Nonrandomized studies are not always found even when selection criteria for health systems intervention reviews include them: a methodological study

Polypharmacy in multimorbid older adults: protocol for a systematic review

BACKGROUND

Polypharmacy, the concurrent use of multiple medications, consistently evokes a negative connotation, notably because it is associated with a plethora of adverse events. Nonetheless, the number of individuals exposed to polypharmacy is increasing steeply, especially for older people with multiple diseases. There is a need to carefully study the phenomenon at the population scale to full assess the associated health outcomes. Yet, this reveals a complex task because there exists no consensus indicator of polypharmacy. In fact, the definitions of polypharmacy are heterogeneous and its predisposing factors and associated outcomes are not well defined. The goal of this systematic review is to summarize the literature on polypharmacy in multimorbid individuals aged 65 years and over, targeting three objectives: (1) to identify the definitions of polypharmacy that are used in the context of multimorbidity among older individuals (≥65 years); (2) to ascertain predisposing and concurrent factors associated with polypharmacy; and (3) to describe positive and negative outcomes of polypharmacy among older individuals, including hospitalizations, mortality and costs.

METHODS

We will include publications from 2004 to 2016 that target four concepts: polypharmacy, older individuals, multimorbidity and positive/negative outcomes. The search will be performed using EBM Reviews, Embase, Global Health, MEDLINE, AgeLine, CINAHL, Health Policy Reference Center, Public Affairs Index, SocINDEX and Google Scholar. Two independent reviewers will screen the articles, extract the information and evaluate the methodological quality of included studies. The results will be presented in tables and narrative summaries will be performed. We will perform meta-analyses (objective 3) if the heterogeneity is not important.

DISCUSSION

This review will help describe the various ways of conceptualizing polypharmacy and how it is associated with health outcomes. We have selected outcomes most relevant for public surveillance performed with administrative databases. Other positive and negative outcomes have been associated with polypharmacy but may not be included in the review.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42014014989.

Advancing the field of health systems research synthesis

Those planning, managing and working in health systems worldwide routinely need to make decisions regarding strategies to improve health care and promote equity. Systematic reviews of different kinds can be of great help to these decision-makers, providing actionable evidence at every step in the decision-making process. Although there is growing recognition of the importance of systematic reviews to inform both policy decisions and produce guidance for health systems, a number of important methodological and evidence uptake challenges remain and better coordination of existing initiatives is needed. The Alliance for Health Policy and Systems Research, housed within the World Health Organization, convened an Advisory Group on Health Systems Research (HSR) Synthesis to bring together different stakeholders interested in HSR synthesis and its use in decision-making processes. We describe the rationale of the Advisory Group and the six areas of its work and reflects on its role in advancing the field of HSR synthesis. We argue in favour of greater cross-institutional collaborations, as well as capacity strengthening in low- and middle-income countries, to advance the science and practice of health systems research synthesis. We advocate for the integration of quasi-experimental study designs in reviews of effectiveness of health systems intervention and reforms. The Advisory Group also recommends adopting priority-setting approaches for HSR synthesis and increasing the use of findings from systematic reviews in health policy and decision-making.

Optimizing the delivery of contraceptives in low- and middle-income countries through task shifting: a systematic review of effectiveness and safety

Objective

To assess the effectiveness and safety of task shifting for the delivery of injectable contraceptives, contraceptive implants, intrauterine devices (IUDs), tubal ligation and vasectomy in low- and middle-income countries.

Methods

Multiple electronic databases were searched up to 25 May 2012 for studies which had assessed the delivery of contraceptives by health workers with lower levels of training, compared to delivery by health workers usually assigned this role, or compared to no organized provision of contraceptives. We included randomized controlled trials, non-randomized controlled trials, controlled before-after studies, and interrupted time series. Data were extracted using a standard form and the certainty of the evidence found was assessed using GRADE.

Results

We identified six randomized controlled trials published between 1977 and 1995 that assessed the safety and effectiveness of task shifting for the delivery of long-term contraceptives. Two studies assessed IUD insertion by nurses compared to doctors, two assessed IUD insertion by auxiliary nurse-midwives compared to doctors, one assessed tubal ligation by midwives compared to doctors, and one assessed the delivery of vasectomy by medical students compared to doctors. In general, little or no difference was found in contraceptive outcomes between cadres. Study design limitations and the low number of eligible studies, however, allow only limited conclusions to be drawn.

Conclusions

The findings indicate that task shifting for the delivery of long-term contraceptives may be a safe and effective approach to increasing access to contraception. Further research is needed because the certainty of the evidence identified is variable.

Electronic supplementary material

The online version of this article (doi:10.1186/s12978-015-0002-2) contains supplementary material, which is available to authorized users.

Interventions aimed at communities to inform and/or educate about early childhood vaccination

BACKGROUND

A range of strategies are used to communicate with parents, caregivers and communities regarding child vaccination in order to inform decisions and improve vaccination uptake. These strategies include interventions in which information is aimed at larger groups in the community, for instance at public meetings, through radio or through leaflets. This is one of two reviews on communication interventions for childhood vaccination. The companion review focuses on face-to-face interventions for informing or educating parents.

OBJECTIVES

To assess the effects of interventions aimed at communities to inform and/or educate people about vaccination in children six years and younger.

SEARCH METHODS

We searched CENTRAL, MEDLINE, EMBASE and five other databases up to July 2012. We searched for grey literature in the Grey Literature Report and OpenGrey. We also contacted authors of included studies and experts in the field. There were no language, date or settings restrictions.

SELECTION CRITERIA

Individual or cluster-randomised and quasi-randomised controlled trials, interrupted time series (ITS) and repeated measures studies, and controlled before-and-after (CBA) studies. We included interventions aimed at communities and intended to inform and/or educate about vaccination in children six years and younger, conducted in any setting. We defined interventions aimed at communities as those directed at a geographic area, and/or interventions directed to groups of people who share at least one common social or cultural characteristic. Primary outcomes were: knowledge among participants of vaccines or vaccine-preventable diseases and of vaccine service delivery; child immunisation status; and unintended adverse effects. Secondary outcomes were: participants' attitudes towards vaccination; involvement in decision-making regarding vaccination; confidence in the decision made; and resource use or cost of intervention.

DATA COLLECTION AND ANALYSIS

Two authors independently reviewed the references to identify studies for inclusion. We extracted data and assessed risk of bias in all included studies.

MAIN RESULTS

We included two cluster-randomised trials that compared interventions aimed at communities to routine immunisation practices. In one study from India, families, teachers, children and village leaders were encouraged to attend information meetings where they received information about childhood vaccination and could ask questions. In the second study from Pakistan, people who were considered to be trusted in the community were invited to meetings to discuss vaccine coverage rates in their community and the costs and benefits of childhood vaccination. They were asked to develop local action plans and to share the information they had been given and continue the discussions in their communities.The trials show low certainty evidence that interventions aimed at communities to inform and educate about childhood vaccination may improve knowledge of vaccines or vaccine-preventable diseases among intervention participants (adjusted mean difference 0.121, 95% confidence interval (CI) 0.055 to 0.189). These interventions probably increase the number of children who are vaccinated. The study from India showed that the intervention probably increased the number of children who received vaccinations (risk ratio (RR) 1.67, 95% CI 1.21 to 2.31; moderate certainty evidence). The study from Pakistan showed that there is probably an increase in the uptake of both measles (RR 1.63, 95% CI 1.03 to 2.58) and DPT (diptheria, pertussis and tetanus) (RR 2.17, 95% CI 1.43 to 3.29) vaccines (both moderate certainty evidence), but there may be little or no difference in the number of children who received polio vaccine (RR 1.01, 95% CI 0.97 to 1.05; low certainty evidence). There is also low certainty evidence that these interventions may change attitudes in favour of vaccination among parents with young children (adjusted mean difference 0.054, 95% CI 0.013 to 0.105), but they may make little or no difference to the involvement of mothers in decision-making regarding childhood vaccination (adjusted mean difference 0.043, 95% CI -0.009 to 0.097).The studies did not assess knowledge among participants of vaccine service delivery; participant confidence in the vaccination decision; intervention costs; or any unintended harms as a consequence of the intervention. We did not identify any studies that compared interventions aimed at communities to inform and/or educate with interventions directed to individual parents or caregivers, or studies that compared two interventions aimed at communities to inform and/or educate about childhood vaccination.

AUTHORS' CONCLUSIONS

This review provides limited evidence that interventions aimed at communities to inform and educate about early childhood vaccination may improve attitudes towards vaccination and probably increase vaccination uptake under some circumstances. However, some of these interventions may be resource intensive when implemented on a large scale and further rigorous evaluations are needed. These interventions may achieve most benefit when targeted to areas or groups that have low childhood vaccination rates.'

Inclusion of nonrandomized studies in Cochrane systematic reviews was found to be in need of improvement

OBJECTIVES

Nonrandomized studies (NRSs) are considered to provide less reliable evidence for intervention effects. However, these are included in Cochrane reviews, despite discouragement. There has been no evaluation of when and how these designs are used. Therefore, we conducted an overview of current practice.

STUDY DESIGN AND SETTING

We included all Cochrane reviews that considered NRS, conducting inclusions and data extraction in duplicate.

RESULTS

Of the included 202 reviews, 114 (56%) did not cite a reason for including NRS. The reasons were divided into two major categories: NRS were included because randomized controlled trials (RCTs) are wanted (N = 81, 92%) but not feasible, lacking, or insufficient alone or because RCTs are not needed (N = 7, 8%). A range of designs were included with controlled before-after studies as the most common. Most interventions were nonpharmaceutical and the settings nonmedical. For risk of bias assessment, Cochrane Effective Practice and Organisation of Care Group's checklists were used by most reviewers (38%), whereas others used a variety of checklists and self-constructed tools.

CONCLUSION

Most Cochrane reviews do not justify including NRS. When they do, most are not in line with Cochrane recommendations. Risk of bias assessment varies across reviews and needs improvement.

Helping people make well-informed decisions about health care: old and new challenges to achieving the aim of the Cochrane Collaboration

The aim of the Cochrane Collaboration is to help people make well-informed decisions about health care by preparing, maintaining and promoting the accessibility of systematic reviews of the effects of health care interventions. This aim is as relevant now as it was 20 years ago, when the Cochrane Collaboration was established. Substantial progress has been made toward addressing challenges to achieving the Collaboration's aim. At the same time, a huge amount of work remains to be done. Current challenges include improving the quality of reviews, methodological challenges, meeting the needs of contributors and users and taking on new challenges while staying focused on the Collaboration's aim. Radical thinking and substantial change may be needed to identify and implement pragmatic strategies to ensure that reviews are up-to-date and informative. Methodological challenges include the development and application of better methods for addressing explanatory factors, incorporating non-randomized evidence and making comparisons across multiple interventions. Innovations in editorial processes and strategies to meet the needs of low- and middle-income countries and diverse users of Cochrane reviews are needed. Finally, although it is important to consider broadening the aims of the Collaboration to include types of questions other than the effects of interventions and types of products other than the Cochrane Library, we should not lose sight of the aim of the Cochrane Collaboration. Addressing that aim is still a major challenge that requires the collaboration of thousands of people around the world and continuing improvements in the methods used to achieve that aim.