Predictors of mortality and length of stay in patients with hospital-acquired Clostridioides difficile infection: a population-based study in Alberta, Canada.

In a population-based, five-year retrospective cohort study of 5304 adult patients with hospital-acquired Clostridioides difficile infection across Alberta (N=101 hospitals), 30-day all-cause and attributable mortality were 12.2% and 4.5%, respectively. Patients >75 years of age had the highest odds of attributable mortality (odds ratio (OR) 9.34, 95% confidence interval (CI) 2.92-29.83) and largest difference in mean length of stay (11.7 days, 95% CI 8.2-15.2). A novel finding was that elevated white blood cell count at admission was associated with reduced attributable mortality (OR 0.67, 95% CI 0.50-0.90) which deserves further study. Advancing age was incrementally and significantly associated with all outcomes.

The association between sociodemographic and clinical characteristics and poor glycaemic control: a longitudinal cohort study.

AIMS: People with diabetes and poor glycaemic control are at higher risk of diabetes-related complications and incur higher healthcare costs. An understanding of the sociodemographic and clinical characteristics associated with poor glycaemic control is needed to overcome the barriers to achieving care goals in this population. METHODS: We used linked administrative and laboratory data to create a provincial cohort of adults with prevalent diabetes, and a measure of HbA1c that occurred at least 1 year following the date of diagnosis. The primary outcome was poor glycaemic control, defined as at least two consecutive HbA1c measurements ≥ 86 mmol/mol (10%), not including the index measurement, spanning a minimum of 90 days. We used multivariable Cox proportional hazards models to evaluate the association between baseline sociodemographic and clinical factors and poor glycaemic control. RESULTS: In this population-based cohort of 169 890 people, younger age was significantly associated with sustained poor glycaemic control, with a hazard ratio (HR) of 3.08, 95% CI (2.79-3.39) for age 18-39 years compared with age ≥ 75 years. Longer duration of diabetes, First Nations status, lower neighbourhood income quintile, history of substance abuse, mood disorder, cardiovascular disease, albuminuria and high LDL cholesterol were also associated with poor glycaemic control. CONCLUSIONS: Although our results may be limited by the observational nature of the study, the large geographically defined sample size, longitudinal design and robust definition of poor glycaemic control are important strengths. These findings demonstrate the complexity associated with poor glycaemic control and indicate a need for tailored interventions.

Association between participation in a brief diabetes education programme and glycaemic control in adults with newly diagnosed diabetes.

AIMS: To determine the association between participation in a brief introductory didactic diabetes education programme and change in HbA1c among individuals with newly diagnosed diabetes. METHODS: We identified a population-based cohort of adults newly diagnosed with diabetes between October 2005 and June 2008 in Calgary, Canada, and conducted a retrospective cohort study by linking administrative and laboratory data with programme attendance data. We matched individuals who attended the programme within the first 6 months after diagnosis with those who did not attend, based on their propensity scores. We measured the change in HbA1c between time of diagnosis and 6-18 months later to determine the association between programme participation and change in HbA1c . RESULTS: HbA1c was measured at baseline and follow-up for 7793 individuals, including 803 programme participants. After propensity score matching, programme participation was associated with a significantly greater adjusted mean reduction in HbA1c between baseline and follow-up of 3.3 mmol/mol (95% CI 2.2-4.3) or 0.30% (95% CI 0.20-0.39). There was a significant interaction between baseline HbA1c and programme participation-the difference in adjusted mean reduction in HbA1c associated with programme participation ranged from 2.7 mmol/mol (0.25%) at baseline HbA1c of 53 mmol/mol (7%) to 6.2 mmol/mol (0.56%) at baseline HbA1c of 97 mmol/mol (11%). CONCLUSION: Despite its brevity, participation in a diabetes education programme was associated with an additional reduction in HbA1c in newly diagnosed people that was comparable with that reported in trials of programmes targeted at those with prevalent diabetes.

Bariatric surgery: a systematic review and network meta-analysis of randomized trials.

The clinical efficacy and safety of bariatric surgery trials were systematically reviewed. MEDLINE, EMBASE, CENTRAL were searched to February 2009. A basic PubCrawler alert was run until March 2010. Trial registries, HTA websites and systematic reviews were searched. Manufacturers were contacted. Randomized trials comparing bariatric surgeries and/or standard care were selected. Evidence-based items potentially indicating risk of bias were assessed. Network meta-analysis was performed using Bayesian techniques. Of 1838 citations, 31 RCTs involving 2619 patients (mean age 30-48 y; mean BMI levels 42-58 kg/m(2) ) met eligibility criteria. As compared with standard care, differences in BMI levels from baseline at year 1 (15 trials; 1103 participants) were as follows: jejunoileal bypass [MD: -11.4 kg/m(2) ], mini-gastric bypass [-11.3 kg/m(2) ], biliopancreatic diversion [-11.2 kg/m(2) ], sleeve gastrectomy [-10.1 kg/m(2) ], Roux-en-Y gastric bypass [-9.0 kg/m(2) ], horizontal gastroplasty [-5.0 kg/m(2) ], vertical banded gastroplasty [-6.4 kg/m(2) ], and adjustable gastric banding [-2.4 kg/m(2) ]. Bariatric surgery appears efficacious compared to standard care in reducing BMI. Weight losses are greatest with diversionary procedures, intermediate with diversionary/restrictive procedures, and lowest with those that are purely restrictive. Compared with Roux-en-Y gastric bypass, adjustable gastric banding has lower weight loss efficacy, but also leads to fewer serious adverse effects.

A description of the costs of living and standard criteria deceased donor kidney transplantation.

Kidney transplantation improves quality of life and survival and is associated with lower health care costs compared with dialysis. We described and compared the costs of living and standard criteria for deceased donor kidney transplantation. Patients included adult recipients of a first kidney-only transplant between April 1, 1998, and March 31, 2006, as well as their donor information. All costs (outpatient care, diagnostic imaging, inpatient care, physician claims, laboratory tests and transplant medications) for 2 years after transplant for recipients and transplant-related costs prior to transplant (donor workup and management) were included. Complete cost information was available for 357 recipients. The mean total 2-year cost of transplantation, including donor costs, for recipients of living and deceased donors was $118 347 (95% confidence interval [CI], 110 395-126 299) and $121 121 (95% CI 114 287-127 956), respectively (p = 0.7). The mean cost for a living donor was $18 129 (95% CI 16 845-19 414) and for a deceased donor was $36 989 (95% CI 34 421-39 558). Living donor kidney transplantation has similar costs at 2 years compared with deceased donor transplantation. These results can be used by health care decision makers to inform strategies to increase donation.

Practice pattern variation in oral glucocorticoid therapy after the induction of response in proliferative lupus nephritis.

Glucocorticoids are standard therapy for induction of response in proliferative lupus nephritis. However, the optimal duration of glucocorticoid therapy is uncertain. We surveyed physicians who treat lupus nephritis regarding their use of glucocorticoids in proliferative lupus nephritis after induction of response and regarding factors associated with different practice patterns. We administered a questionnaire of standardized cases assessing glucocorticoid use after induction of response to specialists with expertise in proliferative lupus nephritis. We examined the association between continuation of glucocorticoids and patient and physician characteristics. Of 90 invited participants, 72 (80%) responded. A total of 24 (33%) respondents attempted to discontinue glucocorticoids in all scenarios, 21 (29%) continued glucocorticoids in all scenarios, and 27 (38%) attempted to discontinue in some scenarios but not others. Responses varied according to the physician group (p < 0.001) and by years in practice (p < 0.001). Of those who discontinued glucocorticoids in selected scenarios, 15/27 (55%) were influenced by the characteristics of the induction of response, 16/27 (59%) by past lupus history, and 9/27 (33%) by the tolerance and use of immunosuppression. We conclude that glucocorticoid therapy after induction of response in proliferative lupus nephritis is varied. This variability likely represents clinical equipoise. A randomized trial evaluating the effect of glucocorticoid use after induction of response is warranted.

The economics of home nocturnal hemodialysis: how should we cost the benefits?

Home nocturnal hemodialysis (HNHD) has been established as a safe and effective way to provide dialysis for patients who require renal replacement therapy. Non-randomized studies have shown that patients switched to HNHD have improvements in blood pressure, left ventricular mass and quality of life. At present, there are no RCTs or long-term observational studies demonstrating a clear reduction in cardiovascular events or mortality. Several HNHD centers have published articles documenting the costs of this modality as compared to conventional HD. Some of these studies have found HNHD to provide significant cost savings, while others have found the two modalities to be relatively equivalent in terms of costs. In this paper, we review the results of these costing studies and illustrate some of the limitations associated with these studies including the lack of randomization, inconsistent reporting of HNHD start-up costs, potential patient selection biases and limited follow-up. On balance, it appears premature to conclude that HNHD is cost-saving in comparison to conventional hemodialysis. However, two ongoing randomized trials, which are collecting resource use information, will help to answer this question. Once these data are available, a formal economic evaluation should be done to determine the impact of HNHD on both clinical outcomes and costs. This information will assist decision-makers in determining whether to make HNHD more widely available.

Mortality of Canadians treated by peritoneal dialysis in remote locations.

Patients residing in remote locations may be more likely to initiate peritoneal dialysis when starting renal replacement therapy to avoid relocation. These patients may have reduced access to medical care, however. To examine the hypothesis that patients residing some distance from their nephrologists would be more likely to select peritoneal dialysis but have an increased risk of mortality, we used prospectively collected data in a random sample of 26,775 patients initiating dialysis in Canada between 1990 and 2000. The distance between the patient's residence at dialysis inception and the practice location of their nephrologists was calculated. We used Cox proportional hazard models to determine the adjusted relation between this distance and clinical outcomes over a mean follow-up period of 2.5 years up to 14 years. Remote-dwelling patients were more likely than urban dwellers to commence peritoneal dialysis in distances ranging from 50 to greater than 300 km than those residing within 50 km. The adjusted rates of death and the adjusted hazard ratio among patients initiating peritoneal dialysis was significantly higher in those living further from the nephrologists than those living within 50 km. Further study into the quality of care delivered to remote-dwelling patients on peritoneal dialysis is needed.

Restricting cadaveric kidney transplantation based on age: the impact on efficiency and equity.

BACKGROUND: Caring for patients with end-stage renal disease (ESRD) is resource intense, and health care costs for this small segment of the population continue to rise. When compared to long-term dialysis as a therapy for ESRD, kidney transplantation increases survival, improves quality of life, and is cost saving. METHODS: We used decision analytic techniques to determine if cadaveric kidney transplantation is cost-effective in all age groups. We then looked at the impact of a strategy of restricting access to transplantation to those under 60 years of age to determine the impact on overall clinical outcomes and costs, as well as the outcomes and costs within each age group. RESULTS: Equal access to cadaveric kidney transplantation resulted in an increase in expected life years (7.4 vs 6.7 years) and a significant cost savings ($376,577 vs $568,670 per patient) compared to a strategy of long-term dialysis therapy over a 25-year time horizon. This pattern was seen for the overall cohort, and for all four age groups individually. Restricting access to transplantation to patients under the age of 60 resulted in only a very small improvement in expected life years and small cost savings under base-case assumptions. As expected, older patients were adversely impacted by this strategy. CONCLUSION: We have shown that transplantation is cost-effective for all age groups. A strategy of restricting access to transplantation to younger patients does not result in large cost savings and provides only small improvements in expected life-years at the expense of significantly worse outcomes in older patients.

Patient and allograft survival of Indo Asian and East Asian dialysis patients treated in Canada.

Kidney failure is relatively common among Canadians of Asian origin. However, little is known about the health outcomes after initiation of renal replacement therapy in this population. Our study evaluates differences in the likelihood of renal transplantation and graft loss among Asian and white patients. We studied 21 523 adults of East Asian, Indo Asian or white ethnicity who had initiated dialysis in Canada from 1990-2000. Subjects were followed until death, loss to follow-up or end of study (2004). The proportion of the eligible subjects who were East Asian, Indo Asian, or white was 6, 3, and 91%, respectively. Compared to white patients, East Asian and Indo Asian patients were significantly less likely to receive a renal transplant after adjusting for potential confounding factors. This disparity is greater for transplants from living donors as compared to those from deceased donors. The adjusted death censored graft loss in transplant recipients was not significantly different between ethnic groups. The adjusted risk of death following transplantation, however, was significantly lower in Indo Asian than in white patients. Our findings show that in a Canadian population, patients of East Asian or Indo Asian origin had lower rates of renal transplantation than white patients, especially for living donor transplantation. These findings warrant further study, especially given the good graft outcomes in these individuals.

Home care assistance and the utilization of peritoneal dialysis.

Peritoneal dialysis (PD) may be declining because the elderly often have barriers to self-care PD. The objective of this study was to determine whether the availability of home care increases utilization of PD. In 134 incident chronic dialysis patients (median age 73), 108 (81%) had at least one medical or social condition, which was a potential barrier to self-care PD. Eighty percent of patients living in regions where home care was available were considered eligible for PD compared to 65% in regions without home care (P=0.01, adjusted). Each barrier reduced the probability of being eligible for PD by 26% (odds ratio 0.74, per condition, P=0.02) adjusted for age, sex, predialysis care, in-patient start, and availability of home care. In regions with and without home care, 59 and 58% of eligible patients choose PD when they were offered it (P=NS). The utilization of PD in the incident end-stage renal disease (ESRD) population living in regions with and without home care was 47 and 37%, respectively (P=0.27). The mean rate of home care visits over the first year was 4.3 per week (maximum available was 14 per week). Of the 22 assisted patients, 15 required chronic support, five graduated to self-care, and two started with self-care but later required assistance. Adverse events were similar between assisted PD and traditional modalities. Barriers to self-care PD are very common in the elderly ESRD population but home care assistance significantly increases the number of patients who can be safely offered PD.

Economic implications of screening strategies in arteriovenous fistulae.

Practice guidelines recommend performing angiography in arteriovenous fistulae (AVF) when access blood flow (Qa) is < 500 ml/min, but a Qa threshold of <750 ml/min is more sensitive for stenosis. No economic evaluation has evaluated the optimal Qa threshold for angiography in AVF, or Determined whether screening AVF is more economically efficient than intervening only when AVF is thrombosed. We compared two screening strategies using Qa thresholds of <750 and <500 ml/min, respectively, with no access screening. Expected per-patient access-related costs (in 2002 Canadian dollars) were $3910, $5130, and $5250 in the no screening, QA500, and QA750 arms, respectively over 5 years. Notably, screening strategies did not reduce expected access-related costs under any clinically plausible scenario. The cost to prevent one episode of AVF failure appeared to be approximately $8000-$10,000 over 5 years for both screening strategies, compared with no screening. Although the incremental cost effectiveness of screening (compared to no screening) was similar in the base case for the QA500 and QA750 strategies, the relative economic attractiveness of the QA750 strategy was adversely affected under several plausible scenarios. Also, the QA750 strategy would require many additional angiograms to prevent an additional episode of AVF failure compared with the QA500 strategy. Screening of AVF resulted in a modest increase in net costs and seems to require a net expenditure of approximately $9000 to prevent one episode of AVF failure. If screening is adopted, our findings suggest that angiography should be performed when Qa is <500 rather than <750 ml/min, especially when access to angiography is limited.

Association between residence location and likelihood of kidney transplantation in Aboriginal patients treated with dialysis in Canada.

For reasons that are not well understood, Aboriginal people with end-stage renal disease (ESRD) have lower rates of kidney transplantation. We hypothesized that distance between residence location and the closest transplant center was greater in Aboriginal dialysis patients and would partially explain the lower rate of transplantation in this population. We studied a random sample of 9905 patients initiating dialysis in Canada between 1990 and 2000. We calculated the distance between residence location at dialysis inception and the closest transplant center. Cox proportional hazards models were used to examine the relation between residence location and the likelihood of transplantation over a median period of 2.3 years. The proportion of Aboriginal participants living 300 km from the closest transplant center was 25, 18, 18, and 39% respectively, compared with 55, 19, 11, and 15% among white subjects. The relative likelihood of transplantation was significantly lower for Aboriginal compared to white participants across all four distance strata, with no apparent effect of residence location. For example, the relative likelihood of transplantation was hazard ratio (HR) 0.47, 95% confidence interval (CI) (0.31-0.72) in Aboriginal participants residing 300 km from the closest transplant center. Results were similar for transplants from deceased donors and living donors, and in all seven regions studied. In conclusion, remote location of residence does not explain the lower rate of kidney transplantation among Aboriginal people treated for ESRD in Canada.

Cost of intensive care unit-acquired bloodstream infections.

Intensive care unit-acquired (ICU-acquired) bloodstream infections (BSI) are an important complication of critical illness. The objective of this study was to quantify the excess length of stay, mortality and cost attributable to ICU-acquired BSI. A matched cohort study was conducted in all adult ICUs in the Calgary Health Region between 1 May 2000 and 30 April 2003. One hundred and forty-four patients with ICU-acquired BSI were matched (1:1) to patients without ICU-acquired BSI. Patients with ICU-acquired BSI had a significantly increased median length of ICU stay {15.5 [interquartile range (IQR) 8-26] days vs 12 [IQR 7-18.5] days, P=0.003} and median costs of hospital care [85,137 dollars (IQR 45,740-131,412 dollars) vs 67,879 dollars (IQR 35,043-115,915 dollars, P=0.02) compared with patients without ICU-acquired BSI. The median excess length of ICU stay was two days and the median cost attributable to ICU-acquired BSI was 12,321 dollars per case. Sixty (42%) of the cases died compared with 37 (26%) of the controls [P=0.002, attributable mortality 16%, 95% confidence interval (CI) 5.9-26.0%]. Patients with ICU-acquired BSI were at increased risk for in-hospital death (odds ratio=2.64, 95%CI 1.40-5.29). Among survivor-matched pairs, the median excess lengths of ICU and hospital stay attributable to development of ICU-acquired BSI were two and 13.5 days, respectively, and the attributable cost due to ICU-acquired BSI was 25,155 dollars per case survivor. Critically ill patients who develop ICU-acquired BSI suffer excess morbidity and mortality, and incur significantly increased healthcare costs. These data support expenditures on infection prevention and control programmes and further research into reducing the impact of these infections.

Progression of kidney dysfunction in the community-dwelling elderly.

Despite the high prevalence of chronic kidney disease among the elderly, few studies have described their loss of kidney function. We sought to determine the progression of kidney dysfunction among a community-based cohort of elderly subjects. The cohort included 10 184 subjects 66 years of age or older, who had one or more outpatient serum creatinine measurements during each of two time periods: 1 July to 31 December 2001 and 1 July to 31 December 2003. A mixed effects model, including covariates for age, gender, diabetes mellitus, and comorbidity, was used to determine the rate of decline in estimated glomerular filtration rate (eGFR, in ml/min/1.73 m2) per year over a median follow-up of 2.0 years. Subjects with diabetes mellitus had the greatest decline in eGFR of 2.1 (95% CI 1.8-2.5) and 2.7 (95% CI 2.3-3.1) ml/min/1.73 m2 per year in women and men, respectively. The rate of decline for women and men without diabetes mellitus was 0.8 (95% CI 0.6-1.0) and 1.4 (95% CI 1.2-1.6) ml/min/1.73 m2 per year. Subjects with a study mean eGFR<30 ml/min/1.73 m2, both those with and without diabetes mellitus, experienced the greatest decline in eGFR. In conclusion, we found that the majority of elderly subjects have no or minimal progression of kidney disease over 2 years. Strategies aimed at slowing progression of kidney disease should consider underlying risk factors for progression and the negligible loss of kidney function that occurs in the majority of older adults.

Quality of life in patients treated with hemodialysis or peritoneal dialysis: what are the important determinants?

BACKGROUND: Patients with end-stage renal disease (ESRD) have significant impairments in health-related quality of life (HRQOL). In part, this is due to the intrusiveness of the treatment (hemodialysis or peritoneal dialysis) that is required. It is unclear whether hemodialysis or peritoneal dialysis is associated with a higher HRQOL. METHODS: 192 prevalent patients who self-selected treatment with hemodialysis (either in-center, satellite or home/self-care hemodialysis) or peritoneal dialysis were studied to determine whether treatment with hemodialysis or peritoneal dialysis is associated with a higher HRQOL. Demographic, laboratory and clinical information (including the presence of comorbid conditions using the Charlson comorbidity index) was assessed at baseline. The outcome of interest was HRQOL, which was measured using the Kidney Disease Quality of Life-Short Form (KDQOL-SF), the Short-Form 36 (SF-36) and the EuroQol EQ-5D at baseline and after 6 and 12 months of follow-up. RESULTS: There was no significant difference in HRQOL scores for the SF-36, the EQ-5D and for 9 of 11 KDQOL dimensions for patients treated with hemodialysis or peritoneal dialysis at baseline. As expected, HRQOL was significantly lower for patients who had more comorbid disease, required assistance with their daily care, and for patients with less than a grade 12 education. After controlling for the effect of other important variables, HRQOL (as measured by the EQ-5D visual analog or index scores) did not differ between hemodialysis and peritoneal dialysis patients. HRQOL was stable over time, both for patients who started on hemodialysis or peritoneal dialysis. CONCLUSIONS: There is no significant difference in HRQOL for prevalent ESRD patients treated with hemodialysis or peritoneal dialysis. It will be important to determine if this finding holds true for incident patients treated with hemodialysis or peritoneal dialysis.

An economic evaluation of early versus late referral of patients with progressive renal insufficiency.

Patients with progressive renal insufficiency (PRI) who start renal replacement therapy (RRT) within 4 months of seeing a nephrologist (late referral) have increased morbidity, mortality, and health care costs. We performed an economic evaluation of early versus late referral of patients with PRI to a multidisciplinary clinic. A decision analysis was performed from the perspective of the health care provider, using a Markov model to simulate progression of PRI and survival of patients on RRT. Our simulated patient cohort comprised 1,000 patients with PRI and estimated creatinine clearance of 20 mL/min. The study time horizon was 5 years. Clinical and cost data were taken from published Canadian and U.S. data, where available. Where published data were lacking, we used data from our prospectively maintained database. The study intervention was attendance at a PRI clinic where patients receive treatment to slow the rate of renal progression, receive treatment of complications of PRI, and are prepared for RRT. Endpoints were total cost of patient care, patient life-years, patient life-years free of RRT, and hospital admission days. Early referral resulted in cost savings and improved patient survival along with more life-years free of RRT and fewer hospital inpatient days. Cost-effectiveness was unaffected by univariate sensitivity analyses. Cost-effectiveness decreased as rates of renal function loss for patients referred early versus late approximated each other. In conclusion, early referral of patients with PRI to a multidisciplinary clinic appears cost-effective.

The Southern Alberta Renal Program database: a prototype for patient management and research initiatives.

The Southern Alberta Renal Program (SARP) database was developed to respond to an urgent need for local information on clinical outcomes, laboratory information, and health care costs, and to enable our local renal program to monitor the implementation of established clinical practice guidelines. The database captures detailed demographic, clinical, and laboratory information and is unique by also capturing comorbidity, health-related quality of life and costing information for patients with end-stage renal disease (ESRD) in southern Alberta, storing the information in one common database. By collecting information on patient comorbidity, health outcomes and costs, the SARP database has enabled many quality assurance initiatives as well as research opportunities for projects involving patients with ESRD. Due to the availability of links with other available local clinical and administrative databases, information is collected with a minimal need for manual data entry. This type of database is a method by which health programs could improve the quality of patient care. Programs caring for patients with chronic medical conditions such as ESRD should examine how computer databases could assist in clinical care and improve the efficiency with which that care is delivered to their patients.

Reviewing the reviewers: the quality of reporting in three secondary journals.

BACKGROUND: Secondary journals such as ACP Journal Club (ACP), Journal Watch (JW) and Internal Medicine Alert (IMA) have enormous potential to help clinicians remain up to date with medical knowledge. However, for clinicians to evaluate the validity and applicability of new findings, they need information on the study design, methodology and results. METHODS: Beginning with the first issue in March 1997, we selected 50 consecutive summaries of studies addressing therapy or prevention and internal medicine content from each of the ACP, JW and IMA. We evaluated the summaries for completeness of reporting key aspects of study design, methodology and results. RESULTS: All of the summaries in ACP reported study design, as compared with 72% of the summaries in JW and IMA (p < 0.001). In summaries of randomized controlled trials the 3 secondary journals were similar in reporting concealment of patient allocation (none reported this), blinding status of participants (ACP 62%, JW 70% and IMA 70% [p = 0.7]), blinding status of health care providers (ACP 12%, JW 4% and IMA 4% [p = 0.4]) and blinding status of judicial assessors of outcomes (ACP 4%, JW 4% and IMA 0% [p = 0.4]). ACP was the only one to report whether investigators conducted an intention-to-treat analysis (in 38% of summaries [p < 0.001]), and it was more likely than the other 2 journals to report the precision of the treatment effect (as a p value or 95% confidence interval) (ACP 100%, JW 0% and IMA 55% [p < 0.001]). INTERPRETATION: Although ACP provided more information on study design, methodology and results, all 3 secondary journals often omitted important information. More complete reporting is necessary for secondary journals to fulfill their potential to help clinicians evaluate the medical literature.