100th issue of Quince

Quince has been published for 100 issues, since December 1997. For back copies see the web page (URL on the banner above).

In that time evidence-based medicine has moved from a interest of a largely scientific community to the mainstream, with NICE ensuring that products used by the NHS are backed by evidence of cost-effectiveness and the Healthcare Commission and Healthcare Inspectorate Wales ensuring that such guidelines are carried out.

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Patient participation in consultation

This study set out to describe the range and effectiveness of intervention strategies designed to enhance patient participation in the consultation process. A systematic review of published literature (1976-2004) was undertaken. Controlled trials in English were included. Data regarding study design, intervention characteristics, patient populations and study results were extracted.

One hundred and forty-six articles describing 137 trials were reviewed. Patient-targeted coaching and educational materials, and provider-targeted communication skills training had a substantial impact on communication. Information feedback to providers from patient-reported outcome measures (PROMs) benefits provider diagnosis and management of patient conditions.

Communication and patient diagnosis and management benefit most from the interventions. Although patient satisfaction and health status were two of the most frequently measured outcomes, overall, the interventions appeared to have less impact on patient self-efficacy, attitudes and behaviours, patient satisfaction, health status and resource use.

Overall the evidence is insufficient strongly to advocate one approach to enhancing patient participation in the consultation process. More rigorous research design with clearly specified intervention strategies and appropriately defined outcomes assessed over both the short and long term is required.

Although limited and inconclusive, the most extensive and most encouraging evidence to enhance patient participation in the consultation process is available for three patient-targeted intervention strategies (coaching, educational materials and PROMs feedback to providers) and one provider-targeted intervention strategy (communication skills training).

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Diagnosis of  DVT and pulmonary embolism in pregnancy

Diagnosing deep vein thrombosis (DVT) and pulmonary embolism (PE) in pregnancy is challenging. Many of the common diagnostic tests, including compression ultrasonography (CUS), ventilation-perfusion scintigraphy (VQ scan) and helical computed tomography (hCT) that have been extensively investigated in non-pregnant patients, have not been appropriately validated in pregnancy.

Extrapolating results of diagnostic studies of DVT and PE in non-pregnant patients to those who are pregnant may not be correct because during pregnancy, physiologic and anatomic changes may affect diagnostic test results, presentation and natural history of VTE.

The authors performed a systematic analysis of published studies addressing accurate diagnostic testing for DVT and PE in pregnancy. Their search yielded four articles of sufficient quality, three studies investigating diagnostic testing in patients with a clinical suspicion of DVT or PE and one study in patients with a clinical suspicion of PE.

From that systematic analysis investigating diagnostic testing for a clinical suspicion of DVT in pregnancy they concluded that two studies support withholding anticoagulant therapy in pregnant women with a clinical suspicion of DVT and normal results on serial IPG, however, IPG is no longer used; One study demonstrated that a normal CUS at presentation combined with a normal D-dimer test or an abnormal D-dimer test combined with normal serial CUS appears promising for safely excluding DVT in pregnant patients, but too few patients were included in this pilot-study to draw firm conclusions.

Another study investigated pregnant patients with a clinical suspicion of PE and this study concluded that in patients with normal or non-diagnostic VQ scans, withholding anticoagulant therapy might be safe, but this needs confirmation in larger studies. Recommendations on diagnostic testing of pregnant patients with a clinically suspected DVT or PE  were provided in the article.

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The prevalence of stillbirths: a systematic review.

The stillbirth rate is an important indicator of access to and quality of antenatal and delivery care. Obtaining overall estimates across various regions of the world is not straightforward due to variation in definitions, data collection methods and reporting.

The authors conducted a systematic review of a range of pregnancy-related conditions including stillbirths and performed meta-analysis of the subset of studies reporting stillbirth rates. They examined variation across rates and used meta-regression techniques to explain observed variation.

They identified 389 articles on stillbirth prevalence among the 2580 included in the systematic review. We included 70 providing 80 data sets from 50 countries in the meta-analysis.

Pooled prevalence rates show variation across various subgroup categories. Rates per 100 births are higher in studies conducted in less developed country settings as compared to more developed, of inadequate quality as compared to adequate, using sub-national sample as compared to national, reporting all stillbirths as compared to late stillbirths, published in non-English as compared to English and as journal articles as compared to non-journal.

The results of the meta-regression show the significance of two predictor variables - development status of the setting and study quality - on stillbirth prevalence.

Overall stillbirth prevalence at the community level is typically less than 1% in more developed parts of the world and could exceed 3% in less developed regions. Regular reviews of stillbirth rates in appropriately designed and reported studies are useful in monitoring the adequacy of care. Exploring these methodological issues will lead to improved standards for assessing the burden of reproductive ill-health.

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