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Wyatt K.D.,Mayo Medical School | Wyatt K.D.,Knowledge and Evaluation Research Unit | Branda M.E.,Knowledge and Evaluation Research Unit | Branda M.E.,Center for the Science of Healthcare Delivery | And 12 more authors.
Implementation Science | Year: 2014

Objective: To quantify the extent to which clinicians use clinically-efficacious decision aids as intended during implementation in practice and how fidelity to usage instructions correlates with shared decision making (SDM) outcomes. Methods: Participant-level meta-analysis including six practice-based randomized controlled trials of SDM in various clinical settings encompassing a range of decisions.Results: Of 339 encounters in the SDM intervention arm of the trials, 229 were video recorded and available for analysis. The mean proportion of fidelity items observed in each encounter was 58.4% (SD = 23.2). The proportion of fidelity items observed was significantly associated with patient knowledge (p = 0.01) and clinician involvement of the patient in decision making (p <0.0001), while no association was found with patient decisional conflict or satisfaction with the encounter.Conclusion: Clinicians' fidelity to usage instructions of point-of-care decision aids in randomized trials was suboptimal during their initial implementation in practice, which may have underestimated the potential efficacy of decision aids when used as intended. © 2014 Wyatt et al.; licensee BioMed Central Ltd.


PubMed | Center for the Science of Healthcare Delivery, Chinese PLA General Hospital, Mayo Medical School and Zhejiang University
Type: Journal Article | Journal: Journal of physical therapy science | Year: 2016

[Purpose] Ultrasound-guided ilioinguinal/iliohypogastric (II/IH) nerve and transversus abdominis plane (TAP) blocks have been increasingly utilized in patients for perioperative analgesia. We conducted this meta-analysis to evaluate the clinical efficacy of ultrasound-guided II/IH nerve or TAP blocks for perioperative analgesia in patients undergoing open inguinal surgery. [Subjects and Methods] A systematic search was conducted of 7 databases from the inception to March 5, 2015. Randomized controlled trials (RCTs) comparing the clinical efficacy of ultrasound-guided vs. landmark-based techniques to perform II/IH nerve and TAP blocks in patients with open inguinal surgery were included. We constructed random effects models to pool the standardized mean difference (SMD) for continuous outcomes and the odds ratio (OR) for dichotomized outcomes. [Results] Ultrasound-guided II/IH nerve or TAP blocks were associated with a reduced use of intraoperative additional analgesia and a significant reduction of pain scores during day-stay. The use of rescue drugs was also significantly lower in the ultrasound-guided group. [Conclusion] The use of ultrasound-guidance to perform an II/IH nerve or a TAP block was associated with improved perioperative analgesia in patients following open inguinal surgery compared to landmark-based methods.


PubMed | Center for the Science of Healthcare Delivery and Mayo Medical School
Type: Journal Article | Journal: Journal of hospital medicine | Year: 2016

Elevated cardiac troponin (cTn) is often observed in patients with acute decompensated heart failure (ADHF). We assessed the magnitude of association and quality of supporting evidence between cTn and clinically important outcomes in persons hospitalized for ADHF.We searched MEDLINE In-Process & Other Non-Indexed Citations, MEDLINE, Embase, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Scopus from inception through February 28, 2015. The outcomes analyzed included hospital length of stay (LOS), readmissions, and mortality. Random effects meta-analysis was used to combine outcomes across studies.We included 26 clinical studies. A detectable or elevated cTn was associated with increased LOS (odds ratio [OR]: 1.05; 95% confidence interval [CI]: 1.01-1.10), increased in-hospital mortality (OR: 2.57; 95% CI: 2.27-2.91), and a composite of mortality and major adverse events (OR: 1.33; 95% CI: 1.03-1.71) during hospitalization. ADHF patients with a detectable or elevated cTn were at increased risk for mortality and composite of mortality and readmission over the short term (mortality OR: 2.11; 95% CI: 1.43-3.12; composite OR: 2.81; 95% CI: 1.60-4.92), intermediate term (mortality OR: 2.21; 95% CI: 1.46-3.35; composite OR: 2.30; 95% CI: 1.78-2.99), and long term (mortality OR: 3.69; 95% CI: 2.64-5.18; composite OR: 3.49; 95% CI: 2.08-5.84). The overall confidence in estimates was moderate.Among ADHF patients, a detectable or elevated cTn identifies subjects at increased risk for adverse clinical outcomes during acute hospitalization and those at higher risk for postdischarge mortality and composite of readmission and mortality. Journal of Hospital Medicine 2016;11:446-454. 2016 Society of Hospital Medicine.


Elraiyah T.,Mayo Medical School | Elraiyah T.,Center for the Science of Healthcare Delivery | Sonbol M.B.,Mayo Medical School | Sonbol M.B.,Georgia Regents University | And 12 more authors.
Journal of Clinical Endocrinology and Metabolism | Year: 2014

Context: Exogenous dehydroepiandrosterone (DHEA) therapy has been proposed to replenish the depletion of endogenous DHEA and its sulfate form, which occurs with advancing age and is thought to be associated with loss of libido and menopausal symptoms.Objective: We conducted a systematic review and meta-analysis to summarize the evidence supporting the use of systemic DHEA in postmenopausal women with normal adrenal function.Methods: We searched MEDLINE, EMBASE, Psyc Info, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Scopus through January 2014. Pairs of reviewers, working independently, selected studies and extracted data from eligible randomized controlled trials (RCTs). We used the random-effects model to pool across studies and evaluated heterogeneity using the I2 statistic.Results: We included 23 RCTs with moderate to high risk of bias enrolling 1188 women. DHEA use was not associated with significant improvement in libido or sexual function (standardized mean difference, 0.35; 95% confidence interval, -0.02 to 0.73; P value =.06; I2 = 62%). There was also no significant effect of DHEA on serious adverse effects, serum lipids, serum glucose, weight, body mass index, or bone mineral density. This evidence warranted low confidence in the results, mostly due to imprecision, risk of bias, and inconsistency across RCTs.Conclusions: Evidence warranting low confidence suggests that DHEA administration does not significantly impact sexual symptoms or selected metabolic markers in postmenopausal women with normal adrenal function. Copyright © 2014 by the Endocrine Society.


Elraiyah T.,Mayo Medical School | Elraiyah T.,Center for the Science of Healthcare Delivery | Sonbol M.B.,Mayo Medical School | Sonbol M.B.,Georgia Regents University | And 13 more authors.
Journal of Clinical Endocrinology and Metabolism | Year: 2014

Context: The use of T has been suggested to improve women's health during the postmenopausal period.Objective: We conducted a systematic review and meta-analysis of randomized trials to summarize the best available evidence regarding the benefits and harms of systemic T in postmenopausal women with normal adrenal function.Methods: A comprehensive search of MEDLINE, EMBASE, PsycInfo, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, EBSCO CINAHL, and Scopus was conducted through January 2014. We conducted study selection, data extraction, and appraisal in duplicate. Random-effects meta-analysis was used to pool results.Results: We identified 35 randomized trials (n = 5053) at a moderate risk of bias. T use was associated with statistically significant improvement in various domains of sexual function and personal distress in postmenopausal women, although the majority of the trials did not have specific or contemporary diagnostic criteria for androgen deficiency in women. T use was also associated with a reduction in total cholesterol, triglyceride, and high-density lipoprotein and an increase in low-density lipoprotein and in the incidence of acne and hirsutism. No significant effect was noted on anthropometric measures and bone density. Long-term safety data were sparse, and the quality of such evidence was low.Conclusion: Despite the improvement in sexual function associated with T use in postmenopausal women, long-term safety data are lacking. Copyright © 2014 by the Endocrine Society.


Elraiyah T.,Molecular Therapeutics | Elraiyah T.,Knowledge and Evaluation Research Unit | Gionfriddo M.R.,Knowledge and Evaluation Research Unit | Gionfriddo M.R.,Mayo Medical School | And 3 more authors.
Journal of Clinical Epidemiology | Year: 2015

Objectives To assess how well do the black box warnings present and communicate evidence in a way that is consistent with evidence-based patient-centered practice, through evaluating the boxed warning on teriparatide-induced osteosarcoma. Study Design and Setting We critically appraised teriparatide black box warning for osteosarcoma by reviewing human and animal studies that were used as basis for the warning. We also evaluated the quality of the evidence using the Grading of Recommendations Assessment, Development and Evaluation framework. Results We found that this warning was based on very low-quality evidence that was derived primarily from animal studies. The quality of evidence was rated down because of high risk of bias in addition to inconsistency, indirectness, and imprecision of the estimates. The warning does not provide sufficient guidance for practice like an implementation tool or an evidence profile to clarify the limitations of the evidence. Conclusion Black box warning for teriparatide-associated osteosarcoma does not explicitly present the quality of evidence, and therefore, it could be of limited use in evidence-based practice. We propose that black box warnings should include an evidence profile and an implementation guide to be more useful in evidence-based patient-centered practice. © 2015 Elsevier Inc. All rights reserved.


Gou S.,Mayo Medical School | Oxentenko S.C.,Mayo Medical School | Eldrige J.S.,Mayo Medical School | Xiao L.,Nanshan Hospital | And 5 more authors.
American Journal of Physical Medicine and Rehabilitation | Year: 2014

Intervertebral disk degeneration has been considered an irreversible process characterized by a decrease in cell viability, attenuation of proteoglycan and type II collagen synthesis, and dehydration of nucleus pulposus. Stem cell therapy specifically addresses the degenerative process and offers a potentially effective treatment modality. Current preclinical studies show that mesenchymal stem cells have the capacity to repair degenerative disks by differentiation toward chondrocyte-like cells, which produce proteoglycans and type II collagen. There has been evidence that mesenchymal stem cell transplantation into the intervertebral disk increases the intradiskal magnetic resonance imaging T2 signal intensity, increases the disk height, and decreases the degenerative grade in animal models. Appropriate selection of cell carriers/matrix is important because it may prevent cell leakage into the spinal canal and provide an environment that facilitates cell proliferation and differentiation. Although human cell therapy trials for degenerative disk disease are on the horizon, potential issues might arise. The authors hereby review the current state of regenerative cell therapy in degenerative disk disease, with emphasis in cell source, techniques for cellular expansion, induction, transplantation, potential benefit, and risks of the use of this novel medical armamentarium in the treatment of degenerative disk disease. Copyright © 2014 by Lippincott Williams & Wilkins.


Brinjikji W.,Mayo Medical School | Murad M.H.,Center for the Science of Healthcare Delivery | Rabinstein A.A.,Mayo Medical School | Cloft H.J.,Mayo Medical School | And 2 more authors.
American Journal of Neuroradiology | Year: 2015

BACKGROUND AND PURPOSE: A number of studies have suggested that anesthesia type (conscious sedation versus general anesthesia) during intra-arterial treatment for acute ischemic stroke has implications for patient outcomes. We performed a systematic review and meta-analysis of studies comparing the clinical and angiographic outcomes of the 2 anesthesia types. MATERIALS AND METHODS: In March 2014, we conducted a computerized search of MEDLINE and EMBASE for reports on anesthesia and endovascular treatment of acute ischemic stroke. Using random-effects meta-analysis, we evaluated the following outcomes: recanalization rate, good functional outcome (mRS ≤ 2), asymptomatic and symptomatic intracranial hemorrhage, death, vascular complications, respiratory complications, procedure time, time to groin, and time from symptom onset to recanalization. RESULTS: Nine studies enrolling 1956 patients (814 with general anesthesia and 1142 with conscious sedation) were included. Compared with patients treated by using conscious sedation during stroke intervention, patients undergoing general anesthesia had higher odds of death (OR = 2.59; 95% CI, 1.87-3.58) and respiratory complications (OR = 2.09; 95% CI, 1.36 -3.23) and lower odds of good functional outcome (OR = 0.43; 95% CI, 0.35-0.53) and successful angiographic outcome (OR = 0.54; 95% CI, 0.37-0.80). No difference in procedure time (P = .28) was seen between the groups. Preintervention NIHSS scores were available from 6 studies; in those, patients receiving general anesthesia had a higher average NIHSS score. CONCLUSIONS: Patients with acute ischemic stroke undergoing intra-arterial therapy may have worse outcomes with general anesthesia compared with conscious sedation. However, the difference in stroke severity at the onset may confound the comparison in the available studies; thus, a randomized trial is necessary to confirm this association. © 2015, American Society of Neuroradiology. All rights reserved.


Dankbar G.C.,Mayo Medical School | Hayward M.J.,Center for the Science of Healthcare Delivery
Operations Research for Health Care | Year: 2012

In this report, we share highlights of the fourth annual Mayo Clinic Systems Engineering and Operations Research conference. The conference provided a forum for system engineers, operations researchers, clinicians, managers and administrators to share experiences, learning and success stories from their work in applying analytical and modeling tools to a range of problems. This report represents a snapshot of the challenges faced in acute health care, the techniques being deployed and the progress being made by engineers and operations researchers in helping to improve the quality and value of services. © 2012 Elsevier Ltd.


PubMed | Mayo Medical School and Center for the Science of Healthcare Delivery
Type: Journal Article | Journal: Pain practice : the official journal of World Institute of Pain | Year: 2016

Spinal cord stimulators (SCS) are used to treat various chronic pain states. Establishing patient outcomes in terms of pain control, opioid medication use, and overall satisfaction is vital in maintaining SCSs role in clinical practice.All patients who underwent SCS implantation between January 2001 and December 2011 at a tertiary academic pain medicine center were included if he or she underwent permanent cervical or thoracolumbar dorsal column SCS implantation and age was 18 or greater. For the 199 patients who met inclusion criteria, data were collected retrospectively. Preimplant information included indication for implantation, Numeric Rating Scale (NRS) score, and dose in oral morphine equivalents (OME). Postimplant NRS score was recorded at 6months and 1year. OME requirement and patient satisfaction were determined at 1year postimplantation.This data set showed an overall decrease in OME requirements and NRS scores at both 6months and 1year. These differences were statistically significant (P<0.01) compared to preimplantation values. Additionally, 84.27% of patients were satisfied with their implants at 1year. Patient outcomes were analyzed further in respect to implant indication; groups included failed back surgery syndrome (FBSS), complex regional pain syndrome (CRPS), angina, and other. For all groups, there were statistically significant (P<0.01) decreases in NRS scores at 6months and 1year. In the FBSS and CRPS groups, statistically significant (P<0.02) decreases in OME usage existed.Retrospective review of patients with spinal cord stimulators revealed OME reduction at 1year for those patients in the FBSS and CRPS groups; patient satisfaction at 1year and NRS score reduction at 6months and 1year were statistically significant for all groups.

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