Strength Of Evidence For Effects Research Articles

Coronary Sinus Reducing Stent for the Treatment of Refractory Angina Pectoris: A Health Technology Assessment.

AimTo summarize the evidence on the clinical effectiveness and safety of coronary sinus reducing stent (CSRS) therapy in refractory angina pectoris (AP) patients.MethodsWe performed a systematic literature search in common databases (n=4). The evidence obtained was summarized according to GRADE methodology. A health technology assessment (HTA) was conducted using the HTA Core Model® for Rapid Relative Effectiveness Assessment. Primary outcomes for the clinical effectiveness domain were the proportion of patients with improvement in two or more Canadian Cardiovascular Society (CCS) angina score classes, overall mean reduction of CCS class, and Seattle Angina Questionnaire (SAQ) quality of life (QoL) score improvement. Outcomes for the safety domain were adverse device effects (ADEs) and serious adverse device effects (SADEs).ResultsOne randomized controlled trial (RCT) was identified. Outcomes that showed statistically significant differences between CSRS and sham treatment (in favor of CSRS) were CCS angina score improvement of one or two classes, overall mean reduction of CCS class, and SAQ QoL score improvement. Concerning safety, the sham-controlled trial data indicate that there were fewer SADEs in the intervention group (19%) than in the control group (46%). SADEs reported in observation studies ranged from none to 30%. The most frequently reported SADEs were death and stable angina. In the RCT, the only case of death occurred in the control group. Concerning clinical effectiveness, the risk of bias (RoB) was rated to be low, and concerning safety, the RoB was rated to range from low to moderate. As assessed by GRADE, the overall strength of evidence for effectiveness and safety was moderate. Internal and external validity of the evidence base were low.ConclusionEven though the current evidence indicates that the assessed technology, CSRS, is potentially more effective than sham intervention for refractory AP patients, the lack of internal validity of the studies undermines the partially positive results.

Evidence-Based Amphibian Conservation: A Case Study on Toad Tunnels

Although the search for the drivers of amphibian declines continues, there is a need to implement conservation actions. Conservation science usually does not deliver clear answers about which conservation actions are most effective and which ones should be implemented. Furthermore, results often cannot be used directly by conservationists. Given that resources are limited, there is a need to know which conservation actions and management interventions are most likely to succeed. The goal of evidence-based conservation is to assess the effectiveness of conservation actions qualitatively and quantitatively, and comparative effectiveness studies are a powerful tool to evaluate different conservation actions. We use a case study on toad tunnels to discuss the benefits and limitations of comparative effectiveness studies. Although we show that wider tunnels are used by a higher proportion of individuals, the strength of evidence for effects of other characteristics of amphibian tunnels on tunnel use was weak. Despite some equivocal results, our case study illustrates that the approach can readily be used to study the effectiveness of conservation actions and to derive recommendations for conservationists and managers that can be used directly to improve future conservation interventions.

Priority-setting for obesity prevention-The Assessing Cost-Effectiveness of obesity prevention policies in Australia (ACE-Obesity Policy) study.

The aim of the ACE-Obesity Policy study was to assess the economic credentials of a suite of obesity prevention policies across multiple sectors and areas of governance for the Australian setting. The study aimed to place the cost-effectiveness results within a broad decision-making context by providing an assessment of the key considerations for policy implementation. The Assessing Cost-Effectiveness (ACE) approach to priority-setting was used. Systematic literature reviews were undertaken to assess the evidence of intervention effectiveness on body mass index and/or physical activity for selected interventions. A standardised evaluation framework was used to assess the cost-effectiveness of each intervention compared to a ‘no intervention’ comparator, from a limited societal perspective. A multi-state life table Markov cohort model was used to estimate the long-term health impacts (quantified as health adjusted life years (HALYs)) and health care cost-savings resulting from each intervention. In addition to the technical cost-effectiveness results, qualitative assessments of implementation considerations were undertaken. All 16 interventions evaluated were found to be cost-effective (using a willingness-to-pay threshold of AUD50,000 per HALY gained). Eleven interventions were dominant (health promoting and cost-saving). The incremental cost-effectiveness ratio for the non-dominant interventions ranged from AUD1,728 to 28,703 per HALY gained. Regulatory interventions tended to rank higher on their cost-effectiveness results, driven by lower implementation costs. However, the program-based policy interventions were generally based on higher quality evidence of intervention effectiveness. This comparative analysis of the economic credentials of obesity prevention policies for Australia indicates that there are a broad range of policies that are likely to be cost-effective, although policy options vary in strength of evidence for effectiveness, affordability, feasibility, acceptability to stakeholders, equity impact and sustainability. Implementation of these policies will require sustained co-ordination across jurisdictions and multiple government sectors in order to generate the predicted health benefits for the Australian population.

Spatiotemporal variation in mechanisms driving regional-scale population dynamics of a Threatened grassland bird.

To achieve national population targets for migratory birds, landscape‐level conservation approaches are increasingly encouraged. However, knowledge of the mechanisms that drive spatiotemporal patterns in population dynamics are needed to inform scale‐variant policy development. Using hierarchical Bayesian models and variable selection, we determined by which mechanism(s), and to what extent, changes in quantity and quality of surrogate grassland habitats contributed to regional variation in population trends of an obligatory grassland bird, Bobolink (Dolichonyx oryzivorous). We used North American Breeding Bird Survey data to develop spatially explicit models of regional population trends over 25 years across 35 agricultural census divisions in Ontario, Canada. We measured the strength of evidence for effects of land‐use change on population trends over the entire study period and over five subperiods. Over the entire study period, one region (Perth) displayed strong evidence of population decline (95% CI is entirely below 0); four regions displayed strong evidence of population increase (Bruce, Simcoe, Peterborough, and Northumberland). Population trends shifted spatially among subperiods, with more extreme declines later in time (1986–1990: 28% of 35 census divisions, 1991–1995: 46%, 1996–2000: 40%, 2001–2005: 66%, 2006–2010: 82%). Important predictors of spatial patterns in Bobolink population trends over the entire study period were human development and fragmentation. However, factors inferred to drive patterns in population trends were not consistent over space and time. This result underscores that effective threat identification (both spatially and temporally) and implementation of flexible, regionally tailored policies will be critical to realize efficient conservation of Bobolink and similar at‐risk species.

Protective effects of anti-oxidant supplementations on contrast-induced nephropathy after coronary angiography: an updated and comprehensive meta-analysis and systematic review.

This systematic review with meta-analysis sought to determine the strength of evidence for effects of antioxidants (AO) such as N-acetyl cysteine (NAC), vitamin C, vitamin E, and alpha-lipoic acid on the incidence of contrast-in-duced nephropathy (CIN), requirement for haemodialysis, level of serum creatinine, and mortality after coronary angiography. After Medline, Embase, Elsevier, Sciences online database, and Google Scholar literature searches, studies with randomised controlled design were selected for the meta-analysis. The effect sizes measured were odds ratio (OR) for categorical variables and standard mean difference (SMD) with 95% confidence interval (CI) for calculating differences between mean changes of serum creatinine in intervention and control groups. A value of p < 0.1 for Q test or I2 > 50% indicated significant heterogeneity between the studies. Literature search of all major databases retrieved 2350 studies. After screening, a total of 49 trials were identified that reported outcomes. Pooled treatment effect analysis revealed that NAC (OR of 0.79; 95% CI 0.69-0.9; p = 0.000), vitamin C (0.63; 95% CI 0.45-0.89; p = 0.000), and vitamin E (OR of 0.5; 95% CI 0.27-0.92; p = 0.026) could significantly reduce the incidence of CIN. NAC (SMD of -0.119; 95% CI -0.191 - 0.046; p = 0.000), but not vitamin C (SMD of -0.08; 95% CI -0.22-0.04; p = 0.1) and vitamin E (-0.25; 95% CI -0.46-0.05; p = 0.1), could significantly reduce mean levels of serum creatinine. Nevertheless, AO could not reduce the incidence of mortality, with an OR of 0.94 (95% CI 0.69-1.28; p = 0.7). Overall, antioxidants such as NAC, vitamin C, and vitamin E can reduce the incidence of CIN, while only NAC might be able to significantly lower serum creatinine levels. There is no impact of AO supplementation on mortality.

Nonpharmacological Approaches to Pain, Anxiety, and Dyspnea: Expanding Your Bedside Toolbox (328)

1.Summarize the strength of evidence for effectiveness of hypnosis, cognitive-behavior therapy, and meditation in managing three palliative care symptoms.2.Practice and demonstrate two non-pharmacological approaches to alleviation of anxiety, pain, and dyspnea.3.Discuss how to gain confidence to teach two non-pharmacological techniques to other members of their interdisciplinary team. Many palliative care patients experience severe symptoms including pain, anxiety, and dyspnea. Palliative care clinicians are well trained in using pharmacological methods in alleviating these symptoms, but evidence-based training in non-pharmacological methods is less available. Strong evidence exists for the effectiveness of hypnosis, cognitive-behavior therapy, and meditation in managing distress, but hospice and palliative care clinicians often feel unequipped to use these tools. During this session, participants will identify the parameters for matching non-pharmacological techniques to patient symptoms based on current evidence and practice. A palliative care physician, psychiatrist, and public health professional will demonstrate utilization of hypnosis, cognitive-behavior therapy, and meditation for symptoms of pain, anxiety, and dyspnea. Participants will work in small groups to develop these skills and gain confidence in using them to ease patient suffering in their own settings. Participants will also learn how to effectively teach these techniques to other members of their interdisciplinary team.