Despite more than a decade of research on hospitalists and their performance, disagreement still exists regarding whether and how hospital-based physicians improve the quality of inpatient care delivery. This systematic review summarizes the findings from 65 comparative evaluations to determine whether hospitalists provide a higher quality of inpatient care relative to traditional inpatient physicians who maintain hospital privileges with concurrent outpatient practices.n = 65). After proposing a conceptual framework for evaluating inpatient physician performance, major findings on quality are summarized according to their percentage change, direction and statistical significance.Articles on hospitalist performance published between January 1996 and December 2010 were identified through MEDLINE, Embase, Science Citation Index, CINAHL, NHS Economic Evaluation Database and a hand-search of reference lists, key journals and editorials. Comparative evaluations presenting original, quantitative data on processes, efficiency or clinical outcome measures of care between hospitalists, community-based physicians and traditional academic attending physicians were included (n = 30), patients lost to follow-up (n = 42) and estimates of effect or random variability (n = 35); inappropriate use of statistical tests (n = 55); and failure to adjust for established confounders (n = 37).The majority of reviewed articles demonstrated that hospitalists are efficient providers of inpatient care on the basis of reductions in their patients' average length of stay (69%) and total hospital costs (70%); however, the clinical quality of hospitalist care appears to be comparable to that provided by their colleagues. The methodological quality of hospitalist evaluations remains a concern and has not improved over time. Persistent issues include insufficient reporting of source or sample populations (Future research should include an expanded focus on the specific structures of care that differentiate hospitalists from other inpatient physician groups as well as the development of better conceptual and statistical models that identify and measure underlying mechanisms driving provider-outcome associations in quality. In recent years, escalating healthcare costs, a rising prevalence of chronic comorbid diseases and increasing dependence on new technologies have combined to change the nature of inpatient care in North America. Faced with a growing need for cost-effective delivery, hospitals increasingly require that their practicing physicians enhance patient flow and lower operating costs while improving the clinical quality of care provided to their patients. In light of these demands, many hospitals have adopted the hospitalist model as one of the primary methods of achieving these objectives. First introduced in 1996, hospitalists, defined as physicians who specialize in delivering comprehensive medical care to hospitalized patients, have become one of the dominant groups of healthcare providers of inpatient care in North American hospitals . Upon diAdvocates of the hospitalist model argue that hospitalists offer a number of advantages compared with traditional inpatient physician models. The on-site availability of a hospitalist ensures that a dedicated provider is readily available to answer questions, order and manage tests and respond during acute medical crises. By specializing in the management and treatment of common inpatient conditions, this routinization of care is also argued to enhance hospitalists' clinical expertise in complex and comorbid disease management, translating to improved clinical processes and potentially better patient outcomes in comparison to their colleagues, who may manage fewer cases of a given condition over the same period of time -7. On-siIn 1998, researchers began evaluating the performance of newly instituted hospitalist programs by comparing full-time hospitalists to traditional academic attending physicians or community-based physicians on the basis of core indicators of effectiveness and efficiency ,14. WhilThe current systematic review synthesizes the findings of 65 evaluations of hospitalist performance to determine whether the hospitalist model improves the quality of inpatient care delivery compared to traditional inpatient physician models. After proposing a conceptual framework for evaluating hospitalist performance, major findings are summarized according to three core areas of quality: the processes of care delivery, operating efficiency and clinical outcomes of treatment. We also critique the methodological quality of selected publications, exploring whether the quality of hospitalist evaluations have improved over time and offering recommendations to guide the design and analysis of future comparative evaluations.Although several systematic reviews of hospitalist care have been published, most recent reviews were restricted to specific subsets of the hospitalist literature  and key editorials.A comprehensive search of the literature was conducted using MEDLINE, Embase, Science Citation Index, CINAHL and the NHS Economic Evaluation Database for the following exploded medical subject heading terms and keywords: "hospitalist" and "hospital-based medicine." The search was restricted to abstracts published between January 1996 and December 2010, excluding conference abstracts. No language restrictions were imposed. Additional citations were then identified through manual searches of the references and works-cited lists of selected articles as well as previous systematic reviews, relevant journals  describe a comparative analysis between physicians identified or labelled as 'hospitalists' and traditional inpatient physician models involving community-based physicians, traditional academic attending physicians or a combination of both; 2) generate original, quantitative data in one of the three healthcare quality areas of interest ; (3) differentiate hospitalists from their counterparts in terms of their structural attributes ; and (4) include a sample population of hospitalized patients. Using these prespecified criteria, abstracts were independently assessed, with any discrepancies resolved by consensus. Seventy-seven articles met these initial inclusion criteria. Upon examination of the full papers, five of these articles were excluded because control patients received significant cross-over of care from the hospitalist physicians -34, and  generateOne author (HLW) extracted data on each study's design, sample and source population characteristics, institutional setting, a description of hospitalist and comparative care models, risk adjustment techniques employed, and relevant findings. Hospitalist practice models were then classified into three broad design types: private hospitalists hired on contract to provide inpatient care at one or more institutions, salaried faculty hospitalists with no teaching responsibilities, and academic hospitalist attending physicians who worked on the inpatient unit for three to twelve months per year and were involved in the training of residents and medical students. Comparison physicians were similarly classified according to the following traditional practice models: outpatient practices  and traditional academic attending physicians who served on the inpatient unit for one to three months per year supervising residents and medical students and maintaining outpatient clinic hours while on-service. Multiple practice types and the use of comanagement models, physician's assistants, nurse practitioners, and discharge planners are indicated where appropriate.P value ≤0.05 was reported. Summary measures based on unadjusted analyses are indicated by asterisks (*), and those without accompanying P values or confidence intervals are indicated by an alveolar click (ǂ).The major findings from the included studies were synthesized within our conceptual framework according to the following three areas of quality: processes of care delivery, operating efficiency, and clinical outcomes of treatment. Relationships are summarized by each indicator's percentage change, direction, and statistical significance. A summary of the 65 included articles and their overall findings are presented in Table To assess the methodological quality of the included literature, we used a 27-item checklist developed by Downs and Black  that wasDescriptive characteristics summarizing the 65 articles are presented in Table n = 7; 78%). The remaining 56 evaluations used one of the following observational designs: interrupted time series , prospective cohorts , retrospective cohorts , and before and after . In most observational studies, the design of the hospitalist intervention precluded randomization as community-based physicians elected to manage their own hospitalized patients.Only one of the sixty-five reviewed articles employed a true randomized, controlled study design in which the first patient enrolled was randomly allocated to either hospitalist or traditional care at the time of admission . Subsequn = 27; 42%). Twenty-five evaluations examined outcomes among adults ages 18 and older, three were restricted to older adults (ages 65 and older), and ten focused on paediatric patients. Among the 63 evaluations conducted in the United States, insurance status was rarely used as an exclusion criterion . Four studies examined outcomes of hospitalist care among commercial health maintenance organization (HMO) enrolees, three evaluated Medicare or Medicaid recipients, and one involved a source population who received care through Veterans Affairs hospitals [The majority of studies were not restricted with respect of the ages of study participants . Of the eleven evaluations conducted across multiple facilities, ten included at least one teaching hospital (91%). While most articles evaluated quality of care among patients in a general medical or surgical service , one was restricted to the provision of care within the ICU [Eighty-three percent of all evaluations were conducted within teaching hospitals or units and involved single-site comparisons  and 49% (n = 32) of publications, respectively. Thirteen evaluations compared the quality of inpatient care among patients managed on academic ward teams led by hospitalist attending physicians with those managed by traditional academic physicians attending on the inpatient service for one to three months per year (20%). Seventeen additional evaluations compared patients in nonteaching hospitalists with those managed by traditional academic attending physicians (26%), and seven compared patients of academic hospitalists to patients managed by community-based physicians (11%). Fourteen evaluations compared the performance of nonteaching hospitalists with community-based physicians (22%), and the fourteen remaining articles involved comparisons across several different physician models (22%). Finally, seven articles examined hospitalist comanagement practices in which hospitalists provided general medical care to patients assigned to surgical (n = 6) or cardiac (n = 1) teaching teams.Considerable variation exists in the number of study participants and healthcare providers included across evaluations  of the 65 reviewed articles demonstrated improved quality under hospitalist care on at least one indicator. Three additional papers suggested similar trends in performance (4%); however, the authors failed to report the statistical significance of their findings ,60,61. On = 9; 35%), followed by several indicators of resource utilization, including radiology , laboratory testing , and the use of haematology services . These outcomes were frequently identified retrospectively on the basis of hospital administrative and financial databases, although primary chart abstraction was used for some indicators in 11 evaluations (42%).Twenty-six comparative evaluations examined the processes of care delivery between hospitalists and their colleagues. Among these evaluations, twenty-two indicators of clinical processes and five indicators of interpersonal processes were examined. Clinical process indicators included measures of diagnostic and procedural utilization, adherence to evidence-based clinical practice guidelines for the treatment of common conditions and ICU transfers, while interpersonal process indicators explored consultation rates to various subspecialty providers, the frequency of family contact, and communication patterns with patients' primary care physicians. Subspecialty consultation rates were the most commonly explored process indicator of hospitalist quality (n = 4). Only one of the three articles reported minor improvements in cardiac testing among nonacademic hospitalists compared to community-based physicians; however, the utilization of diagnostic testing by hospitalists remained higher and more invasive than that provided by cardiologists [On the basis of our review of the literature, there appear to be few differences in the processes of care delivery between hospitalists, traditional academic attending physicians, and community-based physicians. Of the eleven studies conducted to evaluate the utilization of ancillary services , only four studies reported significant declines in the number of services used by hospitalists, three of which were based on unadjusted analyses ,65,66. Nologists .n = 6), and one article described increased use of ICUs by hospitalists for patients with advanced stage lung cancer during these patients' final hospitalization [Only two of nine studies found significant declines (22%) in subspecialty consultation rates ,68, one lization . While olization ,53, theret al. [et al. found no significant differences in processes of care between managing physicians, regardless of the physicians' prior experience in managing patients with known HIV infection [Hospitalist and nonhospitalist physicians were equally likely to provide core measures of care for patients with pneumonia and immunosuppression. While Rifkin et al.  found thet al. -73. Siminfection . Hospitanfection , anothernfection . Neithernfection . No signP = 0.14). Nonhospitalist healthcare providers were similar in their use of opioids, although hospitalists were more likely to prescribe long-acting benzodiazepines in the 48 hours prior to death to aid patients' comfort and anxiety.While less evidence is available regarding best practices for palliative care, the on-site availability of hospitalists may lead to enhanced efforts to communicate with dying patients and their families, resulting in improvements in the quality of end-of-life care. In a comprehensive study of palliative care patterns by academic hospitalists and community-based physicians, Auerbach and Pantilat  found thFifty-nine articles examined the efficiency of care delivery between inpatient physician models, the findings of which are summarized in Figure n = 22), and less than one-third of these used methods to adjust for the clustering of patients within physicians (n = 6). Thirteen evaluations found no significant differences in length of stay between healthcare providers (22%), the majority of which involved comparisons between hospitalist and traditional attending physicians , and seven evaluations reported longer lengths of stay among hospitalists (12%). Fifty-seven percent of these evaluations involved comparisons between private hospitalists hired on contract and traditional academic attending physicians (n = 4).As illustrated in Figure n = 7), and 63% of investigations showed similar cost reductions between nonacademic hospitalists and traditional academic attending physicians (seven of eleven studies). Three evaluations reporting lower costs by hospitalists added length of stay as a covariate to their regression analyses [Of the 43 articles examining hospital costs or charges, 27 showed significant reductions in the average or median cost of care under the hospitalist model (63%). Three additional papers suggested similar cost savings; however, the authors of these papers failed to disclose the statistical significance of their findings ,61,78. Canalyses ,79,80. IHospitalists may also improve the timeliness of emergency surgical care. In three studies where admission and preoperative assessments were conducted by hospitalists as opposed to a member of the surgical team, mean time to surgery was reduced by 35% to 50% ,81,82. An = 35; 69%), and chart validation occurred in five of these evaluations (n = 14%). A summary of the findings is displayed in Figure Fifty-one evaluations examined the relationship between hospitalist delivery models and clinical outcomes of treatment. Outcomes were frequently identified retrospectively using patient-level data captured in discharge databases and/or death registries , although seven studies looked at death within other periods after discharge . Seven of the thirty-five evaluations reported significant declines (20%) in mortality rates among hospitalist providers, including two quasi-experimental studies [n = 34; 79%). Six authors reported declines in readmissions within 30 days of discharge [Although our analysis suggests that hospitalists can improve the efficiency of inpatient care delivery, there is little evidence to suggest this translates into measurable improvements in the effectiveness of care provision to their patients. Thirty-seven studies analyzed mortality or survival rate as one indicator of hospitalist quality. Mortality was most frequently defined as occurring 'in-hospital' , emergency department and outpatient follow-up visits within 30 days of discharge , patient and/or parent satisfaction (n = 8), and patients' self-reported health (n = 3). Five of the eight articles which examined complications or adverse events found no significant differences between providers [et al. [et al. [Additional outcome indicators included in-hospital complications and adverse events , and forty-three percent did not describe their sample and/or source populations or state patient inclusion or exclusion criteria (n = 30). More than half of reviewed articles did not describe the intervention and comparative care in enough detail to determine how many physicians actually delivered care to the patient sample and how this might have differed from care provided to the source population (n = 34). Only 22% of study authors included a statement on whether physicians were provided incentives to enhance their quality or efficiency (n = 14), and 34% of study authors did not indicate whether hospitalist care was mandatory for their patients (n = 22). These two issues are of particular concern, as their disclosure is necessary for interpreting the validity of any performance variations demonstrated across providers.Despite more than a decade of research on hospitalist performance and several calls to improve the rigor of study design, reporting, and analyses ,20,25,90n = 30), only 15% used the appropriate hierarchical or clustered methods necessary for linking physician characteristics to patient outcomes in studies of provider performance. All of these issues decrease the internal validity of hospitalist evaluations, making it difficult for readers, clinicians, and policy analysts to assess the extent to which improvements in performance outcomes can be attributed to hospitalist care as opposed to unmeasured or unadjusted confounding variables.More than half of all studies also contained serious methodological errors, many of which could have been easily corrected. Twenty-six evaluations (40%) used insufficient sample sizes to demonstrate a clinically meaningful effect, and thirty-five (54%) appeared to use the wrong denominators when calculating incidence and risk for treatment outcomes . Fifteen studies (23%) made no attempt to adjust findings for potential confounding or bias, and another twenty-two studies (34%) used partially adjusted models that excluded one or more known confounders, such as patient age, sex, and/or insurance status; case mix; and the severity of the patient's condition. Finally, while 51% of studies used analyses that adjusted for some confounding factors in multivariable models . Calculating each article's percentage rating (study score ÷ 32), articles with poor quality ratings  typically had missing descriptions of source populations, inclusion and exclusion criteria, and the number of hospitalist and comparative care providers, all of which limit the external validity and representativeness of potentially important findings. The majority of poor quality studies also failed to disclose numerators or denominators for their outcome data (78%) and estimates of random variability (75%) for one or more main indicators, making it impossible for readers to assess the accuracy of the authors' analyses and conclusions. In contrast, articles with high quality ratings  were transparent in their reporting, used randomized or quasi-randomized designs (67%), and made extensive attempts to account for selection bias and known sources of confounding (100%), all of which translated to high internal and external validity. It should be noted that because of the nature of inpatient care, it would be difficult for any study evaluation to obtain a perfect quality score, as concealment of allocation, even after randomization, is rarely feasible.Restricting studies to those conducted since the publication of Coffman and Rundall's systematic review  demonstrn = 14). The findings appear to be consistent with our earlier conclusions, suggesting improved efficiency by hospitalist providers (86%) with no subsequent improvements in processes (67%) or clinical outcomes of care (71%). Of the three studies which showed better [n = 35; 77%) were equally likely to report gains in efficiency, they were also more likely to report improvements in the processes (54%) and outcomes of care (30%), the majority of which were unadjusted (70%) and likely driven by confounding.To assess the sensitivity of our conclusions to the methodological quality of the literature, we examined performance outcomes for those studies that received adequate or high quality ratings ; however, there were few significant differences between physicians on process measures  or clinical outcomes . Taken together, our review of the current evidence suggests that hospitalists provide a level of clinical care that is comparable to that of their colleagues; however, their enhanced on-site availability and additional time spent on service suggests that the hospitalists' primary value likely comes from their ability to provide the same quality of clinical care in shorter periods of time, as evidenced by reductions in patients' average length of hospital stay reported in selected studies. Decreases in operating costs appear to be achieved largely by an increase in patient processing as opposed to reductions in the type and intensity of services provided. While there is no evidence to suggest that hospitalists provide a higher quality of clinical care, improvements in efficiency do not appear to come at the expense of clinical outcomes or patient and family satisfaction.Despite these promising findings, many of the included studies had important methodological limitations, which decreases our confidence that findings reflect an accurate indication of hospitalist performance. Small sample sizes and inadequate statistical power were an issue in many studies, making it difficult to comment on whether hospitalists can decrease the incidence of rare outcomes such as in-hospital mortality or readmissions. The nonrandom allocation of patients frequently resulted in selection bias to preferred physician structures, where important covariates such as patient age, sex, ethnicity, insurance status, and preexisting comorbidities were often excluded from statistical models. Together, these factors resulted in poorly matched comparison groups and unadjusted biases. Finally, the statistical analyses used in selected studies were rarely conducted appropriately. Clinical indicators were frequently estimated among populations that were not actually at risk for the outcomes of interest, and inferences about quality were made at the level of providers without accounting for the clustering of patients within physicians. Furthermore, these methodological issues persist despite numerous calls urging researchers to enhance the rigor and reporting of the care provided by hospitalists compared with that offered by other healthcare providers.et al. [n = 35), we found little evidence to support processes or outcome improvements by hospitalists; however, 40% (n = 13) of the evaluations included in Peterson's review were found to have low quality scores in our review using the modified Downs and Black checklist [Our findings are consistent with those reported in previous systematic reviews by Coffman and Rundall  and Landet al.  suggestiet al. , which fhecklist .In this systematic review, we propose a modified version of Donabedian's  frameworRecognizing that hospitalists are now firmly entrenched within a large proportion of North American hospitals, if we wish to improve the quality of inpatient care delivery and introduce funding models that reward providers and/or institutions on the basis of their performance, further descriptive research labelling, categorizing, and analyzing of physicians according to their practice structures alone is unlikely to advance the research field in a way that will help inform organizational decision-making or health policy. Future research should instead shift toward developing better conceptual and theoretical models that identify and measure specific structural differences between physician practices, organizational issues that affect hospitalist groups, and the process mechanisms whereby hospitalist-based physicians have an increased opportunity to intervene.et al. [On the basis of the findings of this review, we suggest that one of the key structural characteristics driving efficiency improvements among hospitalists is likely the increased time spent attending on the inpatient service and its subsequent impact on inpatient volume. Hundreds of articles published over the past three decades have shown that processes utilized and outcomes of care achieved are better among healthcare providers who perform them more frequently ,91. Theset al. , who fouBy examining the quality of general inpatient care as a function of a physician's annual case volume, we can also extend the application of this literature to other healthcare models around the world which have instituted parallel inpatient practices without necessarily establishing formalized hospitalist programs. For example, inpatient care delivery in Australia, New Zealand, the United Kingdom, Singapore, and several other former British colonies is similar to the North American hospitalist model in that primary care is handed over to a separate system of specialists and consultants  once a patient is admitted. Like the hospitalist, the specialist then 'owns' the patient for the duration of hospitalization, providing the majority of their clinical services within the hospital setting. In this manner, several structural characteristics of the hospitalist and specialist models overlap: Both have high annual inpatient volume, which theoretically enhances clinical expertise and improves patient outcomes, and both operate in a routine environment where familiarity with staff, services, and technological resources support efficient practice. There are, however, a few key differences. Hospitalists tend to practice using a team-based approach where patients, call hours, and vacation time are rotated according to prearranged contracts, while specialists still tend to operate individually, negotiating their work hours directly with the hospital administration. Furthermore, inpatient specialists frequently hold higher levels of medical certification than many North American hospitalists, especially in Canada, where more than 90% of hospitalists hold only a general medical licence and no formalized training in hospital medicine . FinallyInterestingly, none of the hospitalist evaluations published to date have examined process indicators relating to the timeliness of care delivery, which would theoretically drive efficiency gains within our conceptual framework. In addition, transitions of care and communication patterns among hospitalists, patients, and their primary care physicians remain virtually unexplored and are important areas for further work. While computationally complex, this review highlights the need for multilevel, multisite studies which integrate the organizational effects of hospitals with more complete and informative data on the structure of hospitalist programs when undertaking evaluations of provider performance. Superior statistical models need to be used that control for patient, physician, and hospital-level confounding to understand whether higher inpatient quality reflects better hospital staffing and/or administration, organizational cultures that support hospitalist groups, or true improvements in the processes of care delivery by hospitalist physicians. Finally, the general quality of reporting in published studies can be improved by stating source populations, any inclusion versus exclusion criteria, patient and physician sample sizes within each comparison arm, and the number of patients lost to follow-up or excluded because of missing data. Disclosure of any performance incentives and funding sources, as well as the role of additional healthcare providers, should also be encouraged.a priori according to the Participants, Interventions, Comparisons and Outcomes, or PICO, method [To our knowledge, this is the most comprehensive review of hospitalist performance conducted to date. While formal registration of the review was not undertaken, extensive attempts were made to prevent review-level bias, and the design, population, research questions, and literature search methods were all specified , method  as well , method . We incl, method . We testDespite these strengths, several weaknesses in our review should be noted. Given the heterogeneity of designs and outcomes examined among studies, we were unable to conduct formal meta-analyses or generate summary estimates of risk for any of the outcome measures. While meta-analysis would be powerful for estimating the overall impact of hospitalists on the effectiveness and efficiency of inpatient care delivery, the validity of this approach rests largely on the quality of reporting in the original studies, and 53% of the reviewed studies did not report enough information to compute standard effect sizes and/or margins of error. The pooling of results is also considered inappropriate when unadjusted biases are suspected. Despite this limitation, decreases in the length of stay and the cost of care were demonstrated across all practice settings and patient populations, strongly suggesting that hospitalists do improve the efficiency of care delivery. Assessing the methodological quality of individual studies is widely accepted as good practice in systematic reviews of randomized, controlled trials; however, the use of quality assessment tools to appraise observational studies is less established. We used a validated and reliable checklist that has demonstrated high internal consistency and good test-retest and interrater reliability for both randomized and nonrandomized studies . NonetheDespite the methodological limitations that decrease the quality of the published literature on hospitalist performance, common themes emerged from this review. Hospitalist physicians are efficient providers of inpatient care as observed by reductions in patients' average length of stay and total hospital costs; however, the clinical quality of hospitalist care is comparable to that provided by their colleagues. Opportunities for further research include an expanded focus on the specific structures of care that differentiate hospitalists from other inpatient physicians as well as on the development of better conceptual and statistical models that identify and measure the pathways of care that these structural differences are thought to influence.The authors declare that they have no competing interests.HLW conceived of the systematic review, performed data collection and drafted the manuscript for publication. RHG and HLW were jointly responsible for the study's design, analyses and interpretation. Both authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1741-7015/9/58/prepubIndividual study results on hospitalist performance. Contains detailed results from the 65 included articles stratified by the type of quality area examined .Click here for fileChecklist for assessing study quality, modified from Downs and Black. [d Black. . ProvideClick here for filePRISMA Checklist: Do Hospitalist Physicians Improve the Quality of Inpatient Care? [nt Care? .Click here for file


Since 2004, the HIV Vaccines and Microbicides Resource Tracking Working Group has employed a comprehensive methodology to track resource trends in R&D for biomedical HIV prevention options, including HIV vaccines, microbicides, PrEP, treatment as prevention, vertical transmission prevention and adult voluntary medical male circumcision.Data were collected on annual disbursements by public, private and philanthropic funders for product development, clinical trials and trial preparation, community education and policy advocacy efforts in order to estimate annual investment in HIV prevention R&D. Investment trends were assessed and compared by year, prevention technology type, type of funder and geographic location.Since 2000, there has been significant growth in funding support for HIV prevention research and development. However, in 2011 HIV prevention research began to face increased funding pressures as governments worldwide decreased or flat-lined budgets in many areas of global health and as philanthropic donors worked to revise their investment strategies. Competing funding priorities affected funding for HIV prevention R&D. Still, despite those various funding pressures, the field of HIV prevention research progressed significantly in 2011, with new findings that advanced the field and promising new trials underway.Monitoring funding trends for HIV prevention research is particularly important at this time of critical juncture between economic uncertainty and the point at which the scientific community has articulated a much clearer pathway to the end of the HIV epidemic. Monitoring funding provides the fact base for policy advocacy around spending levels and allocations that will sustain investments in the research required to build on the success of recent trials; bring novel HIV prevention candidates into the pipeline; and support the follow-on clinical trials needed to assure the safety, immunogenicity, efficacy and acceptability of new HIV prevention products.


Due to physiological and cognitive changes that occur with aging, accurate physical activity (PA) measurement in older adults represents a unique challenge. The primary purpose of this study was to systematically review measures of PA and their use and appropriateness with older adults. A secondary aim was to determine the level of agreement between PA measures in older adults.Literature was identified through electronic databases. Studies were eligible if they examined the correlation and/or agreement between at least 2 measures, either indirect and/or direct, of PA in older adults (> 65 years of age).Thirty-six studies met eligibility criteria. The indirect and direct measures of PA across the studies differed widely in their ability to address the key dimensions  of PA in older adults. The average correlation between indirect and direct measures was moderate (r=0.38). The correlation between indirect and other indirect measures (r=0.29) was weak, while correlations between direct measures with other direct measures were high . Agreement was strongest between direct PA measures with other direct measures in both real world and laboratory settings. While a clear trend regarding the agreement for mean differences between other PA measures  did not emerge, there were only a limited number of studies that reported comparable units.Despite the lack of a clear trend regarding the agreement between PA measures in older adults, the findings underscore the importance of valid, accurate and reliable measurement. To advance this field, researchers will need to approach the assessment of PA in older adults in a more standardized way . Until then researchers should be cautious when choosing measures for PA that are appropriate for their research questions and when comparing PA levels across various studies. Older adults represent one of the fastest growing segments of our population. Worldwide, the proportion of adults aged 65 years and over was about 8 percent 521 million) in 2011 and it is anticipated that they could account for about 11 percent 939 million) of the total population by 2030[ million 9 millionCurrent physical activity (PA) guidelines encourage older adults to engage in at least 150 minutes of moderate- to vigorous-intensity aerobic PA per week and to engage in muscle and bone strengthening activities at least 2 days per week,5. DespiInterventions aimed at improving levels of PA  p. 126, in olderIndirect measures rely on self-report,20-22 anDirect measures of PA assess energy expenditure or actuaRecent systematic reviews have compared direct and indirect measures of PA in adult and pediLiterature searches of direct and indirect PA measures in older adults were conducted using ISI Web of knowledge, AgeLine, PsychINFO, Medline, and SPORT Discus  did not compare at least two measures of PA, (2) involved a target population that included any participants less than 65 years of age, (3) were not written in English, or (4) were dissertations or conference presentations. Eligible direct measures included pedometry, accelerometry, heart rate monitoring, direct and indirect calorimetry, doubly labeled water, and direct observation. Eligible indirect measures included questionnaires, surveys, interviews, and activity records/logs/diaries. Other report  was considered an ineligible measure due to the possible heterogeneity of reporters .The primary author initially screened identified studies based on the study title and abstract. Duplicates, articles that were not published in English, and irrelevant studies were manually removed. Potential studies were briefly scanned to see if they met eligibility criteria. Manual cross-referencing of bibliographies of the selected articles was also completed , direct measures, units of measurement for direct measure, duration of direct measurement, indirect measures of PA, units of measurement for indirect measurement, length of recall, and time between each PA measure, correlations, and mean differences were extracted by the one author (KK) and a second author checked the data (RR). If level of agreement was not reported in the reviewed articles, but the units of measurement were comparable percent mean difference (indirect mean – direct mean/direct mean × 100) or absolute mean differences (direct mean – direct mean or indirect mean – indirect mean) were calculated. Units were converted to comparable units whenever possible. In many cases, units across the various measures of PA were not comparable; therefore, it was not possible to examine agreement between these PA instruments. As such, average correlations between: 1) direct and indirect measures; 2) indirect and indirect measures, and 3) direct and direct measures were also computed and adjusted/weighted by sample size. Since the correlation coefficient is not a linear function of the magnitude of the relation between two functions, and cannot simply be ‘averaged’, all correlations  were first converted to Fisher’s Z, means and 95% confidence intervals (CIs) were computed, and then transformed back to correlation coefficients using CoA total of 8736 titles and abstracts were identified through online searches and were screened for inclusion. Of these records, 247 were examined more closely to determine their relevance after duplicates, non-English and clearly irrelevant articles (were not related to PA measurement) were eliminated. After eliminating additional studies that were not about PA measurement (N=7), did not examine at least 2 PA measures (N=134), did not involve the target population (N= 69), were dissertations, theses, and conferences/abstracts (N=1), 36 studies met inclusion criteria. Within these 36 studies, there were 21 studies that compared indirect with direct PA measures,26,32-50Of the 21 studies examining the relationship between direct and indirect PA measures, nineteen reported correlational analyses,42,45-50Participants in eligible studies ranged from 65 to 99 years of age. Sample sizes ranged from eight to more The quality of all included studies was assessed (n=36) using the tool described above. Scores on this tool ranged from 9 to 19 out of a maximum score of 22 points. The mean score on the tool was 14.7 (2.3). Of the 36 studies, 29 were considered modest quality (score of 6 to 16) and 7 were considered high quality (17 to 22). None were categorized as poor (0 to 5). Scores on the reporting criteria ranged from 3 to 9 (maximum 9 points) with a mean of 6.4 (1.3). The mean score on the external validity scale (out of 3) was 1.3 (0.5). The internal validity of the reviewed studies ranged from 2 to 10 with a mean score of 6.9 (1.6). For more information about the quality ratings see Additional fileThirty-two different indirect measures were used to assess PA in the identified studies. These can be divided into two broad groups of PA questionnaires  or activity logs ,23,66. TSelf-report measures were classified by type according to the system described by Neilson and colleagues. In thisAs can be seen from TableSix different types of direct measures were employed, including accelerometers, pedometers, doubly labeled water, indirect calorimetry, heart rate monitoring, and direct observation. Detailed description of these instruments is outside of the scope of this review. For more information about these direct measures of PA instruments please refer existing review chapters and websites on PA measurement e.g.,,21,23,66Four of the six measures permit calculation of type of activity by intensity, but provide very little or no information about the major types of PA. For exaThe results of studies of direct and indirect PA measures containing comparable units (n=6) are summarized in Table = 0.36 to 0.40). The average correlation between direct and indirect measures of total PA in samples of men only , studies including mixed samples of men and women  were also moderate, while the average correlation in samples of women only was weak .While only 6 studies contained comparable data between indirect and direct measures, many reported on the association between variables. The correlations between direct and indirect measures of total levels of PA, regardless of direct method employed, fell in the weak to high range (−0.02 to 0.79). When all studies regardless of sample  were considered, the average correlation between indirect and direct measurement of total levels of PA was moderate As can be seen in TableIn contrast to the limited studies evaluating agreement between indirect PA measures, many studies looked at the association of indirect measures with other indirect measures. Correlations between indirect measures of total levels of PA were in the weak to high range (0.15 to 0.85). When all studies , and studies including mixed samples of men and women  were considered average correlations between indirect measures of total PA were weak. When correlations in samples of women only were considered, the average correlation was moderate .The findings regarding agreement between direct measures are grouped into those that measured PA levels in the real world , the most common comparisons were between pedometers or accelerometer step counts and observed step counts . With self-paced walking, pedometers  generally underestimated observed step counts, with percent agreement varying from −13% to +2%-65. LikeTwo measures examined the agreement between indirect calorimetry and accelerometry in estimating energy expenditure during exercise ,62. AcceIn most cases, studies comparing direct PA measures examined agreement rather than correlation. Of the studies looking at real world PA behavior, three studies reported correlational analyses between direct methods of measuring PA  with correlations ranging from 0.37 to 0.97 ,43,55.The remaining studies also involved mixed samples of men and women and compared direct measures of PA in a laboratory setting with correlations varying considerably from weak (r =−0.28) for steps counted by direct observation and pedometry to stronReliable and valid assessment of PA in older adults is an important area of research. The quality of existing studies examining measurement of physical activity in older adults was moderate. Although the quality of the articles published on this topic was generally moderate and none of the studies were of poor quality, only 7 of the 36 studies were classified as high quality. These findings are informative but they need to be considered with some caution due to quality limitations of the studies at present. Without higher quality studies, significant gaps in our knowledge and understanding of PA measurement in older adults will remain. Higher quality research is needed to get a clearer picture of patterns of PA, to design interventions to promote PA, and to monitor changes in patterns of PA in older adults. To do so, researchers need to select valid measurement tools, and use stronger more consistent research methodology and superior reporting of results. Although systematic reviews of direct and indirect PA measurement tools have been conducted in adult and pediatric populations,22, to tThe indirect measures that were reviewed differed widely in their ability to address the key PA dimensions in older adults. While self-report measures, including the more detailed PA questionnaires and activity logs, can be an excellent source of information of the dimensions of PA  in older adults, key limitations with respect to their use in older adults were identified in the selected studies. For instance, the high prevalence of assigning metabolic equivalents to activities in the reviewed studies is problematic considering standard tables developed with younger populations tend to overestimate the intensity of PA in older adults populations. Age neuDirect measures of PA are generally considered to be more valid measures of PA than indirect measures. Like the reviewed self-report measures, the direct measures in this review varied in their ability to capture the key dimensions of PA. In particular, accelerometry and pedometry, the most frequently used direct measures in this review, are limited in their ability to capture type of activity. The direct measures in the selected studies were generally limited to the assessment of type of activity by intensity. While this PA dimension is very useful for addressing questions related to dose response to PA, it provides very limited information about the patterns of activity of older adults. Accelerometry, indirect calorimetry, and heart rate monitoring allow for evaluation of bouts of continuous activity above a predetermined intensity threshold, as well as total time above predetermined thresholds. These tools can provide a picture of the shorter and sporadic forms of activity in which older adults may participate. However, accelerometry, the least invasive and time intensive of the three types of measurement, is known to be less accurate at detecting PA at lower intensities, so bouts of continuous low intensity activity may be missed. Doubly labeled water, accelerometry, indirect calorimetry, and heart rate monitoring provide estimates of energy expenditure, however, there is a debate in the literature about the appropriateness of the calculations to estimate energy expenditure, especially for older adults populations,24,68.A major limitation identified in the studies of direct PA measures was the methodological inconsistencies across studies . Decisions about cut-points for classifying intensity levels, as well as selection of epoch lengths varied considerably across studies of accelerometers in this review. Moreover, within a single PA measurement tool, such as accelerometry, PA can be quantified in very different ways. For instance, the reviewed studies varied considerably in epoch lengths and cut-points for determination of PA intensity classifications and provided limited rationale provided for their choices. Although work has been done examining epoch lengths on estimates of physical activity in children, little research has been conducted with adults and even less with older adults. As has been found in recent work with post-menopausal women, it seems appropriate that shorter epoch lengths  will derive more accurate estimates of physical activity in populations of older adults than longer epoch lengths ; however, the same study also found that relations of physical activity to most health outcomes did not vary by epoch lengths. MoreoveAdditional objectives of this study were to assess the agreement and association between: 1) indirect and direct measures, 2) indirect and other indirect measures, and 3) direct and other direct measures. Unfortunately, a clear pattern regarding the agreement of measures in these three groups did not emerge. Inconsistency in the type of results reported and the lack of comparable data in studies comparing 1) indirect and direct measures and 2) indirect measures with other indirect measures precluded the evaluation of percent agreement (or absolute difference) in the majority of instances. Findings regarding agreement between direct measures with other direct measures were mixed, with some measures yielding high levels of agreement and others not. Most studies of agreement between direct measures in this review examined accelerometers, pedometers, and direct observation. The limited scope of current research examining agreement between PA measures makes it difficult to compare across studies and to generalize results.Studies of older adults relied primarily on correlational analyses to compare and to validate measures of PA in older adults. Similar to the systematic reviews of Adamo and colleagues and PrinDespite the lack of clear trend regarding the agreement of PA measures in older adults, the findings provide useful information about research needs in this important field. Consistent with papers on pediatric and adult population agreement and correlations between measures were weak to moderate. The measurement of PA is complex across all populations and as one can see from this review, the measurement of PA involves additional unique challenges in older adults. Not only does PA involve a number of separate dimensions, but it also is not a static behavior. We cannot assume that physical activities are performed at the same intensity across person or time. There is considerable inter-individual variability  and intra-individual variability . Moreover, the accuracy of our instruments also contributes to the weak to moderate correlations and agreement between measures.Choosing the appropriate tool to measure PA in older adults is also complex. PA levels and patterns are more a reflection of biological age than chronological age. However, as Shephard points oWith regards to the appropriateness of PA measures in older adults, qualitative work is needed to help gain a better understanding of how older adults feel about these methods of measurement and the level of burden that is being place on them. Moreover, qualitative work can be used to help design new measures that address PA constructs specific to older adults or to improve on existing measures. Further work is needed to develop standard metabolic cost tables and equations that are specific to older adults. Questionnaire items should also be carefully developed to address not only the types of activities in which older adults participate and the generally more sporadic nature of older adult’s activities, but should also allow older adult to report on their perceived intensity during activity to allow for exploration of this important aspect of their PA. With regards to direct PA measures, further work is needed to address methodological inconsistencies , especially in older adults where limited research has been conducted. Achieving consensus within the research community in this regard is an important research goal. Assessment of factors such as health status, medical conditions and medications, changes in mood, depression, and anxiety, and fatigue, pain, and concentration and distractibility,22,23 thIn conclusion, considerable work is needed to advance the field of PA measurement in older adults. There are significant gaps in our knowledge about agreement between PA measures in older adults. Researchers should be cautious when choosing measures for PA and in comparing PA levels across studies, especially when different tools are being used.PA: Physical activity; GPS: Global positioning systems; CI: Confidence interval; PASE: Physical Activity Scale for the Elderly; CHAMPS: Community Healthy Activities Model Program for Seniors Activities Questionnaire for Older Adults; YPAS: The Yale Physical Activity Survey; PAQ: Physical activity questionnaires; FITT: Frequency, Intensity, Type, Time.The authors declare that they have no competing interests.KK and RR conceived the paper and methods. KK participated in the coordination of the search, conducted the literature search, assessed study quality, analyzed and interpreted the results, and drafted the majority of the manuscript. RR also provided comments to the writing. All authors advised on the initial concept, edited and approved the final manuscript.KK is a research assistant and PhD candidate in the School of Exercise Science, Physical and Health Education, and the Department of Psychology at the University of Victoria, Canada.RR is a professor and Canadian Cancer Society Senior Scientist in the School of Exercise Science, Physical and Health Education, University of Victoria, Canada.PJN is a Professor in the School of Exercise Science, Physical and Health Education, University of Victoria, Canada.HT is the Director of the Centre on Aging and Professor in the Department of Psychology at the University of Victoria, Canada.SM is a Professor in the Department of Psychology at the University of Victoria, Canada.Search strategy for ISI Web of Knowledge and EBSCOhost (October 2011). Description: This file contains the search terms used in this review, the databases that were searched and the hit rates for search terms.Click here for fileQuality of studies using the tool developed by Hagstromer & Bowles[. Description: This file contains the results from the tool used to assess the quality of each study included in the review. Each study was assessed by series of questions listed below the table.& Bowles. DescriClick here for fileTitle: Characteristics of studies comparing direct and indirect measures of physical activity in older adults. Description: This document contains a table in which the key details , age range), sample size, direct measure (units), indirect measure (units), measurement details  of studies comparing direct and indirect measures of physical activity in older adults have been summarized.Click here for fileCharacteristics of studies comparing indirect measures of physical activity in older adults. Description: This document contains a table in which the key details , age range), sample size, direct measure (units), indirect measure (units), measurement details  of studies comparing indirect measures of physical activity with other indirect measures of physical activity in older adults have been summarized.Click here for fileCharacteristics of studies comparing direct measures of physical activity in older adults. Description: This document contains a table in which the key details , age range), sample size, direct measure (units), indirect measure (units), measurement details  of studies comparing direct measures of physical activity with other direct measures of physical activity in older adults have been summarized.Click here for file


Standardised or ‘plain’ tobacco packaging was introduced in Australia in December 2012 and is currently being considered in other countries. The primary objective of this systematic review was to locate, assess and synthesise published and grey literature relating to the potential impacts of standardised tobacco packaging as proposed by the guidelines for the international Framework Convention on Tobacco Control: reduced appeal, increased salience and effectiveness of health warnings, and more accurate perceptions of product strength and harm.Electronic databases were searched and researchers in the field were contacted to identify studies. Eligible studies were published or unpublished primary research of any design, issued since 1980 and concerning tobacco packaging. Twenty-five quantitative studies reported relevant outcomes and met the inclusion criteria. A narrative synthesis was conducted.Studies that explored the impact of package design on appeal consistently found that standardised packaging reduced the appeal of cigarettes and smoking, and was associated with perceived lower quality, poorer taste and less desirable smoker identities. Although findings were mixed, standardised packs tended to increase the salience and effectiveness of health warnings in terms of recall, attention, believability and seriousness, with effects being mediated by the warning size, type and position on pack. Pack colour was found to influence perceptions of product harm and strength, with darker coloured standardised packs generally perceived as containing stronger tasting and more harmful cigarettes than fully branded packs; lighter coloured standardised packs suggested weaker and less harmful cigarettes. Findings were largely consistent, irrespective of location and sample.The evidence strongly suggests that standardised packaging will reduce the appeal of packaging and of smoking in general; that it will go some way to reduce consumer misperceptions regarding product harm based upon package design; and will help make the legally required on-pack health warnings more salient. Smoking is the largest single cause of avoidable morbidity and mortality in much of the world, being a risk factor for six of the eight leading causes of death globally th World Health Assembly in 1995. It came into force in 2005 and is now one of the most widely embraced treaties in the history of the United Nations, with almost 90% of the global population covered through 177 Parties to the Convention, as of August 2013. The objective of the FCTC, as outlined in Article 3, is “to protect present and future generations from the devastating health, social, environmental and economic consequences of tobacco consumption and exposure to tobacco smoke” In response to these risks the first global public health treaty, the Framework Convention on Tobacco Control (FCTC), was formally initiated at the 48Two of these demand reduction measures are controls on tobacco advertising, promotion and sponsorship, and packaging and labelling, identified as priority areas during the development of the FCTC There have been a small number of recent reviews of literature on standardised packaging The primary aim of the systematic review was to assess the impact of standardised tobacco packaging, based upon the potential benefits of standardised packaging proposed by the guidelines for Articles 11 and 13 of the FCTC st August 2011 was set for receipt of full text papers for screening. We did not limit our studies to papers in English, and a number of French studies were included. Studies were managed by the EPPI-Centre's online review software (EPPI-Reviewer 4.0) The review aimed to include all standardised tobacco packaging primary research studies, conducted since 1980. Twenty-one electronic databases from the fields of health, public health, social science and social care were searched in June and July 2011 as were fourteen websites, including Google Scholar and the Legacy Tobacco Documents Library, a digital archive of tobacco industry documents  from which 169 papers were retrieved for full text screening by two reviewers. From these, 41 papers were included for data extraction.All studies were coded using a standard classification system Different quality criteria were used for each study design, following principles of good practice for critical appraisal of primary research This article reports on a sub-set of 25 studies from the full systematic review which report outcomes relating to the potential benefits identified in the guidelines for Articles 11 and 13 of the FCTC, as described above. Eight studies that employed qualitative methods only and four studies that examined other outcomes, such as facilitators and barriers to the introduction of standardised packaging policies or its impact on smoking-related attitudes, beliefs and behavioural intentions, are not included in this paper but their results are outlined elsewhere A framework that encompassed the range of impacts measured was constructed in order to structure the findings Impact of standardised packaging on appealImpact of standardised packaging on the salience and effectiveness of health warningsImpact of standardised packaging on perceptions of product strength and harm.A narrative synthesis was presented with care taken to avoid ‘vote counting’ of statistically significant results; vote counting fails to take account of the relative size of studies, their methodological quality or the magnitude of their effects The 25 quantitative studies reported in this article comprised 18 cross-sectional surveys with an experimental (between- or within-subjects) design, three cross-sectional surveys without an experimental design, three mixed methods studies and one intervention study. Full details and summary findings are given in Twenty-one studies Twenty-one studies examined perceptions or ratings of the attractiveness of standardised packs. Findings were highly consistent, with all studies reporting that standardised packs were considered less ‘appealing’, ‘attractive’, ‘cool’, ‘stylish’ and ‘attention-grabbing’ than branded equivalent packs, by both adults and children , and 11–17 year olds were significantly more likely than 18–29 year olds  to rate standardised packs as unattractive From the studies which examined sub-group differences in the appeal and attractiveness of standardised packs, some patterns emerged. Overall, non-smokers and younger respondents were more affected by standardised packaging. For example, an experimental between-subjects design study with over 1,000 11–49 year olds in Australia found that smokers were significantly Seven studies examined whether standardised packs increase people's ability to notice and recall the health warnings on packs or whether standardised packs affect the perceived seriousness and believability of the warnings An experimental between-subjects study that tracked respondents' eye movements (saccades) towards pack images shown on a computer screen suggested that standardised packs attracted more eye movements towards the health warning than did branded packs, among non-smokers (p = 0.001) and weekly smokers (p = 0.001), although there was no difference for daily smokers (p = 0.35) Fourteen studies examined whether and how standardised packs impact on perceptions of the harm and strength of cigarette products, packs and brands Mixed results were reported in the eight studies which measured the impact of standardised packs on perceptions of tar and nicotine strength , across four paired comparisons: branded vs. standardised white packs (for two different brands), branded vs. standardised brown packs (for two different brands), standardised white packs with and without a descriptor term ‘Smooth’, and standardised brown packs with and without a descriptor term ‘Gold’ Studies which compared sub-group differences in participants' responses found that in general, smokers were more likely to have misperceptions about the harmfulness of packs, both standardised and branded, than non-smokers. For example, a survey of 16–19 year olds in the UK found that smokers were more likely than non-smokers to believe that both branded and standardised packs would be a lower health risk  and contain less tar  This review examined 25 quantitative studies that explored consumer perceptions or responses to the impact of standardised or ‘plain’ packaging of tobacco products on appeal, salience and effectiveness of on-pack health warnings, and perceptions of product strength and harm. As the review was carried out when no country had introduced standardised packaging, studies were limited to experimental designs, surveys or observational studies. Despite the range of designs, there was considerable consistency between study findings. Overall, the available research suggested consistently that standardised or plain packaging reduced the appeal of cigarettes. Although findings were mixed, standardised packs also tended to increase the salience of health warnings and to address smokers' misconceptions about product strength and harm that arise from existing branded packs.Findings from the review are consistent in a number of respects with the wider marketing literature, where packaging is a well-established marketing tool The findings in respect to pack colour are also consistent with wider literature. For a wide range of consumer goods, pack colour is considered one of the most important features of packaging design There are also similarities between findings in the included studies on health warnings, and the wider warnings literature. Globally, on-pack health warnings vary considerably, particularly in respect to type, size and positioning This review had a number of limitations. As standardised packaging research can never truly replicate real market conditions until it is fully implemented, as it was in Australia in December 2012, a full evaluation of the real world impact was not possible at the time of the review. This limits the types of study design that can be employed to assess standardised packaging, with designs which help increase confidence in the findings  not feasible In addition, the included studies also failed to consider level of nicotine dependence among smokers and analysis seldom considers ethnicity or socio-economic status, which limits our understanding of possible impacts upon different population segments. In this particular article, studies employing qualitative methods were not included, but they were reported in the wider review that served as the basis for this work, and these qualitative studies contained similar themes and findings This review differs from previous reviews Finally, while there were a limited number of studies and designs within the review, the findings were largely consistent across different designs, countries, populations, smokers and non-smokers suggesting that we can be fairly confident about the potential effects of standardised packaging.The extant literature strongly suggests that standardised packaging will reduce pack, product and user appeal, that it will go some way to reduce consumer misperceptions regarding product harm based upon package design, and will help make the legally required on-pack health warnings more salient. Further research can build upon the existing findings in a number of ways. Research in low- and middle-income countries, ideally exploring perceptions of standardised packaging for a range of tobacco products, would be informative. Research using study designs that more closely approximate what consumers experience while using standardised packs in naturalistic settings could help provide insight into the potential impacts of standardised packaging, at least in countries where is has not been introduced. In Australia, with all legitimate tobacco products on the market available only in standardised packs, research exploring the impact of standardised packaging on consumer cognitions, emotions and behaviours is required. The use of longitudinal research, pre- and at multiple time-points post-standardised packaging, to monitor the perceptions of youth and adult smokers and non-smokers would be of considerable value. Such research, and indeed studies elsewhere, should build income, ethnicity and dependence level, where possible, into the sampling strategy.Appendix S1Databases & Search Strategy.(DOCX)Click here for additional data file.Appendix S2Data Extraction Coding Tool.(DOCX)Click here for additional data file.Table S1Methodological characteristics and main findings of quantitative studies examining appeal, salience of health warnings and perceptions of product harm/strength.(DOCX)Click here for additional data file.Checklist S1PRISMA Checklist.(DOCX)Click here for additional data file.


Previous reviews of the diagnostic performances of physical tests of the hip in orthopedics have drawn limited conclusions because of the low to moderate quality of primary studies published in the literature. This systematic review aims to build on these reviews by assessing a broad range of hip pathologies, and employing a more selective approach to the inclusion of studies in order to accurately gauge diagnostic performance for the purposes of making recommendations for clinical practice and future research. It specifically identifies tests which demonstrate strong and moderate diagnostic performance.A systematic search of Medline, Embase, Embase Classic and CINAHL was conducted to identify studies of hip tests. Our selection criteria included an analysis of internal and external validity. We reported diagnostic performance in terms of sensitivity, specificity, predictive values and likelihood ratios. Likelihood ratios were used to identify tests with strong and moderate diagnostic utility.Only a small proportion of tests reported in the literature have been assessed in methodologically valid primary studies. 16 studies were included in our review, producing 56 independent test-pathology combinations. Two tests demonstrated strong clinical utility, the patellar-pubic percussion test for excluding radiologically occult hip fractures  and the hip abduction sign for diagnosing sarcoglycanopathies in patients with known muscular dystrophies . Fifteen tests demonstrated moderate diagnostic utility for diagnosing and/or excluding hip fractures, symptomatic osteoarthritis and loosening of components post-total hip arthroplasty.We have identified a number of tests demonstrating strong and moderate diagnostic performance. These findings must be viewed with caution as there are concerns over the methodological quality of the primary studies from which we have extracted our data. Future studies should recruit larger, representative populations and allow for the construction of complete 2×2 contingency tables. The diagnostic value of many physical tests in orthopedic practice has been called into question and a number of these tests have been found to correspond poorly with anatomical models ,2. In soRecently, several diagnostic reviews of physical tests of the hip have been published -8 and thi) which physical tests of the hip or physical clinical prediction rules have valid evidence from which their diagnostic performance in clinical practice can be calculated; andii) whether any physical tests or clinical prediction rules have strong diagnostic utility; andiii) whether any physical tests or clinical prediction rules have moderate diagnostic utility.In this systematic review, a preliminary search of various textbooks, medical journal databases, websites and grey literature sources was conducted to identify physical tests of the hip. Subsequently, an electronic database search strategy was developed, aided by a medical librarian  compare a physical (index) test for the diagnosis of a particular hip pathology against a ‘gold standard’ (reference) test representing the true diagnostic result. Physical tests were defined as non-invasive bedside maneuvers, beyond inspection, point tenderness and palpation alone, which were intended to increase the probability of a particular diagnosis; andii) report sufficient information to construct complete 2×2 contingency tables; andiii) recruit predominantly adult populations (where ages were indicated); andiv) be written in English.Studies were excluded if they:i) used physical tests under anesthesia or intra-operatively; orii) used physical tests to diagnose vascular or neurologic pathologies.Studies were also excluded if they did not meet our criteria for internally and externally valid methodology. These criteria are listed below.iii) For the purposes of internal validity, reference tests could not: (1) be dependent upon the index test result for interpretation, (2) be discredited for diagnosing the chosen pathology, or (3) allow for only partial construction of 2×2 contingency tables (e.g. by excluding persons with negative index test results from the study).iv) For the purposes of external validity, (1) the sample population had to reasonably represent a typical population presenting for diagnosis in clinical practice , and (2) the index test needed to provide a threshold for dichotomizing results.Assessments of validity were made independently by two authors and disputes arbitrated by a third author. No further restrictions were placed on study design, date of publication or clinical setting.For the literature search in 2010, one author screened citations for inclusion on the basis of their title. The remaining citations were assessed independently by two authors, first by title and abstract and then by full text. Opposing views regarding inclusion were resolved by arbitration with the remaining authors. When new tests were identified, new search strategies were executed for them using Medline, Embase and Embase Classic  with the latter being used to further identify tests demonstrating “strong” and “moderate” diagnostic utility. We favor the use of likelihood ratios because they offer the most valuable and comprehensive diagnostic information in the individual patient ,10. RougOnly a small proportion of hip tests identified in our preliminary search had their diagnostic performance assessed in methodologically valid primary studies. We identified sixteen studies containing data that satisfied our inclusion and exclusion criteria -26 Figu. This prTwo physical tests demonstrated strong diagnostic utility with the patellar-pubic percussion (PPP) test strongly excluding radiologically occult hip fractures  , and theFifteen independent test-pathology combinations demonstrated, at most, moderate diagnostic utility Table . These iPrevious reviews of physical tests have found much of the existing literature to be methodologically flawed and insufficient for guiding clinical practice. This review sought to identify clinically useful physical tests or combinations of tests that demonstrated strong and moderate diagnostic performance. This information could potentially be used to form future clinical prediction rules or guide future research. We found the PPP test strongly excluded radiologically occult hip fractures and the hip abduction sign strongly diagnosed sarcoglycanopathies in patients with known muscular dystrophies. In addition, we identified a number of tests with moderate usefulness for diagnosing and/or excluding hip fractures, symptomatic osteoarthritis and loosening of components post-THA.While some of our results are promising at face value, the raw data needs to be considered in more detail.Firstly, it is possible that we have overstated the utility of the PPP test since we have based our conclusions primarily on a single study by Tiru et al. . Two othThe hip abduction sign may also not perform as strongly as we suggested because Khadilkar and Singh  relied oThere was significant uncertainty about the true diagnostic performance of some of the moderately useful physical tests because of the small sample populations recruited in the primary studies ,13,24-26While we acknowledge that previous hip test reviews have found much of the literature to be methodologically flawed, we did not use cumulatively-scored quality assessment tools to analyze our data as the implications of these numerical values are not clear . InsteadThere is valid evidence for the diagnostic performance of only a small proportion of physical tests of the hip in routine clinical practice. Two tests demonstrated strong diagnostic utility, the patellar-pubic percussion test for excluding radiologically occult hip fractures and the hip abduction sign for diagnosing sarcoglycanopathies in patients with known muscular dystrophies. In addition, we identified a number of tests with moderate usefulness for diagnosing and/or excluding hip fractures, symptomatic osteoarthritis and loosening of components post-THA. The primary studies from which our data are derived contain methodological flaws that bias their results. Future studies should recruit larger and more representative populations and allow for construction of complete 2×2 contingency tables.THA: Total hip arthroplasty; +LR: Positive likelihood ratio; -LR: Negative likelihood ratio; CI: Confidence interval; CINAHL: Cumulative Index to Nursing and Allied Health Literature; FN: False negatives; FP: False positives; LR: Likelihood ratio; NPV: Negative predictive value; PPV: Positive predictive value; TN: True negatives; TP: True positives.The authors declare that they have no competing interests.LAR contributed to the design of the review; acquisition, analysis and interpretation of data; and drafting and revising of the manuscript. SA contributed to the conception and design of the review; analysis and interpretation of data; and revising of the manuscript. JMN contributed to the conception and design of the review; analysis and interpretation of data; and drafting and revising of the manuscript. RM contributed to the conception and design of the review; analysis and interpretation of data; and revising of the manuscript. SS contributed to the acquisition, analysis and interpretation of data, and revising of the manuscript. IAH contributed to the conception and design of the study; analysis and interpretation of the data; and revision of the manuscript. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2474/14/257/prepubSearch strategy for Medline, Embase, Embase Classic and CINAHL. File shows search strategy, search terms and results for Medline, Embase, Embase Classic and CINAHL.Click here for fileDiagnostic performances of physical test-hip pathology combinations included in review. File is a table of diagnostic characteristics of physical test-hip pathology combinations  from studies included in this review.Click here for fileDiagnostic performances of physical test-hip pathology combinations from excluded studies (2×2 contingency tables). File is a table of diagnostic characteristics of physical test-hip pathology combinations  from excluded studies that allowed for the construction of complete 2×2 contingency tables.Click here for fileOverview of excluded studies and case reports not presented in complete 2×2 contingency tables. File is a basic description of studies and case reports that were excluded from our studies and did not allow for the construction of complete 2×2 contingency tables .Click here for file


The spread of WNV in California is tracked. Culex tarsalis collected near El Centro, Imperial County. WNV transmission then increased and spread in Imperial and Coachella Valleys, where it was tracked by isolation from pools of Cx. tarsalis, seroconversions in sentinel chickens, and seroprevalence in free-ranging birds. WNV then dispersed to the city of Riverside, Riverside County, and to the Whittier Dam area of Los Angeles County, where it was detected in dead birds and pools of Cx. pipiens quinquefasciatus. By October, WNV was detected in dead birds collected from riparian corridors in Los Angeles, west to Long Beach, and through inland valleys south from Riverside to San Diego County. WNV was reported concurrently from Arizona in mid-August and from Baja, Mexico, in mid-November. Possible mechanisms for virus introduction, amplification, and dispersal are discussed.West Nile virus (WNV) was first isolated in California during July 2003 from a pool of  Flavivirus, Flaviviridae) into New York City in 1999, the public health community has chronicled the unimpaired spread of this virus across North America from the Atlantic to the Pacific Coasts  transmission and nuisance mosquito problems, California residents have supported special local mosquito and vector control districts that currently protect ca. 33.9 million people (88% of the state's population) over a combined area of ca. 166,107 km2. The associated California Encephalitis Virus Surveillance Program, which has been in place for more than 35 years . Consequently, the initial detection of WNV in most areas occurred after introduction and amplification and frequently was heralded by the discovery of dead crows or horses and humans with neurologic illness. California is somewhat unique in that an extensive arbovirus surveillance program has remained intact statewide. Because of endemic SLEV and western equine encephalomyelitis virus . These data were included to describe temperature conditions when virus was active and rainfall events associated with the intrusion of moist monsoon conditions from the Gulf of Mexico.Climate data from Coachella Valley and the Los Angeles basin were downloaded from National Oceanographic and Atmospheric Administration weather stations from the California Integrated Pest Management website (2 traps) operated without light  (Mosquitoes were collected biweekly at permanent sites by using dry ice-baited CDC-style traps (COut light  and gravut light . Samplinay (EIA)  and for ay (EIA) . Three s1 were bled biweekly by lancet prick of the comb and samples mailed to the Viral and Rickettsial Diseases Laboratory, California Department of Health Services, where they were screened for antibody by WEEV or WNV/SLEV antigens with an EIA  to separate those with antibody to WNV or SLEV. The locations of sentinel chicken flocks sampled during the summer of 2003 are summarized in Statewide, 212 sentinel flocks of 10 white leghorn hens eachh an EIA . Flavivi2 were collected weekly at two wetland sites along the north shore of the Salton Sea by using 8 to 10 mist nets and 1 to 2 grain-baited ground traps, as described previously  and 20 seroconversions of sentinel chickens to both viruses detected at multiple flocks .Climatic conditions at the time of WNV introduction included above average temperatures and several rainfall events associated with the extension of the southwestern monsoon into southeastern California . NormallCx. pipiens quinquefasciatus collected by gravid female traps  did not seem to be a productive surveillance method in Los Angeles, and all birds to date have tested negative, including those trapped at Whittier Narrows.Our data during 2003 clearly showed that WNV introduction, amplification, and widespread dispersal occurred with few human or horse cases, indicating that such cases are insensitive indicators of WNV presence and enzootic activity levels. Most humans in rural southern California reside in homes with some form of air-conditioning and thereby may be protected from mosquito contact during the evening . Unknownhttp://westnile.ca.gov/Publications.htm). Initial responses included enhanced surveillance, expanded larval control operations, and preparation for emergency adult control. Extended surveillance in Imperial County by the Imperial County Health Department, Coachella Valley Mosquito and Vector Control District, and University of California, Davis, and the development of a dead bird surveillance program by the California Department of Health Services during 2002 are examples of new programs that proved useful in tracking WNV during 2003. Detection of WNV in southeastern California during 2003 triggered adult mosquito control operations to interrupt transmission at wetlands and to protect residents of the small towns of Niland in Imperial County and Mecca in Coachella Valley. Dead bird surveillance data in urban Los Angeles were used to direct focal larval control operations and to launch public education programs through various media events. Surveillance activities in southern California continued during the winter of 2003 to 2004 and have included mosquito pool submission, sentinel chicken testing, live bird sampling and testing, and dead bird reporting and testing. All findings have been negative through mid-February 2004, despite surveillance near wetlands along the Salton Sea and at the Whittier Narrows crow roost, perhaps indicating that transmission ceased, despite mild winter conditions. Positive after-hatching-year and second-year resident birds from Coachella Valley have been collected, but these birds presumably were infected during 2003; all winter resident birds, such as White-crowned Sparrows, have remained negative. Planned and ongoing operational responses during spring 2004 have been coordinated at the local, regional, and state levels but necessarily vary among agencies because of local ecology, politics, and funding. The introduction of WNV into California and its anticipated amplification during the next few years will provide a rigorous test of how well a widespread integrated vector management approach to mosquito control can protect the residents of California from mosquito-borne disease.California health agencies and vector control districts have been preparing for the introduction of WNV since movement into the West seemed eminent, and state guidelines for escalated control responses to surveillance data have been prepared (


To critically review the currently available evidence of studies comparing robotic partial nephrectomy (RPN) and open partial nephrectomy (OPN).A comprehensive review of the literature from Pubmed, Web of Science and Scopus was performed in October 2013. All relevant studies comparing RPN with OPN were included for further screening. A cumulative meta-analysis of all comparative studies was performed and publication bias was assessed by a funnel plot.Eight studies were included for the analysis, including a total of 3418 patients (757 patients in the robotic group and 2661 patients in the open group). Although RPN procedures had a longer operative time , patients in this group benefited from a lower perioperative complication rate , shorter hospital stay , less estimated blood loss. Transfusions, conversion to radical nephrectomy, ischemia time and estimated GFR change, margin status, and overall cost were comparable between the two techniques. The main limitation of the present meta-analysis is the non-randomization of all included studies.RPN appears to be an efficient alternative to OPN with the advantages of a lower rate of perioperative complications, shorter length of hospital stay and less blood loss. Nevertheless, high quality prospective randomized studies with longer follow-up period are needed to confirm these findings. Nephron-sparing surgery (NSS) has been recommended as the reference standard of care for localized renal cell carcinoma due to equivalent oncological, improved functional outcomes and better long-term survival compared to those of radical nephrectomy Robotic-assisted laparoscopy allows for improved dexterity, high-definition, three-dimensional optics, tremor filtration, and an ergonomic setting to enhance surgeon comfort. A recently published systematic review and meta-analysis of RPN versus LPN shows that the RPN series offers a significantly less warm ischemic time than with an LPN procedure The aim of this study is to systematically search and analyze the currently available literature to compare the surgical outcomes of RPN with OPN.“open”, “robotic/robot-assisted”, and “partial nephrectomy”. Searches were restricted to publications in English. The electronic search was done in October 9, 2013.The systematic review was done according to the Cochrane review guidelines. A systematic literature search was done using the electronic database including Pubmed, Web of Science and Scopus. Searches were performed in [Title/Abstract/Topic Subject] with the following terms of Article selection was according to the Preferred Reporting Items for Systematic Reviews and Meta-analysis of Observational Studies in Epidemiology Recommendations for studies reporting. All relevant randomized controlled trials  and retrospective comparative studies (cohort or case-control studies) comparing robotic partial nephrectomy (RPN) with open partial nephrectomy (OPN) were included for further screening. Studies comparing OPN, LPN and OPN were also included as long as the data of RPN and OPN could be extracted. Review articles, case reports, conference paper, short survey, note editorials, letters to the editor, and animal experimental studies were excluded. When multiple reports describing the same population were published, the most recent or complete report was used. Two independent reviewers completed this process and all disagreements were resolved by their consensus.Studies comparing RPN with OPN were included. Articles comparing OPN, LPN and OPN were also included as long as the data of RPN and OPN could be extracted. Two independent authors reviewed the full texts of the included studies. Patient demographic characteristics, peri- and post- operative outcomes between the two procedures were compared. The following data was extracted from each eligible study: patients demographics, tumor size and nephrometry score, operative time, ischemia time, estimated blood loss, transfusion rate, conversion rate and complication rates. Postoperative complications were captured during the inpatient setting and within 30 days after surgery, and classified according to the Clavien-Dindo grading system The level of evidence was rated for each included study according to the most updated criteria provided by the Center for Evidence-Based Medicine in Oxford, UK X2-test and Inconsistency (I2) P<0.10 indicated the presence of heterogeneity, I2<50% indicated acceptable heterogeneity. Publication bias was assessed by a funnel plot. Review Manager software  was used for analysis.A meta-analysis was performed to assess the outcomes of RPN when compared with OPN. Odds ratio (OR) or Risk ratio (RR) and mean difference (MD) or standardized mean difference (SMD) was used for binary variables and continuous parameters, respectively. For studies presenting continuous data as medians and range values, means and standard deviations (SD) were calculated using the methodology described by Hozo et al The literature search yielded 164 studies, of which 8 were selected in the final analysis including 3418 cases (757 cases for RPN and 2661 cases for OPN) . No addiAmong the included studies, there was one prospective non-randomized comparative study (level of evidence: 2) The overall complication rate was significantly lower for the RPN group by pooling the data from 6 studies There was no significant difference between the two groups in terms of perioperative transfusion rate  . Four stThere was no statistical difference found between RPN and OPN regarding ischemia time   and eGFRThere was a significantly shorter postoperative hospital stay in the RPN group   and lessFive studies Three studies compared costs associated with partial nephrectomy using robotic and open approaches, pooling the data of 2350 patients in these three studies showed no statistical difference between the RPN and OPN groups .The present meta-analysis pooled the current available evidences comparing RPN with OPN in the treatment of the localized kidney tumor. No significant difference was observed between the two techniques regarding baseline demographics, except for gender and the tumor size, the weighted mean of which was lower for tumors treated with RPN. This can be regarded as a selection bias, and explained partially by the fact that the system was initially recommended for small masses. In the study of a two-year observational multicenter outcomes research of RPN versus OPN by Minervini et al, the clinical tumor size was significantly different between the two groups, whereas the tumor nephrometry score measured by PADUA was comparable The incidence of perioperative complications was significantly lower following RPN. In the subgroup analysis of postoperative complications, both minor and major complications more frequently occurred following OPN, whereas there was no Clavien grade 5 (death) complication in either group. Lucas et al reported one grade 4a complication in the RPN group (stroke) The other encouraging finding in favor of robotic surgery was the shorter length of hospital stay, with a difference reaching statistical significance between the two groups. Besides, we unexpectedly found that the cost of RPN was not significantly higher than that of OPN (p = 0.22). Laydner et al assessed the Cleveland Clinic data and found that the increased cost of RPN due to instrumentation and supplies can be offset by decreased cost of hospitalization compared with the OPN group The pooled data of operative time showed a significant difference between the two techniques, which was longer for the RPN . The observed difference of approximately 40 min can be pertaining to the preparation and docking of the robot. Masson-Lecomte et al found the difference become insignificant when “skin-to-skin” time compared (excluding the setup and docking time), whereas the total operating room occupation was more than 100 min over the operative time itself for RPN There was a significant lower amount of estimated blood loss in the RPN group. However, in the present study, we found that there were more unclamping cases in the OPN (p = 0.03). This fact may have biased the parameter of estimated blood loss favoring RPN. The pooled data showed comparable ischemia time, postoperative renal function impairment and positive margin rate between the two techniques, which was also true in patients with moderate or high complex tumors, as reported by Simhan et al All dichotomous outcomes had a low heterogeneity, but which was significant for most of the continuous variables. Factors of different sample sizes, multiple surgeons with different surgical experience, tumor complexity, the variety of ischemia  may contribute to the study-between-study heterogeneity. The fact that none of the RPN series in the included studies were totally performed within the surgeon's learning curve Click here for additional data file.