Medical care
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Randomized controlled trials (RCTs) remain the accepted "gold standard" for determining the efficacy of new drugs or medical procedures. Randomized trials alone, however, cannot provide all the relevant information decision makers need to determine the relative risks and benefits when choosing the best treatment of individual patients or weighing the implications of particular policies affecting medical therapies. ⋯ Even the most rigorously designed RCTs leave many questions central to medical decision making unanswered. Research using cohort and case-control designs, disease and intervention registries, and outcomes studies based on administrative data can all shed light on who is most likely to benefit from the treatment, and what the important tradeoffs are. This suggests the need to revise the traditional evidence hierarchy, whereby evidence progresses linearly from basic research to rigorous RCTs. This revised hierarchy recognizes that other research designs can provide important evidence to strengthen our understanding of how to apply research findings in practice.
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The issues of weighing benefits and harms and of shared decision-making have become increasingly important in recent years. There is limited knowledge and lack of adequate data on the most transparent method of communicating the information. In this article we discuss examples of communicating benefits and harms for well-known therapeutics, illustrating that relative risk estimates are not helpful for communicating the chance of experiencing adverse events. ⋯ We conclude that consistently depicting benefit and harm information in frequencies can substantially improve the communication of benefits and harms. Investigators should be requested to provide frequency data along with relative risk information in the publication of their scientific findings. Currently, even in the highest impact medical journals, evidence of benefits and harms is not consistently presented in ways that facilitate accurate interpretation.
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To describe patterns in physician and hospital utilization among rural and urban populations in China and to determine factors associated with any differences. ⋯ Three national approaches should be considered in reforming the healthcare system in China: universal insurance coverage, higher amounts of insurance coverage, and increasing the population's level of education. In addition, access issues in remote areas and by rural minority Chinese population should be addressed.
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Comparative Study
Comorbidity and outcomes of coronary artery bypass graft surgery at cardiac specialty hospitals versus general hospitals.
Cardiac specialty hospitals assert better patient outcomes and efficiency, whereas general hospitals contend they attract healthier patients. ⋯ Favorable patient selection may occur at cardiac specialty hospitals. Although healthier patients fare comparably across types of hospitals, patients with greater comorbid disease seem to experience worse 30-day postdischarge mortality at specialty hospitals.
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The risk of bankruptcy before and after brain or spinal cord injury: a glimpse of the iceberg's tip.
Injury and illness are often cited as causes of bankruptcy. However, the incidence of bankruptcy after an acute medical event is unknown. ⋯ The risk of bankruptcy postinjury is not negligible. There is an increase in bankruptcy postinjury, most evident in Medicaid patients. Better rehabilitation, workforce reintegration, and disability programs might reduce bankruptcy postinjury.