Table S1: Search strategy for corresponding randomized controlled trials of identified practices

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Pearl Curtis
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1 Appendix 1 (as supplied by the authors): Supplementary Tables 1 and 2 Table S1: Search strategy for corresponding randomized controlled trials of identified practices The Claim Search strategy for RCT RCT identified nivolumab Nivolumab versus chemotherapy in and melanoma, filtered by clinical trials patients with advanced melanoma and sorted by best match. Results who progressed after anti-ctla-4 reviewed by abstract to identify treatment (CheckMate 037): a randomized clinical trials with nivolumab randomised, controlled, open-label, Nivolumab for metastatic melanoma has so monotherapy versus a control group. 2 phase 3 trial. 28 Nivolumab was impressive a response rate and progression separate high quality trials superior to decarbazine in free survival, akin to a parachute, that Checkmate 66 (and choice of examining overall survival is not comparator seemed a straw man, necessary. 27 given year trial was performed) 29 Insulin analogues are superior to regular human insulin for achieving glycemic control in type 1 diabetics. 30 Empirical de-worming therapy of children in endemic areas has clinical benefit. 33 Stenting for renal artery stenosis benefits some patients so greatly, it is a parachute. 35 Stenting for renal artery stenosis benefits some patients so greatly, it is a parachutes. 37 Simulation based training for medical personnel obviously improve patient outcomes in critical care medicine 38 Simulation based training for medical personnel obviously improve patient outcomes in critical care medicine 40 Recognition and treatment of pre-diabetes leads to improved patient outcomes. 41 Treating diabetes will agents that lower blood sugar will invariably lead to improved cardiovascular outcomes. 43 insulin analogues type 1 diabetes and glycemic control filtered by clinical trials and systematic reviews. Results reviewed by abstract to identify systematic reviews and meta analyses that compared insulin analogues to human insulin derivatives in type I diabetes with outcomes including glycemic control. Multiple trials identified, we included 2 large systematic reviews of long and short acting analogues versus regular human insulin derivatives. Medline search for deworming and endemic, filtered by clinical trials and systematic reviews. Results reviewed by abstract to identify randomized trials of systematic reviews investigating empiric deworming therapy in areas of endemic helminth infections. renal artery stenosis and stenting filtered by clinical trials and systematic reviews. 1 high quality randomized controlled trial renal artery stenosis and stenting filtered by clinical trials and systematic reviews. 1 high quality randomized controlled trial simulation critical care and randomized, filtered by clinical trials. Results reviewed by abstract to identify trials with a clinical outcome. simulation critical care and randomized, filtered by clinical trials. Results reviewed by abstract to identify trials with a clinical outcome. diabetes, incidence and metformin, filtered by clinical trials. Results reviewed individually at abstract level. The first study resulted was accepted as it is a well known and well conducted study on the topic with a positive result. Several, including large meta analyses such as "Systematic review and meta-analysis of short-acting insulin analogues in patients with diabetes mellitus. 31 ", "Long-acting insulin analogues vs. NPH human insulin in type 1 diabetes. A metaanalysis. 32 " Cochrane reviews of multiple RCTs, including " Deworming drugs for soil-transmitted intestinal worms in children: effects on nutritional indicators, haemoglobin, and school performance. 34 " Stenting and Medical Therapy for Atherosclerotic Renal-Artery Stenosis. 36 Stenting and Medical Therapy for Atherosclerotic Renal-Artery Stenosis. 36 Multiple, including "Simulation improves procedural protocol adherence during central venous catheter placement: A randomized controlled trial. 39 " Multiple, including " Simulation improves procedural protocol adherence during central venous catheter placement: A randomized controlled trial. 39 " Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. 42 diabetes cardiovascular mortality and A1C, filtered by clinical trials. Results reviewed ACCORD 44, UKPDS 45, VADT 46

2 10 Most of current IVF use and application is so obviously beneficial at conceiving children it does not require randomized trials. 47 at abstract level for primary results from prior large RCTs, three articles were chosen due to being well-known studies with high quality data. IVF and Randomized, filtered by clinical trials. Results were reviewed by title and abstract to identify a trial comparing IVF to normal or expectant management. A multicentre randomized controlled trial of expectant management versus IVF in women with fallopian tube patency The use of pancreatic enzyme replacement for patients with cystic fibrosis and pancreatic insufficiency has clear clinical benefit. 49 Intracranial pressure monitoring for severe traumatic brain injury provides useful information that improves outcomes. 51 Photodynamic therapy improves outcomes in glioblastoma multiform. 53 Metastasectomy improves outcomes pulmonary colorectal cancer 55 Intra-arterial thrombolysis improves clinical outcomes in acute basilar artery thrombosis 57 Peptide receptor radionucleotide therapy for neuroendocrine tumors is of clear benefit 59 Hyperbaric oxygen therapy improves skin graft healing and survival. 61 Use of ultrasound guidance during embryo transfer in IVF is obviously beneficial 64 The benefit of of hyperthermic intraperitoneal chemotherapy in peritoneal mesothelioma is so obvious, it is akin to a parachute 68 Cystic fibrosis and pancreatic insufficiency, filtered by clinical trials. Results were reviewed at title and abstract level to identify a randomized clinical trial of pancreatic enzyme replacement. intracranialpressure monitoring and TBI filtered by clinical trials. Results reviewed by title and abstract. First result was a well known and high quality study and was accepted. malignant glioma and photodynamic therapy filtered by clinical trial. Results reviewed at title and abstract level for randomized trial in GBM comparing phototherapy to no phototherapy. pulmonary metastatectomy and colorectal cancer, filtered by clinical trial. Results reviewed at title and abstract level, and 1 abstract describing an ongoing trial was intraarterial thrombolysis, basilar stroke, and randomized, filtered by clinical trial. Results reviewed by title and abstract until a randomized trial was Neuroendocrine tumor and 177lu (reference in citing article), filtered by clinical trials. Results reviewed by title and abstract yielding 1 randomized study at the time of the search. hyperbaric oxygen and skin graft filtered by clinical trials. Results were reviewed at title and abstract level. As this initial search only resulted in a single study from 1967, search was broadened to systematic reviews which yielded the second article. ultrasound guidance and embryo transfer filtered by clinical trials. Results reviewed at title and abstract level for a randomized study of ultrasound guided transfer compared to prior standard clinical touch method. hyperthermic chemotherapy and mesothelioma filtered by clinical trial. study could be A Efficacy and safety of Pancreaze for tratment of exocrine pancreatic insuffiency due to cystic fibrosis. 50 A trial of intracranial-pressure monitoring in traumatic brain injury. 52 ALA and malignant glioma: fluorescence-guided resection and photodynamic treatment. 54 Pulmonary metastasectomy in colorectal cancer: the PulMiCC trial. 56 Results of a multicentre, randomised controlled trial of intraarterial urokinase in the treatment of acute posterior circulation ischaemic stroke. 58 NETTER-1 Phase III in Patients With Midgut Neuroendocrine Tumors Treated With 177Lu-DOTATATE: Efficacy and Safety Results. 60 Influence of hyperbaric oxygen on the survival of split skin grafts. 62, Xie ZX, Li CY. Changes in arterial flow after flap grafting under various tensions. 63 Ultrasound-guided embryo transfer: a prospective randomized controlled trial. 65 Surgery plus intraoperative peritoneal hyperthermic chemotherapy to treat peritoneal carcinomatosis

3 Sucralfate and mucositis filtered by clinical trial. Magic mouthwash plus sucralfate versus benzydamine hydrochloride for the treatment of radiationinduced mucositis study could be A 20 The use of sucralfate for oral mucositis is of such great benefit that it should be considered level 1A evidence based on observational studies. 70 dental restoration replacement and composite filtered by clinical trial. Study of the success and survival of dental composite restorations being repaired instead of being replaced study could be A 21 Repair of defective dental restorations with composite restoration should be considered over replacement strategies, despite lack of RCT data 80 hygiene and CMV filtered by clinical trial. Results were reviewed at title and abstract level Clinical trial of behavioral modification to prevent congenital cytomegalovirus for a randomized clinical trial. study could be A clinicaltrials.gov 22 Use of hygiene education interventions for the prevention of CMV transmission is beneficial, akin to a parachute 81 search protocol level for intensive care unit and establishment filtered by clinical trial. Results were reviewed at title and abstract level for a randomized clinical trial. study could be A 23 Having an intensive care unit in a hospital is of benefit 66 nasal photodisinfection chlorhexidine and infection filtered by clinical trial. Results were reviewed at title and abstract level 24 Positive results from observational trial of nasal photodisinfection and chlorhexidine wipes for prevention of skin and soft tissue infections are sufficient for implementation of practice. 67 for a randomized clinical trial. study could be A clinicaltrials.gov search protocol level for endoscopic and cystic duct filtered by clinical trial. Results were reviewed at title and abstract level for a randomized clinical trial. study could be A 25 Endoscopic decompression of symptomatic cystic duct obstruction is beneficial, akin to a parachute. 69 emergent and airway management filtered by clinical trial for a randomized clinical trial. level. study could be A 26 Emergency airway management is a form of "parachute medicine" The benefit of CSF lavage following CSF and

4 intrathecal injection of excess or wrong drugs is so beneficial, it is akin to a parachute 72 The use of covered stents for coronary artery perforation is beneficial, despite lack of RCT data. 73 Surgical management of acute epidural hematoma is beneficial, despite lack of RCT data 74 Perispinal etanercept in the setting of poststroke neurologic dysfunction has therapeutic benefit, despite lack of RCT data 75 IVF is effective in couples without a chance of spontaneous pregnancy, akin to a parachute 76 Requiring short fingernails among providers will decrease rates of infection transmission. 77 Use of new adhesive for spinal cord stimulator implantation was effective and can be safely implemented under guise of "mechanism based medicine", akin to a parachute 78 Mechanical ventillation in lung injury is beneficial 79 Lavage filtered by clinical trial. Results were reviewed at title and abstract level for a randomized clinical trial. study could be A clinicaltrials.gov search protocol level for covered stents and coronary perforation be A clinicaltrials.gov search protocol level for acute epidural hematoma and surgery be A clinicaltrials.gov search protocol level for etanercept, stroke and perispinal be A clinicaltrials.gov search protocol level for IVF and complete inertility filtered by clinical trial. Results were reviewed at title and abstract level for a randomized clinical trial. study could be A fingernails and infection filtered by clinical trial. study could be A adhesive and spinal cord stimulator filtered by clinical trial. Results were reviewed at title and abstract level for a randomized clinical trial. study could be A mechanical ventilation, respiratory failure and acute lung injury filtered by clinical trial.

5 35 Osseointegrated dental implants are beneficial for treating total or partial edentulism, akin to a parachute 82 study could be A osseointegrated dental implant and be A clinicaltrials.gov search protocol level for Table S2: Discussion regarding feasibility of clinical trial for parachute practices that have not been tested in a randomized trial Our rebuttal Should it be tested in a randomized Claim trial? Having an intensive care unit in a hospital is We have no rebuttal. of benefit 66 Positive results from observational trial of This intervention could be very easily This practice could be subject to nasal photodisinfection and chlorhexidine subjected to a randomized trial, and we RCT. wipes for prevention of skin and soft tissue are not convinced by the quality of infections are sufficient for implementation evidence that they site as their trial was of practice. 67 small and single-centered. I selective patients as described in the article, we agree that this intervention is likely the only reasonable option and thus should not be subjected to RCT. As Endoscopic decompression of symptomatic indications for this procedure grow there cystic duct obstruction is beneficial, akin to may be certain indications that should be a parachute. 69 investigated by RCT. Emergency airway management is a form We have no rebuttal of "parachute medicine" 71 The benefit of CSF lavage following We have no rebuttal intrathecal injection of excess or wrong drugs is so beneficial, it is akin to a parachute 72 The use of covered stents for coronary We have no rebuttal artery perforation is beneficial, despite lack of RCT data. 73 Surgical management of acute epidural We have no rebuttal. hematoma is beneficial, despite lack of RCT data 74 Perispinal etanercept in the setting of poststroke neurologic dysfunction has therapeutic benefit, despite lack of RCT data 75 IVF is effective in couples without a chance of spontaneous pregnancy, akin to a parachute 76 Requiring short fingernails among providers will decrease rates of infection transmission. 77 This is a practice that we feel strongly could and should be subjected to a randomized trial. Namely, as this is a procedural practice with difficult to measure outcomes such as strength and coordination, it is likely to be heavily biased by a sham effect. We have no rebuttal While we admit that randomized trials of hygiene and infection control can often be challenging, we would argue that it could very easily be tested I randomized fashion, This could be subject to RCT. This practice could be subject to RCT

6 and thus is very likely not a parachute. This practice could be very easily tested in This practice could be subject to Use of new adhesive for spinal cord a randomized, if not blinded, study. There RCT. stimulator implantation was effective and is minimal harm in testing different can be safely implemented under guise of adhesive strategies and likely a great deal "mechanism based medicine", akin to a of user variability that would make a parachute 78 randomized study ideal. Mechanical ventillation in lung injury is We have no rebuttal to this claim. beneficial 79 Osseointegrated dental implants are beneficial for treating total or partial edentulism, akin to a parachute 82 As we are not dentists we cannot rely on our own clinical experience to understand the validity of this claim. We can imagine, however, that this could very easily be tested in a clinical trial and that osseointegrated implants may not be superior to other types of replacements, like dentures. This practice could be subject to RCT

Covered Critical Illness Conditions Appendix

Covered Critical Illness Conditions Appendix Effective Date: February 1, 2010 This Appendix contains definitions for those Conditions that are covered under the Manulife Financial Group Critical Illness