To conduct a series of focus groups with primary care physicians to determine the optimal format of a shortened, focused systematic review.
Materials and methods
Prototypes for two formats of a shortened systematic review were developed and presented to participants during focus group sessions. Focus groups were conducted with primary care physicians who were in full- or part-time practice. An iterative process was used so that the information learned from the first set of focus groups (Round 1) influenced the material presented to the second set of focus groups (Round 2). The focus group discussions were recorded, transcribed verbatim, and analyzed.
Each of the two rounds of testing included three focus groups. A total of 32 physicians participated (Round 1:16 participants; Round 2:16 participants). Analysis of the transcripts from Round 1 identified three themes including ease of use, clarity, and implementation. Changes were made to the prototypes based on the results so that the revised prototypes could be presented and discussed in the second round of focus groups. After analysis of transcripts from Round 2, four themes were identified, including ease of use, clarity, brevity, and implementation. Revisions were made to the prototypes based on the results.
Primary care physicians provided input on the refinement of two prototypes of a shortened systematic review for clinicians. Their feedback guided changes to the format, presentation, and layout of these prototypes in order to increase usability and uptake for end-users.
evidence-based practice; focus groups; review literature as topic; qualitative research
Evidence suggests that systematic reviews are used infrequently by physicians in clinical decision-making. One proposed solution is to create filtered resources so that information is validated and refined in order to be read quickly. Two shortened systematic review formats were developed to enhance their use in clinical decision-making.
To prepare for a full-scale trial, we conducted a pilot study to test methods and procedures in order to refine the processes. A recruitment email was sent to physicians practicing full- or part-time in family medicine or general internal medicine. The pilot study took place in an online environment and eligible physicians were randomized to one of the systematic review formats (shortened or full-length) and instructed to read the document. Participants were asked to provide the clinical bottom line and apply the information presented to a clinical scenario. Participants’ answers were evaluated independently by two investigators against “gold standard” answers prepared by an expert panel.
Fifty-six clinicians completed the pilot study within a 2-month period with a response rate of 4.3 %. Agreement between investigators in assessing participants’ answers was determined by calculating a kappa statistic. Two questions were assessed separately, and a kappa statistic was calculated at 1.00 (100 % agreement) for each.
Agreement between investigators in assessing participants’ answers is satisfactory. Although recruitment for the pilot study was completed in a reasonable time-frame, response rates were low and will require large numbers of contacts. The results indicate that conducting a full-scale trial is feasible.
Electronic supplementary material
The online version of this article (doi:10.1186/s13012-015-0303-4) contains supplementary material, which is available to authorized users.
Numerous, often multi-faceted regimens are available for treating complex wounds, yet the evidence of these interventions is recondite across the literature. We aimed to identify effective interventions to treat complex wounds through an overview of systematic reviews.
MEDLINE (OVID interface, 1946 until October 26, 2012), EMBASE (OVID interface, 1947 until October 26, 2012), and the Cochrane Database of Systematic Reviews (Issue 10 of 12, 2012) were searched on October 26, 2012. Systematic reviews that examined adults receiving care for their complex wounds were included. Two reviewers independently screened the literature, abstracted data, and assessed study quality using the Assessment of Multiple Systematic Reviews (AMSTAR) tool.
Overall, 99 systematic reviews were included after screening 6,200 titles and abstracts and 422 full-texts; 54 were systematic reviews with a meta-analysis (including data on over 54,000 patients) and 45 were systematic reviews without a meta-analysis. Overall, 44% of included reviews were rated as being of high quality (AMSTAR score ≥8). Based on data from systematic reviews including a meta-analysis with an AMSTAR score ≥8, promising interventions for complex wounds were identified. These included bandages or stockings (multi-layer, high compression) and wound cleansing for venous leg ulcers; four-layer bandages for mixed arterial/venous leg ulcers; biologics, ultrasound, and hydrogel dressings for diabetic leg/foot ulcers; hydrocolloid dressings, electrotherapy, air-fluidized beds, and alternate foam mattresses for pressure ulcers; and silver dressings and ultrasound for unspecified mixed complex wounds. For surgical wound infections, topical negative pressure and vacuum-assisted closure were promising interventions, but this was based on evidence from moderate to low quality systematic reviews.
Numerous interventions can be utilized for patients with varying types of complex wounds, yet few treatments were consistently effective across all outcomes throughout the literature. Clinicians and patients can use our results to tailor effective treatment according to type of complex wound. Network meta-analysis will be of benefit to decision-makers, as it will permit multiple treatment comparisons and ranking of the effectiveness of all interventions.
Please see related article: http://dx.doi.org/10.1186/s12916-015-0326-3
Electronic supplementary material
The online version of this article (doi:10.1186/s12916-015-0288-5) contains supplementary material, which is available to authorized users.
Complex wound; Effectiveness; Systematic review; Treatment; Ulcer; Wounds
The burden of chronic disease is a global phenomenon, particularly among people aged 65 years and older. More than half of older adults have more than one chronic disease and their care is not optimal. Chronic disease management (CDM) tools have the potential to meet this challenge but they are primarily focused on a single disease, which fails to address the growing number of seniors with multiple chronic conditions.
Methods and analysis
We will conduct a systematic review alongside a realist review to identify effective CDM tools that integrate one or more high-burden chronic diseases affecting older adults and to better understand for whom, under what circumstances, how and why they produce their outcomes. We will search MEDLINE, EMBASE, CINAHL, AgeLine and the Cochrane Library for experimental, quasi-experimental, observational and qualitative studies in any language investigating CDM tools that facilitate optimal disease management in one or more high-burden chronic diseases affecting adults aged ≥65 years. Study selection will involve calibration of reviewers to ensure reliability of screening and duplicate assessment of articles. Data abstraction and risk of bias assessment will also be performed independently. Analysis will include descriptive summaries of study and appraisal characteristics, effectiveness of each CDM tool (meta-analysis if appropriate); and a realist programme theory will be developed and refined to explain the outcome patterns within the included studies.
Ethics and dissemination
Ethics approval is not required for this study. We anticipate that our findings, pertaining to gaps in care across high-burden chronic diseases affecting seniors and highlighting specific areas that may require more research, will be of interest to a wide range of knowledge users and stakeholders. We will publish and present our findings widely, and also plan more active dissemination strategies such as workshops with our key stakeholders.
Trial registration number
Our protocol is registered with PROSPERO (registration number CRD42014014489).
GENERAL MEDICINE (see Internal Medicine); INTERNAL MEDICINE
The aim of this study was to evaluate the usability of two formats of a shortened systematic review for clinicians.
Materials and methods
Usability of the prototypes was assessed using three cycles of iterative testing. 10 participants were asked to complete tasks of locating information or items within two prototypes and ‘think aloud’ while being audio taped. Interviews were also audio recorded and participants completed a systematic usability scale.
Revisions were made between each iteration in order to address issues identified by participants. Finding information relating to the number of studies in the meta-analysis, and locating the number of studies in the entire systematic review were revealed as areas needing attention during the usability evaluation.
Iterative testing combined with a multifaceted approach to usability testing offered essential insight into aspects of the prototypes that required modifications. Alterations were made in order to create finalised versions of the two shortened systematic review formats.
Review Literature as Topic; PRIMARY CARE; Evidence Based Practice
Heart failure (HF) is a leading reason for hospitalisation and readmissions to hospital, particularly among individuals older than 65 years of age. The prognosis of patients with HF is grim, with high rates of mortality risk and hospital readmissions. The transition period early after hospital discharge represents a window of opportunity to positively influence patient outcomes using quality improvement (QI) strategies. However, little is known about which QI interventions exist for early events of HF after discharge, so the main objective of our study is to conduct a scoping review of the literature to determine which QI strategies are effective for reducing hospital readmissions and mortality for patients with HF who transition from the hospital back into independent living. We will also investigate which elements contribute to effective QI strategies.
Methods and analysis
We will search the literature in MEDLINE, EMBASE, CINAHL and the Cochrane library for randomised controlled trials and systematic reviews evaluating QI interventions aimed at improving outcomes for patients with HF transitioning from the hospital back into the community. Two reviewers will independently apply our eligibility criteria at level 1 (abstract/title) and level 2 (full-text) screening; disagreements will be resolved through consensus. We will extract data in duplicate on study characteristics, population, setting, QI intervention and outcomes. We will synthesise results descriptively and explore QI elements to determine which aspect contributes to its impact. We will also consider synthesis of our data according to several conceptual frameworks such as Wagner's Chronic Care Model.
Discussion and dissemination
The findings of this scoping review will be used to determine which elements should comprise a QI intervention aimed at facilitating the transition of newly admitted patients with HF back into the community. We will disseminate our findings through publications, presentations as well as through a stakeholder meeting to generate key messages most relevant to each.
Hip fractures are a significant cause of morbidity and mortality and care of hip fracture patients places a heavy burden on healthcare systems due to prolonged recovery time. Measuring quality of care delivered to hip fracture patients is important to help target efforts to improve care for patients and efficiency of the health system. The purpose of this study is to synthesise the evidence surrounding quality of care indicators for patients who have sustained a hip fracture. Using a scoping review methodology, the research question that will be addressed is: “What patient, institutional, and system-level indicators are currently in use or proposed for measuring quality of care across the continuum for individuals following a hip fracture?”.
Methods and analysis
We will employ the methodological frameworks used by Arksey and O'Malley and Levac et al. The synthesis will be limited to quality of care indicators for individuals who suffered low trauma hip fracture. All English peer-reviewed studies published from the year 2000-most recent will be included. Literature search strategies will be developed using medical subject headings and text words related to hip fracture quality indicators and the search will be peer-reviewed. Numerous electronic databases will be searched. Two reviewers will independently screen titles and abstracts for inclusion, followed by screening of the full text of potentially relevant articles to determine final inclusion. Abstracted data will include study characteristics and indicator definitions.
To improve quality of care for patients and create a more efficient healthcare system, mechanisms for the measurement of quality of care are required. The implementation of quality of care indicators enables stakeholders to target areas for improvement in service delivery. Knowledge translation activities will occur throughout the review with dissemination of the project goals and findings to local, national, and international stakeholders.
Quality Indicators; Hip Fractures; Quality of Healthcare; Outcomes Assessment
Knowledge translation (KT) supports use of evidence in healthcare decision making but is not widely practiced. Mentoring is a promising means of developing KT capacity. The purpose of this scoping systematic review was to identify essential components of mentoring that could be adapted for KT mentorship.
Key social sciences and management databases were searched from January 2002 to December 2011 inclusive. Empirical research in non-healthcare settings that examined mentorship design and impact for improving job-specific knowledge and skill were eligible. Members of the study team independently selected eligible studies, and extracted and summarized data.
Of 2,101 search results, 293 were retrieved and 13 studies were eligible for review. All but one reported improvements in knowledge, skill, or behavior. Mentoring program components included combining preliminary workshop-based training with individual mentoring provided either in person or remotely; training of mentors; and periodic mentoring for at least an hour over a minimum period of six months. Barriers included the need for infrastructure for recruitment, matching, and training; lack of clarity in mentoring goals; and limited satisfaction with mentors and their availability. Findings were analyzed against a conceptual framework of factors that influence mentoring design and impact to identify issues warranting further research.
This study identified key mentoring components that could be adapted for KT mentorship. Overall, few studies were identified. Thus further research should explore whether and how mentoring should be tailored to baseline knowledge or skill and individual KT needs; evaluate newly developed or existing KT mentorship programs based on the factors identified here; and examine whether and how KT mentorship develops KT capacity. The conceptual framework could be used to develop or evaluate KT mentoring programs.
Knowledge translation; Mentorship
Simulation-based learning is increasingly used by healthcare professionals as a safe method to learn and practice non-technical skills, such as communication and leadership, required for effective crisis resource management (CRM). This systematic review was conducted to gain a better understanding of the impact of simulation-based CRM teaching on transfer of learning to the workplace and subsequent changes in patient outcomes.
Studies on CRM, crisis management, crew resource management, teamwork, and simulation published up to September 2012 were searched in MEDLINE®, EMBASE™, CINAHL, Cochrane Central Register of Controlled Trials, and ERIC. All studies that used simulation-based CRM teaching with outcomes measured at Kirkpatrick Level 3 (transfer of learning to the workplace) or 4 (patient outcome) were included. Studies measuring only learners’ reactions or simple learning (Kirkpatrick Level 1 or 2, respectively) were excluded. Two authors independently reviewed all identified titles and abstracts for eligibility.
Nine articles were identified as meeting the inclusion criteria. Four studies measured transfer of simulation-based CRM learning into the clinical setting (Kirkpatrick Level 3). In three of these studies, simulation-enhanced CRM training was found significantly more effective than no intervention or didactic teaching. Five studies measured patient outcomes (Kirkpatrick Level 4). Only one of these studies found that simulation-based CRM training made a clearly significant impact on patient mortality.
Based on a small number of studies, this systematic review found that CRM skills learned at the simulation centre are transferred to clinical settings, and the acquired CRM skills may translate to improved patient outcomes, including a decrease in mortality.
Electronic supplementary material
The online version of this article (doi:10.1007/s12630-014-0143-8) contains supplementary material, which is available to authorized users.
Colorectal cancer (CRC) poses a serious health problem worldwide. While screening is effective in reducing CRC mortality, participation in screening tests is generally suboptimal and social inequities in participation are frequently reported. The goal of this review is to synthesise factors that influence an individual’s decision to participate in CRC screening, and to explore how those factors vary by sex, ethnicity and socioeconomic status.
A primary search of Cumulative Index to Nursing and Allied Health Literature (CINAHL), MEDLINE, EMBASE, PsycINFO, and a secondary search of grey literature and articles taken from references of included articles (from inception to July 2013).
A systematic review and Meta-study synthesis of qualitative studies that address perceived benefits and barriers to participation in CRC screening tests among adults 50 years of age or older.
The two-staged Meta-study methodology by Paterson will be used to conduct this review. In stage 1, similarities/differences, patterns and themes will be identified across three levels of analysis while preserving the context of original studies. In stage 2, synthesis will extend beyond the analysis to generate new theory of the phenomenon through a process called Meta-synthesis.
This review offers to generate a framework to better understand benefits and barriers that affect decision-making to participate in CRC screening among different sectors of the population. This framework will be a relevant tool for policy makers in framing educational materials, for patient-centered communication, and for researchers interested in the science of equity. This review is registered in PROSPERO (registration number: CRD42013005025).
Qualitative Research; Social Medicine
Bariatric surgery is the only weight-loss treatment available that results in both sustained weight loss and improvements of obesity-related comorbidities. Individuals who meet the eligibility criteria for bariatric surgery are generally older, come from racial or ethnic minorities, are economically disadvantaged, and have low levels of education. However, the population who actually receives bariatric surgery does not reflect the individuals who need it the most. The objective is to conduct a systematic review of the literature exploring the inequities to the access of bariatric surgery.
EMBASE and Medline databases will be searched for observational studies that compared at least one of the PROGRESS-PLUS sociodemographic characteristics of patients eligible for bariatric surgery to those who actually received the procedure. Articles published in the year 1980 to present with no language restrictions will be included. For inclusion, studies must only include adults (≥18 years old) who meet National Institutes of Health (NIH) eligibility criteria for bariatric surgery defined as having either (1) a body mass index (BMI) of 40 kg/m2 or greater; or (2) BMI of 35 kg/m2 or greater with significant weight-related comorbidities. Eligible interventions will include malabsorptive, restrictive, and mixed bariatric procedures.
There appears to be inequities in access to bariatric surgery. In order to resolve the health inequity in the treatment of obesity, a synthesis of the literature is needed to explore and identify barriers to accessing bariatric surgery. It is anticipated that the results from this systematic review will have important implications for advancing solutions to minimize inequities in the utilization of bariatric surgery.
Bariatric surgery; Sociodemographic disparities; Obesity; Systematic review
Systematic reviews provide evidence for clinical questions, however the literature suggests they are not used regularly by physicians for decision-making. A shortened systematic review format is proposed as one possible solution to address barriers, such as lack of time, experienced by busy clinicians. The purpose of this paper is to describe the development process of two shortened formats for a systematic review intended for use by primary care physicians as an information tool for clinical decision-making.
We developed prototypes for two formats (case-based and evidence-expertise) that represent a summary of a full-length systematic review before seeking input from end-users. The process was composed of the following four phases: 1) selection of a systematic review and creation of initial prototypes that represent a shortened version of the systematic review; 2) a mapping exercise to identify obstacles described by clinicians in using clinical evidence in decision-making; 3) a heuristic evaluation (a usability inspection method); and 4) a review of the clinical content in the prototypes.
After the initial prototypes were created (Phase 1), the mapping exercise (Phase 2) identified components that prompted modifications. Similarly, the heuristic evaluation and the clinical content review (Phase 3 and Phase 4) uncovered necessary changes. Revisions were made to the prototypes based on the results.
Documentation of the processes for developing products or tools provides essential information about how they are tailored for the intended user. One step has been described that we hope will increase usability and uptake of these documents to end-users.
Review literature as topic; Evidence-based medicine
Knowledge translation (KT also known as research utilisation, translational medicine and implementation science) is a dynamic and iterative process that includes the synthesis, dissemination, exchange and ethically sound application of knowledge to improve health. After the implementation of KT interventions, their impact on relevant outcomes should be monitored. The objectives of this scoping review are to: (1) conduct a systematic search of the literature to identify the impact on healthcare outcomes beyond 1 year, or beyond the termination of funding of the initiative of KT interventions targeting chronic disease management for end-users including patients, clinicians, public health officials, health services managers and policy-makers; (2) identify factors that influence sustainability of effective KT interventions; (3) identify how sustained change from KT interventions should be measured; and (4) develop a framework for assessing sustainability of KT interventions.
Methods and analysis
Comprehensive searches of relevant electronic databases (eg, MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials), websites of funding agencies and websites of healthcare provider organisations will be conducted to identify relevant material. We will include experimental, quasi-experimental and observational studies providing information on the sustainability of KT interventions targeting chronic disease management in adults and focusing on end-users including patients, clinicians, public health officials, health services managers and policy-makers. Two reviewers will pilot-test the screening criteria and data abstraction form. They will then screen all citations, full articles and abstract data in duplicate independently. The results of the scoping review will be synthesised descriptively and used to develop a framework to assess the sustainability of KT interventions.
Discussion and dissemination
Our results will help inform end-users (ie, patients, clinicians, public health officials, health services managers and policy-makers) regarding the sustainability of KT interventions. Our dissemination plan includes publications, presentations, website posting and a stakeholder meeting.
knowledge translation; sustainability; implementation; research utilization; fidelity
Pregabalin is used in the treatment of postherpetic neuralgia, diabetic neuropathic pain, partial seizures, anxiety disorders and fibromyalgia. Recognized adverse effects associated with its use include cognitive impairment, somnolence and dizziness. Heart failure associated with pregabalin has been described, however the strength of this association has not been well characterized. To examine this further, we will conduct a systematic review of the risk of heart failure and edema associated with use of pregabalin.
We will include all studies (experimental, quasi-experimental, observational, case series/reports, drug regulatory reports) that examine the use of pregabalin compared to placebo, gabapentin or conventional care. Our primary outcome is heart failure and the secondary outcomes include edema and weight gain. We will search electronic databases (MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials), and grey literature sources (trial registries, conference abstracts) to identify relevant studies. To ensure literature saturation, we will contact drug manufacturers, conduct forward citation searching, and scan the reference lists of key articles and included studies. We will not restrict inclusion by language or publication status.
Two reviewers will screen citations (titles and abstracts) and full-text articles, conduct data abstraction, and appraise risk of bias. Random-effects meta-analysis will be conducted if the studies are deemed heterogeneous in terms of clinical, statistical and methodological factors but still suitable for meta-analysis.
The results of this review will assist physicians to better appreciate pregabalin’s risk for edema or congestive heart failure and will be pertinent to the thousands of patients worldwide who are administered this medication.
Our protocol was registered in the PROSPERO database (CRD42012002948).
Edema; Heart failure; Observational studies; Pregabalin; Randomized controlled trials; Systematic review
After a spinal cord injury, quality of life, as well as the determinants of quality of life, has been widely assessed. However, to date, there have been no systematic reviews on the impact of quality improvement strategies, including self-management strategies, on the quality of life and well-being of individuals with a spinal cord injury. The current protocol outlines a strategy for a systematic review that aims to identify, assess, and synthesize evidence on the impact of quality improvement strategies on the quality of life and physical and psychological well-being of individuals with spinal cord injury.
All study designs, except qualitative studies will be included. Studies reporting on quality improvement including audit and feedback, case management, team changes, electronic patient registries, clinician education, clinical reminders, facilitated relay of clinical information to clinicians, patient education, (promotion of) self-management, patient reminder systems, and continuous quality improvement among individuals with spinal cord injury will be included. The primary outcome is quality of life. The secondary outcomes are physical and psychological well-being. Studies will be included regardless of publication status, year of dissemination, or language of dissemination. Potentially relevant articles not written in English will be translated. We will search Medline, CINAHL, EMBASE, and PsycINFO. The use of these databases will be supplemented by other data sources, including unpublished data. Two independent reviewers will conduct all levels of screening, data abstraction, and quality appraisal. Results will be grouped according to the target group of the varying quality improvement strategies (that is, health system, health-care professionals, or patients) and/or by any other noteworthy grouping variable, such as etiology of spinal cord condition or by sex. If deemed appropriate, a meta-analysis will be conducted.
This systematic review will identify those quality improvement strategies aimed at the health system, health-care professionals, and patients that impact the quality of life and well-being of individuals with spinal cord injury. Knowledge and application of such quality improvement strategies may reduce inappropriate health-care utilization costs, such as acute care inpatient readmission in the years post injury. Prospero registry number: CRD42012003058.
Quality of life; Well-being; Spinal cord injury; Quality improvement; Systematic review; Protocol
Despite the availability of clinical practice guidelines (CPGs), optimal hypertension control is not achieved in many parts of the world; one of the challenges is the volume of guidelines on this topic and their variable quality. To systematically review the quality, methodology, and consistency of recommendations of recently-developed national CPGs on the diagnosis, assessment and the management of hypertension.
MEDLINE, EMBASE, guidelines' websites and Google were searched for CPGs written in English on the general management of hypertension in any clinical setting published between January 2006 and September 2011. Four raters independently appraised each CPG using the AGREE-II instrument and 2 reviewers independently extracted the data. Conflicts were resolved by discussion or the involvement of an additional reviewer. Eleven CPGs were identified. The overall quality ranged from 2.5 to 6 out of 7 on the AGREE-II tool. The highest scores were for “clarity of presentation” (44.4% −88.9%) and the lowest were for “rigour of development” (8.3%–30% for 9 CGPs). None of them clearly reported being newly developed or adapted. Only one reported having a patient representative in its development team. Systematic reviews were not consistently used and only 2 up-to-date Cochrane reviews were cited. Two CPGs graded some recommendations and related that to levels (but not quality) of evidence. The CPGs' recommendations on assessment and non-pharmacological management were fairly consistent. Guidelines varied in the selection of first-line treatment, adjustment of therapy and drug combinations. Important specific aspects of care (e.g. resistant hypertension) were ignored by 6/11 CPGs. The CPGs varied in methodological quality, suggesting that their implementation might not result in less variation of care or in better health-related outcomes.
More efforts are needed to promote the realistic approach of localization or local adaptation of existing high-quality CPGs to the national context.
The enhanced recovery after surgery (ERAS) programme is a multimodal evidence-based approach to surgical care which begins in the preoperative setting and extends through to patient discharge in the postoperative period. The primary components of ERAS include the introduction of preoperative patient education; reduction in perioperative use of nasogastric tubes and drains; the use of multimodal analgesia; goal-directed fluid management; early removal of Foley catheter; early mobilization, and early oral nutrition. The ERAS approach has gradually evolved to become the standard of care in colorectal surgery and is presently being used in other specialty areas such as vascular surgery. Currently there is little evidence available for the implementation of ERAS in this field. We plan to conduct a systematic review of this literature with a view to incorporating ERAS principles into the management of major elective vascular surgery procedures.
We will search EMBASE (OVID, 1947 to June 2012), Medline (OVID, 1948 to June 2012), and Cochrane Central Register of Controlled Trials (Wiley, Issue 1, 2012). Searches will be performed with no year or language restrictions. For inclusion, studies must look at adult patients over 18 years. Major elective vascular surgery includes carotid, bypass, aneurysm and amputation procedures. Studies must have evaluated usual care against an ERAS intervention in the preoperative, perioperative or postoperative period of care. Primary outcome measures are length of stay, decreased complication rate, and patient satisfaction or expectations. Only randomized controlled trials will be included.
Most ERAS approaches have been considered in the context of colorectal surgery. Given the increasing use of multiple yet different aspects of this pathway in vascular surgery, it is timely to systematically review the evidence for their independent or combined outcomes, with a view to implementing them in this clinical setting. Results from this review will have important implications for vascular surgeons, anaesthetists, nurses, and other health care professionals when making evidenced-based decisions about the use of ERAS in daily practice.
Vascular surgery; Enhanced recovery after surgery; ERAS; Fast-track; Systematic review
A knowledge synthesis attempts to summarize all pertinent studies on a specific question, can improve the understanding of inconsistencies in diverse evidence, and can identify gaps in research evidence to define future research agendas. Knowledge synthesis activities in healthcare have largely focused on systematic reviews of interventions. However, a wider range of synthesis methods has emerged in the last decade addressing different types of questions (e.g., realist synthesis to explore mediating mechanisms and moderators of interventions). Many different knowledge synthesis methods exist in the literature across multiple disciplines, but locating these, particularly for qualitative research, present challenges. There is a need for a comprehensive manual for synthesis methods (quantitative/qualitative or mixed), outlining how these methods are related, and how to match the most appropriate knowledge synthesis method to answer a research question. The objectives of this scoping review are to: 1) conduct a systematic search of the literature for knowledge synthesis methods across multi-disciplinary fields; 2) compare and contrast the different knowledge synthesis methods; and, 3) map out the specific steps to conducting the knowledge syntheses to inform the development of a knowledge synthesis methods manual/tool.
We will search relevant electronic databases (e.g., MEDLINE, CINAHL), grey literature, and discipline-based listservs. The scoping review will consider all study designs including qualitative and quantitative methodologies (excluding economic analysis or clinical practice guideline development), and identify knowledge synthesis methods across the disciplines of health, education, sociology, and philosophy. Two reviewers will pilot-test the screening criteria and data abstraction forms, and will independently screen the literature and abstract the data. A three-step synthesis process will be used to map the literature to our objectives.
This project represents the first attempt to broadly and systematically identify, define and classify knowledge synthesis methods (i.e., less traditional knowledge synthesis methods). We anticipate that our results will lead to an accepted taxonomy for less traditional knowledge synthesis methods, and to the development and implementation of a methods manual for these reviews which will be relevant to a wide range of knowledge users, including researchers, funders, and journal editors.
Approximately 35 million people world-wide have Alzheimer’s disease and this is projected to nearly double by 2030. Cognitive enhancers, including cholinesterase inhibitors (for example, donepezil, galantamine and rivastigmine) and memantine (N-methyl-D-aspartic acid (NMDA) receptor antagonist) have been approved for the treatment of Alzheimer’s disease in many countries. Our objective is to evaluate the comparative effectiveness, safety, and cost of cognitive enhancers for Alzheimer’s disease through a systematic review.
Studies examining the efficacy, safety, and cost of cognitive enhancers compared to placebo, supportive care, and other cognitive enhancers for Alzheimer’s patients will be included. The primary outcome is cognition and secondary outcomes include function, behavior, quality of life, safety, and cost. Experimental studies (randomized controlled trials, quasi-randomized controlled trials, controlled clinical trials), quasi-experimental studies (controlled before-after, interrupted time series), and observational studies (cohort, case–control studies) will be eligible for inclusion. Inclusion will not be limited by publication status, time period or language of dissemination.
We will search electronic databases (for example, MEDLINE, Cochrane Central Register of Controlled Trials, EMBASE, CINAHL, Ageline) from inception onwards. The electronic database search will be supplemented by searching for grey literature (for example, conference proceedings, searches in Google and relevant organization websites). Two reviewers will independently screen the studies for inclusion using the eligibility criteria established a priori and independently extract data. Risk of bias will be assessed using the Cochrane Risk of Bias tool for experimental and quasi-experimental studies and the Newcastle Ottawa Scale for observational studies. If deemed appropriate, meta-analysis and network (that is, indirect comparisons) meta-analysis will be conducted.
Our systematic review will inform the decision of healthcare providers, policy-makers, Alzheimer’s patients and family members about the use of cognitive enhancers, by improving their understanding of the costs, benefits and harms that are associated with these agents.
PROSPERO registry number
The burden of H1N1 among socially disadvantaged populations is unclear. We aimed to synthesize hospitalization, severe illness, and mortality data associated with pandemic A/H1N1/2009 among socially disadvantaged populations.
Studies were identified through searching MEDLINE, EMBASE, scanning reference lists, and contacting experts. Studies reporting hospitalization, severe illness, and mortality attributable to laboratory-confirmed 2009 H1N1 pandemic among socially disadvantaged populations (e.g., ethnic minorities, low-income or lower-middle-income economy countries [LIC/LMIC]) were included. Two independent reviewers conducted screening, data abstraction, and quality appraisal (Newcastle Ottawa Scale). Random effects meta-analysis was conducted using SAS and Review Manager.
Sixty-two studies including 44,777 patients were included after screening 787 citations and 164 full-text articles. The prevalence of hospitalization for H1N1 ranged from 17–87% in high-income economy countries (HIC) and 11–45% in LIC/LMIC. Of those hospitalized, the prevalence of intensive care unit (ICU) admission and mortality was 6–76% and 1–25% in HIC; and 30% and 8–15%, in LIC/LMIC, respectively. There were significantly more hospitalizations among ethnic minorities versus non-ethnic minorities in two studies conducted in North America (1,313 patients, OR 2.26 [95% CI: 1.53–3.32]). There were no differences in ICU admissions (n = 8 studies, 15,352 patients, OR 0.84 [0.69–1.02]) or deaths (n = 6 studies, 14,757 patients, OR 0.85 [95% CI: 0.73–1.01]) among hospitalized patients in HIC. Sub-group analysis indicated that the meta-analysis results were not likely affected by confounding. Overall, the prevalence of hospitalization, severe illness, and mortality due to H1N1 was high for ethnic minorities in HIC and individuals from LIC/LMIC. However, our results suggest that there were little differences in the proportion of hospitalization, severe illness, and mortality between ethnic minorities and non-ethnic minorities living in HIC.
Elderly individuals who have memory problems without significant limitations in activities of daily living are often diagnosed as having mild cognitive impairment (MCI). Some of these individuals progress to dementia. Several cognitive enhancers (for example donepezil, galantamine, rivastigmine, memantine) have been approved for use in people with Alzheimer’s dementia but their use in patients with MCI is unclear. We aimed to determine the comparative effectiveness, safety, and cost of cognitive enhancers for MCI through a systematic review and network (that is, indirect comparisons) meta-analysis.
We will include studies that examine the use of cognitive enhancers compared to placebo, supportive care, or other cognitive enhancers among patients diagnosed with MCI. Outcomes of interest include cognition and function (primary outcomes), as well as behavior, quality of life, safety, and cost (secondary outcomes). We will include all experimental studies (randomized controlled trials, quasi-randomized controlled trials, controlled clinical trials), quasi-experimental studies (controlled before-after, interrupted time series), and observational studies (cohort, case–control). Studies will be included regardless of publication status (that is, we will include unpublished studies), year, or language of dissemination.
To identify potentially relevant material, we will search the following electronic databases from inception onwards: MEDLINE, Cochrane Central Register of Controlled Trials, EMBASE, CINAHL, and Ageline. The electronic database search will be supplemented by scanning the reference lists of included studies, searching Google and organization websites for unpublished or difficult to locate material literature, and contacting experts.
Two reviewers will independently screen the studies for inclusion using the eligibility criteria established a priori and independently extract data. Risk of bias will be assessed using the Cochrane Risk of Bias tool for experimental and quasi-experimental studies and the Newcastle Ottawa Scale for observational epidemiology studies. Meta-analysis and network meta-analysis are planned, if the studies are deemed statistically, methodologically, and clinically homogenous.
Our systematic review will provide important information regarding the benefits, costs, and harms of cognitive enhancers for patients with MCI. This information can be used to assist healthcare providers, policy-makers, MCI patients and their family regarding the use of these agents.
PROSPERO registry number
Systematic reviews have the potential to inform clinical decisions, yet little is known about the impact of interventions on increasing the use of systematic reviews in clinical decision-making.
To systematically review the evidence on the impact of interventions for seeking, appraising, and applying evidence from systematic reviews in decision-making by clinicians.
Medline, EMBASE, CINAHL, Cochrane Central Register of Controlled Trials, and LISA were searched from the earliest date available until July 2009.
Study Selection and Data Extraction
Two independent reviewers selected studies for inclusion if the intervention intended to increase seeking, appraising, or applying evidence from systematic reviews by a clinician. Information about the study population, features of each intervention, methods used to measure the use of systematic reviews and those used to measure professional performance or health care outcomes, existence and use of statistical tests, study outcomes, and comparative data were extracted.
A total of 8,104 titles and abstracts were reviewed, leading to retrieval of 189 full-text articles for assessment; five of these studies met all inclusion criteria. All five studies reported on professional performance behavior; none reported on patient health outcomes. One study reported positive outcomes in improving preventive care. Three studies focused on obstetrical care, with two reporting no impact on professional practice change, and one study reporting increases in the use of prophylactic oxytocin and episiotomy. One study found no improvement in the sealant rate of newly erupted molars among dentists in Scotland.
The small number of studies available for examination indicates the difficulty in summarizing and identifying key aspects in successful strategies that encourage clinicians to use systematic reviews in decision-making. Other concerns lay in selective reporting and lack of blinding during data collection.
The limited empirical data render the strength of evidence weak for the effectiveness and types of interventions that encourage clinicians to use systematic reviews in clinical decision making.
systematic review; evidence-based practice; decision-making; review literature as a topic
It has been proposed by Zamboni and colleagues that multiple sclerosis is caused by chronic cerebrospinal venous insufficiency, a term used to describe ultrasound-detectable abnormalities in the anatomy and flow of intra- and extracerebral veins. We conducted a meta-analysis of studies that reported the frequency of chronic cerebrospinal venous insufficiency among patients with and those without multiple sclerosis.
We searched MEDLINE and EMBASE as well as bibliographies of relevant articles for eligible studies. We included studies if they used ultrasound to diagnose chronic cerebrospinal venous insufficiency and compared the frequency of the venous abnormalities among patients with and those without multiple sclerosis.
We identified eight eligible studies: all included healthy controls, and four of them also included a control group of patients with neurologic diseases other than multiple sclerosis. Chronic cerebrospinal venous insufficiency was more frequent among patients with multiple sclerosis than among the healthy controls (odds ratio [OR] 13.5, 95% confidence interval [CI] 2.6–71.4), but there was extensive unexplained heterogeneity among the studies. The association remained significant in the most conservative sensitivity analysis (OR 3.7, 95% CI 1.2–11.0), in which we removed the initial study by Zamboni and colleagues and added a study that did not find chronic cerebrospinal venous insufficiency in any patient. Although chronic cerebrospinal venous insufficiency was also more frequent among patients with multiple sclerosis than among controls with other neurologic diseases (OR 32.5, 95% CI 0.6–1775.7), the association was not statistically significant, the 95% CI was wide, and the OR was less extreme after removal of the study by Zamboni and colleagues (OR 3.5, 95% 0.8–15.8).
Our findings showed a positive association between chronic cerebrospinal venous insufficiency and multiple sclerosis. However, poor reporting of the success of blinding and marked heterogeneity among the studies included in our review precluded definitive conclusions.
Clinical practice guidelines have the potential to facilitate the implementation of evidence into practice, support clinical decision making, specify beneficial therapeutic approaches, and influence public policy. However, these potential benefits have not been consistently achieved. The limited impact of guidelines can be attributed to organisational constraints, the complexity of the guidelines, and the lack of usability testing or end-user involvement in their development. Implementability has been referred to as the perceived characteristics of guidelines that predict the relative ease of their implementation at the clinical level, but this concept is as yet poorly defined. The objective of our study is to identify guideline attributes that affect uptake in practice by considering evidence from four disciplines (medicine, psychology, management, human factors engineering) to determine the relationship between the perceived characteristics of recommendations and their uptake and to develop a framework of implementability.
A realist-review approach to knowledge synthesis will be used to understand attributes of guidelines (e.g., its text and content) and how changing these elements might impact clinical practice and clinical decision making. It also allows for the exploration of 'what works for whom, in what circumstances, and in what respects'. The realist review will be structured according to Pawson's five practical steps in realist reviews: (1) clarifying the scope of the review, (2) determining the search strategy, (3) ensuring proper article selection and study quality assessment, (4) extracting and organising data, and (5) synthesising the evidence and drawing conclusions. Data will be synthesised according to a two-stage analysis: (1) we will extract and define all relevant guideline attributes from the different disciplines, then create a shortlist of unique attributes and investigate their relationships with uptake, and (2) we will compare and contrast the attributes and guideline uptake within each and between the four disciplines to create a robust framework of implementability.
Creating guidelines that are designed to maximise uptake may be a potentially effective and inexpensive way of increasing their impact. However, this is best achieved by a comprehensive framework to inform the design of guidelines drawing on a range of disciplines that study behaviour change. This study will use a customised realist-review approach to synthesising the literature to better understand and operationalise a complex and under-theorised concept.
Systematic reviews have the potential to inform decisions made by health policymakers and managers, yet little is known about the impact of interventions to increase the use of systematic reviews by these groups in decision making.
We systematically reviewed the evidence on the impact of interventions for seeking, appraising, and applying evidence from systematic reviews in decision making by health policymakers or managers. Medline, EMBASE, CINAHL, Cochrane Central Register of Controlled Trials, Cochrane Methodology Register, Health Technology Assessment Database, and LISA were searched from the earliest date available until April 2010. Two independent reviewers selected studies for inclusion if the intervention intended to increase seeking, appraising, or applying evidence from systematic reviews by a health policymaker or manager. Minimum inclusion criteria were a description of the study population and availability of extractable data.
11,297 titles and abstracts were reviewed, leading to retrieval of 37 full-text articles for assessment; four of these articles met all inclusion criteria. Three articles described one study where five systematic reviews were mailed to public health officials and followed up with surveys at three months and two years. The articles reported from 23% to 63% of respondents declaring they had used systematic reviews in policymaking decisions. One randomised trial indicated that tailored messages combined with access to a registry of systematic reviews had a significant effect on policies made in the area of healthy body weight promotion in health departments.
The limited empirical data renders the strength of evidence weak for the effectiveness and the types of interventions that encourage health policymakers and managers to use systematic reviews in decision making.