Consumer-professional partnership to improve research: the experience of the Cochrane Collaboration's Pregnancy and Childbirth Group

User experiences of structured stakeholder engagement to consider transferability: The TRANSFER approach

BACKGROUND

Systematic reviews are increasingly used to inform decision-making in health, education, social care and environmental protection. However, decision makers still experience barriers to using reviews, including not knowing how findings might translate to their own contexts, and lack of collaboration with systematic review authors. The TRANSFER approach is a novel method that aims to support review authors to systematically and transparently collaborate with stakeholders to consider context and the transferability of review findings from the beginning of the review process. Such collaboration is intended to improve the usefulness and relevance of review findings for decision makers.

OBJECTIVES

We aim to explore the user experience of the TRANSFER approach conversation guide, and in doing so gain a better understanding of the role and perceived value of stakeholder engagement in systematic reviews for informed decision-making.

METHODS

We conducted four user tests of groups using the guide, organized around simulated meetings between review authors and stakeholders. Review authors led the meeting using the TRANSFER approach conversation guide. We audio-recorded and observed the meetings, collected feedback forms and conducted semi-structured interviews with review authors following the meeting. We analysed the data using framework analysis to examine the user experience of the TRANSFER approach conversation guide and of stakeholder engagement more generally.

RESULTS

Seventeen participants in four user groups participated in the user tests. Most participants were generally positive toward the structured approach using the conversation guide, and felt it would be useful in systematic review projects. We observed examples of misunderstanding of the terminology included in the guide, and received multiple suggestions for how to make the conversation guide more user friendly. We observed numerous challenges related to the hypothetical nature of a user test, including lack of familiarity with the review question/topic among participants and lack of preparation for the meeting.

CONCLUSIONS

Review authors and stakeholders are positive toward using a structured approach to guide collaboration within the context of a systematic review. The TRANSFER conversation guide helps participants to discuss the review question and context in a structured way. Such structured collaboration could help to improve the usefulness and relevance of systematic reviews for decision making by improving the review question, inclusion criteria and consideration of transferability of review findings. The conversation guide needs to be modified to improve user experience. Further research is needed to explore stakeholder collaboration and the use of the TRANSFER conversation guide in systematic review processes.

Optimal outcome factors in maternity and newborn care for inpatient (hospital maternity ward-HMW) and outpatient deliveries (outhospital maternity clinics -OMC)

BACKGROUND AND OBJECTIVES

The aim of the study was to use the United States Optimality Index (OI-US) to assess the feasibility of its application in making decisions for more optimal methods of delivery and for more optimal postpartum and neonatal outcomes. Numerous worldwide associations support the option of women giving birth at maternity outpatient clinics and also at home. What ought to be met is the assessments of requirements and what could be characterized as the birth potential constitute the basis for making the right decision regarding childbirth.

MATERIALS AND METHODS

The study is based on a prospective follow-up of pregnant women and new mothers (100 participants) who were monitored and gave birth at the hospital maternity ward (HMW) and pregnant women and new mothers (100 participants) who were monitored and gave birth at the outhospital maternity clinics (OMC). Selected patients were classified according to the criteria of low and medium-risk and each of the parameters of the OI and the total OI were compared.

RESULTS

The results of this study confirm the benefits of intrapartum and neonatal outcome, when delivery was carried out in an outpatient setting. The median OI of intrapartum components was significantly higher in the outpatient setting compared to the hospital maternity ward (97 range from 24 to 100 vs 91 range from 3 to 100). The median OI of neonatal components was significantly higher in the outpatient compared to the inpatient delivery. (99 range from 97 to 100 vs 96 range from 74 to 100). Certain components from the intrapartum and neonatal period highly contribute to the significantly better total OI in the outpatient conditions in relation to hospital conditions.

CONCLUSION

Outpatient care and delivery provide multiple benefits for both the mother and the newborn.

The TRANSFER Approach for assessing the transferability of systematic review findings

BACKGROUND

Systematic reviews are a key input to health and social welfare decisions. Studies included in systematic reviews often vary with respect to contextual factors that may impact on how transferable review findings are to the review context. However, many review authors do not consider the transferability of review findings until the end of the review process, for example when assessing confidence in the evidence using GRADE or GRADE-CERQual. This paper describes the TRANSFER Approach, a novel approach for supporting collaboration between review authors and stakeholders from the beginning of the review process to systematically and transparently consider factors that may influence the transferability of systematic review findings.

METHODS

We developed the TRANSFER Approach in three stages: (1) discussions with stakeholders to identify current practices and needs regarding the use of methods to consider transferability, (2) systematic search for and mapping of 25 existing checklists related to transferability, and (3) using the results of stage two to develop a structured conversation format which was applied in three systematic review processes.

RESULTS

None of the identified existing checklists related to transferability provided detailed guidance for review authors on how to assess transferability in systematic reviews, in collaboration with decision makers. The content analysis uncovered seven categories of factors to consider when discussing transferability. We used these to develop a structured conversation guide for discussing potential transferability factors with stakeholders at the beginning of the review process. In response to feedback and trial and error, the TRANSFER Approach has developed, expanding beyond the initial conversation guide, and is now made up of seven stages which are described in this article.

CONCLUSIONS

The TRANSFER Approach supports review authors in collaborating with decision makers to ensure an informed consideration, from the beginning of the review process, of the transferability of the review findings to the review context. Further testing of TRANSFER is needed.

Treatments for gestational diabetes: a systematic review and meta-analysis

OBJECTIVE

To investigate the effectiveness of different treatments for gestational diabetes mellitus (GDM).

DESIGN

Systematic review, meta-analysis and network meta-analysis.

METHODS

Data sources were searched up to July 2016 and included MEDLINE and Embase. Randomised trials comparing treatments for GDM (packages of care (dietary and lifestyle interventions with pharmacological treatments as required), insulin, metformin, glibenclamide (glyburide)) were selected by two authors and double checked for accuracy. Outcomes included large for gestational age, shoulder dystocia, neonatal hypoglycaemia, caesarean section and pre-eclampsia. We pooled data using random-effects meta-analyses and used Bayesian network meta-analysis to compare pharmacological treatments (ie, including treatments not directly compared within a trial).

RESULTS

Forty-two trials were included, the reporting of which was generally poor with unclear or high risk of bias. Packages of care varied in their composition and reduced the risk of most adverse perinatal outcomes compared with routine care (eg, large for gestational age: relative risk0.58 (95% CI 0.49 to 0.68; I2=0%; trials 8; participants 3462). Network meta-analyses suggest that metformin had the highest probability of being the most effective treatment in reducing the risk of most outcomes compared with insulin or glibenclamide.

CONCLUSIONS

Evidence shows that packages of care are effective in reducing the risk of most adverse perinatal outcomes. However, trials often include few women, are poorly reported with unclear or high risk of bias and report few outcomes. The contribution of each treatment within the packages of care remains unclear. Large well-designed and well-conducted trials are urgently needed.

TRIAL REGISTRATION NUMBER

PROSPERO CRD42013004608.

A systematic scoping review of the evidence for consumer involvement in organisations undertaking systematic reviews: focus on Cochrane

PLAIN ENGLISH SUMMARY

Cochrane is the largest international producer of systematic reviews of clinical trial evidence. We looked for published evidence that reports where consumers (patients and the public) have been involved in Cochrane systematic reviews, and also in reviews published by other organisations.We found 36 studies that reported about consumer involvement either in individual systematic reviews, or in other organisations. The studies showed that consumers were involved in reviews in a range of different ways: coordinating and producing reviews, making reviews more accessible, and spreading the results of reviews ("knowledge transfer"). The most common role was commenting on reviews ("peer reviewing"). Consumers also had other general roles, for example in educating people about evidence or helping other consumers. There were some interesting examples of new ways of involving consumers. The studies showed that most consumers came from rich and English speaking countries. There was little evidence about how consumer involvement had changed the reviews ("impact"). The studies found that consumer involvement needed to be properly supported.In future we believe that more research should be done to understand what kind of consumer involvement has the best impact; that more review authors should report how consumers have been involved; and that consumers who help with reviews should come from more varied backgrounds.

ABSTRACT

Background Cochrane is the largest international producer of systematic reviews, and is committed to consumer involvement in the production and dissemination of its reviews. The review aims to systematically scope the evidence base for consumer involvement in organisations which commission, undertake or support systematic reviews; with an emphasis on Cochrane. Methods In June 2015 we searched six databases and other sources for studies of consumer involvement in organisations which commission, undertake or support systematic reviews, or in individual systematic review processes. All types of reports and evaluations were eligible. Included studies were combined in a narrative synthesis structured by the level of evaluation and the type of involvement. Results We identified 36 relevant studies. Eleven of these were evaluations at the level of a whole organisation; seven of these studied consumer involvement in Cochrane. Ten studies examined individual Cochrane review groups. Twelve studies reported on individual reviews; only two of these were Cochrane reviews. Finally, three studies were themselves syntheses of other studies. The included studies reported varying levels of consumer involvement across a wide range of activities related to review design and conduct. These included activities such as priority setting and outcome definition as well as review-specific roles such as acting as peer referees and producing plain language summaries. The level of satisfaction and awareness of impact was generally higher in studies focused on individual Cochrane review groups than in the organisation-wide studies. Conclusions There was evidence of highly variable levels and types of consumer involvement within and beyond Cochrane, but limited evidence for what makes the most effective methods and levels of involving consumers in review production. Where evidence of impact was found at the level of individual reviews and review groups it underlined the need for properly resourced and supported processes in order to derive the greatest benefit from the lived experiences of consumers who are willing to be involved. Where reviews do involve consumers, their contribution to the final result could be more clearly identified. More rigorous evaluations are needed to determine the best approach to achieving this. Trial registration Not applicable.

Deservingness and gratitude in the context of heart transplantation

Heart transplantation is now routinely offered as a treatment for end-stage heart failure, and the "gift-of-life" metaphor has become pervasive in this context, forming the foundation on which transplantation discourses rest. In this article, we question organ-as-gift understandings of transplantation. One can also legitimately think of the transplanted organ as a donation, with distinct implications in terms of the transplantation experience for the recipient. We explored the transplantation experience of 13 heart recipients in Australia. We conducted semistructured interviews, and our interpretative phenomenological analysis of the data resulted in three themes: deservingness, nuances of gratitude, and giving forward. Our results indicate that differences between organ-as-gift and organ-as-donation understandings of transplantation are more than merely semantic. Organ-as-donation understandings raise the issue of deservingness, with recipients' assessments of their worthiness influencing their posttransplant experience of gratitude and, ultimately, the meaning(s) gleaned from their transplant experiences.

Involving the public in systematic reviews: a narrative review of organizational approaches and eight case examples

This paper reviews the recent literature on public involvement in the systematic review process. We examine how relevant organizations involve the public in their review processes and how the public are involved in individual reviews. We identified nine surveys or reports of public involvement in systematic reviews at an organizational level and eight examples of public involvement in individual reviews. The public was found to be involved in the following stages of the review process: topic prioritization; refining the scope of the review; suggesting, locating and appraising the literature; interpreting findings; and writing up the review. Numerous tensions, facilitating strategies and recommendations for good practice were identified. Future research directions are delineated.

Public involvement in setting a national research agenda: a mixed methods evaluation

BACKGROUND

: A growing body of literature supports the inclusion of patients, other service users, and the wider public in guiding health technology assessment, particularly in relation to interventions and outcomes for evaluative studies.

OBJECTIVE

: To describe the input and influence of public involvement in setting the agenda for a national research program.

METHODS

: The data source was the commissioned research of the UK National Health Service Health Technology Assessment (HTA) program, 1999-2004. The study consisted of a mixed methods evaluation employing document analyses, key informant interviews, and structured non-participant observations. Routine management records of the HTA program were examined for public influence on research topics. The nature and influence of contributions from the public were compared with those of other experts. Structured observations of advisory panel meetings investigated how discussion and decisions related to patient and public perspectives and how panel members responded to public input to the program. Semi-structured interviews gathered the perceptions of staff and advisory panel members.

RESULTS

: The public provided unique contributions both as external experts and as panel members. The value and influence of many of these contributions were acknowledged by staff and panel members. Input from external public experts was least where recruitment was passive (through a website) and where contributions were required in a research question format that may have been unfamiliar to non-researchers. However, public influence at this stage was at least of the same order as that of professional suggestions. Input was most where recruitment effort was greater, where contributions could be made in an open format, and where the responsibility for integrating these into a research question format lay with research program staff. Public experts contributing at this stage often influenced research plans. Their contributions resulted in some important changes, including making patient and carer perspectives explicit, changing the focus of the research, adding new outcomes, refuting the need for the planned research, providing up-to-date prevalence data, and providing plain English background text. At their best, public members of advisory panels were seen as providing useful comment and encouraging greater sensitivity to patient perspectives among other panel members. At their worst, they were seen as lobbying for particular patient groups.

CONCLUSIONS

: Public involvement has influenced decisions about research commissioned by the HTA program with only relatively minor changes to the procedures and resources for managing the program required. This results in outcomes research that incorporates patient and public preferences and values, and that is freely available for evidence-informed health services.

Consumer involvement in systematic reviews of comparative effectiveness research

BACKGROUND

The Institute of Medicine recently recommended that comparative effectiveness research (CER) should involve input from consumers. While systematic reviews are a major component of CER, little is known about consumer involvement.

OBJECTIVE

To explore current approaches to involving consumers in US-based and key international organizations and groups conducting or commissioning systematic reviews ('organizations').

DESIGN

In-depth, semi-structured interviews with key informants and review of organizations' websites.

SETTING AND PARTICIPANTS

Seventeen highly regarded US-based and international (Cochrane Collaboration, Campbell Collaboration) organizations.

RESULTS

Organizations that usually involve consumers (seven of 17 in our sample) involve them at a programmatic level in the organization or in individual reviews through one-time consultation or on-going collaboration. For example, consumers may suggest topics, provide input on the key questions of the review, provide comments on draft protocols and reports, serve as co-authors or on an advisory group. Organizations involve different types of consumers (individual patients, consumer advocates, families and caregivers), recruiting them mainly through patient organizations and consumer networks. Some offer training in research methods, and one developed training for researchers on how to involve consumers. Little formal evaluation of the effects of consumer involvement is being carried out.

CONCLUSIONS

Consumers are currently involved in systematic reviews in a variety of ways and for various reasons. Assessing which approaches are most effective in achieving different aims of consumer involvement is now required to inform future recommendations on consumer involvement in CER.

Public involvement in the systematic review process in health and social care: a narrative review of case examples

OBJECTIVES

To review the evidence on public involvement in the systematic review process in health and social care; to examine the different methods, levels and stages of involving the public; to synthesise the contributions of the public, as well as the identified tensions, facilitating strategies and recommendations for good practice.

METHOD

Systematic literature search and narrative review.

FINDINGS

Seven case examples were found covering the following review topics: patients' perspectives on electro-convulsive therapy; user involvement in nursing, midwifery and health visiting research; treatments for degenerative ataxias; teaching, learning and assessment of law in social work education; HIV health promotion for men who have sex with men; the conceptualisation, measurement, impact and outcomes of public involvement in health research; methods of consumer involvement in developing healthcare policy and research, clinical practice guidelines and patient information material. The public was found to contribute to systematic reviews by: refining the scope of the review; suggesting and locating relevant literature; appraising the literature; interpreting the review findings; writing up the review. Numerous tensions, facilitating strategies and recommendations were identified.

CONCLUSIONS

The issues raised in this paper should assist researchers in developing and conducting systematic reviews with the involvement of the public.

The Cochrane Library review titles that are important to users of health care, a Cochrane Consumer Network project

BACKGROUND

The Cochrane Consumer Network is an internet-based community of international users of health care contributing to the work of The Cochrane Collaboration, whose mission is to inform healthcare decision making through development of systematic reviews of best evidence on healthcare interventions.

OBJECTIVE

To prioritize existing review titles listed on The Cochrane Library from a healthcare user perspective, with particular emphasis on patients, carers and health consumers.

DESIGN

An online survey was developed and after piloting was made available internationally. The broad dissemination strategy targeted Consumer Network members and Cochrane Review Group editorial staff to identify champions who notified patient support groups and participated in snowballing. The first part of the survey defined criteria that could be applied to review titles and asked survey respondents to rank them. The second part asked respondents to select a health area and prioritize review titles that were of importance to them. Each health area corresponded to a Cochrane Review Group.

RESULTS AND DISCUSSION

Sufficient responses were obtained from 522 valid responses to prioritize review topics in 19 health areas. A total of 321 respondents completed the titles assessment. The types of prioritized interventions were determined by the health area. An important observation was the emphasis on lifestyle and non-medication therapies in many of the included health areas. The clearest exception to this broad observation was where acute care is required such as antibiotics for acute respiratory tract and HIV-associated infections and for cardiac conditions. For some cancers, advanced cancer interventions were prioritized. The most important criteria were for the title to convey a clear meaning and the title conveyed that the review would have an impact on health and well-being. The least important criteria were that the topic was newsworthy or prioritized in the healthcare system.

CONCLUSION

This project was able to identify priority Cochrane review topics for users of health care in 19 of the 50 areas of health care covered by The Cochrane Collaboration. Reviews addressing lifestyle and non-medical interventions were strongly represented in the prioritized review titles. These findings highlight the importance of developing readable, informative lay summaries to support evidence-based decision making by healthcare users.

Patient involvement in health research: a contribution to a systematic review on the effectiveness of treatments for degenerative ataxias

This study aims to incorporate patients' perspective in the design of a systematic review of scientific literature on the effectiveness of degenerative ataxias (DA) treatments. 53 patients with DA from different regions of Spain were consulted using the Delphi method, with three rounds via e-mail. In the first round, obtained information was on treatments used and relevant self-perceived health problems related to DA. The following two rounds were used to prioritize and achieve a consensus on the answers. The participation rate was 100% for all rounds. The most relevant self-perceived health problems were limitations in activities of daily living (ADL), visual and auditory problems and diminished self-esteem. The bibliographic search for the systematic review was enriched by these patient contributions. No study offered information on treatment effectiveness for the following problems prioritized by patients: ADL, social relationships, disease acceptance and quality of life. Thus some of the self-perceived DA-related health problems identified by the patients have never been investigated and should be considered to improve future research projects which should be adapted to meet patients' needs. Effective participation of patients can extend the value of systematic reviews to ensure they respond to both clinicians' information needs and patients' expectations.

A clinical evaluation of evidence-based maternity care using the Optimality Index

The Optimality Index-US (OI-US) reflects the use of evidence-based practices in obstetrics. This paper's objective is to apply the OI-US to a "typical" nurse-midwifery service data set to demonstrate its use outside of a research context. The OI-US score for the sample practice was 80%. The OI-US can be used by obstetric and gynecologic nurse clinicians to demonstrate the relationship of various care practices to optimal outcomes.

Making it happen: approaches to involving consumers in Cochrane reviews

The core work of the Cochrane Collaboration is the conduct of systematic reviews dealing with important health care questions. It is the policy of the Collaboration to involve consumers in all stages of the review process: from refining and prioritization of research questions through protocol design, to review conduct and ultimately dissemination of results. It has been difficult to achieve consumer involvement across all parts of the Cochrane Collaboration. Different approaches have been tried and different levels of success have been achieved. This article discusses consumer involvement in the Cochrane review process in relation to the 10 key principles that guide the work of the Cochrane Collaboration: collaboration, building on the enthusiasm of individuals, avoiding duplication, minimizing bias, keeping up to date, striving for relevance, promoting access, ensuring quality, continuity, and enabling wide participation.