SYSTEMATIC REVIEW METHODS

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Unit 1

SYSTEMATIC REVIEW

METHODS

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 Introduction

Schedule

Ground rules

GETTING STARTED

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Class Participation (20%)

 Contribution to class discussions

 Evidence of critical thinking

 Engagement in learning activities

Systematic Review Protocol (80%)

 Group project

 Develop systematic review protocol

 In-class presentation

EVALUATION

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SYSTEMATIC REVIEW PROTOCOL

 Topic concerning the effectiveness of a health care intervention

 Rationale for the topic

 Team members/collaborators

 Clearly focused quantitative review question

 Inclusion and exclusion criteria

 Search strategy

 Assessment of methodological quality of the included studies

 Synthesis approach

 Communicating key messages

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1. Differentiate between different types of reviews.

2. Identify the importance of systematic

reviews in health care policy and practice decisions.

3. Identify the components of high quality systematic reviews.

4. Develop a clearly focused quantitative systematic review question about the effectiveness of an intervention.

OBJECTIVES: UNIT 1

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“A systematic review attempts to collate all empirical evidence that fits pre-specified

eligibility criteria in order to answer a specific research question. It uses explicit, systematic methods that are selected with a view to

minimizing bias thus providing more reliable findings from which conclusions can be drawn and decisions made”

[Cochrane Handbook]

WHAT IS A SYSTEMATIC REVIEW?

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WHY DO A SYSTEMATIC REVIEW

 Identify what we know to inform decisions about practice, programs, policy by

 resolving conflicting evidence

 addressing questions where clinical practice is uncertain

 exploring variations in practice

 Identify what we know and/or do not know to

inform the rationale for conducting research

 When available systematic reviews are

 not up to date, and/or

 poor quality, and/or

 do not sufficiently address the question asked

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INFORM PRACTICE, PROGRAMS,

&/OR POLICY DECISIONS

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INFORM PRACTICE, PROGRAMS,

&/OR POLICY DECISIONS

Cochrane Database Syst Rev. 2013 Dec 5;(12):CD007458. Mobile phone messaging reminders for attendance at healthcare appointme nts.Gurol- Urganci I1, de Jongh T, Vodopivec- Jamsek V, Atun R, Car J.

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Ivers et al. (2014) Journal of General Internal Medicine:

Growing Literature, Stagnant Science?

Systematic Review, Meta-

Regression and

Cumulative Analysis of Audit and Feedback

Inter ventions in Health Care.

INFORM RATIONALE FOR

CONDUCTING RESEARCH

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 Systematic review

strict scientific design

explicit methods where more than one person is involved in each step

pre-specified methods that do not

change in the course of conducting the review

reproducible methods

SYSTEMATIC REVIEW VS.

REVIEW OF THE LITERATURE

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 Scoping review

“Traditional” systematic review

Network meta-analysis

Overview of reviews

Realist reviews

Meta-syntheses

T YPES OF REVIEWS

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NET WORK META - ANALYSIS

A B

C

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

Benefits and harms of inter ventions used in healthcare and health policy [Inter vention Reviews/Aetiology Reviews]

 Wound care teams for preventing and treating pressure ulcers

 Safety of topical corticosteroids in pregnancy



Probable course or future outcome(s) of people with a health problem [Prognosis]

 Individual recovery expectations and prognosis of outcomes in non specific low back pain



Diagnostic Test Accuracy

 PET CT for assessing mediastinal lymph node involvement in patients with suspected resectable non small cell lung cancer



Qualitative

 Healthcare workers’ perceptions and experience on using mHealth technologies to deliver primary healthcare services

SYSTEMATIC REVIEW QUESTIONS

Cochrane Library

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Systematic search of a number of

different sources to identify relevant studies

Select studies for inclusion, based on predefined criteria

Evaluate studies for their strengths and limitations based on clear, predefined criteria

Systematically collect data

Appropriately synthesize data SYSTEMATIC REVIEW:

ESSENTIAL ELEMENTS

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Is the source of all other aspects of the review flow

Should be

identified a priori

 clear, unambiguous

 Structured

 PICO

 PECO

 SPPiCE

REVIEW QUESTION

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Applicable to:

 Intervention Reviews

 Aetiology Reviews

 Prognosis Reviews

 Population(s)

 Intervention(s)/Indicator(s) or Exposure(s)

 Comparator

 Outcome(s)

REVIEW QUESTION: PI/ECO

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 Population

 Group of participants or patients, their clinical problem, and the healthcare setting

 Intervention/Indicator/Exposure/Comparator

 Action(s) being considered

 e.g. treatments, processes of care, social

interventions, educational intervention, risk factors

 Outcome

 Clinical changes in health state or other related changes (e.g. health resource use)

REVIEW QUESTION: PI/ECO

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 Population

Test

Test whose predictive value is being assessed

Reference Standard

“gold standard” test that confirms or refutes the diagnosis

REVIEW QUESTION: TEST ACCURACY

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 Applicable to

Qualitative Reviews

 Sample

Purpose/Phenomenon of Interest

Context

Emphasis

REVIEW QUESTION: SPPICE

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 Driven by the components of the question

 Provide the most valid answer to the question

 Intervention Review

 Appropriate way to

 recruit participants

 “give” participants the intervention(s) and/or comparator(s)

 measure the outcome(s)

REVIEW QUESTION: STUDY DESIGN

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 Intervention Review

 Question

 Which of the many available microbial products improve healing in patients with chronic wounds

 Structured question

 P: patients with various forms of chronic wounds

 I/C: microbial products

 O: wound healing

 Study design: A study that allocates subjects with chronic wounds to alternative therapeutic

interventions of interest and determines the effect of the interventions on wound healing [randomized trial]

REVIEW QUESTION: EXAMPLE

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 How is the disease/condition defined?

 What are the most important characteristics that describe these people (participants)?

 Are there any relevant demographic factors, e.g.

 Age

 Gender

 Ethnicity

 What is the setting, e.g.

 Hospital

 Community

VARIATIONS IN POPULATION

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 What are the experimental and control (comparator) interventions of interest

 Does the intervention have variations, e.g.

dosage/intensity

mode of delivery

personnel who deliver it

frequency of delivery, duration of delivery, timing of delivery)

VARIATIONS IN INTERVENTION

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 Essential for decision-making

 usually have an emphasis on patient- important outcomes

 Potential as well as actual adverse effects

 Relevant to all potential decision makers, including economic data.

 Type of outcome measurements

 Timing of outcome measurements

VARIATIONS IN OUTCOME

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 Question: Are knowledge translation (KT) interventions directed to nurses in tertiary care are effective for improving EBP

knowledge, skills, behaviours, and, as a result, patient outcomes

 Structured Question:

 P: nurses in tertiary care

 I: any KT intervention

 O: EBP knowledge, skills, behaviors

 O: patient outcomes

REVIEW QUESTION: EXAMPLE

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Advantages Disadvantages

Broad:

corticosteroid injection for any tendonitis

• Comprehensive summary of the evidence.

• Ability to assess generalizability of findings across different

implementations of the intervention

• May be more appropriate to prepare an Overview of Reviews

• Searching, data collection, analysis and writing may require more

resources.

• Risk of ‘mixing apples and oranges’

(heterogeneity); interpretation may be difficult.

Narrow:

corticosteroid injection for shoulder tendonitis

• Manageability for review team.

• Ease of reading.

• Evidence may be sparse.

• Findings may not be generalizable to other settings or populations.

• Scope could be chosen by review authors to produce a desired result.

BROAD VS. NARROW: PARTICIPANTS

Cochrane Handbook 5.6.a

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Broad:

any exercise for depression

• Comprehensive summary of the evidence.

• Ability to assess generalizability of findings across types of participants.

• Searching, data collection, analysis and writing may require more resources.

• Risk of ‘mixing apples and oranges’

(heterogeneity); interpretation may be difficult.

Narrow:

supervised running for depression

• Manageability for review team.

• Ease of reading.

• Evidence may be sparse.

• Findings may not be generalizable to other formulations of the intervention.

• Scope could be chosen by review authors to produce a desired result.

BROAD VS. NARROW:

INTERVENTION DEFINITION

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Broad:

interventions for preventing bed- wetting

• Comprehensive summary of the evidence.

• May be unwieldy, and more appropriate to present as an Overview of Reviews

• Searching, data collection, analysis and writing may require more resources.

Narrow:

alarms for

preventing bed- wetting

• Manageability for review team.

• Clarity of objectives and ease of reading.

• May have limited value when not included in an Overview

.

BROAD VS. NARROW:

INTERVENTION/COMPARISON

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Frame the Systematic Review Question

IN-CLASS ACTIVIT Y

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2 Minute Presentation:

Systematic Review Question

IN-CLASS ACTIVIT Y

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Identify Assignment Groups

IN-CLASS ACTIVIT Y

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JUSTIFYING THE REVIEW

 What is the problem/issue?

Why is it important to address the problem/issue?

What is the magnitude of the

problem/issue?

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 Nurses are expected to use research

evidence in practice to improve client and system outcomes.

 International standards of practice identify EBP as an important and integral component of effective nursing practice.

 Although awareness about EBP has increased, it remains inconsistently operationalized for use in practice.

EXAMPLE

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JUSTIFYING THE REVIEW

Are there relevant studies that have been done?

What is the gap in the synthesized literature of these studies?

 Modello di ricerca delle fonti di evidenza 6 S:

http://www.evidencebasednursing.it/6S.html

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 Search databases where systematic reviews are registered

 Prospero http://www.crd.york.ac.uk/PROSPERO/

 Search databases/repositories of systematic reviews, e.g.

 ACCESSSS Federated Search

http://plus.mcmaster.ca/accessss/Default.aspx?Page=1

 Database of Abstracts of Reviews of Effects http://www.crd.york.ac.uk/CRDWeb/

 PubMed Clinical Queries

https://www.ncbi.nlm.nih.gov/pubmed/clinical

 Health Evidence http://healthevidence.org/

 Health Systems Evidence

https://www.healthsystemsevidence.org/

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 Search of organizations producing systematic reviews, e.g.

 Cochrane Collaboration

http://www.cochranelibrary.com/

 Joanna Briggs Institute

http://journals.lww.com/jbisrir/Pages/default.aspx

 Search of guideline developers who conduct systematic reviews to inform their guidelines

 National Guideline Clearinghouse

https://guideline.gov/



NICE

https://www.nice.org.uk/guidance



SIGN

http://sign.ac.uk/



AHRQ

http://www.ahrq.gov/research/findings/evidence-based- reports/index.html



CTFPHC

http://canadiantaskforce.ca/



EPPI Centre

http://eppi.ioe.ac.uk/cms/

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 Previous systematic reviews have focused on effectiveness of knowledge translation (KT) interventions to promote the use of research evidence among healthcare professionals

 No analyses were specific to nurses in these reviews.

 Only one systematic review by Thompson and colleagues considered the effect of KT

interventions on nurses’ research use .

 With a limited number of studies of poor quality,

Thompson and colleagues concluded that there was insufficient evidence to support or refute the use of any specific intervention aimed at increasing research use in nursing.