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Biomedical subjects

M Moher

Publications and source records attributed to M Moher.

At least 19 recordsLinked to original sources
PubMed2005

Workplace interventions for smoking cessation.

BACKGROUND: The workplace has potential as a setting through which large groups of people can be reached to encourage smoking cessation. OBJECTIVES: To categorize workplace interventions for smoking cessation tested in controlled studies and to determine the extent to which they help workers to stop smoking or to reduce tobacco consumption. SEARCH STRATEGY: We searched the Cochrane Tobacco Addiction Group Specialized Register in October 2004, MEDLINE (1966 - October 2004), EMBASE (1985 - October 2004) and PsycINFO (to October 2004). We searched abstracts from international conferences on tobacco and we checked the bibliographies of identified studies and reviews for additional references. SELECTION CRITERIA: We categorized interventions into two groups: a) Interventions aimed at the individual to promote smoking cessation and b) interventions aimed at the workplace as a whole. We applied different inclusion criteria for the different types of study. For interventions aimed at helping individuals to stop smoking, we included only randomized controlled trials allocating individuals, workplaces or companies to intervention or control conditions. For studies of smoking restrictions and bans in the workplace, we also included controlled trials with baseline and post-intervention outcomes and interrupted times series studies. DATA COLLECTION AND ANALYSIS: Information relating to the characteristics and content of all kinds of interventions, participants, outcomes and methods of the study was abstracted by one author and checked by two others. Because of heterogeneity in the design and content of the included studies, we did not attempt formal meta-analysis, and evaluated the studies using qualitative narrative synthesis. MAIN RESULTS: Workplace interventions aimed at helping individuals to stop smoking included ten studies of group therapy, seven studies of individual counselling, nine studies of self-help materials and five studies of nicotine replacement therapy. The results were consistent with those found in other settings. Group programmes, individual counselling and nicotine replacement therapy increased cessation rates in comparison to no treatment or minimal intervention controls. Self-help materials were less effective.Workplace interventions aimed at the workforce as a whole included 14 studies of tobacco bans, two studies of social support, four studies of environmental support, five studies of incentives, and eight studies of comprehensive (multi-component) programmes. Tobacco bans decreased cigarette consumption during the working day but their effect on total consumption was less certain. We failed to detect an increase in quit rates from adding social and environmental support to these programmes. There was a lack of evidence that comprehensive programmes reduced the prevalence of smoking. Competitions and incentives increased attempts to stop smoking, though there was less evidence that they increased the rate of actual quitting. AUTHORS' CONCLUSIONS: We found: 1. Strong evidence that interventions directed towards individual smokers increase the likelihood of quitting smoking. These include advice from a health professional, individual and group counselling and pharmacological treatment to overcome nicotine addiction. Self-help interventions are less effective. All these interventions are effective whether offered in the workplace or elsewhere. Although people taking up these interventions are more likely to stop, the absolute numbers who quit are low. 2. Limited evidence that participation in programmes can be increased by competitions and incentives organized by the employer. 3. Consistent evidence that workplace tobacco policies and bans can decrease cigarette consumption during the working day by smokers and exposure of non-smoking employees to environmental tobacco smoke at work, but conflicting evidence about whether they decrease prevalence of smoking or overall consumption of tobacco by smokers. 4. A lack of evidence that comprehensive approaches reduce the prevalence of smoking, despite the strong theoretical rationale for their use. 5. A lack of evidence about the cost-effectiveness of workplace programmes.

Counseling↗
PubMed2003

Workplace interventions for smoking cessation.

BACKGROUND: The workplace has potential as a setting through which large groups of people can be reached to encourage smoking cessation. OBJECTIVES: To categorise workplace interventions for smoking cessation tested in controlled studies and to determine the extent to which they help workers to stop smoking or to reduce tobacco consumption. SEARCH STRATEGY: We searched the Tobacco Addiction Review Group trials register in November 2002, Medline (1966 - November 2002), EMBASE (1985 - November 2002) and PsycINFO (to November 2002). We searched abstracts from international conferences on tobacco and we checked the bibliographies of identified studies and reviews for additional references. SELECTION CRITERIA: We categorised interventions into two groups: a) Interventions aimed at the individual to promote smoking cessation and b) interventions aimed at the workplace as a whole. We applied different inclusion criteria for the different types of study. For interventions aimed at helping individuals to stop smoking, we included only randomised controlled trials allocating individuals, workplaces or companies to intervention or control conditions. For studies of smoking restrictions and bans in the workplace, we also included controlled trials with baseline and post-intervention outcomes and interrupted times series studies. DATA COLLECTION AND ANALYSIS: Information relating to the characteristics and content of all kinds of interventions, participants, outcomes and methods of the study was abstracted by one reviewer and checked by two others. Because of heterogeneity in the design and content of the included studies, we did not attempt formal meta-analysis, and evaluated the studies using qualitative narrative synthesis. MAIN RESULTS: Workplace interventions aimed at helping individuals to stop smoking included nine studies of group therapy, three studies of individual counselling, eight studies of self-help materials and four studies of nicotine replacement therapy. The results were consistent with those found in other settings. Group programmes, individual counselling and nicotine replacement therapy increased cessation rates in comparison to no treatment or minimal intervention controls. Self-help materials were less effective. Workplace interventions aimed at the workforce as a whole included 13 studies of tobacco bans, two studies of social support, four studies of environmental support, four studies of incentives, six studies of comprehensive (multi-component) programmes and two studies of competitions and recruitment. Tobacco bans decreased cigarette consumption during the working day but their effect on total consumption was less certain. We failed to detect an increase in quit rates from adding social and environmental support to these programmes. There was a lack of evidence that comprehensive programmes reduced the prevalence of smoking. Competitions and incentives increased attempts to stop smoking, though there was less evidence that they increased the rate of actual quitting. REVIEWER'S CONCLUSIONS: We found 1. Strong evidence that interventions directed towards individual smokers increase the likelihood of quitting smoking. These include advice from a health professional, individual and group counselling and pharmacological treatment to overcome nicotine addiction. Self-help interventions are less effective. All these interventions are effective whether offered in the workplace or elsewhere. Although people taking up these interventions are more likely to stop, the absolute numbers who quit are low. 2. Limited evidence that participation in programmes can be increased by competitions and incentives organised by the employer. 3. Consistent evidence that workplace tobacco policies and bans can decrease cigarette consumption during the working day by smokers and exposure of non-smoking employees to environmental tobacco smoke at work, but conflicting evidence about whether they decrease prevalence of smoking or overall consumption of tobacco by smokers. 4. A lack of evidence that comprehensive approaches reduce the prevalence of smoking, despite the strong theoretical rationale for their use. 5. A lack of evidence about the cost-effectiveness of workplace programmes.

Counseling↗
PubMed2001

Cluster randomised controlled trial to compare three methods of promoting secondary prevention of coronary heart disease in primary care.

OBJECTIVE: To assess the effectiveness of three different methods of promoting secondary prevention of coronary heart disease in primary care. DESIGN: Pragmatic, unblinded, cluster randomised controlled trial. SETTING: Warwickshire. SUBJECTS: 21 general practices received intervention; outcome measured in 1906 patients aged 55-75 years with established coronary heart disease. INTERVENTIONS: Audit of notes with summary feedback to primary health care team (audit group); assistance with setting up a disease register and systematic recall of patients to general practitioner (GP recall group); assistance with setting up a disease register and systematic recall of patients to a nurse led clinic (nurse recall group). MAIN OUTCOME MEASURES: At 18 months' follow up: adequate assessment (defined) of 3 risk factors (blood pressure, cholesterol, and smoking status); prescribing of hypotensive agents, lipid lowering drugs, and antiplatelet drugs; blood pressure, serum cholesterol level, and plasma cotinine levels. RESULTS: Adequate assessment of all 3 risk factors was much more common in the nurse and GP recall groups (85%, 76%) than the audit group (52%). The advantage in the nurse recall compared with the audit group was 33% (95% confidence interval 19% to 46%); in the GP recall group compared with the audit group 23% (10% to 36%), and in the nurse recall group compared with the GP recall group 9% (-3% to 22%). However, these differences in assessment were not reflected in clinical outcomes. Mean blood pressure (148/80, 147/81, 148/81 mm Hg), total cholesterol (5.4, 5.5, 5.5 mmol/l), and cotinine levels (% probable smokers 17%, 16%, 19%) varied little between the nurse recall, GP recall, and audit groups respectively, as did prescribing of hypotensive and lipid lowering agents. Prescribing of antiplatelet drugs was higher in the nurse recall group (85%) than the GP recall or audit groups (80%, 74%). After adjustment for baseline levels, the advantage in the nurse recall group compared with the audit group was 10% (3% to 17%), in the nurse recall group compared with the GP recall group 8% (1% to 15%) and in the GP recall group compared with the audit group 2% (-6% to 10%). CONCLUSIONS: Setting up a register and recall system improved patient assessment at 18 months' follow up but was not consistently better than audit alone in improving treatment or risk factor levels. Understanding the reasons for this is the key next step in improving the quality of care of patients with coronary heart disease.

Aged↗
PubMed2001

Putting theory into practice: a cluster randomized trial with a small number of clusters.

Many of the difficulties encountered in the design, organization and analysis of cluster randomized trials arise from the dual nature of such trials; that is, they focus on both the cluster and the individual. A trial now in progress to compare three methods of promoting secondary prevention of coronary heart disease in primary care includes only 21 general practices, but 2142 patients, and thus contains the problems of both small and large samples. With only seven practices in each arm, the trial demanded carefully restricted randomization, may be difficult to analyse, and risks loss of power if one practice should drop out. At the same time, the large number of patients makes for an expensive and administratively complex study. The simultaneous demands of clarity and thoroughness point to an analysis at both cluster and individual level. With two different approaches, however, there may be difficulties of presentation, even if the results agree, and additional problems of interpretation if they do not. Finally, practical considerations may conflict with theoretical demands. Since the trial contained a service element, all patients with heart disease had to be included, even though it would have been more efficient to take only a sample of patients from some practices.

Aged↗
PubMed2001

Patients' and practice nurses' perceptions of secondary preventive care for established ischaemic heart disease: a qualitative study.

A significant proportion of patients with established ischaemic heart disease remain unrecognized in general practice and those who are receiving treatment are experiencing sub-optimal care. The provision of coronary prevention by practice nurses may be an important strategy to improve the quality of this care, and this is feasible and effective. This study explored what occurred during patients' initial assessment for secondary prevention of ischaemic heart disease with a practice nurse and investigated patients' and practice nurses' views ofnurse-led clinics in primary care. Nurses were effective in history taking and offering reassurance and dietary advice, yet were less confident in discussing patients' understandings of heart disease and related medication. Practice nurse-led coronary preventive care is acceptable to both nurses and patients. Further practice nurse education is required in heart disease, cardiac medications and skills necessary for exploring and challenging patients' understandings of these issues.

Adult↗
PubMed2000

Systematic reviews and meta-analyses on treatment of asthma: critical evaluation.

OBJECTIVE: To evaluate the clinical, methodological, and reporting aspects of systematic reviews and meta-analyses on the treatment of asthma and to compare those published by the Cochrane Collaboration with those published in paper based journals. DESIGN: Analysis of studies identified from Medline, CINAHL, HealthSTAR, EMBASE, Cochrane Library, personal collections, and reference lists. STUDIES: Articles describing a systematic review or a meta-analysis of the treatment of asthma that were published as a full report, in any language or format, in a peer reviewed journal or the Cochrane Library. MAIN OUTCOME MEASURES: General characteristics of studies reviewed and methodological characteristics (sources of articles; language restrictions; format, design, and publication status of studies included; type of data synthesis; and methodological quality). RESULTS: 50 systematic reviews and meta-analyses were included. More than half were published in the past two years. Twelve reviews were published in the Cochrane Library and 38 were published in 22 peer reviewed journals. Forced expiratory volume in one second was the most frequently used outcome, but few reviews evaluated the effect of treatment on costs or patient preferences. Forty reviews were judged to have serious or extensive flaws. All six reviews associated with industry were in this group. Seven of the 10 most rigorous reviews were published in the Cochrane Library. CONCLUSIONS: Most reviews published in peer reviewed journals or funded by industry have serious methodological flaws that limit their value to guide decisions. Cochrane reviews are more rigorous and better reported than those published in peer reviewed journals.

Asthma↗
PubMed2000

An assessment of morbidity registers for coronary heart disease in primary care. ASSIST (ASSessment of Implementation STrategy) trial collaborative group.

BACKGROUND: Organised care delivered systematically to all patients with established coronary heart disease (CHD) can reduce their risk factors and improve their quality of life. Therefore, identifying all patients with established CHD in a general practice population is an important first step for delivering this effective healthcare. However, there is little information on how registers are compiled, the factors that predict inclusion on the register or the relationship between registration and level of care provided. AIM: To assess the completeness of morbidity registers for CHD in primary care, the factors that predict inclusion on the register, and the relationship between registration and level of care provided. METHOD: Observational study at baseline of 1979 patients aged 55 to 75 years with established CHD in 18 general practices recruited for a cluster randomised controlled trial. RESULTS: The proportion of CHD patients correctly identified on practice morbidity registers varied from 29.3% to 100%. Four factors were significantly and independently associated with being on a register: a relevant surgery contact since diagnosis (OR = 2.1, 95% CI = 1.6%-2.9%); a relevant repeat prescription since diagnosis (OR = 1.6, 95% CI = 1.1%-2.3%); a diagnosis of myocardial infarction (OR = 1.5, 95% CI = 1.2%-1.9%); and a revascularisation procedure (OR = 1.5, 95% CI = 1.1%-2.0%). Inclusion on a register was strongly associated with being adequately assessed (i.e. assessed for smoking status, blood pressure, and cholesterol) (OR = 1.8, 95% CI = 1.3%-2.3%) and with treatment with aspirin or a lipid-lowering agent (OR = 1.4 for each agent). CONCLUSION: A wide variation in registration levels between practices exists. There is evidence that practices using multiple methods of case detection achieve higher levels of registration. The association between registration and better care does not prove causality but an effective call-recall system is impossible without complete registration.

Aged↗
PubMed1998

Does quality of reports of randomised trials affect estimates of intervention efficacy reported in meta-analyses?

BACKGROUND: Few meta-analyses of randomised trials assess the quality of the studies included. Yet there is increasing evidence that trial quality can affect estimates of intervention efficacy. We investigated whether different methods of quality assessment provide different estimates of intervention efficacy evaluated in randomised controlled trials (RCTs). METHODS: We randomly selected 11 meta-analyses that involved 127 RCTs on the efficacy of interventions used for circulatory and digestive diseases, mental health, and pregnancy and childbirth. We replicated all the meta-analyses using published data from the primary studies. The quality of reporting of all 127 clinical trials was assessed by means of component and scale approaches. To explore the effects of quality on the quantitative results, we examined the effects of different methods of incorporating quality scores (sensitivity analysis and quality weights) on the results of the meta-analyses. FINDINGS: The quality of trials was low. Masked assessments provided significantly higher scores than unmasked assessments (mean 2.74 [SD 1.10] vs 2.55 [1.20]). Low-quality trials (score < or = 2), compared with high-quality trials (score > 2), were associated with an increased estimate of benefit of 34% (ratio of odds ratios [ROR] 0.66 [95% CI 0.52-0.83]). Trials that used inadequate allocation concealment, compared with those that used adequate methods, were also associated with an increased estimate of benefit (37%; ROR=0.63 [0.45-0.88]). The average treatment benefit was 39% (odds ratio [OR] 0.61 [0.57-0.65]) for all trials, 52% (OR 0.48 [0.43-0.54]) for low-quality trials, and 29% (OR 0.71 [0.65-0.77]) for high-quality trials. Use of all the trial scores as quality weights reduced the effects to 35% (OR 0.65 [0.59-0.71]) and resulted in the least statistical heterogeneity. INTERPRETATION: Studies of low methodological quality in which the estimate of quality is incorporated into the meta-analyses can alter the interpretation of the benefit of intervention, whether a scale or component approach is used in the assessment of trial quality.

Bias↗
PubMed1998

Methodology and reports of systematic reviews and meta-analyses: a comparison of Cochrane reviews with articles published in paper-based journals.

CONTEXT: Review articles are important sources of information to help guide decisions by clinicians, patients, and other decision makers. Ideally, reviews should include strategies to minimize bias and to maximize precision and be reported so explicitly that any interested reader would be able to replicate them. OBJECTIVE: To compare the methodological and reporting aspects of systematic reviews and meta-analyses published by the Cochrane Collaboration with those published in paper-based journals indexed in MEDLINE. DATA SOURCES: The Cochrane Library, issue 2 of 1995, and a search of MEDLINE restricted to 1995. STUDY SELECTION: All 36 completed reviews published in the Cochrane Database of Systematic Reviews and a randomly selected sample of 39 meta-analyses or systematic reviews published in journals indexed by MEDLINE in 1995. DATA EXTRACTION: Number of authors, trials, and patients; trial sources; inclusion and exclusion criteria; language restrictions; primary outcome; trial quality assessment; heterogeneity testing; and effect estimates. Updating by 1997 was evaluated. RESULTS: Reviews found in MEDLINE included more authors (median, 3 vs 2; P<.001), more trials (median, 13.5 vs 5; P<.001), and more patients (median, 1280 vs 528; P<.001) than Cochrane reviews. More Cochrane reviews, however, included a description of the inclusion and exclusion criteria (35/36 vs 18/39; P<.001) and assessed trial quality (36/36 vs 12/39; P<.001). No Cochrane reviews had language restrictions (0/36 vs 7/39; P<.01). There were no differences in sources of trials, heterogeneity testing, or description of effect estimates. By June 1997, 18 of 36 Cochrane reviews had been updated vs 1 of 39 reviews listed in MEDLINE. CONCLUSIONS: Cochrane reviews appear to have greater methodological rigor and are more frequently updated than systematic reviews or meta-analyses published in paper-based journals.

Meta-Analysis as Topic↗
PubMed1996

Who needs antiplatelet therapy?

A series of overviews or meta-analyses of randomized clinical trials prepared by the Antiplatelet Trialists' Collaboration were published in the British Medical Journal in January 1994. They demonstrated that prolonged courses of medium-dose aspirin were very effective at preventing both fatal and non-fatal myocardial infarction and stroke in patients at high risk of occlusive vascular disease. The aim of this review is to provide the general practitioner with a practical guide to the use of aspirin in patients at high and low risk of occlusive vascular disease and to discuss appropriate dosages and contraindications to treatment in the light of all the recent evidence.

Aspirin↗