Urine MattersCADTH Rapid Response

EVIDENCE FOR POLICY AND CLINICAL DECISIONS

Presented at:Urine Matters: UTI Care Pathways for Enhanced Collaboration & Antibiotic Safety in Seniors

Charlottetown, PEI

February 10, 2015

Dr. Janice Mann

Knowledge Mobilization

CADTH

@JUSTSAYIT_MD

JANICEM@CADTH.CA

“ Industry/manufacturer

information is saying…”

What evidence do I need?

Where did I get this evidence?

What’s the quality of the

evidence?

How does it compare to

alternatives?

Can it be used safely and

effectively in all settings?

Do the results make practical

sense in my (local) setting?

Can we actually afford this?

Who is this benefitting – me or

my patient? The hospital? All?

Is it safe, ethical, & Health

Canada approved?

“This new policy needs

some clarification…”

“My clinical service is

thinking about buying this...”

“A colleague and I differ on

choice of treatment…”

“I have a really good idea

for a new provincial

protocol…”

What is a health technology?

• Pharmaceuticals (drugs, blood products, vaccines)

• Diagnostics

• Medical, dental, surgical devices and procedures

Health Technology Assessment

• Systematic evaluation of the evidence on the properties,

effects, and/or impacts of health care technology

Role of HTA

Reliable and timely delivery of (synthesized and

appraised) evidence

• Is it safe?

• For whom does it work and when?

• Is it better than what we already have/do?

• Does it provide value for money?

• Can we afford it? Can we afford not to?

• What’s the trade-off?

• What else needs to be considered?

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Sustainability

Improved clinical

outcomes

Finding the Right Balance

Why use HTA Evidence in Policy and

Clinical Decision-Making?

• Rigorous

• Balanced

• Relevant

• Synthesis of large volume of research

• Freely available

• Positive experience of decision-makers who have used HTA

How to use HTA Evidence in

Decision-Making

• HTA provides the EVIDENCE piece to the decision-making

puzzle.

But…

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“HTA reports take too long to

develop, delaying important

policy decisions impacting

patient care.”

Health Technology Assessment Task Group

Health technology strategy 1.0

Federal/Provincial/Territorial Advisory

Committee on Information and EmergingTechnologies

What is CADTH’s Rapid Response

Service?

• Constant, rapid, and often expensive advances in health

technologies make evidence-based information essential in

healthcare decision-making.

• While comprehensive assessments are used to support

many important deliberations, the urgency of some

decisions requires a more immediate response.

• To support these time-sensitive decisions, CADTH launched

its Health Technology Inquiry Service in February of 2005.

This service is now known as CADTH’s Rapid Response

Service.

Rapid Response – How it Works

• Rapid Response topics are requested by CADTH

customers which avoids lengthy and labour intensive

prioritization processes

• To facilitate these requests, CADTH Liaison Officers in the

provinces and territories can work with the requestors.

• Requests are acknowledged within 24 hours, and if they fall

within the scope of CADTH’s work, the process begins.

• A call with the requestor will take place to further refine the

issue, research questions are developed, and timelines are

set.

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Rapid Response – How it Works

• Modifying standard HTA review techniques to

accommodate accelerated evidence synthesis including:

• using a single-author approach

• limiting the literature search to studies published within

the last five years

• limiting the journals and grey literature that are searched

• Formal meta-analyses of the data are not performed, but

rather the findings from the literature are summarized in

narrative form and the studies critically appraised.

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CADTH Rapid Response Service

• > 60% of requests are for non-drug technologies: medical

devices, procedures, tests, interventions

Types of Reports:

• Reference list (~ 1 week)

• Summary of abstracts (~ 2 weeks)

• Summary with critical appraisal (~ 4-6 weeks)

• Systematic review (~ 4-5 months)

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CADTH’s Rapid Response Service

• Rapid Responses are always tailored to meet the needs

and timelines of the requestor and are subject to the quality

and quantity of the published literature.

• Turn-around times depend on you! When do you need the

evidence? How much appraisal or assistance do you need

for that evidence?

• Requestor information is confidential.

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Submission Process

Overall Service

Timeliness of Delivery

Quality of the Report

Percent Respondent Level of Satisfaction

CADTH Rapid Response Customer Satisfaction

Very Satisfied Satisfied Dissatisfied Very Disastisfied

• To search our Rapid Response Database for completed

reports:

www.cadth.ca/RapidResponse

• To Request a New Rapid Response contact your local

Liaison Officer:

www.cadth.ca/en/services/liaison-officer

AnExample

“Management of Diabetes in the Long-Term Care Population:

A Review of Guidelines” (December 2013)

www.cadth.ca/media/pdf/htis/dec-

2013/RC0500_RR_RiB_Diabetes_in_LTC_population_e.pdf

Using the Evidence in LTC Settings

Bottom line:

• Establish a policy for screening for diabetes

• Laboratory tests should be performed when diabetes is

suspected

• Test glucose levels (fasting or A1C) every three to six months

• Individualize frequency of the blood glucose monitoring

• Comprehensive monitoring is not appropriate in LTC settings.

Note that these guidelines are for all patients in long-term care

facilities, not necessarily those who are frail and elderly

Rapid Response – For Urine Matters

Urine Testing in Long-Term Care: Guidelines

http://www.cadth.ca/media/pdf/htis/dec-

2014/RB0760%20Urine%20Testing%20LTC%20Final.pdf

• Summary of abstracts

• Looked for evidence-based guidelines for ordering of urine

C&S, dipstick, urinalysis, proper collection, and

interpretation in LTC

• NO GUIDELINES IDENTIFIED

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Rapid Response – For Urine Matters

Urine Testing in Long-Term Care: Clinical and Cost

Effectiveness

http://www.cadth.ca/media/pdf/htis/jan-

2015/RB0764%20Urine%20Testing%20Utility%20Final.pdf

• Summary of abstracts

• Looked for clinical and cost-effectiveness of urine C&S,

dipstick, and urinalysis in LTC

• 3 non-randomized studies identified

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Rapid Response – For Urine Matters

Urine Testing in Long-Term Care: Clinical and Cost

Effectiveness (con’t)

• 1st: compared dipstick to urinalysis for early UTI detection in

LTC – positive dipsticks alone not predictive of UTI

• 2nd: compared dipstick with culture – negative dipsticks to

rule out UTI (88% NPV)

• 3rd: clinical features to identify UTI in LTC (no catheter) –

painful urination, change in urine, and change in mental

status significantly associated with UTI

• No cost-effectiveness evidence found

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Rapid Response – For Urine Matters

Nitrofurantoin for the Treatment of Urinary Tract

Infections in Elderly Males: Safety

http://www.cadth.ca/media/pdf/htis/feb-

2015/RB0787%20Nitrofuratoin%20for%20UTI%20Final.pdf

• Summary of abstracts

• Looked for clinical evidence on safety of nitrofurantoin in

elderly males

• NO EVIDENCE FOUND

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Rapid Response – For Urine Matters

Treatment of Urinary Tract Infections in the Elderly:

Clinical Effectiveness and Guidelines

(web-posting pending)

• Summary of abstracts

• Looked for evidence on comparative effectiveness of long-

term prophylaxis vs. treatment, and guidelines on antibiotic

management of UTIs in the elderly

• 2 evidence-based guidelines found on UTI management

that included the elderly

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Rapid Response – For Urine Matters

Treatment of Urinary Tract Infections in the Elderly:

Clinical Effectiveness and Guidelines

• Both guidelines recommend against antibiotic prophylaxis

for UTIs

• Both recommend against antibiotic treatment of

asymptomatic bacteriuria in catheterized patients

• Scottish: symptomatic UTI in women = trimethoprim or

nitrofurantoin x 3 days (care with nitrofurantoin in elderly),

UTI in adult males = quinolone if prostatitis symptoms

• European: broad spectrum antibiotics with adjustment

based on C&S results

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Rapid Response – For Urine Matters

Development of Antibiotic Resistance to Norfloxacin in

the Treatment of Urinary Tract Infections: Clinical

Evidence (web-posting pending)

• Reference list

• Found 1 non-randomized study: community-acquired UTI

• overall: 14% resistance (norfloxacin & cipro)

• uncomplicated UTI: 8.5% resistance

• complicated UTI: 19.5% resistance

• Significantly more resistance in patients > 50 years, in

males (25% vs. 9%), and if previous antimicrobial tx

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