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Biomedical subjects

Mohit Bhandari

Publications and source records attributed to Mohit Bhandari.

At least 73 records · Page 4Linked to original sources
PubMed2004

Payments for care at private for-profit and private not-for-profit hospitals: a systematic review and meta-analysis.

BACKGROUND: It has been shown that patients cared for at private for-profit hospitals have higher risk-adjusted mortality rates than those cared for at private not-for-profit hospitals. Uncertainty remains, however, about the economic implications of these forms of health care delivery. Since some policy-makers might still consider for-profit health care if expenditure savings were sufficiently large, we undertook a systematic review and meta-analysis to compare payments for care at private for-profit and private not-for-profit hospitals. METHODS: We used 6 search strategies to identify published and unpublished observational studies that directly compared the payments for care at private for-profit and private not-for-profit hospitals. We masked the study results before teams of 2 reviewers independently evaluated the eligibility of all studies. We confirmed data or obtained additional data from all but 1 author. For each study, we calculated the payments for care at private for-profit hospitals relative to private not-for-profit hospitals and pooled the results using a random effects model. RESULTS: Eight observational studies, involving more than 350 000 patients altogether and a median of 324 hospitals each, fulfilled our eligibility criteria. In 5 of 6 studies showing higher payments for care at private for-profit hospitals, the difference was statistically significant; in 1 of 2 studies showing higher payments for care at private not-for-profit hospitals, the difference was statistically significant. The pooled estimate demonstrated that private for-profit hospitals were associated with higher payments for care (relative payments for care 1.19, 95% confidence interval 1.07-1.33, p = 0.001). INTERPRETATION: Private for-profit hospitals result in higher payments for care than private not-for-profit hospitals. Evidence strongly supports a policy of not-for-profit health care delivery at the hospital level.

Canada↗
PubMed2004

Association between industry funding and statistically significant pro-industry findings in medical and surgical randomized trials.

BACKGROUND: Conflicting reports exist in the medical literature regarding the association between industry funding and published research findings. In this study, we examine the association between industry funding and the statistical significance of results in recently published medical and surgical trials. METHODS: We examined a consecutive series of 332 randomized trials published between January 1999 and June 2001 in 8 leading surgical journals and 5 medical journals. Each eligible study was independently reviewed for methodological quality using a 21-point index with 5 domains: randomization, outcomes, eligibility criteria, interventions and statistical issues. Our primary analysis included studies that explicitly identified the primary outcome and reported it as statistically significant. For studies that did not explicitly identify a primary outcome, we defined a "positive" study as one with at least 1 statistically significant outcome measure. We used multivariable regression analysis to determine whether there was an association between reported industry funding and trial results, while controlling for study quality and sample size. RESULTS: Among the 332 randomized trials, there were 158 drug trials, 87 surgical trials and 87 trials of other therapies. In 122 (37%) of the trials, authors declared industry funding. An unadjusted analysis of this sample of trials revealed that industry funding was associated with a statistically significant result in favour of the new industry product (odds ratio [OR] 1.9, 95% confidence interval [CI] 1.3-3.5). The association remained significant after adjustment for study quality and sample size (adjusted OR 1.8, 95% CI 1.1-3.0). There was a nonsignificant difference between surgical trials (OR 8.0, 95% CI 1.1-53.2) and drug trials (OR 1.6, 95% CI 1.1-2.8), both of which were likely to have a pro-industry result (relative OR 5.0, 95% CI 0.7-37.5, p = 0.14). INTERPRETATION: Industry-funded trials are more likely to be associated with statistically significant pro-industry findings, both in medical trials and surgical interventions.

Conflict of Interest↗
PubMed2004

Therapeutic ultrasound and fracture healing: a survey of beliefs and practices.

OBJECTIVE: To explore current beliefs among senior physiotherapy (PT) students and orthopedic surgeons on the clinical utility of therapeutic ultrasound for assisting fracture healing. DESIGN: Cross-sectional survey. SETTING: University. PARTICIPANTS: Orthopedic surgeons, senior orthopedic surgery residents, and PT students in their final 6 months of study. INTERVENTIONS: Not applicable. Main outcome measures Percentage of respondents reporting specific perceptions on (1) the role of therapeutic ultrasound in fracture healing, (2) clinical use of therapeutic ultrasound for fracture healing, (3) rationale for not using therapeutic ultrasound for healing fractures, and (4) what constitutes a clinically significant difference in fracture healing time. Between-group comparisons were conducted for survey responses. RESULTS: The response rate was 20 of 22 (90.9%) orthopedic surgeons, 5 of 5 (100%) senior orthopedic residents, and 34 of 50 (68.0%) senior PT students. The majority of senior PT students (58.8%) and orthopedic residents and surgeons (60.0%) surveyed reported the belief that therapeutic ultrasound may help in assisting fracture healing in some cases. However, the majority of respondents do not use this modality (60.0% of surgeons, 88.2% of Senior PT students), with most surgeons (32.0%) citing lack of evidence and most senior PT students (58.8%) indicating lack of availability as the predominant barrier. Thirty-two percent of surgeons felt that ultrasound was contraindicated and harmful to healing fractures, or that it was of no use, and 20.5% of PT students reported the belief that ultrasound was contraindicated and was, or may be, harmful to healing bone. Most orthopedic residents and surgeons (52.0%) reported that a reduction in fracture healing time of 4 weeks would be clinically significant versus senior PT students, the majority of whom (64.7%) indicated that a reduction of 2 weeks would be clinically significant. CONCLUSIONS: Some surgeons and PT students believed that therapeutic ultrasound is contraindicated and harmful to healing bone; however, most believed that therapeutic ultrasound may help in assisting fracture healing, in at least some cases. Current usage of this modality is rare, primarily due to the perceived lack of evidence and lack of availability. Large randomized trials are needed to define further the role of ultrasound in fracture healing.

Attitude of Health Personnel↗
PubMed2004

An observational study found that authors of randomized controlled trials frequently use concealment of randomization and blinding, despite the failure to report these methods.

BACKGROUND AND OBJECTIVE: Readers of randomized controlled trials (RCTs) commonly assume that what was not reported did not occur. We undertook an observational study to determine whether concealment of randomization or blinding was used in RCTs that failed to report these bias-reducing strategies. METHODS: We recorded the reporting of concealment of randomization and blinding in 105 RCTs. We subsequently contacted the authors and determined if they had used these methodological safeguards. RESULTS: We successfully obtained data from 98 authors. The authors in the full-text publications of these 98 RCTs failed to report the presence or absence of concealment of randomization in 55%, and the blinding status of participants in 26%, health care providers in 64%, data collectors in 84%, outcome assessors in 83%, and data analysts in 96%. In direct contact, authors frequently reported concealing randomization (96%; 95% confidence interval CI=87-100%), blinding participants (20%; 95% CI=7-41%), blinding health care providers (65%; 95% CI=52-77%), blinding data collectors (65%; 95% CI=53-75%), blinding outcome assessors (79%; 95% CI=69-87%), and blinding data analysts (50%; 95% CI=40-60%), despite not reporting the use of these methodological safeguards in their publications. CONCLUSIONS: Readers should not assume that bias-reducing procedures not reported in an RCT did not occur.

Bias↗
PubMed2004

The impact of non-injury-related factors on disability secondary to whiplash associated disorder type II: a retrospective file review.

BACKGROUND: There is evidence to suggest that Whiplash Associated Disorders (WADs) are influenced by physical trauma and psychosocial factors, as well as by medicolegal and compensation systems. OBJECTIVE: To investigate the impact of noninjury related variables on self-reported disability at initial assessment among patients presenting with WAD type II injuries. DESIGN AND SETTING: We reviewed a total of 1101 consecutive files of patients presenting to a single chiropractor's office in British Columbia, Canada. We included those who met the inclusion criteria. We extracted demographic variables and noninjury related information from 33 eligible patient files. We calculated correlations between variables and created a multivariable linear regression model to evaluate their relative associations with Neck Disability Index (NDI) scores on presentation. RESULTS: Higher NDI scores on initial assessment correlated with female sex (r = 0.40, P =.02), a greater number of subsequent treatments (r = 0.44, P =.01), a higher number of providers seen before presentation (r = 0.40, P =.02), and most strongly with the involvement of a lawyer (r = 0.73, P <.01). A multivariable linear regression model found that only female sex (P =.03) and the involvement of a lawyer (P =.01) remained significantly associated with higher NDI scores on presentation (adjusted R2 = 0.68 for the model). Female sex was associated with a 10-point increase in NDI scores on presentation (beta coefficient = 10.5; 95% confidence interval [CI] 2.8-18.2), and involvement of a lawyer was associated with a 15-point increase in NDI scores on presentation (beta coefficient = 14.9; 95% CI 5.0-24.7). CONCLUSION: Our analysis of WAD type II patients in receipt of compensation found that higher self-reported disability on initial assessment was associated with female sex and in particular by retaining a lawyer. Large prospective studies are needed to establish the validity of these findings.

Adult↗
PubMed2004

The need for education in evidence-based orthopedics: an international survey of AO course participants.

BACKGROUND: As evidence-based practitioners, surgeons need to understand study methodology to critically appraise and conduct research. OBJECTIVE: To determine current understanding of study methodology and critical appraisal among participants at an international educational meeting. METHODS: We surveyed participants attending the 76th and 77th AO Course (December 2002) in Davos, Switzerland. We obtained information regarding participant age, gender, clinical and research experience, subspecialty area and respondents' roles in the AO course. The survey questions were formatted into three areas: evidence-based orthopedics, randomization and blinding issues. RESULTS: 532 participants completed the questionnaire. They represented 78 countries, the majority of which (31%) were from German-speaking countries. A greater proportion of participants trusted randomized controlled trials (89%) and meta-analyses of randomized trials (81%) when compared with case series and case reports. 60 respondents (11%) had never heard of the term "randomization" as a study design method to limit bias, and 114 respondents (21%) had never heard of the term "blinding" as a method of reducing bias in surgical research. When those who had heard of blinding were asked to define the term "double-blind", 20 different definitions resulted. Having completed the survey, nine-tenths of the respondents endorsed the need for training of surgeons in research methodology.

Adult↗
PubMed2004

The impact of time of admission on major complications and mortality in patients undergoing emergency trauma surgery.

BACKGROUND: Previous studies have shown a relationship between time of admission to hospital and mortality rates; however, it is uncertain whether such a relationship exists for patients requiring emergency trauma surgery. METHODS: We included all trauma patients, except those with moderate to severe burns, who presented to a university-affiliated level 1 trauma center and underwent surgery, from 1995 until 2001 (n = 1044). We conducted univariate and multivariate analyses in which the dependent variables were in-hospital mortality and major complications, and the independent variables were the time of presentation to the trauma centre (nighttime vs. daytime, weekend vs. weekday, month of year, and year), age, sex, injury severity score, type of operative procedure, and total number of operative procedures. RESULTS: None of the factors related to time of presentation were associated with major complications or mortality. Factors predictive of increased mortality were higher ISS (odds ratio 1.07; 95% confidence interval 1.03-1.08), older age (1.04; 1.03-1.07), operations involving the cardiovascular system (1.7; 1-2.6), "miscellaneous" operative procedures (1.8; 1.1-2.9), and major complications (2.4; 1.4-4.2). INTERPRETATION: Time of presentation for emergency trauma surgery was not associated with differences in major complications or in mortality.

Adolescent↗
PubMed2004

A prospective cost analysis following operative treatment of unstable ankle fractures: 30 patients followed for 1 year.

BACKGROUND: Ankle fractures remain one of the commonest injuries requiring operation. Quality of life and the overall costs associated with the treatment of such injuries are rarely reported. We did a pilot study to determine the cost of treating patients operatively with unstable ankle fractures and to measure the patients' quality of life (utility scores) over time. PATIENTS AND METHODS: 30 patients (17 men) were eligible and included in the study. They were on the average 52 (18-81) years old. All patients had type B Weber fractures (OTA 44B). RESULTS: The mean utility score from the Health Utilities Index immediately after surgery was 0.4. At 12 months follow-up, this score had increased to 0.78. The cost was, on average, USD 2,143 per patient. INTERPRETATION: Our findings indicate that patients operated on for ankle fractures had significant gains in health at an acceptable cost. These results provide data for studies of larger sample size.

Adolescent↗
PubMed2004

How reliable are reliability studies of fracture classifications? A systematic review of their methodologies.

Two independent reviewers performed a search in MEDLINE and EMBASE for fracture classification reliability studies. Data were obtained on classifications, image modalities, fracture selection processes, sample sizes and their justification, type and number of raters, practical issues for the classification sessions, statistical methods, and results. A 10-item checklist was devised for quality assessment of methodologies. 44 studies assessing 32 fracture classification systems were included. We found a wide variation of methodologies. For instance, the median number of raters was 5 (2-36) and the median number of fractures was 50 (10-200). This selection was considered representative in 17/44 of the studies. The true distribution of classification categories was estimated in 9 studies. The kappa coefficient was mostly used (39/44) to quantify the raters' agreement. Methodological issues are discussed. Given limitations in the use and interpretation of kappa coefficients, investigators should consider alternative methods that focus upon the accuracy of the classification systems. The development and adoption of a systematic methodological approach to the development and validation of fracture classification systems is needed.

Fractures, Bone↗
PubMed2004

Four part fractures of the proximal humerus.

BACKGROUND: Four part fractures of the proximal humerus represent approximately 5% of all proximal humeral fractures. Treatment options for these displaced fractures include nonoperative treatment, open reduction and internal fixation, and arthroplasty. Presently, there is a lack of consensus on the optimal management strategy for this complex injury. OBJECTIVE: To determine the effect of alternate devices in the management of four part proximal humerus fractures in patients on the risks of reoperation, need for implant removal at 1 year, and pain.

Arthroplasty↗
PubMed2004

Acute nondisplaced fractures of the scaphoid.

BACKGROUND: The optimal management for undisplaced scaphoid fractures has been the focus of much debate. Investigators have advocated internal fixation of these fractures; however, whether surgery improves clinically relevant patient outcomes compared with casting remains unknown. OBJECTIVE: To determine the effect of internal fixation versus casting for undisplaced scaphoid fractures on the rates of union, return to work, grip strength, and range of motion.

Adolescent↗
PubMed2004

Health-related quality of life following operative treatment of unstable ankle fractures: a prospective observational study.

BACKGROUND: Although Weber type B ankle fractures are often considered benign with a good prognosis, evidence from observational studies suggests that 17% to 24% of such patients may have less satisfactory outcomes. Although the explanation for variability in outcomes remains unclear, previous studies of other surgical procedures have suggested nonsurgery-related causes account for much of the variability in outcomes. METHODS: We conducted a prospective observational cohort study to evaluate health-related quality of life in 30 patients with unstable ankle fractures who were otherwise healthy. Only patients from 2 university-affiliated hospitals sustaining unstable type B Weber injury patterns requiring surgery were eligible. Patients provided detailed baseline information regarding alcohol consumption, smoking habits, and educational level. Patients completed the short form 36 questionnaire and a visual analogue pain scale at regular follow-up intervals. RESULTS: The average patient age was 51.6 years (SD 15.2 years), and 57% (17 out of 30) were male. The majority of fractures were the result of a fall (67%, 20 out of 30), and all were closed injuries. Almost half of all patients were smokers (47%, 14 out of 30), whereas 43% consumed alcohol on a weekly basis (13 out of 30). Forty-three percent of patients (13 out of 30) had obtained an elementary or high school level of education. Patients experienced significant improvements in all domains of the SF-36 questionnaire (P < 0.001), except general health, which remained essentially normal over the 24-month period. Study patients achieved scores similar to age-matched U.S. normative data across 6 of the 8 domains (Role Emotional, Social Function, Mental Health, Bodily Pain, Vitality, and General Health). However, patients' physical function and role physical scores remained significantly lower than US norms at 24 months (21.8 and 20.7 points lower on a 100-point scale, respectively; P < 0.001). Smoking history (P = 0.02), presence of a medial malleolar fracture (P = 0.02), and lower levels of education (P = 0.01) were significant independent predictors of lower physical function up to 3 months postoperation. Lower mental health domain scores were significantly associated with alcohol use (P = 0.02) and increasing age (P = 0.04). CONCLUSIONS: As is the case in many other areas, social factors may be important determinants of outcome in patients with traumatic fractures. Optimal orthopedic care may involve attention to modifiable risk factors, including smoking and alcohol consumption.

Adolescent↗
PubMed2004

Fractures of the shaft of the ulna.

BACKGROUND: The optimal management for ulnar shaft fractures remains debatable. Investigators have advocated nonoperative management as well as internal fixation of these fractures. OBJECTIVE: The primary objective of this study was to determine the effect of alternative management strategies of fractures of the ulnar shaft on rates of union, infection, and functional outcomes. A secondary objective was to examine outcomes after alternative strategies in managing patients with bone defects.

Fracture Fixation↗
PubMed2004

Interrater reliability in grading abstracts for the orthopaedic trauma association.

Only a small proportion of submitted abstracts to the annual meeting of the Orthopaedic Trauma Association can be accepted for podium presentation. Annual program committee members must ensure that the selection of abstracts is free from bias and transparent to investigators. The objectives of this study are to examine the consistency of reviewers in grading abstracts submitted for podium presentations at the 2001 and 2002 Annual Meetings of the Orthopaedic Trauma Association and to evaluate whether the grades of the actual podium presentations at the meeting are consistent with the grades based on abstracts only. Reviewers independently graded all abstracts submitted to the Orthopaedic Trauma Association for presentation in a blinded manner. Abstracts submitted by members of the review panel were independently adjudicated by six reviewers who were not members of the committee. Before final decision-making, all reviewers met to discuss the abstracts submitted for oral presentation. Among the 440 papers reviewed in 2001 and 438 papers reviewed in 2002, the interreviewer reliability for abstract review was 0.23 and 0.27, respectively. Despite disagreements in the quality of the abstracts, reviewers achieved consensus by discussions to determine the final program. Agreement among unblinded reviewers of the 67 and 73 podium presentations during the 2001 and 2002 meetings, respectively, did not improve interreviewer agreement. Of the papers of the 2002 meeting that ultimately ranked in the top 20 after the full presentation of the papers, 15 papers originally had been ranked less than 20 in the initial grading. Only one of the top three papers of the meeting originally was ranked in the top three before the meeting.

Abstracting and Indexing↗
PubMed2004

Systematic reviews of nonrandomized clinical studies in the orthopaedic literature.

We systematically reviewed systematic reviews of surgical orthopaedic interventions published between 1996 and 2001 to document when and how nonrandomized studies were included. From more than 10,000 citations examined in various electronic databases, 58 orthopaedic systematic reviews were eligible for inclusion based on specific criteria. Thirty of these (52%) included nonrandomized studies, 15 of which found no randomized controlled trials. Systematic reviews were more likely to include randomized controlled trials if nondistinguishable operations were compared (if participants could be blinded). Only six of the systematic reviews that included nonrandomized studies (20%) assessed the quality of primary studies. Heterogeneity of studies was a major concern. In 21 of the systematic reviews that included nonrandomized studies (70%), data for groups treated similarly were pooled across studies, and outcomes for pooled groups were compared. The conclusions of systematic reviews that included nonrandomized studies are weakened by the limitations of nonrandomized study designs. The absence of established methods for including nonrandomized studies in systematic reviews, and consequently variability in the methods adopted, also limits the comparability of such reviews. Therefore the findings of systematic reviews that include nonrandomized studies should be interpreted with caution.

Clinical Trials as Topic↗
PubMed2004

Interobserver agreement in the application of levels of evidence to scientific papers in the American volume of the Journal of Bone and Joint Surgery.

BACKGROUND: Since January 2003, all clinical scientific articles published in the American volume of The Journal of Bone and Joint Surgery (JBJS-A) have included a level-of-evidence rating. The aim of the current study was to evaluate the interobserver agreement among reviewers, with varying levels of epidemiology training, in categorizing the levels of evidence of these clinical studies. METHODS: Fifty-one consecutive clinical papers published in the American volume of JBJS were identified by a computerized search of the table of contents from January 2003 through June 2003. Each paper was blinded so that only the title, abstract (without the level of evidence designated), and methods section were provided to the reviewers. The papers were coded and were randomly organized in a binder. Six surgeons graded each blinded paper for (1) the type of study (therapeutic, prognostic, diagnostic test, or economic or decision analysis), (2) the level of evidence (on a scale of I through V), and (3) the subcategory within the particular level of evidence. Three surgeons were members of JBJS American Editorial Board, two surgeons were reviewers for JBJS-A, and one surgeon was an active researcher not formally associated with JBJS-A. The reviewers did not receive any formal training in the application of the classification system, but each was provided with a detailed description of the classification system used by JBJS-A. Intraclass correlation coefficients with 95% confidence intervals were determined for the reviewers' agreement regarding the type of study, level of evidence, and subcategory within the level of evidence. RESULTS: The majority (69%) of the fifty-one included articles were studies of therapy, and 57% of the studies constituted Level-IV evidence. The intraclass correlation coefficients for the agreement among all reviewers with regard to the study type, level of evidence, and subcategory within the level of evidence ranged from 0.61 to 0.75. Reviewers trained in epidemiology demonstrated greater agreement (range in intraclass correlation coefficients, 0.99 to 1.0), across all aspects of the classification system, than did reviewers who were not trained in epidemiology (range in intraclass correlation coefficients, 0.60 to 0.75). CONCLUSIONS: These findings suggest that epidemiology and non-epidemiology-trained reviewers can apply the levels-of-evidence guide to published studies with acceptable interobserver agreement. The validity of this system remains a question for future research.

Evidence-Based Medicine↗