Timothy J Wilt

Massachusetts General Hospital, Boston, Massachusetts, United States

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Publications (268)1524.43 Total impact

  • Hanna E Bloomfield, Andrew Olson, Timothy J Wilt
    Annals of internal medicine 12/2014; 161(12):924-5. · 13.98 Impact Factor
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    ABSTRACT: Clinical practice guidelines should be based on the best scientific evidence derived from systematic reviews of primary research. However, these studies often do not provide evidence needed by guideline development groups to evaluate the tradeoffs between benefits and harms. In this article, the authors identify 4 areas where models can bridge the gaps between published evidence and the information needed for guideline development applying new or updated information on disease risk, diagnostic test properties, and treatment efficacy; exploring a more complete array of alternative intervention strategies; assessing benefits and harms over a lifetime horizon; and projecting outcomes for the conditions for which the guideline is intended. The use of modeling as an approach to bridge these gaps (provided that the models are high-quality and adequately validated) is considered. Colorectal and breast cancer screening are used as examples to show the utility of models for these purposes. The authors propose that a modeling study is most useful when strong primary evidence is available to inform the model but critical gaps remain between the evidence and the questions that the guideline group must address. In these cases, model results have a place alongside the findings of systematic reviews to inform health care practice and policy.
    Annals of internal medicine 12/2014; 161(11):812-8. · 13.98 Impact Factor
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    ABSTRACT: Purpose: To inform the VA Office of Health Promotion and Disease Prevention we conducted a systematic review to examine the effects of cancer screening shared decision making (SDM) interventions. Method: We searched MEDLINE, CINAHL, PsycINFO, and relevant journals from 1995 through 2013 for randomized controlled trials (RCTs) of cancer screening SDM interventions in adults in clinical settings. We extracted key study population and intervention characteristics and the effect of SDM on three outcomes of interest. Outcomes of interest drawn from the Ottawa Decision Support Framework included: (1) Decision Quality (informed, values-based, patient involvement), (2) Decision Action (screening preference/intention, screening behavior), and (3) Decision Impact (decisional conflict, health services use, decision satisfaction). Result: We identified twenty-two eligible RCTs evaluating SDM interventions for: breast (k=2), colorectal (k=3), and prostate (k=17) cancer screening. More than half of all SDM interventions included a values clarification exercise (k=15), but few used a theoretical framework (k=7). SDM intervention effects on outcomes varied. For Decision Quality, knowledge was assessed in the majority of studies (n=19), and in all cases SDM increased knowledge. Studies measured values and patient involvement less often (k=5 and k=11, respectively) and found no consistent effect. Eleven studies assessed Decision Action with no consistent SDM effect of SDM. Screening intention was evaluated for breast (k=2) and prostate cancer (k=9). Three studies assessed screening preference, all colorectal cancer. Screening behavior was assessed in 16 studies, ranging from 2 weeks to 1 year. SDM enhanced Decision Impact as measured by a consistent decrease in decisional conflict (k=12). However, SDM had no consistent effect on health services use (k=6) or decision satisfaction (k=2), though outcomes were infrequently reported. Conclusion: SDM interventions for cancer screening consistently increase patient knowledge and often decrease decisional conflict. However, there have been varying intervention effects on Decision Action or Decision Impact. Research is needed to guide future SDM intervention development to enhance the effect on decision action and impact.
    The 36th Annual Meeting of the Society for Medical Decision Making; 10/2014
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    ABSTRACT: Prostate cancer is a common malignancy in men and the worldwide burden of this disease is rising. Lifestyle modifications such as smoking cessation, exercise, and weight control offer opportunities to reduce the risk of developing prostate cancer. Early detection of prostate cancer by prostate-specific antigen (PSA) screening is controversial, but changes in the PSA threshold, frequency of screening, and the use of other biomarkers have the potential to minimise the overdiagnosis associated with PSA screening. Several new biomarkers for individuals with raised PSA concentrations or those diagnosed with prostate cancer are likely to identify individuals who can be spared aggressive treatment. Several pharmacological agents such as 5α-reductase inhibitors and aspirin could prevent development of prostate cancer. In this Review, we discuss the present evidence and research questions regarding prevention, early detection of prostate cancer, and management of men either at high risk of prostate cancer or diagnosed with low-grade prostate cancer.
    The Lancet Oncology 10/2014; 15(11):e484-e492. · 25.12 Impact Factor
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    ABSTRACT: Objective. Evaluate the evidence for effects of inpatient antimicrobial stewardship programs (ASPs) on patient, prescribing, and microbial outcomes. Design. Systematic review. Methods. Search of MEDLINE (2000 through November 2013), Cochrane Library, and reference lists of relevant studies. We included English language studies with patient populations relevant to the United States (ie, infectious conditions and prescriptions required for antimicrobials) that evaluated ASP interventions and reported outcomes of interest. Study characteristics and outcomes data were extracted and reviewed by investigators and trained research personnel. Results. Few intervention types (eg, audit and feedback, guideline implementation, and decision support) substantially impacted patient outcomes, including mortality, length of stay, readmission, or incidence of Clostridium difficile infection. However, most interventions were not powered adequately to demonstrate impacts on patient outcomes. Most interventions were associated with improved prescribing patterns as measured by decreased antimicrobial use or increased appropriate use. Where reported, ASPs were generally associated with improvements in microbial outcomes, including institutional resistance patterns or resistance in the study population. Few data were provided on harms, sustainability, or key intervention components. Studies were typically of short duration, low in methodological quality, and varied in study design, populations enrolled, hospital setting, ASP intent, intervention composition and implementation, comparison group, and outcomes assessed. Conclusions. Numerous studies suggest that ASPs can improve prescribing and microbial outcomes. Strength of evidence was low, and most studies were not designed adequately to detect improvements in mortality or other patient outcomes, but obvious adverse effects on patient outcomes were not reported.
    10/2014; 35(10):1209-1228.
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    ABSTRACT: The American College of Physicians recently published a guideline on screening for CKD that recommends against screening for CKD in asymptomatic adults without risk factors. The generally accepted criteria for population-based screening for disease state that screening should improve important clinical outcomes while limiting harms for those individuals screened. However, CKD screening does not meet these criteria. There is currently no evidence evaluating or demonstrating benefits for providing early treatment for patients identified via screening who do not have risk factors. On the other hand, harms are associated with the screening and include false-positive results, unnecessary testing and treatment, and disease labeling.
    Clinical journal of the American Society of Nephrology : CJASN. 09/2014;
  • John M Hollingsworth, Timothy J Wilt
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    ABSTRACT: Benign prostatic hyperplasia (BPH) is a highly prevalent and costly condition that affects older men worldwide. Many affected men develop lower urinary tract symptoms, which can have a negative impact on their quality of life. In the past, transurethral resection of the prostate (TURP) was the mainstay of treatment. However, several efficacious drug treatments have been developed, which have transformed BPH from an acute surgical entity to a chronic medical condition. Specifically, multiple clinical trials have shown that α adrenoceptor antagonists can significantly ameliorate lower urinary tract symptoms. Moreover, 5α reductase inhibitors, alone or combined with an α adrenoceptor antagonist, can reverse the natural course of BPH, reducing the risk of urinary retention and the need for surgical intervention. Newer medical regimens including the use of antimuscarinic agents or phosphodiesterase type 5 inhibitors, have shown promise in men with predominantly storage symptoms and concomitant erectile dysfunction, respectively. For men who do not adequately respond to conservative measures or pharmacotherapy, minimally invasive surgical techniques (such as transurethral needle ablation, microwave thermotherapy, and prostatic urethral lift) may be of benefit, although they lack the durability of TURP. A variety of laser procedures have also been introduced, whose improved hemostatic properties abrogate many of the complications associated with traditional surgery.
    BMJ Clinical Research 08/2014; 349:g4474. · 14.09 Impact Factor
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    ABSTRACT: The Agency for Healthcare Research and Quality (AHRQ) has funded systematic reviews of comparative effectiveness research in 17 areas over the last 10 years as part of a federal mandate. These reviews provide a reliable and unbiased source of comprehensive information about the effectiveness and risks of treatment alternatives for patients and clinicians. This article describes comparative effectiveness research, provides an overview of how physicians can use it in clinical practice, and references important contributions made by the Minnesota Evidence-based Practice Center.
    Minnesota medicine 08/2014; 97(8):49-51.
  • Amir Qaseem, Timothy Wilt, Thomas D Denberg
    Annals of internal medicine 07/2014; 161(1):83-84. · 13.98 Impact Factor
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    ABSTRACT: Pelvic examination is often included in well-woman visits even when cervical cancer screening is not required.
    Annals of internal medicine 07/2014; 161(1):46-53. · 13.98 Impact Factor
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    ABSTRACT: Behavioral change is critical for improving health outcomes in patients with chronic obstructive pulmonary disease. An educational approach alone is insufficient; changes in behavior, especially the acquisition of self-care skills, are also required. There is mounting evidence that embedding collaborative self-management (CSM) within existing health care systems provides an effective model to meet these needs. CSM should be integrated with pulmonary rehabilitation programs, one of the main goals of which is to induce long-term changes in behavior. More research is needed to evaluate the effectiveness of assimilating CSM into primary care, patient-centered medical homes, and palliative care teams.
    Clinics in Chest Medicine 06/2014; 35(2):337-351. · 2.07 Impact Factor
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    ABSTRACT: Family and caregiver interventions typically aim to develop family members' coping and caregiving skills and to reduce caregiver burden. We conducted a systematic review of published randomized controlled trials (RCTs) evaluating whether family-involved interventions improve patient outcomes among adults with cancer.
    Journal of General Internal Medicine 05/2014; · 3.28 Impact Factor
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    ABSTRACT: Tissue-preserving focal therapies, such as brachytherapy, cryotherapy, high-intensity focused ultrasound and photodynamic therapy, aim to target individual cancer lesions rather than the whole prostate. These treatments have emerged as potential interventions for localized prostate cancer to reduce treatment-related adverse-effects associated with whole-gland treatments, such as radical prostatectomy and radiotherapy. In this article, the Prostate Cancer RCT Consensus Group propose that a novel cohort-embedded randomized controlled trial (RCT) would provide a means to study men with clinically significant localized disease, which we defined on the basis of PSA level (≤15 ng/ml or ≤20 ng/ml), Gleason grade (Gleason pattern ≤4 + 4 or ≤4 + 3) and stage (≤cT2cN0M0). This RCT should recruit men who stand to benefit from treatment, with the control arm being whole-gland surgery or radiotherapy. Composite outcomes measuring rates of local and systemic salvage therapies at 3-5 years might best constitute the basis of the primary outcome on which to change practice.
    Nature Reviews Clinical Oncology 04/2014; · 15.03 Impact Factor
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    CancerSpectrum Knowledge Environment 03/2014; · 14.07 Impact Factor
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    ABSTRACT: Nonhealing ulcers affect patient quality of life and impose a substantial financial burden on the health care system. To systematically evaluate benefits and harms of advanced wound care therapies for nonhealing diabetic, venous, and arterial ulcers. MEDLINE (1995 to June 2013), the Cochrane Library, and reference lists. English-language randomized trials reporting ulcer healing or time to complete healing in adults with nonhealing ulcers treated with advanced therapies. Study characteristics, outcomes, adverse events, study quality, and strength of evidence were extracted by trained researchers and confirmed by the principal investigator. For diabetic ulcers, 35 trials (9 therapies) met eligibility criteria. There was moderate-strength evidence for improved healing with a biological skin equivalent (relative risk [RR], 1.58 [95% CI, 1.20 to 2.08]) and negative pressure wound therapy (RR, 1.49 [CI, 1.11 to 2.01]) compared with standard care and low-strength evidence for platelet-derived growth factors and silver cream compared with standard care. For venous ulcers, 20 trials (9 therapies) met eligibility criteria. There was moderate-strength evidence for improved healing with keratinocyte therapy (RR, 1.57 [CI, 1.16 to 2.11]) compared with standard care and low-strength evidence for biological dressing and a biological skin equivalent compared with standard care. One small trial of arterial ulcers reported improved healing with a biological skin equivalent compared with standard care. Overall, strength of evidence was low for ulcer healing and low or insufficient for time to complete healing. Only studies of products approved by the U.S. Food and Drug Administration were reviewed. Studies were predominantly of fair or poor quality. Few trials compared 2 advanced therapies. Compared with standard care, some advanced wound care therapies may improve the proportion of ulcers healed and reduce time to healing, although evidence is limited. Department of Veterans Affairs, Veterans Health Administration, Office of Research and Development, Quality Enhancement Research Initiative.
    Annals of internal medicine 10/2013; 159(8):532-542. · 13.98 Impact Factor
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    ABSTRACT: The Prostate Cancer Intervention Versus Observation Trial (PIVOT) randomized 731 men with localized prostate cancer to radical prostatectomy or observation. We describe the methods and results for cause-of-death assignments in PIVOT, and compare them to alternative strategies for ascertaining prostate cancer-specific mortality, as well as to the methods and results in the similar Scandinavian Prostate Cancer Group Study 4 (SPCG-4) trial. Three PIVOT Endpoints Committee members, blinded to randomized treatment assignments, reviewed medical records and death certificates when available to assign a cause of death using a primary and a secondary adjudication question. Initial disagreements were resolved through discussion. The level of initial agreement among committee members was examined, as well as guesses at randomized treatment assignments for a convenience sample of cases. Final cause of death determinations were compared to death certificates. Complete agreement on cause of death by all three committee members before any discussion was achieved in 200/354 (56%) cases on the primary and 209/354 (59%) cases on the secondary. However, complete agreement on the primary rose to 306/354 (86%) when 'definite' and 'probably' categories were collapsed, as planned a priori. The three committee members' proportions of correct guesses of randomized treatment assignment were 82/121 (68%), 113/148 (76%), and 99/134 (74%). Using the committee's final adjudications as a gold standard, death certificates had suboptimal sensitivities, specificities, or predictive values depending on how they were used to determine cause of death. There was no separate 'gold standard' by which to judge the accuracy of the final endpoints committee adjudications, and useful death certificates could not be obtained on about a third of PIVOT participants who died. The low level of initial agreement on cause of death among endpoint committee members and the potential for biased determinations due to partial unblinding to treatment assignment raise methodologic concerns about using prostate cancer mortality as an endpoint in clinical trials like PIVOT.
    Clinical Trials 08/2013; · 2.20 Impact Factor
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    ABSTRACT: Primary care providers frequently recommend, administer, or prescribe health care services that are unlikely to benefit their patients. Yet little is known about how to reduce provider overuse behavior. In the absence of a theoretically grounded causal framework, it is difficult to predict the contexts under which different types of interventions to reduce provider overuse will succeed and under which they will fail. In this article, we present a framework based on the theory of planned behavior that is designed to guide overuse research and intervention development. We describe categories of primary care provider beliefs that lead to the formation of intentions to assess the appropriateness of services, and propose factors that may affect whether the presence of assessment intentions results in an appropriate recommendation. Interventions that have been commonly used to address provider overuse behavior are reviewed within the context of the framework.
    Medical Care Research and Review 08/2013; · 3.01 Impact Factor
  • Michael Levitt, Timothy Wilt, Aasma Shaukat
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    ABSTRACT: The majority of the world's adult population and an estimated 80 million Americans are hypolactasic and hence malabsorb ingested lactose. Although lactose malabsorption is easily identified, less readily assessed is the clinically important question of how often does this malabsorption induce symptoms. This review summarizes: (1) knowledge concerning the etiology and diagnosis of hypolactasia and the pathophysiology of the symptoms of lactose malabsorption and (2) the results of well-controlled trials of the symptomatic response of lactose malabsorbers to varying dosages of lactose and the efficacy of therapeutic interventions to alleviate these symptoms. We conclude that the clinical significance of lactose malabsorption has been overestimated by both the lay public and physicians in that commonly ingested doses of lactose (ie, the quantity in a cup of milk) usually do not cause perceptible symptoms when ingested with a meal. Symptoms occur when the lactose dosage exceeds that in a cup of milk or when lactose is ingested without other nutrients. Simple dietary instruction, rather than the use of commercial products to reduce lactose intake, is recommended for the vast majority of lactose-malabsorbing subjects.
    Journal of clinical gastroenterology 04/2013; · 2.21 Impact Factor
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    ABSTRACT: Optimum management to prevent recurrent kidney stones is uncertain. To evaluate the benefits and harms of interventions to prevent recurrent kidney stones. MEDLINE, Cochrane, and other databases through September 2012 and reference lists of systematic reviews and randomized, controlled trials (RCTs). 28 English-language RCTs that studied treatments to prevent recurrent kidney stones and reported stone outcomes. One reviewer extracted data, a second checked accuracy, and 2 independently rated quality and graded strength of evidence. In patients with 1 past calcium stone, low-strength evidence showed that increased fluid intake halved recurrent composite stone risk compared with no treatment (relative risk [RR], 0.45 [95% CI, 0.24 to 0.84]). Low-strength evidence showed that reducing soft-drink consumption decreased recurrent symptomatic stone risk (RR, 0.83 [CI, 0.71 to 0.98]). In patients with multiple past calcium stones, most of whom were receiving increased fluid intake, moderate-strength evidence showed that thiazides (RR, 0.52 [CI, 0.39 to 0.69]), citrates (RR, 0.25 [CI, 0.14 to 0.44]), and allopurinol (RR, 0.59 [CI, 0.42 to 0.84]) each further reduced composite stone recurrence risk compared with placebo or control, although the benefit from allopurinol seemed limited to patients with baseline hyperuricemia or hyperuricosuria. Other baseline biochemistry measures did not allow prediction of treatment efficacy. Low-strength evidence showed that neither citrate nor allopurinol combined with thiazide was superior to thiazide alone. There were few withdrawals among patients with increased fluid intake, many among those with other dietary interventions and more among those who received thiazide and citrate than among control patients. Reporting of adverse events was poor. Most trial participants had idiopathic calcium stones. Nearly all studies reported a composite (including asymptomatic) stone recurrence outcome. In patients with 1 past calcium stone, increased fluid intake reduced recurrence risk. In patients with multiple past calcium stones, addition of thiazide, citrate, or allopurinol further reduced risk. Agency for Healthcare Research and Quality.
    Annals of internal medicine 04/2013; 158(7):535-43. · 13.98 Impact Factor
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    ABSTRACT: BACKGROUND:: The US Preventive Services Task Force recommended against prostate-specific antigen (PSA) screening for prostate cancer based primarily on 2 large long-term randomized-controlled trials (RCTs) and a systematic review of harms resulting from screening. OBJECTIVE:: To support use of large, long-term randomized trials as the evidence base for clinical guidelines on screening and to draw attention to limitations of modeling studies used for this purpose. METHODS:: We respond to critiques of use of RCTs as the primary evidence base, considering the results of the Prostate, Lung, Colorectal and Ovarian (PLCO) and European Randomized Study of Screening for Prostate Cancer (ERSPC) trials, documented harms resulting from PSA screening, and methodological concerns with modeling studies. RESULTS:: The PLCO and ERSPC provided 11-13 years of follow-up on over 250,000 subjects. The PLCO, despite limitations, is most representative of US populations, screening and treatment practices, and showed no mortality benefit resulting from annual PSA testing after 13 years of follow-up. The confidence interval was narrow and precluded more than a 13% relative mortality reduction. Competing causes of mortality in older men make it progressively less likely that longer follow-up will demonstrate a large absolute reduction in disease-specific mortality. With continued screening, the increasing prevalence of asymptomatic cancers in older men will increase the rate of overdiagnosis. Potential harms from screening and treatment are significant. CONCLUSIONS:: Projections from models are subject to mistaken assumptions and investigator biases, and should not be accorded the same weight as evidence from RCTs. Current empiric evidence is sufficient to support the US Preventive Services Task Force guideline that clinicians should recommend against PSA screening for prostate cancer.
    Medical care 04/2013; 51(4):301-303. · 3.24 Impact Factor

Publication Stats

8k Citations
1,524.43 Total Impact Points


  • 2000–2013
    • Massachusetts General Hospital
      • Hospital Medicine Unit
      Boston, Massachusetts, United States
    • Blue Cross and Blue Shield Association, Technology Evaluation Center (TEC)
      Chicago, Illinois, United States
  • 1994–2013
    • University of Minnesota Duluth
      • Medical School
      Duluth, Minnesota, United States
  • 2004–2012
    • University of New Mexico
      • • Division of General Internal Medicine
      • • School of Medicine
      Albuquerque, NM, United States
    • Geisel School of Medicine at Dartmouth
      Hanover, New Hampshire, United States
  • 1999–2012
    • U.S. Department of Veterans Affairs
      • • Center for Chronic Disease Outcomes Research (CCDOR)
      • • Geriatric Research, Education and Clinical Center (GRECC)
      • • General Internal Medicine
      Washington, D. C., DC, United States
  • 1990–2012
    • Minneapolis Veterans Affairs Hospital
      • Department of Veterans Affairs
      Minneapolis, Minnesota, United States
  • 2011
    • University of Michigan
      • Department of Radiology
      Ann Arbor, MI, United States
  • 2007–2011
    • Monash University (Australia)
      • School of Public Health and Preventive Medicine
      Melbourne, Victoria, Australia
    • University of Washington Seattle
      • Department of Urology
      Seattle, WA, United States
  • 2003–2011
    • University of Minnesota Twin Cities
      • • Division of Health Policy and Management
      • • Department of Orthopaedic Surgery
      • • Department of Medicine
      • • School of Public Health
      Minneapolis, MN, United States
    • Northwest Medical Center
      Tucson, Arizona, United States
  • 2000–2011
    • BC Cancer Agency
      Vancouver, British Columbia, Canada
  • 2009–2010
    • University of California, San Diego
      • Division of Urology
      San Diego, California, United States
    • University of Ottawa
      Ottawa, Ontario, Canada
    • Cook County Hospital
      Chicago, Illinois, United States
    • Ottawa Hospital Research Institute
      • Clinical Epidemiology Program
      Ottawa, Ontario, Canada
  • 2000–2009
    • Velindre NHS Trust
      Cardiff, Wales, United Kingdom
  • 2008
    • Oregon Health and Science University
      Portland, Oregon, United States
  • 2006
    • Edward Hines, Jr. VA Hospital
      Hines, Oregon, United States
    • The University of Hong Kong
      Hong Kong, Hong Kong
    • University of California, Los Angeles
      • Department of Urology
      Los Angeles, CA, United States
  • 2005
    • Hennepin County Medical Center
      Minneapolis, Minnesota, United States
    • Sichuan University
      • Department of Urology
      Chengdu, Sichuan Sheng, China
  • 1995
    • University of Wisconsin, Madison
      • Department of Surgery
      Madison, MS, United States