• Share
  • Email
  • Embed
  • Like
  • Save
  • Private Content
Week 3
 

Week 3

on

  • 576 views

 

Statistics

Views

Total Views
576
Views on SlideShare
398
Embed Views
178

Actions

Likes
0
Downloads
0
Comments
0

2 Embeds 178

https://www.learn.ed.ac.uk 177
https://global.slu.edu 1

Accessibility

Upload Details

Uploaded via as Microsoft PowerPoint

Usage Rights

© All Rights Reserved

Report content

Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

Cancel
  • Full Name Full Name Comment goes here.
    Are you sure you want to
    Your message goes here
    Processing…
Post Comment
Edit your comment

    Week 3 Week 3 Presentation Transcript

    • Systematic reviews Dr Graeme D. Smith Senior Lecturer Nursing Studies University of EdinburghMSc Advanced Nursing Practice Research Methods
    • Systematic reviewsReading:Parahoo K (2006) Chapter 7: Literature reviews. In:Nursing Research: principles, process and issues pp134-144. Plagrave, New York.Moore Z & Cowman S (2008) Chapter 10: the Cochrane database and meta-analysis. In Watson R et al. Nursing Research Methods. Churchill Livingstone, Edinburgh
    • Reviewing literature Evidence base Literature review Systematic review Meta analysis PRISMA statement
    • Rigour in systematic reviews: PRISMA statementEvidence based medicine (practice):‘Evidence based medicine (practice) is the conscientious, explicit and judicious use of current best evidence in making decisions about care of individual patients’ Sackett (1996)Ref: Sackett DL (1996) Evidence based medicine : what it is and what it isn’t British Medical Journal 312: 71-2
    • Rigour in systematic reviews: PRISMA statement Evidence based health care Evidence based practice Evidence based nursingWhat do we mean by best evidence? Studies/trials that use rigorous, explicit, with reproducible methods
    • Rigour in systematic reviews: PRISMA statementFive steps of evidence-based practice:1. Formulate focused (clinical) question2. Search the literature for evidence3. Rate the quality of the available studies4. Apply evidence to particular (clinical) situation5. Assess outcomes of decision Guyatt et al 1992Ref Guyatt GH et al (1992) Evidence-based Medicine Working Group JAMA 268: 2420-2425
    • Rigour in systematic reviews: PRISMA statement
    • Rigour in systematic reviews: PRISMA statement
    • Why are systematic reviews important?Searching and reviewing the literature can tell you: if studies on the subject have been done before what others have learned how practice has changed as a consequence of the data problems experienced in researching the subject who & where work has been done
    • Rigour in systematic reviews:PRISMA statement: Evidence
    • Rigour in systematic reviews: PRISMA statementCATEGORIES OF EVIDENCE (BSG) Ia: Evidence obtained from meta-analysis of randomised controlled trials. Ib: Evidence obtained from one randomised controlled trial IIa: Evidence obtained from at least one well designed controlled study without randomisation IIb: Evidence obtained from at least one other type of well designed quasi-experimental study III: Evidence obtained from well designed descriptive studies: comparative studies and case studies IV: Evidence obtained from expert committee reports, or opinions or clinical experience of respected authorities.
    • Rigour in systematic reviews: PRISMA statementGRADING OF RECOMMENDATIONS (BSG) Recommendations are based on the level of evidence presented in support and are graded accordingly Grade A requires at least one randomised controlled trial of good quality addressing the topic of recommendation. Grade B requires the availability of clinical studies without randomisation on the topic of recommendation Grade C requires evidence from category IV in the absence of directly applicable clinical studies.
    • Rigour in systematic reviews: PRISMA statementFailings in traditional reviews:Inadequate & incomplete analysis of evidence Two land mark papers in 1990’s ‘Textbook reviews & narratives were woefully inadequate in summarising knowledge’ Antman EM et al. (1992) ‘If original studies of effect of clot Tx after heart attacks had been reviewed systematically benefits of therapy would have been apparent in mid-1970’s’ Lau J et al. (1992)
    • Rigour in systematic reviews: PRISMA statementFailings in traditional reviews: Reviews always been part of health science Assessing effectiveness of interventions Synthesis of research is not always rigorous Historically reviewers rarely began with open mind ‘dispassionate review hard to achieve’ Build a case to support their own views Narrative studies are rarely explicit selected/assessed
    • Literature reviews and nursing practice Nursing embraces challenge of conducting systematic reviews Journal of Advanced Nursing: over years 1990-2006 34 reviews published 1st appeared 1998 increasing trend… Requirement of high quality evidence in nursing practice now more important than ever Cochrane/JBI etc helps in this process
    • Rigour in systematic reviews: PRISMA statementDefinition of rigour: ‘use of demanding standards: the application of precise and exacting standards in the doing of something’ Encarta World English Dictionary
    • Rigour in systematic reviews: PRISMA statementLiterature Review vs. Systematic review What is the difference? Literature Review:‘ is an examination of the literature from the author’s perspective’
    • Rigour in systematic reviews: PRISMA statementLiterature Review vs. Systematic review What is the difference? Data from selected studies are combined and compared If data can not be combined: ‘strength of evidence is assessed’ ‘to evaluate the results’ Conclusions are made on the basis of: ‘results found’ ‘presence or absence of supporting evidence’
    • Rigour in systematic reviews: PRISMA statementSystematic Reviews: Research is a big topic How do we access and use literature?Common problems Finding the appropriate literature Making sense of contradictory findings Inadequate information Statistics ? Therefore – systematic reviews!
    • Rigour in systematic reviews: PRISMA statementDefinition of systematic review:‘A systematic review is a review of a clearly formulated question that uses systematic & explicit methods to identify, select & critically appraise relevant research & to collect & analyse data from studies included in that review’ Cochrane 2005Ref: Green et al (2005) Cochrane handbook for systematic reviews of interventions www.cochrane.org/resources/glossary.htm
    • Rigour in systematic reviews: PRISMA statementSystematic reviews: Statistical methods (meta-analysis) may or may not be used to analyse & summarise results of included studiesDefinition of meta-analysis:‘use of statistical techniques in a systematic review to integrate the results of included studies’ Cochrane 2005Ref: Green et al (2005) Cochrane handbook for systematic reviews of interventions www.cochrane.org/resources/glossary.htm
    • Meta-analysisReference:Ankem, K. (2005). Approaches to meta- analysis: a guide for LIS researchers. Library & Information Science Research, 27(2), 164-176.The Meta Analysis of Research Studies http://www.edres.org/meta/
    • Rigour in systematic reviews: PRISMA statementUseful website for systematic reviews:Cochrane Collaboration www.ich.ucl.ac.ukNHS Centre for Reviews & Dissemination www.york.ac.uk/inst/crd/welcome.htmCentre for Evidence-based Medicine at Oxford www.cebm.jr2.ox.ac.ukJoanna Briggs Institute www.joannabriggs.edu.au
    • Rigour in systematic reviews: PRISMA statementMedline 3500 health care journalsEMBASE emphasis on European literatureBritish Nursing Index British & other major journalsCINAHL nursing, education & allied professionsPub-Med all major journals projects in the NHSSOCSCI education, psychology & sociology
    • Personal experience of systematic reviewsSmith GD, Watson R, Thompson DR (2008) Older people and inflammatory bowel disease: a systematic review. Journal of Nursing and Healthcare of Chronic Illness 17 (11) 400-406.
    • IBD & Older people: a systematic review Objective: to review all published papers comparing inflammatory bowel disease in older and younger people. Design: systematic review. Search strategy: MEDLINE, CINAHL, EMBASE and Cochrane databases were searched 1990 to 2005 inclusive. Keywords: systematic review, older people, chronic illness, inflammatory bowel disease, ulcerative colitis, Crohn’s disease
    • IBD & Older people: a systematic reviewSearch strategy: Papers were read by two independent researchers (GDS & RW) selected if they compared younger and older people with inflammatory bowel disease excluded if they did not or were concerned with other aspects of gastroenterology
    • IBD & Older people: a systematic reviewResults: seven papers fulfilled the selection criteria the clinical features of inflammatory bowel disease are similar in younger and older people as are indications for surgery, survival and the usual wide spectrum of severity of disease Corticosteroid treatment carries additional risk for older people A gerontological and psychosocial perspective was lacking from the papers reviewed
    • IBD & Older people: a systematic reviewConclusion: The clinical features of inflammatory bowel disease are similar in younger and older people The possibility exists that quality of life and adjustment in older people depend on age of onset This has not been investigated Future lines of enquiry taking psychosocial aspects of inflammatory bowel disease into account in older people are explored.
    • IBD & Older people: a systematic reviewRelevance to clinical practice: Nurses are playing an increasingly important role in the assessment and management of IBD patients Little is known about factors which could be predicative of poorer HRQoL Poor understanding of the impact non- intestinal manifestations upon HRQoL in IBD in older people
    • Irritable bowel syndrome & HRQoL Physical Psychosocial Ab An do xie ty Pa mina in l l tion a s g mo lem E ob atin Pr Blo el Bo w Soc Dis ial ed ter abitAl H abi lity Dy Sexu sfu al k nc tio or n W
    • IBS & hypnotherapy: a systematic reviewSystematic review of GDH in IBS (2006) Nine electronic databases searched 18 studies identified four randomised controlled trials two controlled trials 12 uncontrolled studies ALL indicate that GDH has some benefit ALL had methodological limitationsWilson S et al (2006) The effectiveness of hypnotherapy in the management of irritable bowel syndrome. Alimentary Pharmacology & Therapeutics 24:769-780.
    • Rigour in systematic reviews: An updateHot off the press:Moher D, Liberati A, Tetzlaff J & Altman DG (2009) Preferred reporting items for systematic reviews and meta-analysis: the PRISMA statement. British Medical Journal: 339:2535-42.
    • Rigour in systematic reviews: An updateSystematic reviews increasingly important in health care: Help keep health professionals up to date Starting point for clinical guidelines Justification for research funding Swingler et al (2003)Swingler GH, Volmink J & Ioannidis JP (2003) Number of published systematic reviews and global burden of disease.. British Medical Journal: 327: 1083-1084
    • Rigour in systematic reviews: An updateValue of systematic review depends on: What was done? What was found? Clarity of reportingAllow readers’ ability to assess thestrengths and weaknesses of review
    • Rigour in systematic reviews: An updateThe PRISMA statement: 27 item checklist Four phase flow diagramIt allows: Authors to improve reporting of systematic reviews & meta-analysis Critical appraisal of published reviews Useful to scientific journals
    • Rigour in systematic reviews: PRISMA statementHistory evaluation of quality of reviews 1985-1986 study Mulrow (1987) 50 review articles (meta-analysis) Four top medical journals None met explicit scientific criteria Led to formation of QUOROM ‘Quality of reporting of meta-analysis’Ref: Mulrow CD (1987) The medical review article: The state of the science. Ann Intern Med 106: 485-488
    • Rigour in systematic reviews: PRISMA statementQUOROM: QUality Of Reporting Of Meta- analysis Focused on the reporting of meta-anlaysis of RCT’sRef: Moher D et al (1994) Improving the quality of reporting the meta-analysis of randomised controlled trials: The QUOROM statement . Lancet 354: 1896-1900
    • Rigour in systematic reviews: PRISMA statementPRISMA statement: 27 item checklist Four phase flow diagram PRISMA aims to: help authors improve reporting help readers appraise reviews PRISMA is NOT: ‘a quality assessment instrument to gauge the quality of a systematic review’
    • Rigour in systematic reviews: An updateFrom QUOROM to PRISMA: Differs in several respects PRISMA ‘decouples’ several items in QUOROM checklist Checklist items are now linked ‘consistency across review reports’ Flow diagram has been modified
    • Rigour in systematic reviews: An updateFlow diagram of information: PRISMA Identification Screening Eligibility Included
    • Rigour in systematic reviews: Checklist of items: PRISMA statementChecklist of items: PRISMA statement Title Abstract Introduction Methods Results Discussion Funding
    • Rigour in systematic reviews: Checklist of items: PRISMA statementTitle: Identify the report as a systematic analysis, meta-analysis or both
    • Rigour in systematic reviews: Checklist of items: PRISMA statementAbstract (structured summary): Background Objectives Data sources Study eligibility criteria Participants Interventions
    • Rigour in systematic reviews: Checklist of items: PRISMA statementAbstract (structured summary): Study appraisal/synthesis methods Results Limitations Conclusions Implications (clinical) of key findings Systematic review registration number
    • Rigour in systematic reviews: Checklist of items: PRISMA statementIntroduction: Rationale Description of the rationale for the review in context of what is already known ObjectivesProvide an explicit of questions being addressedImportance of PICOS
    • Rigour in systematic reviews: Checklist of items: PRISMA statementPICOS ‘a taxonomy used in EBM’ Participants Interventions Comparisons Outcomes Study design
    • Rigour in systematic reviews: Checklist of items: PRISMA statementPICOS Used commonly in EBM Help to find best evidence Help to formulate questions PICOS is NOT prescriptive Doesn’t tell someone how to do intervention or comparison
    • Rigour in systematic reviews: Checklist of items: PRISMA statementExample of PICO: ↑ levels of obesity/diabetes in teenagers in area Examine levels obesity/diabetes in youth club Develop intervention to↓ obesity/diabetesPopulation: youth club membersIntervention: improve food types at youth clubComparison: food served before the interventionOutcome: Are better foods served after study
    • Rigour in systematic reviews: PRISMA statement: Methods Protocol and  Data items registration  Risk of bias in Eligibility criteria individual studies Information sources  Summary measures Search  Synthesis of results Study selection  Risk of bias across Data collection studies process  Additional analysis
    • Rigour in systematic reviews: PRISMA statement: MethodsEligibility criteria: Criteria for eligibility in review ‘rationale’ ‘justification’ Specific study characteristics (PICOS) Report characteristics years considered language
    • Rigour in systematic reviews: PRISMA statement: MethodsInformation sources: Description of all information sources databases dates of coverage contact with study authors additional ‘hand’ searches Date last searched
    • Rigour in systematic reviews: PRISMA statement: Methods Search full electronic search strategy search could be repeated Study selection process for study selection inclusion/ exclusion criteria
    • Rigour in systematic reviews: PRISMA statement: Methods Risk of bias in individual studies description of method used Risk of bias across studies affect cumulative evidence i.e. publication bias Additional analysis description of methods i.e. meta-regression
    • Rigour in systematic reviews: PRISMA statement: Results Study selection Study characteristics Risk of bias within studies Results of individual studies Synthesis of results Risk of bias across studies Additional analysis
    • Rigour in systematic reviews: Checklist of items: PRISMA statement Study selection give number of studies screened how were these screened? accessed for eligibility? number of studies in the review reasons for exclusion ‘ideally a flow diagram’
    • Rigour in systematic reviews: Checklist of items: PRISMA statement Study characteristics (for each study) study size PICOS follow-up period etc. Risk of bias within studies (each study) present data on risk of bias ? outcome level analysis
    • Rigour in systematic reviews: PRISMA statement: ResultsResults of individual studies: Benefits and harm for all outcomes Simple summary data -intervention group Effect estimates & confidence intervalsSynthesis of results: Present results of each meta-analysis include confidence intervals
    • Rigour in systematic reviews: Checklist of items: PRISMA statementDiscussion: Summary of evidence Limitations ConclusionsFunding: Describe source of funding for systematic review & other support
    • Rigour in systematic reviews: PRISMA statement: DiscussionSummary of evidence: Summary of main findings Strength of evidence for each outcome Consider relevance to key groups i.e. health care providers
    • Rigour in systematic reviews: PRISMA statement: DiscussionLimitations: Limitations study & outcome level risk of bias Limitations at review level incomplete retrieval identified research reporting biasConclusions: General interpretation of results Implications for future research
    • Rigour in systematic reviews: PRISMA statement: CautionSystematic ReviewsBeware of: Reviews that cover too few studies: To few journals/databases Avoids ‘grey’ unpublished literature Selection suits author’s bias
    • Rigour in systematic reviews: PRISMA statement: CautionBeware of: Review pays little attention to ‘quality’ of individual studies included: No attempt made to sort strong from weak Only identifies weakness in studies contradictory to his / her position
    • Rigour in systematic reviews: PRISMA statement: CautionBeware of (cont): Reviews that gloss over contradictory findings The majority doesn’t always rule in research ‘Trust me, I am the expert’ reviews Weak description of how lit. was selected = Reader unable to draw conclusions on adequacy Inadequate descriptions of methodologies used = Reader not in position to draw their own conclusion
    • Rigour in systematic reviews: PRISMA statement: CautionBeware of (cont): Inadequate descriptions about differences… in clients, programs, settings = Reader can’t interpret consistent findings Inadequate descriptions of actual statistical results of reviewed studies = Reader can’t draw conclusions about strength of effect in the study
    • Rigour in systematic reviews: PRISMA statement: DiscussionSummary: Performing a systematic review is not easy Requires meticulous searching & considerable attention to methodological detail – before viewed as ‘systematic’ Clear guidance: PRISMAChalmers I, Altman DG (1995) Systematic Reviews. London: BMJ Publishing Group
    • Rigour in systematic reviews: An update Thank you Questions Dr Graeme D. Smith Graeme.Smith@ed.ac.uk