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Background Health research teams increasingly partner with stakeholders to produce research that is relevant, accessible, and widely used. Previous work has covered stakeholder group identification. Objective We aimed to develop factors for health research teams to consider during identification and invitation of individual representatives in a multi-stakeholder research partnership, with the aim of forming equitable and informed teams. Design Consensus development. Participants We involved 16 stakeholders from the international Multi-Stakeholder Engagement (MuSE) Consortium, including patients and the public, providers, payers of health services/purchasers, policy makers, programme managers, peer review editors, and principal investigators. Approach We engaged stakeholders in factor development and as co-authors of this manuscript. Using a modified Delphi approach, we gathered stakeholder views concerning a preliminary list of 18 factors. Over two feedback rounds, using qualitative and quantitative analysis, we concentrated these into ten factors. Key Results We present seven highly desirable factors: ‘expertise or experience’, ‘ability and willingness to represent the stakeholder group’, ‘inclusivity (equity, diversity and intersectionality)’, ‘communication skills’, ‘commitment and time capacity’, ‘financial and non-financial relationships and activities, and conflict of interest’, ‘training support and funding needs’. Additionally, three factors are desirable: ‘influence’, ‘research relevant values’, ‘previous stakeholder engagement’. Conclusions We present factors for research teams to consider during identification and invitation of individual representatives in a multi-stakeholder research partnership. Policy makers and guideline developers may benefit from considering the factors in stakeholder identification and invitation. Research funders may consider stipulating consideration of the factors in funding applications. We outline how these factors can be implemented and exemplify how their use has the potential to improve the quality and relevancy of health research.

Background As systematic reviews’ limited coverage of the medical literature necessitates decision-making based on unsystematic review, we investigated a possible advantage of systematic review (aside from dataset size and systematic analysis): does systematic review avoid potential bias in sampling primary studies from high impact factor journals? If randomized controlled trials (RCTs) reported in higher-impact journals present different treatment benefits than RCTs reported in lower-impact journals, readers who focus on higher-impact journals for their rapid literature reviews may introduce bias which could be mitigated by complete, systematic sampling. Methods We randomly sampled Cochrane Library (20 July 2005) treatment reviews that measured mortality as a binary outcome, published in English or French, with at least five RCTs with one or more deaths. Our domain-based assessment of risk of bias included funding source, randomness of allocation sequence, blinding, and allocation concealment. The primary analysis employed logistic regression by a generalized linear model with a generalized estimating equation to estimate the association between various factors and publication in a journal with a high journal impact factor (JIF). Results From the 29 included systematic reviews, 189 RCTs contributed data. However, in the primary analyses comparing RCT results within meta-analyses, there was no statistically significant association: unadjusted odds of greater than 50% mortality protection in high-JIF (> 5) journals were 1.4 (95% CI 0.42, 4.4) and adjusted, 2.5 (95% CI 0.6, 10). Elements of study quality were weakly, inconsistently, and not statistically significantly correlated with journal impact factor. Conclusions Journal impact factor may have little to no association with study results, or methodological quality, but the evidence is very uncertain.

Background There are many technologies designed to improve medication safety. Although limited evidence supports their use, there are pressures to implement them. Objective To determine the uptake of technologies designed to improve medication safety, plans for adopting technologies, attitudes towards technology use, and perceptions of medication error. Methods We performed a cross-sectional survey of pharmacy directors at Canada’s 100 largest acute-care hospitals. Results Seventy-eight per cent of surveyed hospitals responded. Responding hospitals averaged 499 beds and 29% were teaching facilities. Hospital frequently used clinical pharmacy services (97% of hospitals), pharmacy-based intravenous admixture services (81%), computerized decision support modules for pharmacy order entry systems (77%), unit-dose drug distribution systems (75%) and computerized medication administration records (67%). Hospitals infrequently used bar-coding (9% of hospitals) and computerized physician order entry (9%). A majority of respondents and hospitals favoured expanded use of new technologies and planned for increased uptake. Respondents chose as their hospital’s next investment: automated dispensing (33%), bar-coding (25%) and computerized physician order entry (12%). Conclusion Canadian hospitals appear poised to make sizeable investments in poorly evaluated technologies that address medication safety.

Study design Systematic review. Objective To determine the effectiveness of transcutaneous electrical nerve stimulation (TENS) in the management of chronic LBP. Summary of background data Chronic low back pain (LBP) affects a significant proportion of the population. TENS was introduced more than 30 years ago as an adjunct to pharmacologic pain management. However, despite its widespread use, the usefulness of TENS in chronic LBP is still controversial. Methods We searched MEDLINE, EMBASE, PEDro, and the Cochrane Central Register of Controlled Trials (Issue 2, 2005), up to April 1, 2005. Only randomized controlled clinical trials (RCTs) evaluating the effect of TENS on chronic LBP were included. Two reviewers independently selected trials and extracted data using predetermined forms. Heterogeneity was tested with Cochrane's Q test. A fixed effect model was used throughout for calculating continuous variables, except where heterogeneity existed, in which case a random effects model was used. Results are presented as weighted mean differences with 95% confidence intervals (95% CI), where the difference between the treated and control groups was weighted by the inverse of the variance. Standardized mean differences were calculated by dividing the difference between the treated and control by the baseline variance. Standardized mean differences were used when different scales were used to measure the same concept. Dichotomous outcomes were analyzed with odds ratios. Results Two RCTs (175 patients) were included. They differed with respect to study design, methodologic quality, inclusion and exclusion criteria, characteristics of TENS application, treatment schedule, cointerventions, and measured outcomes. In one RCT, TENS produced significantly greater pain relief than the placebo control. However, in the other RCT, no statistically significant differences between treatment and control groups were shown for multiple outcome measures. Preplanned subgroup analyses, intended to examine the impact of different stimulation parameters, sites of TENS application, treatment durations, and baseline patient characteristics were not possible because of the small number of included trials. Conclusions Evidence for the efficacy of TENS as an isolated intervention in the management of chronic LBP is limited and inconsistent. Larger, multicenter, RCTs are needed to better resolve its role in this condition. Increased attention should be given to the risks and benefits of long-term use, which more appropriately addresses the realities of managing chronic low back pain.

Department of Pediatrics, Division of Pediatric Gastroenterology and Nutrition, Department of Laboratory Medicine and Pathology, Stollery Children’s Hospital, University of Alberta, Edmonton, Alberta, Canada, Departments of Genetics, Pediatric Gastroenterology, Hepatology and Nutrition and Pathology, Necker-Enfants Malades Hospital, Paris Descartes University, Paris, France Correspondence to Hien Q. Huynh, MBBS, FRACP, FRCPC (Hon), Division of Pediatric Gastroenterology and Nutrition, Stollery Children’s Hospital, University of Alberta, Edmonton Clinic Health Academy (ECHA), 4th Floor, Room 4-579, 11405, 87th Avenue, Edmonton, Alberta, Canada T6G 1C9 Tel: + 1 780 248 5420; fax: + 1 780 248 5628; e-mail: hien.huynh@ualberta.ca

OBJECTIVES: The primary objectives were to evaluate the quality of development and reporting of American Academy of Pediatrics (AAP) guidelines and to determine the level of evidence underlying the recommendations. METHODS: Two reviewers scored each guideline by using the Appraisal of Guidelines for Research and Evaluation II (AGREE-II) instrument and determined the level of evidence for each recommendation in each guideline. Subgroup analyses compared AAP guidelines published before and after key changes in AAP guideline development policy and compared internal with endorsed guidelines. RESULTS: For the 28 current guidelines, the highest average scores on AGREE-II were in scope and purpose (75%) and clarity of presentation (73%). The lowest average scores were in editorial independence (17%) and applicability (30%). The only domain that improved after AAP policy updates was editorial independence (P = .01). Of the 190 treatment recommendations, 43% were based on experimental studies, 30% on observational studies, and 27% on expert opinion or no reference. Compared with early guidelines, late guidelines included a higher proportion of treatment recommendations based on experimental studies (P = .05). CONCLUSIONS: There was no clear improvement in the quality of development and reporting of AAP clinical practice guidelines over time. Routine application of AGREE-II to guideline development could enhance guideline quality. The proportion of guideline recommendations based on experimental evidence has increased slightly over time. Pediatric research agendas should be matched to vital gaps in the evidence underlying pediatric guidelines.

There are many technologies designed to improve medication safety. Although limited evidence supports their use, there are pressures to implement them.To determine the uptake of technologies designed to improve medication safety, plans for adopting technologies, attitudes towards technology use, and perceptions of medication error. Methods We performed a cross-sectional survey of pharmacy directors at Canada's 100 largest acute-care hospitals.Seventy-eight per cent of surveyed hospitals responded. Responding hospitals averaged 499 beds and 29% were teaching facilities. Hospital frequently used clinical pharmacy services (97% of hospitals), pharmacy-based intravenous admixture services (81%), computerized decision support modules for pharmacy order entry systems (77%), unit-dose drug distribution systems (75%) and computerized medication administration records (67%). Hospitals infrequently used bar-coding (9% of hospitals) and computerized physician order entry (9%). A majority of respondents and hospitals favoured expanded use of new technologies and planned for increased uptake. Respondents chose as their hospital's next investment: automated dispensing (33%), bar-coding (25%) and computerized physician order entry (12%).Canadian hospitals appear poised to make sizeable investments in poorly evaluated technologies that address medication safety.

Background Low back pain (LBP) affects a large proportion of the population. Transcutaneous electrical nerve stimulation (TENS) was introduced more than 30 years ago as an alternative therapy to pharmacological treatments for chronic pain. However, despite its widespread use, the effectiveness of TENS is still controversial. Objectives The aim of this systematic review was to determine the efficacy of TENS in the treatment of chronic LBP. Search strategy We searched MEDLINE, EMBASE, PEDro and the Cochrane Controlled Trials Register up to June 1, 2000. Selection criteria Only randomized controlled clinical trials of TENS for the treatment of patients with a clinical diagnosis of chronic LBP were included. Abstracts were excluded unless further data could be obtained from the authors. Data collection and analysis Two authors independently selected trials and extracted data using predetermined forms. Heterogeneity was tested with Cochran's Q test. A fixed effects model was used throughout for continuous variables, except where heterogeneity existed, in which case, a random effects model was used. Results are presented as weighted mean differences (WMD) with 95% confidence intervals (95% CI), where the difference between the treated and control groups was weighted by the inverse of the variance. Standardized mean differences (SMD) were calculated by dividing the difference between the treated and control by the baseline variance. SMD were used when different scales were used to measure the same concept. Dichotomous outcomes were analyzed with odds ratios. Main results Five trials were included, with 170 subjects randomized to the placebo group receiving sham-TENS and 251 subjects receiving active TENS (153 for conventional mode, 98 for acupuncture-like TENS). The schedule of treatments varied greatly between studies ranging from one treatment/day for two consecutive days, to three treatments/day for four weeks. There were no statistically significant differences between the active TENS group when compared to the placebo TENS group for any outcome measures. Subgroup analysis performed on TENS application and methodological quality did not demonstrate a significant statistical difference. Remaining pre-planned subgroup analysis was not conducted due to the small number of included trials and the variety of outcome measures reported. Authors' conclusions The results of the meta-analysis present no evidence to support the use of TENS in the treatment of chronic low back pain. Clinicians and researchers should consistently report the characteristics of the TENS device and the application techniques used. New trials on TENS should make use of standardized outcome measures. This meta-analysis lacked data on how TENS effectiveness is affected by four important factors: type of applications, site of application, treatment duration of TENS, optimal frequencies and intensities.