Complex Fractures PSP Question Verification Form

The purpose of this Question Verification Form is to enable Priority Setting Partnerships (PSPs) to describe clearly how they checked that their questions were unanswered, before starting the interim prioritisation stage of the process. 

The JLA requires PSPs to be transparent and accountable in defining their own scope and evidence checking process. This will enable researchers and other stakeholders to understand how individual PSPs decided that their questions were unanswered, and any limitations of their evidence checking. 

Name of the PSP

Complex Fractures

Please describe the scope of the PSP

The PSP aim is to identify the unanswered questions about complex fractures from the patient, carer, and clinical perspectives.

The PSP definition of a complex fracture will mirror the scope of the NICE guidelines for complex fractures: https://www.nice.org.uk/guidance/ng37. This will include:

• Pelvis and acetabular fractures
• Extremity fractures associated with

1. More than one fracture
2. Open fractures
3. Open fractures

The PSP scope will include the following aspects of care in the first 12 months following injury:

• Both operative and non-operative care of bony and soft tissue injuries, wounds, and incisions
• Rehabilitation both physical and mental, including occupational therapy and return to work
• Service design and delivery

The PSP excludes from its scope questions about:

• Fractures in children and younger people (less than 18 years old)
• Emergency department and pre-hospital care
• Isolated Hand injuries

Please provide a brief overview of your approach to checking whether the questions were unanswered

Questions submitted by patients and clinicians to the survey were collated and categorised into indicative questions. These preliminary questions were agreed on by the Steering Group. The verification process aimed to determine which of these questions are unanswered by research to date.

Our search strategy was stepwise starting with the most reliable sources and working down. This enabled answered questions to be identified efficiently.

The following process was followed for each question:

1. Guidelines (NICE, SIGN, Royal College, or Professional association) were reviewed to determine whether they covered that question. If they did, then evidence behind the guidelines was reviewed. Where this evidence was low-quality, e.g. observational research or expert consensus, this was discussed with the steering group to determine whether to consider the question answered or unanswered.
2. Cochrane reviews were searched using keywords specific to each question. Where a review called for further research, the question was not considered answered. If the systematic review was older than 5 years old, recent RCTs were also searched to ensure the question had not been answered more recently.
3. Database searches on OVID and Google Scholar were conducted using keywords specific to each question. Randomised controlled trials (RCTs) were reviewed and if no strong conclusion could be drawn from the study, the question was considered unanswered.
4. Ongoing and future trials were reviewed on registries. These were used to identify questions that may be answered in the coming years. The aim was not to exclude questions at this stage but to take these in to account to help refine the questions for the interim workshops and prioritise those taken to the final workshop.

Please list the type(s) of evidence you used to verify your questions as unanswered

• National Guidelines (NICE, SIGN, Royal College, or Professional association)
• Systematic Reviews (including Cochrane)
• If systematic reviews were older than 5 years, recent RCTs were reviewed
• If no systematic reviews available, any RCTs were reviewed
• Ongoing and future trials were logged

Please list the sources that you searched in order to identify that evidence

Systematic review or RCT evidence found via:

• Cochrane Central Register of Controlled Trials (https://www.cochranelibrary.org)
• OVID (databases included Pubmed, CINAHL, AMED, BNI, EMBASE, HBE, Medline, and PschINFO);
• Google Scholar (https://scholar.google.co.uk);
• the WHO International Clinical Trials Registry Platform Search Portal (http://www.who.int/ictrp/en),
• Current Controlled trials (http://www.isrctn.com),
• the US National Institute of Health Trials Registry (https://clinicaltrials.gov)
• Published UK national guidelines – NICE, SIGN, BOA, BAPRAS

What search terms did you use?

Keywords of each question were used in each database and tailored to each question.
Examples of keywords were:

• exp "Bones of Lower Extremity"/ OR exp "Bones of Upper Extremity"/ OR pelvi*.ti,ab.OR acetabul*.ti,ab.
  AND
• exp Fractures, Bone/ OR fractur*.ti,ab. OR (broke or broken or break*).ti,ab.

Please describe the parameters of the search (eg time limits, excluded sources, country/language) and the rationale for any limitations

• All guidelines were in English. All studies were included however, recent evidence in the last 5 years was seen to be stronger than older evidence.
• The search was limited to English only for clinical guidelines.
• No language limitation for systematic reviews or studies.

Names of individuals who undertook the evidence checking

• Harry Claireaux.
• Uncertainties were discussed with the Steering Group.

On what date was the question verification process completed?

• 24 Nov 2020

Any other relevant information

• Consultant surgeons from 2 academic centres (WE and XG) confirmed no significant papers were missed which could provide answers to the shortlisted questions.

Version 0.2 Date 24NOV2020