Randomized controlled trials in relapsed/refractory follicular lymphoma: a systematic review and meta-analysis.

This systematic literature review evaluated the clinical efficacy and safety of interventions used in relapsed/refractory follicular lymphoma. Primary efficacy outcomes were objective response rate, progression-free survival and overall survival. Safety endpoints were grade 3/4 toxicities, serious adverse events and withdrawals or deaths due to toxicity. Studies were selected if they were randomized controlled trials reporting on the efficacy or safety of treatments for relapsed or refractory follicular lymphoma, and if outcomes were reported separately from trials that included other lymphoid neoplasms. We used the Bucher method for conducting adjusted indirect comparisons within a meta-analysis. We identified 10 randomized controlled trials of treatments for relapsed/refractory follicular lymphoma. The most prominent drug investigated (alone or in combination) was rituximab. Most trials did not report median overall survival. Two trials reported median event-free survival (range, 1.2-23.2 months). Six of ten trials reported objective response rate (range, 9-93%). Meta-analysis showed only one statistically significant result: rituximab + bortezomib yielded a significantly higher objective response rate than rituximab monotherapy (relative risk, 1.28; 95% confidence interval, 1.11-1.47). Otherwise, there were no discernable differences in overall survival or progression-free survival, partly due to insufficient reporting of results in the clinical trials. The relatively small number of randomized controlled trials, few overlapping treatment arms, and variability in the randomized controlled trial features and in the endpoints studied complicate the formal comparison of therapies for relapsed/refractory follicular lymphoma. Additional well-designed randomized controlled trials are needed to fully understand the relative outcomes of older and more recently developed therapies.

Randomized controlled trials in relapsed/refractory chronic lymphocytic leukemia: a systematic review and meta-analysis.

This systematic literature review with meta-analysis was conducted on the clinical efficacy and safety of interventions used in the treatment of chronic lymphocytic leukemia (CLL). We systematically searched databases (PubMed, Cochrane Library, and Embase; 1997 to August 2, 2012), conference abstracts, bibliographic reference lists, recent reviews, and Clinicaltrials.gov. Primary efficacy outcomes were objective response rate, progression-free survival, and overall survival. Safety end points were Grade 3/4 toxicities, serious adverse events, withdrawals because of toxicity, and deaths due to toxicity. Studies were selected if they were randomized controlled trials (RCTs) reporting on the efficacy or safety of relapsed or refractory CLL and if outcomes for CLL were reported separately from trials that included other lymphoid neoplasms. We used the Bucher method for conducting adjusted indirect comparisons within a meta-analysis. We identified 6 RCTs of pharmacologic treatment for relapsed/refractory CLL. The most common drugs investigated (alone or in combination) were fludarabine and cyclophosphamide. When reported, median overall survival ranged from 27.3 to 52.9 months, and overall response rate from 58% to 82%. Although meta-analysis of efficacy results was considered, details are not presented because only 3 studies qualified and the common comparator treatment was not clinically relevant. The relatively small number of RCTs, few overlapping treatment arms, and variability in end points studied make it difficult to formally compare therapies for relapsed/refractory CLL. Significant variability in RCT features presents a further challenge to meaningful comparisons. Additional well-designed RCTs are needed to fully understand the relative efficacy and safety of older and more recently developed therapies.

Adoption and use of health information technology in physician practice organisations: systematic review.

BACKGROUND: Health information technology (HIT) has the potential to improve clinical outcomes, increase health provider productivity and reduce healthcare costs. Over half of all patient care is delivered in physician practice organisations, yet adoption and utilisation of HIT in these groups lags behind inpatient facilities. OBJECTIVE: To better understand current utilisation rates along with benefits and barriers to HIT adoption in physician practice organisations. METHODS: Published literature on the adoption and use of HIT in physician practice organisations within the USA between 12 January 2004 and 12 January 2009 and indexed in MEDLINE and EMBASE was included in the systematic review. Grey literature was also searched. Studies related to the adoption and use of HIT in hospitals and community health centres were excluded. RESULTS: A total of 119 articles were eligible for inclusion in the review. Adoption rates across physician groups remain low, with between 9% and 29% of practices having implemented electronic medical records. HIT improves clinical outcomes, increases the use of vaccinations and improves medication adherence. Furthermore, HIT adoption leads to cost savings for physician groups, improves staff productivity and enriches patient-provider interactions. The largest barrier to HIT adoption in physician groups is the high initial and ongoing costs of electronic systems. Lack of sufficient training, a disorganised or non-receptive practice culture and technological problems such as inadequate connectivity appear to impede effective HIT use. CONCLUSIONS: HIT has the potential to positively impact on physician practice organisations, although significant and diverse barriers block adoption. Research into these obstacles should be coupled with efforts to understand barriers to effective implementation after HIT adoption.