Chest
Volume 148, Issue 1, July 2015, Pages 32-54
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Evidence-Based Medicine
Assessment of Intervention Fidelity and Recommendations for Researchers Conducting Studies on the Diagnosis and Treatment of Chronic Cough in the Adult

https://doi.org/10.1378/chest.15-0164Get rights and content

BACKGROUND

Successful management of chronic cough has varied in the primary research studies in the reported literature. One of the potential reasons relates to a lack of intervention fidelity to the core elements of the diagnostic and/or therapeutic interventions that were meant to be used by the investigators.

METHODS

We conducted a systematic review to summarize the evidence supporting intervention fidelity as an important methodologic consideration in assessing the effectiveness of clinical practice guidelines used for the diagnosis and management of chronic cough. We developed and used a tool to assess for five areas of intervention fidelity. Medline (PubMed), Scopus, and the Cochrane Database of Systematic Reviews were searched from January 1998 to May 2014. Guideline recommendations and suggestions for those conducting research using guidelines or protocols to diagnose and manage chronic cough in the adult were developed and voted upon using CHEST Organization methodology.

RESULTS

A total of 23 studies (17 uncontrolled prospective observational, two randomized controlled, and four retrospective observational) met our inclusion criteria. These articles included 3,636 patients. Data could not be pooled for meta-analysis because of heterogeneity. Findings related to the five areas of intervention fidelity included three areas primarily related to the provider and two primarily related to the patients. In the area of study design, 11 of 23 studies appeared to be underpinned by a single guideline/protocol; for training of providers, two of 23 studies reported training, and zero of 23 reported the use of an intervention manual; and for the area of delivery of treatment, when assessing the treatment of gastroesophageal reflux disease, three of 23 studies appeared consistent with the most recent guideline/protocol referenced by the authors. For receipt of treatment, zero of 23 studies mentioned measuring concordance of patient-interventionist understanding of the treatment recommended, and zero of 23 mentioned measuring enactment of treatment, with three of 23 measuring side effects and two of 23 measuring adherence. The overall average intervention fidelity score for all 23 studies was poor (20.74 out of 48).

CONCLUSIONS

Only low-quality evidence supports that intervention fidelity strategies were used when conducting primary research in diagnosing and managing chronic cough in adults. This supports the contention that some of the variability in the reporting of patients with unexplained or unresolved chronic cough may be due to lack of intervention fidelity. By following the recommendations and suggestions in this article, researchers will likely be better able to incorporate strategies to address intervention fidelity, thereby strengthening the validity and generalizability of their results that provide the basis for the development of trustworthy guidelines.

Section snippets

Summary of Recommendations and Suggestions

  • 1.

    In conducting studies of chronic cough in adults, we recommend that investigators, as a first step, include intervention fidelity in the design of their studies of the diagnosis and treatment of chronic cough, by addressing intervention fidelity in the following 5 areas: study design, training of providers, treatment delivery, treatment receipt, and enactment of treatment (Grade 1C).

  • 2.

    In conducting studies of chronic cough in adults, we recommend, as a second step, that the training of

Systematic Review

The Executive Committee of the CHEST Expert Cough Panel convened a writing committee to develop recommendations or suggestions that pertain to the assessment of intervention fidelity in studies of the use of guidelines or protocols to diagnose and manage chronic cough in adults. This writing committee based its recommendations or suggestions on a systematic review contained within this article. This systematic review follows the “Methodologies for the Development of the Management of Cough:

Results

Systematic review results are addressed first and categorized according to the study aims. This is followed by the results of the process for establishing guideline recommendations or consensus-based suggestions.

Recommendations and Suggestions

Based upon the systematic review, the Expert Cough Panel was able to make a series of recommendations and/or suggestions for the use of intervention fidelity, by those conducting research, in studies of adults with chronic cough who are being diagnosed and managed using an evidence-based clinical practice guideline or protocol. The recommendations or suggestions are presented in stepwise fashion to provide a systematic plan in logical sequential order so that all five areas of intervention

Areas for Future Research and Clinical Practice

To advance the field and provide trustworthy guidelines to guide clinical practice, there are a number of potential future research issues that should be addressed. They are enumerated below:

  • To improve the internal and external validity of future studies seeking to diagnose and manage chronic cough in adults, researchers should use the recommendations and suggestions related to intervention fidelity made in this document. If researchers are not able to use these recommendations, they

Conclusions

Since publication of the 2006 Chest Cough Guidelines, and based upon this systematic review, it is clear that some of the variability in the reporting of successful management patients with chronic cough may be due to lack of intervention fidelity. Using these results, the Expert Cough Panel has been able to make a series of recommendations and suggestions directed at researchers for carrying out future studies of chronic cough in adults. By following the recommendations and suggestions in this

Acknowledgments

Author contributions: C. T. F. and R. S. I. contributed as topic editors for this article; R. L. D. contributed as the appointed methodologist and guided the systematic review that formed the basis for the recommendations; C. T. F., R. L. D., and R. S. I. contributed to the development of the key questions using the PICOTS format, review of the data, and elaboration of recommendations, including their grading; C. T. F. and R. S. I. drafted, wrote, reviewed, and approved the manuscript; and R.

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