Whose fault are wrong predictions: the clinician, the patient or the pigeon?

Carlisle, J. B.

doi:10.1111/anae.14087

Cited by 5 publications

(5 citation statements)

References 8 publications

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“…previously termed the ‘acute risk change’ . Although this seems to be associated with postoperative mortality following cardiac surgery, Carlisle challenged this by suggesting their finding was a mathematical consequence of rounding the pre‐operative but not the postoperative risk . Similarly, if one estimates the distribution of percentage platelet dysfunction from the median reported by Ho et al., it may appear as though the distributions are similar for those who did and did not have an event.…”

Section: Discussionmentioning

confidence: 99%

Recycling old data – an ethical and pragmatic way to generate new evidence?

Charlesworth

Agarwal

2019

Anaesthesia

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In this issue of Anaesthesia, Ho et al. report data suggesting that, for cardiac surgical patients, platelet dysfunction towards the end of cardiopulmonary bypass is associated with adverse postoperative outcomes [1].Following corrections for several confounders, they conclude a 1% increase in platelet dysfunction was associated with a 1% increase in the odds of a composite outcome of adverse events. Before we consider the clinical implications of this finding, there are two important aspects of their paper that warrant further discussion. These relate to the stepped-wedge cluster randomised controlled trial from which the authors retrieved data to test their hypothesis [2] and the recycling of old datasets to answer new research questions. Stepped-wedge cluster randomised controlled trialsThere is already good evidence that patient blood management strategies reduce peri-operative allogeneic blood transfusions and are associated with better postoperative outcomes for patients undergoing all types of major surgery [3,4]. It also seems reasonable that access to intra-operative point-of-care tests of coagulation in combination with integrated transfusion algorithms may reduce the need for allogeneic blood transfusion. That said, before the study by Karkouti et al. [2], the evidence for such strategies was limited to observational, non-controlled studies. In order to build a case for the purchasing of equipment, hospitals, departments, policymakers and clinical managers may ask for randomised controlled trial evidence. There are nevertheless several logistical barriers to a conventional trial such as, but not limited to, the complexity of 'rolling out' the intervention at different timepoints for different patients at different centres. When the intervention is a complex package of care, such as those commonly employed in large multi-centre quality improvement projects [5,6], the stepped-wedge design allows for randomisation of clusters at different time-points ( Fig. 1).In stepped-wedge cluster trials, observations are first made during a baseline period when all clusters are controls, and no participant receives the intervention.Clusters then cross over from the control arm to the intervention arm, but at different time-points. As the study progresses, increasing numbers of clusters cross over to the intervention arm so that by the end of the study, all participants in all clusters are receiving the intervention. As this occurs, data are continually collected post-intervention.The name 'stepped wedge' comes from the stepped wedge shape in Fig. 1.The design of such studies is complicated by many factors, including: the need to determine the number of clusters; the length of each step; the number of clusters randomised at each step and how best to power such

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Section: Discussionmentioning

confidence: 99%

Recycling old data – an ethical and pragmatic way to generate new evidence?

Charlesworth

Agarwal

2019

Anaesthesia

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“…We acknowledge several limitations to our findings. Firstly, the retrospective nature of our analysis prevents any determination of a causal relationship between enhanced care team intervention and survival . As the enhanced care team group is not representative of the overall TARN population, we accept that this may introduce bias when using predicted survival methodology.…”

Section: Discussionmentioning

confidence: 99%

Impact of a physician‐led pre‐hospital critical care team on outcomes after major trauma

Hepple¹,

Durrand²,

Bouamra

et al. 2018

Anaesthesia

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Summary The deployment of physician‐led pre‐hospital enhanced care teams capable of critical care interventions at the scene of injury may confer a survival benefit to victims of major trauma. However, the evidence base for this widely adopted model is disputed. Failure to identify a clear survival benefit has been attributed to several factors, including an inherently more severely injured patient group who are attended by these teams. We undertook a novel retrospective analysis of the impact of a regional enhanced care team on observed vs. predicted patient survival based on outcomes recorded by the UK Trauma Audit and Research Network (TARN). The null hypothesis of this study was that attendance of an enhanced care team would make no difference to the number of ‘unexpected survivors’. Patients attended by an enhanced care team were more seriously injured. Analysis of Trauma Audit and Research Network patient outcomes did not demonstrate an improved adjusted survival rate for trauma patients who were treated by a physician‐led enhanced care team, but confirmed differences in patient characteristics and severity of injury for those who were attended by the team. We conclude that a further prospective multicentre analysis is warranted. An essential prerequisite for this would be to address the current blind spot in the Trauma Audit and Research Network database – patients who die from trauma before ever reaching hospital. We speculate that early on‐scene critical care may convert this cohort of invisible trauma deaths into patients who might survive to reach hospital. Routine collection of data from these patients is warranted to include them in future studies.

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“…Despite much initial promise, the statutory body responsible for providing healthcare information withdrew their funding and support for the website several years ago. In the future, our understanding of peri‐operative mortality could be improved by developing a single database that can accommodate additional information as the patient progresses through their peri‐operative care; a universal system common to all patients having any operation at any centre . At the present time however, it is difficult to assess the quality of clinical databases in the UK and it is unlikely that a study with similar methods would yield the number of patients and level of detail as that presented by Bagchi et al.…”

Section: Confoundersmentioning

confidence: 99%