necessarily achieve the goals of evidence-based policy making, such as maximizing health outcomes for society based on valid and reliable research evidence. Summary In this era of increasing adoption of evidence-based health care models, the rational choice, utility maximizing assumptions in EBDM, must be evaluated to ensure effective and high quality health policy decisions. The cognitive information processing framework will aid health policy decision makers by identifying how their decisions might be subtly influenced by non-rational factors. In this paper we identify some of the biases and potential intervention points and provide some initial suggestions about how the EBDM process can be improved.


Lisa M. Meckley, Dan Greenberg, Joshua T. Cohen, and Peter J. Neumann. The Adoption of Cost-Effectiveness Acceptability Curves in Cost-Utility Analyses. Med Decis Making 2010;30:314-319.

Background. Cost-effectiveness acceptability curves (CEACs) plot the probability that one health intervention is more cost-effective than alternatives, as a function of societal willingness to pay for additional units of health (e.g., life-years or quality-adjusted life-years gained). Objectives. To quantify the adoption of CEACs in published cost-utility analyses (CUAs), and to identify factors associated with CEAC use. Methods. Data from the Tufts Medical Center Cost-Effectiveness Analysis Registry (, a database with detailed information on approximately 1,400 CUAs published in the peer reviewed literature through 2006, was analyzed. The registry includes data on study origin, study methodology, reporting of results, whether CEACs were presented, and a subjective quality score. Univariate and multivariate logistic regression analyses were used to identify factors predicting CEAC use, from their introduction in 1994 through 2006. Results. Approximately 15% of CUAs published since 1994 present a CEAC. The use of CEACs has increased rapidly in recent years, from 2.1% of published CUAs in 2001 to 32.6% in 2006 (P < 0.0001). The most significant predictors of CEAC use were study quality (odds ratio [OR]: 2.26; 95% confidence interval [CI]: 1.80, 2.85), recent publication (OR: 1.99; 95% CI: 1.73, 2.29), and whether studies pertain to the UK (OR: 5.66; 95% CI: 3.67, 8.72) or Sweden (OR: 3.76; 95% CI: 1.67, 8.44). Conclusions. CEAC use is increasing in the published cost-effectiveness literature, especially in UK-based studies.


Dan Greenberg, Allison B. Rosen, Oren Wacht, Jennifer Palmer, and Peter J. Neumann. A Bibliometric Review of Cost-Effectiveness Analyses in the Economic and Medical Literature: 1976-2006. Med Decis Making 2010;30:320-327.


Background. Cost-effectiveness analysis (CEA) presenting a cost per quality-adjusted life year (QALY) ratio is frequently used to determine ‘‘value for money’’ in health care. Despite the proliferation of CEA research, there has been no detailed study focusing on the bibliometric properties of this literature. Objectives. To describe and analyze trends in publications and coauthorship in the CEA literature from 1976 to 2006 and to identify the most prolific authors and research groups conducting CEAs. Methods. The authors used the Tufts Medical Center Registry of original CEAs published through 2006 ( For each article, they recorded the year of publication, the journal title, and the number of contributing authors and their names. Authors were assigned credit based on their weighted contribution to the study (1 credit point for the first and last authors, point for the second author, and 1=n credit points for all other authors, where n reflects the number of coauthors). Results. Approximately 1400 CEAs presenting a cost/QALY ratio were published in 420 journals through 2006. The mean number of contributing authors was 4.7 ± 2.4. Medical journals were characterized by a higher number of coauthors, as compared with the economic and health policy journals: 4.8 ± 2.4 v. 4.2 ± 2.0, P < 0.001. The lowest average number of coauthors was in Medical Decision Making (3.6) and the highest in the Journal of the American College of Cardiology (8.2). The most prolific authors were affiliated with Harvard and Tufts Universities and their affiliated hospitals. The authors identified 4 major research groups that contributed substantially to the field of cost-effectiveness analysis but did not find any substantial academic relationships across these groups. Conclusions. The CEA literature continues to proliferate. Coauthorship trends appear to follow the rapid increase in the mean number of authors found in other publication types.


Jamie C. Brehaut, Ian D. Graham, Timothy J. Wood, Monica Taljaard, Debra Eagles, Alison Lott, Catherine Clement, Anne-Maree Kelly, Suzanne Mason, and Ian G. Stiell. Measuring Acceptability of Clinical Decision Rules: Validation of the Ottawa Acceptability of Decision Rules Instrument (OADRI) in Four Countries. Med Decis Making 2010;30: 398-408.

Background. Clinical decision rules can benefit clinicians, patients, and health systems, but they involve considerable up-front development costs and must be acceptable to the target audience. No existing instrument measures the acceptability of a rule. The current study validated such an instrument. Methods. The authors administered the Ottawa Acceptability of Decision Rules Instrument (OADRI) via postal survey to emergency physicians from 4 regions (Australasia, Canada, United Kingdom, and United States), in the context of 2 recently developed rules, the Canadian C-Spine Rule (C-Spine) and the Canadian CT Head Rule (CT-Head). Construct validity of the 12-item instrument was evaluated by hypothesis testing. Results. As predicted by a priori hypotheses, OADRI scores were 1) higher among rule users than nonusers, 2) higher among those using the rule ‘‘all of the time’’ v. ‘‘most of the time’’ v. ‘‘some of the time,’’ and 3) higher among rule nonusers who would consider using a rule v. those who would not. We also examined explicit reasons given by respondents who said they would not use these rules. Items in the OADRI accounted for 85.5% (C- Spine) and 90.2% (CT-Head) of the reasons given for not considering a rule acceptable. Conclusions. The OADRI is a simple, 12-item instrument that evaluates rule acceptability among clinicians. Potential uses include comparing multiple ‘‘protorules’’ during development, examining acceptability of a rule to a new audience prior to implementation, indicating barriers to rule use addressable by knowledge translation interventions, and potentially serving as a proxy measure for future rule use.


Ronald Sakaguchi. Evidence-Based Dentistry: Achieving a Balance. J Am Dent Assoc 2010;141(5):496-497.


Michael P. Rethman, William Carpenter, Ezra E.W. Cohen, Joel Epstein, Caswell A. Evans, Catherine M. Flaitz, et al. Evidence-Based Clinical Recommendations Regarding Screening for Oral Squamous Cell Carcinomas. J Am Dent Assoc 2010;141(5):509-520.

Background. This article presents evidence-based clinical recommendations developed by a panel convened by the American Dental Association Council on Scientific Affairs. This report addresses the potential benefits and potential risks of screening for oral squamous cell  carcinomas and the use of adjunctive screening aids to visualize and detect potentially malignant and malignant oral lesions. Types of Studies Reviewed. The panel members conducted a systematic search of MEDLINE, identifying 332 systematic reviews and 1,499 recent clinical studies. They selected five systematic reviews and four clinical studies to use as a basis for developing recommendations. Results. The panel concluded that screening by means of visual and tactile examination to detect potentially malignant and malignant lesions may result in detection of oral cancers at early stages of development, but that there is insufficient evidence to determine if screening alters disease-specific mortality in symptomatic people seeking dental care. Clinical Implications. The panel suggested that clinicians remain alert for signs of potentially malignant lesions or early-stage cancers while performing routine visual and tactile examinations in all patients, but particularly in those who use tobacco or who consume alcohol heavily. Additional research regarding oral cancer screening and the use of adjuncts is needed.


Suying Li, Jiannong Liu, David T. Gilbertson, and Allan J. Collins. Economic Effect of Following HbA1c Testing Practice Guidelines in the Elderly Medicare Population: An Instrumental Variable Analysis. American Journal of Medical Quality 2010;25:202-210.

This retrospective follow-up study aimed to evaluate the effect of following glycated hemoglobin (HbA1c) testing practice guidelines on Medicare expenditures. The authors identified 12 635 incident diabetes patients from 1998 and 1999 Medicare 5% claims data and calculated Medicare payments from 2000 to 2003. They applied a 2-stage least-squares model with instrumental variable (IV) methodology to estimate the effect of receiving 2 HbA1c tests annually on Medicare expenditures. Only 27.7% (3503/12 635) of the sample received 2 HbA1c tests annually. IV estimation results showed that receiving the tests was associated with a $953 decrease in Medicare payments per patient-year. Improved HbA1c test rates could save Medicare costs. For each year, 2000 to 2003, the authors estimate that approximately $174 million in Medicare expenditures could have been saved through Medicare patients aged 67 years who developed diabetes in 1998 and 1999, had no diabetes complications at baseline, and subsequently did not receive 2 HbA1c tests annually.


Kenneth F. Schulz, Douglas G. Altman, David Moher, and for the CONSORT Group. CONSORT 2010 Statement: Updated Guidelines for Reporting Parallel Group Randomized Trials. Ann Intern Med 2010;152:726-732.

The CONSORT (Consolidated Standards of Reporting Trials) statement is used worldwide to improve the reporting of randomized, controlled trials. Schulz and colleagues describe the latest version, CONSORT 2010, which updates the reporting guideline based on new methodological evidence and accumulating experience.

Page last updated: Jul 07, 2010
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