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In order to give the best care to patients and families, paediatricians need to integrate the highest quality scientific evidence with clinical expertise and the opinions of the family.1Archimedes seeks to assist practising clinicians by providing “evidence based” answers to common questions which are not at the forefront of research but are at the core of practice. They are based on an original format from the Journal of Accident and Emergency Medicine.2
A word of warning. These best evidence topic summaries (BETs) are not systematic reviews, though they are as exhaustive as a practising clinician can produce. They make no attempt to statistically aggregate the data, nor search the grey, unpublished literature. What Archimedes offers are practical, best evidence based answers to practical, clinical questions.
Each topic follows the same format. A description of the clinical setting is followed by a structured clinical question. (These aid in focusing the mind, assisting searching,3 and gaining answers.4) A brief report of the search used follows—this has been performed in a hierarchical way, to search for the best quality evidence to answer the question.5 A table provides a summary of the evidence and key points of the critical appraisal. For further information on critical appraisal, and the measures of effect (such as number needed to treat, NNT), books by Sackett6 and Moyer7 may help. A commentary is provided to pull the information together, and for accessibility, a box provides the clinical bottom lines.
Readers wishing to submit their own questions—with best evidence answers—are encouraged to read the Instructions for Authors at http://www.archdischild.com. Three topics are covered in this issue of the journal.
Does iron have a place in the management of breath holding spells?
Is omeprazole helpful in the management of children with reflux oesophagitis?
Does oral sucrose reduce the pain of neonatal procedures?
For the uninitiated, the realm of economic analysis appears a fiery pit of sulphur, brimstone, and fiends. I am assured it doesn't get much better after initiation. A short guide to the types of analysis follows:
Cost minimisation: Reports only costs—should be used when good data support the equivalence of the options presented.
Cost effectiveness: Reports the costs and clinical effectiveness of various options, using “natural units” (e.g. years of life, symptoms scores, etc). Does not include utility adjusted reports (see next).
Cost utility: Reports the costs and utilities of option. Utilities are an assessment of quality of life, generally scored from 0 (worst) to 1 (best), and summarised as the equivalent number of years at utility = 1; the quality adjusted life year or QALY. Utilities are measured in various ways, for example: rating scales (“How's life with asthma—from 0 to 10?”); time trade off (“If I could cure you of your diabetes, but you died in five years, would it be worth it? How about 10 years? 15?”); or standard gamble (“If I had a treatment for your cerebral palsy, worked perfectly in 9/10 cases but killed in 1/10, would you take it? How about if it killed in 1/100? etc”).
Cost benefit: Report where the utilities have been given monetary values and an overview is given.