Essential Evidence Plus

MENTAL HEALTH

Annual Vitamin D Supplementation Does Not Improve Mental Well-Being

Clinical question: Does an annual dose of vitamin D improve feelings of well-being in older women?

Bottom line: Annual vitamin D supplementation does not increase feelings of well-being, at least among older women. Level of evidence (LOE)=1b, individual randomized controlled trials (with narrow confidence interval).

Reference: Sanders KM, Stuart AL, Williamson EJ, et al. Annual high-dose vitamin D3 and mental well-being: randomised controlled trial. Br J Psychiatry. 2011;198(5):357-364.

Study design: Randomized controlled trial (double-blinded)

Funding Source: Government

Allocation: Uncertain

Setting: Population-based

Synopsis: The Australian researchers conducting this study recruited 2,317 community-dwelling women 70 years and older. The women were randomized, allocation concealment uncertain, to receive a single yearly dose of 500,000 IU vitamin D3 or placebo every autumn/winter for 3 to 5 consecutive years. Well-being was assessed using 4 different surveys of mental well-being, completed at baseline and immediately before and 3 months after the second dose. Using intention-to-treat analysis, there were no significant differences between the vitamin D group and placebo group despite a 41% higher vitamin D level in the treatment group. The study had an 80% power to find at least a 50% difference in responses, if one existed.

Asking about Suicide Doesn’t Trigger Suicidal Ideation

Clinical question: Does asking about suicidal ideation increase a patient’s feelings that life is not worth living?

Bottom line: Asking about suicide—even asking six questions on the topic—does not increase depressed patients’ thoughts that life is not worth living. LOE=2b, individual cohort study or low-quality randomized controlled trials (<80% follow-up).

Reference: Crawford MJ, Thana L, Methuen C, et al. Impact of screening for risk of suicide: Randomised controlled trial. Br J Psychiatry. 2011;198(5):379-384.

Study design: Randomized controlled trial (single-blinded)

Funding Source: Self-funded or unfunded

Allocation: Unconcealed

Setting: Outpatient (primary care)

Synopsis: These investigators enrolled 443 patients (90% of screened patients) of four urban general practices in London who screened positive for depression. The patients were, on average, 48.5 years old, and 69% were women. The patients were randomized (unconcealed randomization) to be asked either about suicidal ideation or about general health and lifestyle via telephone immediately after enrollment.

To mask the purpose of the study, the patients were told that the study was a screening for health and emotional problems. The authors asked a total of six questions of each group; obviously, in the suicide ideation group, this goes far beyond the typical, “Do you have any thoughts about harming yourself or others?” Follow-up occurred in 79.2% of patients. Analysis was by intention to treat.

At follow-up, a similar proportion of patients in both groups answered “yes” to the question, “In the past two weeks, have you felt your life is not worth living?” (28.0% vs 24.1%, difference not significant). Similar responses to the other questions occurred in both groups. One person in the control group attempted suicide. The study had an 80% power of finding a 50% increase in suicidal ideation if one existed.

 

PAIN

Steroid Injections for Trochanteric Pain

Clinical question: Are corticosteroid injections more effective than usual care in treating patients with trochanteric bursitis?

Bottom line: Patients with trochanteric bursitis treated with corticosteroid injections have better short-term recovery rates than patients receiving usual care, but there are no differences in outcomes 1 year later. LOE=2b, individual cohort study or low-quality randomized controlled trials (<80% follow-up).

Reference: Brinks A, van Rijn RM, Willemsen SP, et al. Corticosteroid injections for greater trochanteric pain syndrome: A randomized controlled trial in primary care. Ann Fam Med. 2011;9(3):226-234.

Study design: Randomized controlled trial (nonblinded)

Funding Source: Foundation

Allocation: Concealed

Setting: Outpatient (primary care)

Synopsis: These authors conducted an open-label randomized trial of steroid injections (n=60) versus usual care (n=60) in adult patients in primary care settings with suspected trochanteric bursitis (also called greater trochanter pain syndrome). The patients had at least 1 week of pain in the lateral hip and had reproducible tenderness on palpation of the greater trochanter. The steroid injections were a combination of 40 mg triamcinolone and lidocaine infiltrated around the trochanter. The control patients (“usual care”) received analgesics with or without physical therapy. The authors evaluated patients for recovery at three months and at one year after treatment. Additionally, they assessed other outcomes at six weeks and three, six, nine, and 12 months after treatment. The researchers used an intention-to-treat analysis to compare the outcomes. At three months, 55% of the patients receiving steroid injections reported having recovered compared with 34% of the control patients (number needed to treat [NNT]=5; 95% CI, 3–26). However, at the end of 1 year, the recovery rate was identical in each group (60%). An ideal study would have used sham injections and placebo analgesics. However, these findings are remarkably similar to the results of other studies of steroid injections for other painful conditions: In the short term, the steroids seem better than alternate treatments, but in the long term, all things seem to wash out.

Manipulation or Mobilization for Neck Pain

LOE=D, very low, any estimate of effect is very uncertain.

Manipulation and mobilization might possibly provide immediate- or short-term benefits for neck pain although the evidence is insufficient. No long-term data are available.

A Cochrane review included 27 studies with a total of 1,522 subjects. The studies compared manipulation or mobilization against no treatment, sham (pretend) treatments, other treatments (such as medication, acupuncture, heat, electrotherapy, soft tissue massage), or each other.

Cervical manipulation for subacute/chronic neck pain: Manipulation alone compared to a control provided short-term pain relief following one to four treatment sessions (SMD pooled -0.90, 95% CI -1.78 to -0.02, statistical heterogeneity I² = 80%; 3 studies, n=130) and 9 or 12 sessions were superior to 3 for pain and disability in cervicogenic headache (1 study, n=25). Manipulation and mobilization produced similar effects on pain, function and patient satisfaction at short- and intermediate-term follow-up.

Thoracic manipulation for acute/chronic neck pain: Thoracic manipulation as an adjunct to electrothermal therapy reduced pain (NNT 7; 46.6% treatment advantage) and increased function (NNT 5; 40.6% treatment advantage) in acute pain in one study (n=45). A single session of thoracic manipulation compared to placebo for chronic neck pain reduced pain at immediate follow-up (NNT 5, 29% treatment advantage; 1 study, n=36).

Mobilization for subacute/chronic neck pain: A combination of Maitland mobilization techniques was similar to acupuncture for immediate pain relief and increased function (1 study, n=51). Neural dynamic mobilizations led to statistically insignificant, but clinically important pain reduction immediately post-treatment in participants with neck pain of mixed duration when compared to pulsed ultrasound (1 study, n=20). Certain mobilization techniques were superior.

Adverse effects were reported in 8 of the 27 studies. Three out of those eight studies reported no side effects. Five studies reported minor and temporary side effects including headache, pain, stiffness, minor discomfort, and dizziness. Rare but serious adverse events, such as stoke or serious neurological deficits, were not reported in any of the trials.

Comment: The quality of evidence is downgraded by study quality (inadequate or unclear allocation concealment and lack of blinding), by inconsistency (heterogeneity in interventions and outcomes and variability in results across studies), and by imprecise results (limited study size for each comparison).

References

1. Gross A, Miller J, D’Sylva J, Burnie SJ, Goldsmith CH, Graham N, Haines T, Brønfort G, Hoving JL. Manipulation or mobilisation for neck pain. Cochrane Database Syst Rev. 2010 Jan 20;(1):CD004249.

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Opioids for Chronic Noncancer Pain

LOE=A, high, further research is very unlikely to change our confidence in the estimate of effect.

Opioids are effective for neuropathic and musculoskeletal pain in the short term, but few patients continue with them in the longer term.

A systematic review including 14 studies with a total of 1,145 subjects was abstracted in DARE. The patients in the included studies had pain from osteoarthritis, diabetic and peripheral neuropathy, phantom limb pain, musculoskeletal pain, postherpetic neuralgia, and mixed types of pain.

For intravenous opioids, mean pain relief with opioids was about 30% for neuropathic and nociceptive pain. Two RCTs found that oxycodone significantly reduced steady pain, brief pain and dynamic allodynia compared with placebo in patients with allodynia. All seven studies assessing the quality of sleep found a significant improvement with opioids. Five RCTs found no significant difference with either an opioid or placebo for various measures of physical activity. Two studies reported lower disability scores with oxycodone compared with placebo.

There was no statistically significant difference in the rates of discontinuation for opioids and placebo (30% versus 26%; RR 1.0, 95% CI: 0.1 to 1.2). The most common reasons for discontinuation were adverse effects with opioids and lack of efficacy with placebo. Patients taking opioids were more likely to report at least one adverse effect than patients taking placebo (80% versus 56%; NNH 4.2, 95% CI: 3.1 to 6.4). The most common adverse effects with opioids were constipation (41% versus 11% with placebo; NNH for 3.4, 95% CI: 2.9 to 4.0), somnolence (29% versus 10% with placebo) and nausea (32% versus 12% with placebo). Opioids also significantly increased vomiting (15% versus 3%), dizziness (20% versus 7%) and itching (15% versus 7%) compared with placebo. The studies found that about 44% of patients remained on opioids after seven months to two years.

A Cochrane review included 26 studies with a total of 4,893 subjects examining long-term opioid management for chronic noncancer pain; 25 of the studies were case series or uncontrolled long-term trial continuations, the other was an RCT comparing two opioids.

Opioids were administered orally (n=3,040), transdermally (n=1,628), or intrathecally (n=231) for at least 6 months. Participants had moderate or severe chronic noncancer pain (CNCP) due to nociceptive or neuropathic pain, or both (back pain, osteoarthritis, myofascial pain, osteoporotic vertebral fracture, trigeminal neuralgia, neuropathic pain, or unspecified or a variety of types of CNCP). The mean duration of pain prior to study enrollment was reported in only 10 studies, most reported an average duration of pain of about eight years.

Many participants discontinued due to adverse effects (oral 22.9%, 95% CI 15.3% to 32.8%; transdermal 12.1%, 95% CI 4.9% to 27.0%; intrathecal 8.9%, 95% CI 4.0% to 26.1%) or insufficient pain relief (oral 10.3%, 95% CI 7.6% to 13.9%; intrathecal 7.6%, 95% CI 3.7% to 14.8%; transdermal 5.8%, 95% CI 4.2% to 7.9%). Signs of opioid addiction were reported in 0.27% of participants in the studies that reported that outcome. All three modes of administration were associated with clinically significant reductions in pain, but the amount of pain relief varied among studies. Findings regarding quality of life and functional status were inconclusive.

References

1. Kalso E, Edwards JE, Moore RA, McQuay HJ. Opioids in chronic non-cancer pain: Systematic review of efficacy and safety. Pain. 2004 Dec;112(3):372-80.
2. Noble M, Treadwell JR, Tregear SJ, et al. Long-term opioid management for chronic noncancer pain. Cochrane Database Syst Rev. 2010;(1):CD006605.

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Behavioral Treatments for Chronic Low Back Pain

LOE=B, moderate, further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.

Operant therapy appears to be more effective than waiting list and behavioral therapy more effective than usual care for short-term pain relief in chronic low back pain patients.

A Cochrane review included 30 studies with a total of 3,438 subjects. Operant therapy was more effective than waiting list (SMD -0.43, 95%CI -0.75 to -0.11; 3 studies, n=153) for short-term pain relief. Little or no difference existed between operant, cognitive, or combined behavioral therapy for short- to intermediate-term pain relief. Behavioral treatment was more effective than usual care for short-term pain relief (MD -5.18, 95%CI -9.79 to -0.57; 2 studies, n=330), but there were no differences in the intermediate- to long-term, or on functional status. There was little or no difference between behavioral treatment and group exercise for pain relief or depressive symptoms over the intermediate to long term. Adding behavioral therapy to inpatient rehabilitation was no more effective than inpatient rehabilitation alone.

Comment: The quality of evidence is downgraded by study quality (inadequate or unclear allocation concealment).

References

1. Henschke N, Ostelo RW, van Tulder MW, et al. Behavioural treatment for chronic low-back pain. Cochrane Database Syst Rev. 2010 Jul 7;(7):CD002014.

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PEDIATRICS

PECARN and CHALICE Best Rules in Children with Head Injuries

Clinical question: Which decision rules for evaluating children with head injuries are the most reliable?

Bottom line: These authors like the PECARN decision rule since it has been used on the largest number of injured children and has decent overall accuracy. However, the CHALICE and UCD rules have better test characteristics, although the UCD rule has not been studied in very many children. LOE=1a, systematic reviews (with homogeneity) of randomized controlled trials.

Reference: Pickering A, Harnan S, Fitzgerald P, Pandor A, Goodacre S. Clinical decision rules for children with minor head injury: A systematic review. Arch Dis Child. 2011;96(5):414-421.

Study design: Meta-analysis (other)

Funding Source: Government

Setting: Emergency department

Synopsis: The authors searched several databases to find studies of the diagnostic accuracy of clinical decision rules in evaluating children with head injuries. To be included, studies had to include at least 20 children, at least half of whom had an initial Glasgow Coma Scale of between 13 and 15. Additionally, the decision rule had to have at least three elements and the children had to have a CT or MRI follow-up to determine the need for neurosurgery. Study inclusion was done in an independent manner with discrepancies settled by discussion. One reviewer assessed the study quality with a second reviewer checking the work. When in doubt, additional reviewers were recruited. Ultimately, they included 16 articles with nearly 80,000 children. Only 4 decision rules were evaluated in more than one study: Children’s Head Injury Algorithm for the Prediction of Important Clinical Events (CHALICE); National Emergency X-Radiography Utilization Study II (NEXUS II); Paediatric Emergency Care Applied Research Network (PECARN); and University of California-Davis (UCD). Two additional rules have only been evaluated once. The characteristics of each test in detecting hemorrhage or need for surgery are summarized below: Rule Se Sp LR+ LR- CHALICE 98% 87% 7.7 0.03 NEXUS II 99% 16% 1.2 0.09 PECARN 97% 59% 2.4 0.06 UCD 100% 88% 8.4 0. The characteristics of each test in detecting the need for surgery are summarized below: Rule Se Sp LR+ LR- CHALICE 100% 70% 3.4 0 PECARN 100% 59% 2.5 0 PECARN (< 2)* 100% 53% 2.1 0 UCD 100% 64% 2.8 0 *The PECARN score for children younger than 2 years.

Se denotes sensitivity; Sp, specificity; LR+, positive likelihood ratio; LR-, negative likelihood ratio.

 

SYSTEMIC SCLREOSIS

Iloprost and Cisaprost for Raynaud’s Phenomenon in Progressive Systemic Sclerosis

LOE=A, high, further research is very unlikely to change our confidence in the estimate of effect.

Intravenous iloprost is effective for Raynaud’s phenomenon in progressive systemic sclerosis.

Seven randomized trials and 322 patients were included in a Cochrane review. Intravenous iloprost is effective in the treatment of Raynaud’s phenomenon secondary to scleroderma at decreasing the frequency of attacks and preventing or healing digital ulcers. The number of digital ulcers healed was highly significant in the i.v. iloprost group (Peto OR 23.17, 95% CI 2.20 to 243.52; 1 study, n=11). Side effects were also more common in in the iloprost patients compared to the placebo subjects (Peto OR 9.44, 95% CI 5.05 to 17.67; 2 studies, n=166). Physician global assessment (with respect to number of subjects improved) was statistically significant with an odds ratio of 2.61 (95% CI 1.27 to 5.38; 1 study, n=122). The effect seems to be prolonged after the intravenous infusion is given. Oral iloprost may have less efficacy, and cisaprost has minimal or no efficacy.

References

1. Pope J, Fenlon D, Thompson A, et al. Iloprost and cisaprost for Raynaud’s phenomenon in progressive systemic sclerosis. Cochrane Database Syst Rev. 1998;(2):CD000953.

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OSTEOARTHRITIS

Therapeutic Ultrasound for Osteoarthritis of the Knee

LOE=C, low, further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.

Therapeutic ultrasound may be beneficial for patients with osteoarthritis of the knee.

A Cochrane review included five small studies with a total of 341 subjects with knee osteoarthritis (OA). No trial included patients with hip OA. Two evaluated pulsed ultrasound, two continuous and one evaluated both pulsed and continuous ultrasound as the active treatment. For pain, there was an effect in favor of ultrasound therapy, which corresponded to a difference in pain scores between ultrasound and control of -1.2 cm on a 10-cm VAS (95% CI -1.9 to -0.6 cm). For function, there was a trend in favor of ultrasound, which corresponded to a difference in function scores of -1.3 units on a standardized WOMAC disability scale ranging from 0 to 10 (95% CI -3.0 to 0.3). A high degree of heterogeneity among the trials was revealed for function (88%). Safety was evaluated in two trials (n=136); no adverse event, serious adverse event or withdrawals due to adverse events occurred in either trial.

Comment: The quality of evidence is downgraded by study quality (unclear allocation concealment, lack of blinding, and inadequate intention-to-treat adherence) and by imprecise results (limited study size for each comparison).

References

1. Rutjes AW, Nüesch E, Sterchi R, Jüni P. Therapeutic ultrasound for osteoarthritis of the knee or hip. Cochrane Database Syst Rev. 2010;(1):CD003132.

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Transcutaneous Electrical Nerve Stimulation for Knee Osteoarthritis

LOE=D, very low, any estimate of effect is very uncertain.

Transcutaneous electrical nerve stimulation might possibly be effective for pain relief in knee osteoarthritis, although the evidence is insufficient.

A Cochrane review included 18 small studies with a total of 813 subjects. Eleven studies used transcutaneous electrical nerve stimulation (TENS), four interferential current stimulation, one both TENS and interferential current stimulation, and two pulsed electrostimulation. The largest trial had 71 subjects. The analysis suggested an overall large SMD of -0.86 (95% CI -1.23 to -0.49), which corresponds to a difference in pain scores of 2.1 cm on a 10-cm VAS between electrostimulation and control. Four studies showed unrealistically large SMDs of twice to three times the magnitude of what would be expected for total joint replacement. The funnel plot was highly asymmetric. The authors discuss as follows: If reporting is inadequate, as was the case in this systematic review, then the standard error as a proxy for study size may be a more precise measure of trial quality than formal assessments of methodological quality. When modeling effects expected in trials as large as the largest trial included in our systematic review, we found effects on pain near null -0.07 (95% CI -0.46 to 0.32), which were clearly smaller than the pooled SMD actually found for pain in the meta-analysis. This corresponds to a difference in pain scores between electrostimulation and control of 0.2 cm on a 10-cm VAS.

There was little evidence that SMDs differed on the type of electrostimulation (P=0.94). The relative risk of being withdrawn or dropping out due to adverse events was 0.97 (95% CI 0.2 to 6.0).

The analysis of function suggested a small SMD of -0.34 (95% CI -0.54 to -0.14), which corresponds to a difference in function scores of 0.7 units on a standardized WOMAC disability scale ranging from 0 to 10, favoring electrostimulation. The funnel plot did not appear asymmetrical.

Comment: The quality of evidence is downgraded by potential reporting bias, by study quality (inadequate or unclear allocation concealment and inadequate intention-to-treat adherence), by inconsistency (heterogeneity in interventions and outcomes and variability in results across studies), and by imprecise results (limited study size for each comparison).

References

1. Rutjes AW, Nüesch E, Sterchi R, et al. Transcutaneous electrostimulation for osteoarthritis of the knee. Cochrane Database Syst Rev. 2009;(4):CD002823.

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FRACTURE

Hip Protectors for Preventing Hip Fractures in Older People

LOE=C, low, further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.

Hip protectors may prevent hip fractures in older people in institutional settings, but not in older people living in their own homes.

A Cochrane review included 16 studies with a total of over 16,000 older people living in nursing care facilities or older adults living at home. Pooling of data from trials conducted in nursing or residential care settings showed a marginally statistically significant reduction in hip fracture risk (RR 0.81, 95% CI 0.66 to 0.99; 13 studies, n=11,573); statistical significance was lost following exclusion of five studies (n=3,757) assessed at high risk of bias (RR 0.93, 95% CI 0.74 to 1.18). Among community dwelling participants, provision of hip protectors showed no reduction in hip fracture incidence (RR 1.14, 95% CI 0.83 to 1.57; 3 studies, n=5,135). There was no evidence of any significant effect of hip protectors on incidence of pelvic or other fractures, or on rate of falls. No important adverse effects were reported but adherence, particularly in the long term, was poor.

A systematic review two included 11 studies on the effectiveness of hip protectors in care homes (5 individually randomized, five cluster randomized controlled trials, one prospective historical control study; essentially the same studies as in the Cochrane review). The rate ratio was 0.67 (95% CI 0.46 to 0.98) for hip fractures (I2=39%). Given the number of cluster randomized trials in the meta-analysis and the sensitivity of the results to the magnitude of the intraclass correlation coefficient, the authors consider it unwise to draw definite conclusions about efficacy.

Comment: The quality of evidence is downgraded by study quality (inadequate or unclear allocation concealment) and by inconsistency (variability in results across studies).

References

1. Gillespie WJ, Gillespie LD, Parker MJ. Hip protectors for preventing hip fractures in older people. Cochrane Database Syst Rev. 2010;(10):CD001255.
2. Oliver D, Connelly JB, Victor CR, et al. Strategies to prevent falls and fractures in hospitals and care homes and effect of cognitive impairment: Systematic review and meta-analyses. BMJ. 2007 Jan 13;334(7584):82.

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Multidisciplinary Rehabilitation for Older People with Hip Fractures

LOE=C, low, further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.

Multidisciplinary inpatient rehabilitation for older people after hip fracture surgery may improve activities of daily living and mobility in the short term but does probably not improve overall outcome or reduce mortality.

A Cochrane review on the effects of multidisciplinary rehabilitation for older patients with hip fracture included 13 trials with a total of 2,498 older, usually female, patients who had undergone hip fracture surgery. Multidisciplinary rehabilitation was provided primarily in an inpatient setting in 11 trials. Pooled results showed no statistically significant difference between intervention and control groups for poor outcome (risk ratio 0.89; 95% CI 0.78 to 1.01), mortality (risk ratio 0.90, 95% CI 0.76 to 1.07) or hospital readmission. Individual trials found better results, often short-term only, in the intervention group for activities of daily living and mobility.

The trial comparing primarily home-based multidisciplinary rehabilitation with usual inpatient care found marginally improved function and a clinically significantly lower burden for carers in the intervention group. Participants of this group had shorter hospital stays, but longer periods of rehabilitation. One trial found no significant effect from doubling the number of weekly contacts at the patient’s home from a multidisciplinary rehabilitation team.

Comment: The quality of evidence is downgraded by inconsistency (heterogeneity in study populations, interventions and outcomes) and by limitations in study quality.

References

1. Handoll HH, Cameron ID, Mak JC, Finnegan TP. Multidisciplinary rehabilitation for older people with hip fractures. Cochrane Database Syst Rev. 2009;(4):CD007125.

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PRACTICE MANAGEMENT

Effects of On-Screen, Point-Of-Care Computer Reminders on Processes and Outcomes of Care

LOE=B, moderate, further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.

Point-of-care computer reminders appear to generally achieve small to modest improvements in provider behavior, but more research is needed to identify what types of reminders work and when.

A Cochrane review included 28 studies (reporting a total of 32 comparisons). Computer reminders achieved a median improvement in process adherence of 4.2% (interquartile range (IQR): 0.8% to 18.8%) across all reported process outcomes, 3.3% (IQR: 0.5% to 10.6%) for medication ordering, 3.8% (IQR: 0.5% to 6.6%) for vaccinations, and 3.8% (IQR: 0.4% to 16.3%) for test ordering. In a sensitivity analysis using the best outcome from each study, the median improvement was 5.6% (IQR: 2.0% to 19.2%) across all process measures and 6.2% (IQR: 3.0% to 28.0%) across measures of medication ordering.

In the eight comparisons that reported dichotomous clinical endpoints, intervention patients experienced a median absolute improvement of 2.5% (IQR: 1.3% to 4.2%). Blood pressure was the most commonly reported clinical endpoint, with intervention patients experiencing a median reduction in their systolic blood pressure of 1.0 mmHg (IQR: 2.3 mmHg reduction to 2.0 mmHg increase).

Comment: The quality of evidence is downgraded by inconsistency (heterogeneity in interventions and outcomes).

References

1. Shojania KG, Jennings A, Mayhew A, Ramsay CR, Eccles MP, Grimshaw J. The effects of on-screen, point of care computer reminders on processes and outcomes of care. Cochrane Database Syst Rev. 2009 Jul 8;(3):CD001096.

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Electronic Retrieval of Health Information by Healthcare Providers to Improve Practice and Patient Care

LOE=D, very low, any estimate of effect is very uncertain.

There is insufficient evidence to support or refute the use of electronic retrieval of healthcare information by healthcare providers to improve practice and patient care.

A Cochrane review included two studies. One study dealt with family physicians, and the other focused on educating nurses and midwives and physicians involved in obstetric practice. Both studies looked at the provision of access to electronically retrievable information.

Neither study found any changes in professional behavior following an intervention that facilitated electronic retrieval of health information.

There was some evidence of improvements in knowledgae about the electronic sources of information reported in one study. Neither study assessed changes in patient outcomes or the costs of provision of the electronic resource and the implementation of the recommended evidence-based practices.

Comment: The quality of evidence is downgraded by inconsistency (heterogeneity in interventions and outcomes) and by imprecise results (limited study size for each comparison). The search strategy for the review may have had a very low specificity. Pragmatically, access to electronic information may be beneficial to the practice of evidence-based health care, but implementation strategies are needed to influence behavior change in healthcare professionals.

References

1. McGowan JL, Grad R, Pluye P, et al. Electronic retrieval of health information by healthcare providers to improve practice and patient care. Cochrane Database Syst Rev. 2009 Jul 8;(3):CD004749.

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