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Biomedical subjects

A R Jadad

Publications and source records attributed to A R Jadad.

At least 37 records · Page 2Linked to original sources
PubMed1999

Prevalence and treatment of pain in older adults in nursing homes and other long-term care institutions: a systematic review.

BACKGROUND: The high prevalence of pain in older adults and its impact in this age group make it a public health issue, yet few studies of pain relief focus on older adults. Residents of long-term care facilities have more cognitive impairment than their community-living counterparts and may have difficulty reporting the presence and severity of pain. This systematic literature review was conducted to determine the prevalence of pain, and the type and effectiveness of interventions that have been used to treat pain in residents of nursing homes. METHODS: Studies were identified by searching MEDLINE (from January 1966 to May 1997), HEALTH (from January 1975 to May 1997), CINAHL (from January 1982 to April 1997), AGELINE (from January 1978 to April 1997) and the Cochrane Library (1997, issue 1) and by performing a manual search of textbooks and reference lists. Studies of any methodological design were included if they estimated the prevalence of pain in nursing homes or other long-term care institutions or evaluated interventions for the treatment of pain in residents. Of the 14 eligible studies, 12 were noncomparative studies, 1 was a comparison study with nonrandomized contemporaneous controls, and 1 was a randomized controlled trial. Information on several factors was extracted from each study, including study design, number of patients and facilities, main outcomes measured, methods used to identify and detect pain, prevalence and types of pain, and interventions used to treat pain. The strength of the evidence provided by each study was also assessed. RESULTS: In the 6 studies with data from self-reporting or chart reviews, the prevalence of pain ranged from 49% to 83%. In the 5 studies with data on analgesic use only, the prevalence of pain ranged from 27% to 44%. Only 3 studies, with just 30 patients in total, evaluated an intervention for the treatment of pain. INTERPRETATION: Despite the high prevalence of pain in residents of nursing homes, there is a lack of studies evaluating interventions to relieve their pain. The authors make recommendations for future studies in this area.

Aged↗
PubMed1999

Lessons from large trials: the MTA study as a model for evaluating the treatment of childhood psychiatric disorder.

OBJECTIVE: To review the methodology of the Multimodal Treatment Study of Children With Attention-Deficit Hyperactivity Disorder (ADHD), the MTA study, and its implications for the design of future child mental health treatment studies. METHOD: The characteristics of large-scale studies envisioned by trialists engaged in cardiovascular and cancer research provide the framework for reviewing key elements of the MTA study--objectives, research questions, measurement, sampling, and exposure to treatment--and discussing important methodological decisions the MTA investigators had to make. RESULTS: The MTA study is a complex, standardized, carefully implemented, randomized control trial. Review of the MTA study indicated that future studies should be aligned clearly with either effectiveness or efficacy objectives but not both. Questions selected for study should be simple, clear, and important. Measurement, sampling, and data collection must adhere to the principle of simplicity to ensure maximum participation. All methodological decisions should be geared to attaining the research objectives: in effectiveness trials, this means evaluating treatments that have a high potential for dissemination if proven successful and recruiting only new referrals from child mental health settings. CONCLUSIONS: The MTA study has raised the standard for technical excellence in child treatment research and will draw attention to some fundamental issues in large-scale child treatment studies, including articulating objectives and questions, setting priorities for measurement and sampling, and identifying treatments for evaluation that have a high probability of dissemination if found effective.

Attention Deficit Disorder with Hyperactivity↗
PubMed1999

The treatment of attention-deficit hyperactivity disorder: an annotated bibliography and critical appraisal of published systematic reviews and metaanalyses.

CONTEXT: The Agency for Health Care Policy and Research charged the McMaster Evidence-based Practice Center with conducting a comprehensive systematic review of the literature on the treatment of attention-deficit hyperactivity disorder (ADHD), with input from various groups of stakeholders. One strategy used to avoid duplication of work included a critical appraisal of existing systematic reviews and metaanalyses. OBJECTIVE: To identify and appraise published metaanalyses and systematic reviews on the treatment of ADHD and to produce an annotated bibliography. DATA SOURCES: Medline, Cumulative Index in Nursing and Allied Health (CINAHL), Healthstar, Psycinfo, and Embase were searched to September 1998; the Cochrane Database (1998 issue 3), selected Internet sites, and the files of investigators were also reviewed. STUDY SELECTION: Review articles described as systematic reviews or metaanalyses or including a Methods section were identified independently by 3 reviewers. DATA EXTRACTION: Two reviewers extracted, by consensus, relevant information on the name, methodological quality, ADHD-related aspects (comorbid disorders, family characteristics) of those reviews; data on the population, study setting, interventions, and outcomes evaluated by the reviews were also retrieved. RESULTS: Thirteen reviews, published from 1982 to 1998, were included. Eight included metaanalysis and 5 a qualitative review. Nonpharmacological treatments were mentioned in 6 reviews and combination therapies in 3. One review focused on the treatment of adults. Forty-seven drugs and 20 adverse effects were mentioned. Most reviews had major methodological flaws. CONCLUSIONS: Most published systematic reviews and metaanalyses on the treatment of ADHD have limited value for guiding clinical, policy, and research decisions. A rigorous, systematic review following established methodological criteria is warranted.

Attention Deficit Disorder with Hyperactivity↗
PubMed1999

Treatment of attention-deficit/hyperactivity disorder.

OBJECTIVES: To determine (a) the long-term and short-term effectiveness and safety of pharmacological and nonpharmacological interventions for attention-deficit/hyperactivity disorder (ADHD) in children and adults and (b) whether combined interventions are more effective than individual interventions. SEARCH STRATEGY: MEDLINE (from 1966), CINAHL (from 1982), HEALTHStar (from 1975), PsycINFO (from 1984), EMBASE (from 1984), and the Cochrane Library searches were completed in November 1997. Reference lists of eligible studies and files of members of the research team and partner organizations were also searched. SELECTION CRITERIA: Studies were selected if they focused on the treatment of ADHD in humans and were published in any language as a full report in peer-reviewed journals. Studies including conditions other than ADHD were reported if separate subgroup analyses for patients with ADHD were provided. DATA COLLECTION AND ANALYSIS: Two reviewers independently extracted data for 41 variables on general characteristics, along with detailed information on interventions, outcomes, and tests. Differences were resolved by consensus or by a third researcher. Studies were not combined quantitatively because the quality of reporting was low and heterogeneity existed across outcome measures and tests. MAIN RESULTS: Seventy-eight studies (77 randomized controlled trials) met the inclusion criteria. Twenty-three studies compared drugs and showed few, if any, differences among methylphenidate (MPH), dextroamphetamine (DEX), and pemoline; studies comparing stimulants with tricyclic antidepressants (2) were inconclusive. Six studies compared drugs with nondrug interventions and showed consistently that stimulants, particularly MPH, may be more effective than nonpharmacological interventions. Twenty studies compared combination therapies with a stimulant or a nondrug intervention alone; no additional beneficial effects for combination therapies were shown. Nine studies compared tricyclic antidepressants with placebo and showed that desipramine may be more effective than placebo; no consistent effect was shown for imipramine. Fourteen studies (13 in school children and 1 in adults) evaluated long-term therapy (> or = 12 weeks) and showed a trend to general improvement regardless of treatment, but the length of followup was inadequate. MPH may reduce behavioral disturbance in children with ADHD while it is taken. Academic performance does not appear to be improved with stimulants. Twelve studies evaluated treatment in adults with ADHD. For MPH vs. placebo, the results were contradictory. Antidepressants may be effective in adults, but no beneficial effect was seen with pemoline, nicotine, or phenylalanine compared with placebo. Thirty-two reports (29 studies) evaluated adverse effects of drug therapy; many of the side effects associated with stimulant use appear to be relatively mild and of short duration and to respond to dosing or timing adjustments. Data are inadequate on the long-term effects and severity of adverse effects of most interventions. CONCLUSIONS: This report describes rigorous systematic reviews on the treatment of ADHD, ready for incorporation into evidence-based clinical practice guidelines or performance measures. The report also provides a detailed description of the many limitations of the evidence available and provides recommendations to fill existing knowledge gaps. Studies on ADHD have low reporting quality, methodological flaws, and heterogeneity across outcome measures and tests. A detailed description is included of the many limitations of the available evidence plus recommendations to fill existing knowledge gaps. Fulfilling such knowledge gaps will not be easy and will require genuine collaboration among decisionmakers.

Adrenergic Uptake Inhibitors↗
PubMed1998

Does quality of reports of randomised trials affect estimates of intervention efficacy reported in meta-analyses?

BACKGROUND: Few meta-analyses of randomised trials assess the quality of the studies included. Yet there is increasing evidence that trial quality can affect estimates of intervention efficacy. We investigated whether different methods of quality assessment provide different estimates of intervention efficacy evaluated in randomised controlled trials (RCTs). METHODS: We randomly selected 11 meta-analyses that involved 127 RCTs on the efficacy of interventions used for circulatory and digestive diseases, mental health, and pregnancy and childbirth. We replicated all the meta-analyses using published data from the primary studies. The quality of reporting of all 127 clinical trials was assessed by means of component and scale approaches. To explore the effects of quality on the quantitative results, we examined the effects of different methods of incorporating quality scores (sensitivity analysis and quality weights) on the results of the meta-analyses. FINDINGS: The quality of trials was low. Masked assessments provided significantly higher scores than unmasked assessments (mean 2.74 [SD 1.10] vs 2.55 [1.20]). Low-quality trials (score < or = 2), compared with high-quality trials (score > 2), were associated with an increased estimate of benefit of 34% (ratio of odds ratios [ROR] 0.66 [95% CI 0.52-0.83]). Trials that used inadequate allocation concealment, compared with those that used adequate methods, were also associated with an increased estimate of benefit (37%; ROR=0.63 [0.45-0.88]). The average treatment benefit was 39% (odds ratio [OR] 0.61 [0.57-0.65]) for all trials, 52% (OR 0.48 [0.43-0.54]) for low-quality trials, and 29% (OR 0.71 [0.65-0.77]) for high-quality trials. Use of all the trial scores as quality weights reduced the effects to 35% (OR 0.65 [0.59-0.71]) and resulted in the least statistical heterogeneity. INTERPRETATION: Studies of low methodological quality in which the estimate of quality is incorporated into the meta-analyses can alter the interpretation of the benefit of intervention, whether a scale or component approach is used in the assessment of trial quality.

Bias↗
PubMed1998

Methodology and reports of systematic reviews and meta-analyses: a comparison of Cochrane reviews with articles published in paper-based journals.

CONTEXT: Review articles are important sources of information to help guide decisions by clinicians, patients, and other decision makers. Ideally, reviews should include strategies to minimize bias and to maximize precision and be reported so explicitly that any interested reader would be able to replicate them. OBJECTIVE: To compare the methodological and reporting aspects of systematic reviews and meta-analyses published by the Cochrane Collaboration with those published in paper-based journals indexed in MEDLINE. DATA SOURCES: The Cochrane Library, issue 2 of 1995, and a search of MEDLINE restricted to 1995. STUDY SELECTION: All 36 completed reviews published in the Cochrane Database of Systematic Reviews and a randomly selected sample of 39 meta-analyses or systematic reviews published in journals indexed by MEDLINE in 1995. DATA EXTRACTION: Number of authors, trials, and patients; trial sources; inclusion and exclusion criteria; language restrictions; primary outcome; trial quality assessment; heterogeneity testing; and effect estimates. Updating by 1997 was evaluated. RESULTS: Reviews found in MEDLINE included more authors (median, 3 vs 2; P<.001), more trials (median, 13.5 vs 5; P<.001), and more patients (median, 1280 vs 528; P<.001) than Cochrane reviews. More Cochrane reviews, however, included a description of the inclusion and exclusion criteria (35/36 vs 18/39; P<.001) and assessed trial quality (36/36 vs 12/39; P<.001). No Cochrane reviews had language restrictions (0/36 vs 7/39; P<.01). There were no differences in sources of trials, heterogeneity testing, or description of effect estimates. By June 1997, 18 of 36 Cochrane reviews had been updated vs 1 of 39 reviews listed in MEDLINE. CONCLUSIONS: Cochrane reviews appear to have greater methodological rigor and are more frequently updated than systematic reviews or meta-analyses published in paper-based journals.

Meta-Analysis as Topic↗
PubMed1998

Rating health information on the Internet: navigating to knowledge or to Babel?

CONTEXT: The rapid growth of the Internet has triggered an information revolution of unprecedented magnitude. Despite its obvious benefits, the increase in the availability of information could also result in many potentially harmful effects on both consumers and health professionals who do not use it appropriately. OBJECTIVES: To identify instruments used to rate Web sites providing health information on the Internet, rate criteria used by them, establish the degree of validation of the instruments, and provide future directions for research in this area. DATA SOURCES: MEDLINE (1966-1997), CINAHL (1982-1997), HEALTH (1975-1997), Information Science Abstracts (1966 to September 1995), Library and Information Science Abstracts (1969-1995), and Library Literature (1984-1996); the search engines Lycos, Excite, Open Text, Yahoo, HotBot, Infoseek, and Magellan; Internet discussion lists; meeting proceedings; multiple Web pages; and reference lists. INSTRUMENT SELECTION: Instruments used at least once to rate the quality of Web sites providing health information with their rating criteria available on the Internet. DATA EXTRACTION: The name of the developing organization, Internet address, rating criteria, information on the development of the instrument, number and background of people generating the assessments, and data on the validity and reliability of the measurements. DATA SYNTHESIS: A total of 47 rating instruments were identified. Fourteen provided a description of the criteria used to produce the ratings, and 5 of these provided instructions for their use. None of the instruments identified provided information on the interobserver reliability and construct validity of the measurements. CONCLUSIONS: Many incompletely developed instruments to evaluate health information exist on the Internet. It is unclear, however, whether they should exist in the first place, whether they measure what they claim to measure, or whether they lead to more good than harm.

Computer Communication Networks↗
PubMed1998

Using anecdotal information in evidence-based health care: heresy or necessity?

Anecdotes are powerful tools that humans use to make decisions. Despite their power and influence, they are sometimes misused, and sometimes undervalued. Ignoring or under-estimating the role of anecdotal information in health care decisions is likely to hinder communication among decision makers, and to retard their uptake of research evidence. Anecdotal information should not be considered as a replacement for, but as a complement to formal research evidence. If evidence-based health care is to meet its potential, the important role of anecdotes must be acknowledged, studied and utilized.

Anecdotes as Topic↗
PubMed1997

How consumers and policymakers can use systematic reviews for decision making.

Systematic reviews can be a very useful decision-making tool because they objectively summarize large amounts of information, identify gaps in medical research, and identify beneficial or harmful interventions. Consumers can use systematic reviews to help them make health care decisions. Policymakers can use systematic reviews to help them make decisions about what types of health care to provide. Despite the potential value of systematic reviews, little evidence of their direct impact on the decisions made by consumers and policymakers is available. We discuss strategies for optimizing the use of systematic reviews by increasing the awareness and identification of reviews, learning to critically evaluate the findings of reviews, and overcoming barriers to the incorporation of reviews into the decision-making process. In addition, the participation of consumers and policymakers in the design, conduct, and reporting of systematic reviews can help to produce reviews that are relevant and understandable to target audiences. Because decisions that involve health care policies and issues are complex processes in which information (such as that provided by systematic reviews) plays only a part, strategies for increasing the use of systematic reviews should be evaluated for their usefulness in the decision-making process.

Decision Making↗
PubMed1997

A guide to interpreting discordant systematic reviews.

Systematic reviews are becoming prominent tools to guide health care decisions. As the number of published systematic reviews increases, it is common to find more than 1 systematic review addressing the same or a very similar therapeutic question. Despite the promise for systematic reviews to resolve conflicting results of primary studies, conflicts among reviews are now emerging. Such conflicts produce difficulties for decision-makers (including clinicians, policy-makers, researchers and patients) who rely on these reviews to help them make choices among alternative interventions when experts and the results of trials disagree. The authors provide an adjunct decision tool--a decision algorithm--to help decision-makers select from among discordant reviews.

Algorithms↗
PubMed1997

Quality and retrieval of obstetrical anaesthesia randomized controlled trials.

PURPOSE: Randomized controlled trials (RCTs) are suitable for meta-analysis and systematic reviews provided they are of high quality and are easy to retrieve. We determined these attributes of RCTs in obstetrical anaesthesia in a sample of available journals that are indexed in MEDLINE. SOURCE: Randomized controlled trials published between January 1985 and December 1994 in seven anaesthetic and three obstetric journals were identified by a MEDLINE search, and by handsearch of the same journals. Each RCT was assigned a quality score by a blinded rater using a reliable and validated scaled. The quality of each RCT was described and compared over time and by journal. The comparative yield of MEDLINE and hand-search was evaluated. PRINCIPAL FINDINGS: Three hundred and forty RCTs were retrieved by MEDLINE and handsearch. Two hundred and twenty seven (65%) were identified by the MEDLINE search and 333 by the handsearch (98%). The median quality score was 3/5. There was no difference in score over time. Anesthesiology had the highest median score, Anaesthesia had the lowest (P < 0.05). CONCLUSIONS: Care must be taken when reviewing obstetrical anaesthesia research. Strategies in addition to a MEDLINE search must be used to identify RCTs since more than one third were missed using MEDLINE alone. Poor quality RCTs are more likely to be biased in favour of a new treatment. Therefore, to increase the validity of reviews sensitivity analyses based on quality should be done.

Anesthesia, Obstetrical↗