Can we systematically review studies that evaluate complex interventions?

Effectiveness of self-management programmes for heart failure with reduced ejection fraction: a systematic review protocol

INTRODUCTION

Chronic disease self-management (CDSM) is a vital component of congestive heart failure (CHF) programmes. Recent CHF guidelines have downgraded CDSM programmes citing a lack of gold-standard evidence. This protocol describes the aims and methods of a systematic review to collate and synthesise the published research evidence to determine the effectiveness of CDSM programmes and interventions for patients treated for CHF.

METHODS

Medline, PubMed, Embase, CENTRAL, CINAHL, Cochrane Central Register of Controlled Trials, PsycINFO, SCOPUS, Web of Science, the Science Citation Index and registers of clinical trials will be searched from 1966 to 2024. In addition, the reference lists of shortlisted articles will be reviewed. Randomised controlled trials, with case management interventions of CDSM and CHF with reported major adverse cardiovascular events (MACEs), will be extracted and analysed. There is no restriction on language. Study protocol template developed from Cochrane Collaboration and Reporting adheres to Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocol guidelines for systematic review and meta-analyses 2020. Two independent authors will apply inclusions and exclusion criteria to limit article search and assess bias and certainty of evidence rating. Data extraction and study description of included studies will include quality appraisal of studies and quantitative synthesis of data will then be undertaken to ascertain evidence for the study aims. Subgroup analyses will be conducted for different CDSM programmes. The primary outcome will be a significant change in MACE parameters between intervention and control arms. Meta-analysis will be conducted using statistical software, if feasible.

ETHICS AND DISSEMINATION

Ethics approval is not sought as the study is not collecting primary patient data. The results of this study will be disseminated through peer-reviewed scientific journals and also presented to audiences through meetings and scientific conferences.

PROSPERO REGISTRATION NUMBER

CRD42023431539.

Educational interventions and their effects on healthcare professionals' digital competence development: A systematic review

INTRODUCTION

The digitalisation of healthcare requires that healthcare professionals are equipped with adequate digital competencies to be able to deliver high-quality healthcare. Continuing professional education is needed to ensure these competencies.

OBJECTIVE

This systematic review aimed to identify and describe the educational interventions that have been developed to improve various aspects of the digital competence of healthcare professionals and the effects of these interventions.

METHODS

A systematic literature review following the Joanna Briggs Institute's guidelines for Evidence Synthesis was conducted. Five electronic databases (CINAHL, PubMed, ProQuest, Scopus and Medic) up to November 2023 were searched for studies. Two researchers independently assessed the eligibility of the studies by title, abstract and full text and the methodological quality of the studies. Data tabulation and narrative synthesis analysis of study findings were performed. The PRISMA checklist guided the review process.

RESULTS

This review included 20 studies reporting heterogeneous educational interventions to develop the digital competence of healthcare professionals. The participants were mainly nurses and interventions were conducted in various healthcare settings. The length of the education varied from a 20-minute session to a six-month period. Education was offered through traditional contact teaching, using a blended-learning approach and through videoconference. Learning was enhanced through lectures, slide presentations, group work, case studies, discussions and practical exercises or simulations. Educational interventions achieved statistically significant results regarding participants' knowledge, skills, attitudes, perception of resources, self-efficacy or confidence and output quality.

CONCLUSIONS

The findings of this review suggest that digital competence education of nurses and allied health professionals would benefit from a multi-method approach. Training should provide knowledge as well as opportunities to interact with peers and instructors. Skills and confidence should be enhanced through practical training. Adequate organisational support, encouragement, and individual, needs-based guidance should be provided.

Feasibility of quality indicators on prehospital advanced airway management in a physician-staffed emergency medical service: survey-based assessment of the provider point of view

OBJECTIVE

We aimed to determine the feasibility of quality indicators (QIs) for prehospital advanced airway management (PAAM) from a provider point of view.

DESIGN

The study is a survey based feasibility assessment following field testing of QIs for PAAM.

SETTING

The study was performed in two physician staffed emergency medical services in Switzerland.

PARTICIPANTS

42 of the 44 emergency physicians who completed at least one case report form (CRF) dedicated to the collection of the QIs on PAAM between 1 January 2019 and 31 December 2021 participated in the study.

INTERVENTION

The data required to calculate the 17 QIs was systematically collected through a dedicated electronic CRF.

PRIMARY AND SECONDARY OUTCOME MEASURES

Primary outcomes were provider-related feasibility criteria: relevance and acceptance of the QIs, as well as reliability of the data collection. Secondary outcomes were effort to collect specific data and to complete the CRF.

RESULTS

Over the study period, 470 CRFs were completed, with a median of 11 per physician (IQR 4-17; range 1-48). The median time to complete the CRF was 7 min (IQR 3-16) and was considered reasonable by 95% of the physicians. Overall, 75% of the physicians assessed the set of QIs to be relevant, and 74% accepted that the set of QIs assessed the quality of PAAM. The reliability of data collection was rated as good or excellent for each of the 17 QIs, with the lowest rated for the following 3 QIs: duration of preoxygenation, duration of laryngoscopy and occurrence of desaturation during laryngoscopy.

CONCLUSIONS

Collection of QIs on PAAM appears feasible. Electronic medical records and technological solutions facilitating automatic collection of vital parameters and timing during the procedure could improve the reliability of data collection for some QIs. Studies in other services are needed to determine the external validity of our results.

Interventions for Behaviour Change and Self-Management of Risk in Stroke Secondary Prevention: An Overview of Reviews

INTRODUCTION

Optimised secondary prevention strategies that include lifestyle change are recommended after stroke. While multiple systematic reviews (SRs) address behaviour change interventions, intervention definitions, and associated outcomes differ between reviews. This overview of reviews addresses the pressing need to synthesise high-level evidence for lifestyle-based behavioural and/or self-management interventions to reduce risk in stroke secondary prevention in a structured, consistent way.

METHODS

Grading of Recommendations Assessment, Development, and Evaluation (GRADE) criteria were applied to meta-analyses, demonstrating statistically significant effect sizes to establish the certainty of existing evidence. Electronic databases MEDLINE, Embase, Epistemonikos, and the Cochrane Library of Systematic Reviews were systematically searched, current to March 2023.

RESULTS

Fifteen SRs were identified following screening, with moderate overlap of primary studies demonstrated (5.84% degree of corrected covered area). Interventions identified could be broadly categorised as multimodal; behavioural change; self-management; psychological talk therapies, albeit with overlap between some theoretical domains. Seventy-two meta-analyses addressing twenty-one preventive outcomes of interest were reported. Best-evidence synthesis identifies that for primary outcomes of mortality and future cardiovascular events post-stroke, moderate certainty GRADE evidence supports multimodal interventions to reduce cardiac events, with no available evidence for outcomes of mortality (all-cause or cardiovascular) or recurrent stroke events. For secondary outcomes addressing risk-reducing behaviours, best-evidence synthesis identifies moderate certainty GRADE evidence for multimodal lifestyle-based interventions to increase physical activity participation, and low certainty GRADE evidence for behavioural change interventions to improve healthy eating post-stroke. Similarly, low certainty GRADE evidence supports self-management interventions to improve preventive medication adherence. For mood self-management post-stroke, moderate GRADE evidence supports psychological therapies for remission and/or reduction of depression and low/very low certainty GRADE evidence for reduction of psychological distress and anxiety. Best-evidence for outcomes addressing proxy physiological measures identified low GRADE evidence supporting multimodal interventions to improve blood pressure, waist circumference, and LDL cholesterol.

CONCLUSION

Effective strategies to redress risk-related health behaviours are required in stroke survivors to complement current pharmacological secondary prevention. Inclusion of multimodal interventions and psychological talk therapies in evidence-based stroke secondary prevention programmes is warranted given the moderate GRADE of evidence that supports their role in risk reduction. Given the overlap in primary studies across reviews, often with overlapping theoretical domains between broad intervention categories, further research is required to identify optimal intervention behavioural change theories and techniques employed in behavioural/self-management interventions.

Learning patient-centredness with simulated/standardized patients: A realist review: BEME Guide No. 68

BACKGROUND

Given the positive outcomes of patient-centred care on health outcomes, future doctors should learn how to deliver patient-centred care. The literature describes a wide variety of educational interventions with standardized patients (SPs) that focus on learning patient-centredness. However, it is unclear which mechanisms are responsible for learning patient-centredness when applying educational interventions with SPs.

OBJECTIVE

This study aims to clarify how healthcare learners and professionals learn patient-centredness through interventions involving SPs in different healthcare educational contexts.

METHODS

A realist approach was used to focus on what works, for whom, in what circumstances, in what respect and why. Databases were searched through 2019. Nineteen papers were included for analysis. Through inductive and deductive coding, CIC'MO configurations were identified to build partial program theories. These CIC'MOs describe how Interventions with SPs change the Context (C→C') such that Mechanisms (M) are triggered that are expected to foster patient-centredness as Outcome.

RESULTS

Interventions with SPs create three contexts which are 'a safe learning environment,' 'reflective practice,' and 'enabling people to learn together.' These contexts trigger the following seven mechanisms: feeling confident, feeling a sense of comfort, feeling safe, self-reflection, awareness, comparing & contrasting perspectives, combining and broadening perspectives. A tentative final program theory with mechanisms belonging to three main learning components (cognitive, regulative metacognitive and affective) is proposed: Interventions with SPs create a safe learning environment (C') in which learners gain feelings of confidence, comfort and safety (affective M). This safe learning environment enables two other mutual related contexts in which learners learn together (C'), through comparing & contrasting, combining and broadening their perspectives (cognitive M) and in which reflective practice (C') facilitates self-reflection and awareness (metacognitive M) in order to learn patient-centeredness.

CONCLUSION

These insights offer educators ways to deliberately use interventions with SPs that trigger the described mechanisms for learning patient-centredness.

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.

Using Qualitative Synthesis to Explore Heterogeneity of Randomized Trials on ICU Diaries

OBJECTIVE

We aimed to identify which set of components differentiates the ICU diaries that were effective in reducing psychologic symptoms after critical illness.

DATA SOURCES

We searched the online databases MEDLINE, OVID, Embase, and EBSCOhost from inception to December 2021.

STUDY SELECTION

Randomized controlled trials (RCTs) of the ICU diary were included, irrespective of the language, with samples of adult patients (≥ 18 yr old) and/or their relatives hospitalized in an ICU for more than 24 hours. Two qualitative syntheses on patients' and healthcare providers' perceptions on the ICU diary were included.

DATA EXTRACTION

Four findings were extracted from the qualitative synthesis of patients' perspectives on the ICU diary. From the RCTs, we extracted the components of the ICU diary and whether the patients were ventilated for at least 3 days. We reported the outcome as effective or not, regardless of the psychiatric symptoms and diagnostic tools used for evaluation. We built a matrix in which each column represented a recommendation for an intervention component derived from the qualitative review, and each row represented whether the components of an individual trial's intervention matched any of the recommendations.

DATA SYNTHESIS

Eight RCTs were included in the final analysis. The sample of five studies consisted of patients under mechanical ventilation (MV) for at least 3 days. Two were positive trials. Three RCTs included family members, and two of those were positive trials.

CONCLUSIONS

For patients under MV for at least 3 days, the ICU diaries that were effective in preventing psychiatric symptoms after critical illness were written by the ICU staff, delivered after hospital discharge, and read with a healthcare professional in order to better understand the diary and the ICU stay. For family members, the presence of photographs was the only characteristic identified a successful ICU diary.

Self-management of musculoskeletal (MSK) conditions: What is most useful to patients? Protocol for a mixed methods systematic review

INTRODUCTION

Musculoskeletal (MSK) conditions are the leading cause of disability in the United Kingdom, leading to ever-growing waiting lists. Clinical guidelines highlight that most musculoskeletal conditions resolve in time and with little clinical input, and so supporting people to self-manage is recommended to optimise healthcare resources. Despite this, the term self-management remains ambiguous and to date no systematic review has evaluated if self-management is a suitable, acceptable, and effective intervention/strategy for managing all MSK conditions.

METHODS AND ANALYSIS

This protocol is informed and reported in line with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA). An advanced convergent qualitative meta-integration mixed-studies design will be used. Using a comprehensive predetermined search strategy, databases, key journals and grey literature will be searched independently by two reviewers. The reviewers will independently assess eligibility, complete data extraction, and evaluate for risk of bias using the Mixed Methods Appraisal Tool (MMAT). The overall quality of included studies will be evaluated using Grading of Recommendations, Assessment, Development and Evaluation (GRADE) guidelines. Data from mixed-methods studies will be transformed using a process of fractionation and analysed alongside the data extracted from the quantitative and qualitative studies, using descriptive analysis and thematic analysis, respectively.

ETHICS AND DISSEMINATION

No research ethics are required for this systematic review since patient data will not be collected. The review will help to inform healthcare professionals and researchers on the most suitable, acceptable, and effective intervention/strategy for self-managing MSK conditions. Results of this review will be submitted for publication in a peer-reviewed journal and conference presentations.

Discharge planning from hospital

BACKGROUND

Discharge planning is a routine feature of health systems in many countries that aims to reduce delayed discharge from hospital, and improve the co-ordination of services following discharge from hospital and reduce the risk of hospital readmission. This is the fifth update of the original review.

OBJECTIVES

To assess the effectiveness of planning the discharge of individual patients moving from hospital.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase and two trials registers on 20 April 2021. We searched two other databases up to 31 March 2020. We also conducted reference checking, citation searching and contact with study authors to identify additional studies.

SELECTION CRITERIA

Randomised trials that compared an individualised discharge plan with routine discharge that was not tailored to individual participants. Participants were hospital inpatients.

DATA COLLECTION AND ANALYSIS

Two review authors independently undertook data analysis and quality assessment using a pre-designed data extraction sheet. We grouped studies by older people with a medical condition, people recovering from surgery, and studies that recruited participants with a mix of conditions. We calculated risk ratios (RRs) for dichotomous outcomes and mean differences (MDs) for continuous data using fixed-effect meta-analysis. When combining outcome data it was not possible because of differences in the reporting of outcomes, we summarised the reported results for each trial in the text.

MAIN RESULTS

We included 33 trials (12,242 participants), four new trials included in this update. The majority of trials (N = 30) recruited participants with a medical diagnosis, average age range 60 to 84 years; four of these trials also recruited participants who were in hospital for a surgical procedure. Participants allocated to discharge planning and who were in hospital for a medical condition had a small reduction in the initial hospital length of stay (MD - 0.73, 95% confidence interval (CI) - 1.33 to - 0.12; 11 trials, 2113 participants; moderate-certainty evidence), and a relative reduction in readmission to hospital over an average of three months follow-up (RR 0.89, 95% CI 0.81 to 0.97; 17 trials, 5126 participants; moderate-certainty evidence). There was little or no difference in participant's health status (mortality at three- to nine-month follow-up: RR 1.05, 95% CI 0.85 to 1.29; 8 trials, 2721 participants; moderate certainty) functional status and psychological health measured by a range of measures, 12 studies, 2927 participants;  low certainty evidence). There was some evidence that satisfaction might be increased for patients (7 trials), caregivers (1 trial) or healthcare professionals (2 trials) (very low certainty evidence). The cost of a structured discharge plan compared with routine discharge is uncertain (7 trials recruiting 7873 participants with a medical condition; very low certainty evidence).

AUTHORS' CONCLUSIONS

A structured discharge plan that is tailored to the individual patient probably brings about a small reduction in the initial hospital length of stay and readmissions to hospital for older people with a medical condition, may slightly increase patient satisfaction with healthcare received. The impact on patient health status and healthcare resource use or cost to the health service is uncertain.

Systematic review of process evaluations of interventions in trials investigating sedentary behaviour in adults

OBJECTIVES

To systematically review and synthesise findings from process evaluations of interventions in trials which measured sedentary behaviour as an outcome in adults to explore: (1) how intervention content, implementation, mechanisms of impact and context influence outcomes and (2) how these interventions are experienced from different perspectives (participants, carers, staff).

DESIGN

Systematic review and narrative synthesis underpinned by the Medical Research Council process evaluation framework.

DATA SOURCES

Databases searches were conducted in March 2019 then updated in May 2020 and October 2021 in: CINAHL, SPORTDiscus, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, AMED; EMBASE, PsycINFO, MEDLINE, Web of Science and ProQuest Dissertations & Theses.

ELIGIBILITY CRITERIA

We included: Process evaluations of trials including interventions where sedentary behaviour was measured as an outcome in adults aged 16 or over from clinical or non-clinical populations. We excluded studies if interventions were delivered in educational or workplace settings, or if they were laboratory studies focused on immediate effects of breaking sitting.

DATA EXTRACTION AND SYNTHESIS

Two independent reviewers extracted and coded data into a framework and assessed the quality of studies using the Mixed Methods Appraisal Tool. We synthesised findings using a narrative approach.

RESULTS

17 process evaluations were included. Five interventions focused on reducing sedentary behaviour or sitting time, 12 aimed to increase physical activity or promote healthier lifestyles. Process evaluations indicated changes in sedentary behaviour outcomes were shaped by numerous factors including: barriers (eg, staffing difficulties and scheduling problems) and facilitators (eg, allowing for flexibility) to intervention delivery; contextual factors (eg, usual lifestyle and religious events) and individual factors (eg, pain, tiredness, illness, age and individual preferences).

DISCUSSION

Intervention requires careful consideration of different factors that could influence changes in sedentary behaviour outcomes to ensure that interventions can be tailored to suit different individuals and groups.

PROSPERO REGISTRATION NUMBER

CRD42018087403.

Application of the Templates TIDieR and CERT Reveal Incomplete Reporting and Poor Replicability of Exercise Interventions for Type 2 Diabetes Mellitus

BACKGROUND

Exercise is strongly recommended for the management of type 2 diabetes mellitus (T2DM). However, incomplete intervention reporting in clinical trials limits the replication of exercise protocols. As previously demonstrated by us for exercise and hypertension, the reporting quality might also be insufficient in studies with respect to T2DM and exercise.

OBJECTIVE

The aim of the study was to assess the completeness of exercise intervention reporting in randomized controlled trials (RCTs) for T2DM.

METHODS

Two independent reviewers applied the Consensus on Exercise Reporting Template (CERT) and the template for intervention description and replication (TIDieR) to 23 exercise trials obtained from the most recent and frequently cited meta-analysis in current guidelines. The completeness of reporting was evaluated, focusing on the F.I.T.T. components (frequency, intensity, time, type). Interrater agreement and associations with publication year and journal impact factor were examined.

RESULTS

Mean CERT score was 11/19 (range 5-17), and 8/12 (range 4-12) for TIDieR. F.I.T.T. components were almost completely described, whereas overall completeness of exercise reporting was 60% and 68% (CERT and TIDieR). Replication of each exercise of the respective program was not possible in 52% of interventions. The majority of items had shown excellent agreement. No associations with publication year or impact factor were found.

CONCLUSION

Exercise interventions were not found to be sufficiently reported in RCTs that currently guide clinical practice in T2DM. Replication in further studies or clinical practice is limited due to poor exercise description. We suggest the use of more specific CERT for reporting results of exercise interventions. Further refinement for internal diseases is needed to better describe exercise interventions.

Establishing quality indicators for prehospital advanced airway management: a modified nominal group technique consensus process

Background

Pre-hospital advanced airway management is a complex intervention composed of numerous steps, interactions, and variables that can be delivered to a high standard in the pre-hospital setting. Standard research methods have struggled to evaluate this complex intervention because of considerable heterogeneity in patients, providers, and techniques. In this study, we aimed to develop a set of quality indicators to evaluate pre-hospital advanced airway management.

Methods

We used a modified nominal group technique consensus process comprising three email rounds and a consensus meeting among a group of 16 international experts. The final set of quality indicators was assessed for usability according to the National Quality Forum Measure Evaluation Criteria.

Results

Seventy-seven possible quality indicators were identified through a narrative literature review with a further 49 proposed by panel experts. A final set of 17 final quality indicators composed of three structure-, nine process-, and five outcome-related indicators, was identified through the consensus process. The quality indicators cover all steps of pre-hospital advanced airway management from preoxygenation and use of rapid sequence induction to the ventilatory state of the patient at hospital delivery, prior intubation experience of provider, success rates and complications.

Conclusions

We identified a set of quality indicators for pre-hospital advanced airway management that represent a practical tool to measure, report, analyse, and monitor quality and performance of this complex intervention.

Routine provision of feedback from patient-reported outcome measurements to healthcare providers and patients in clinical practice

BACKGROUND

Patient-reported outcomes measures (PROMs) assess a patient's subjective appraisal of health outcomes from their own perspective. Despite hypothesised benefits that feedback  on PROMs can support decision-making in clinical practice and improve outcomes, there is uncertainty surrounding the effectiveness of PROMs feedback.

OBJECTIVES

To assess the effects of PROMs feedback to patients, or healthcare workers, or both on patient-reported health outcomes and processes of care.

SEARCH METHODS

We searched MEDLINE, Embase, CENTRAL, two other databases and two clinical trial registries on 5 October 2020. We searched grey literature and consulted experts in the field.

SELECTION CRITERIA

Two review authors independently screened and selected studies for inclusion. We included randomised trials directly comparing the effects on outcomes and processes of care of PROMs feedback to healthcare professionals and patients, or both with the impact of not providing such information.

DATA COLLECTION AND ANALYSIS

Two groups of two authors independently extracted data from the included studies and evaluated study quality. We followed standard methodological procedures expected by Cochrane and EPOC. We used the GRADE approach to assess the certainty of the evidence. We conducted meta-analyses of the results where possible.

MAIN RESULTS

We identified 116 randomised trials which assessed the effectiveness of PROMs feedback in improving processes or outcomes of care, or both in a broad range of disciplines including psychiatry, primary care, and oncology. Studies were conducted across diverse ambulatory primary and secondary care settings in North America, Europe and Australasia. A total of 49,785 patients were included across all the studies. The certainty of the evidence varied between very low and moderate. Many of the studies included in the review were at risk of performance and detection bias. The evidence suggests moderate certainty that PROMs feedback probably improves quality of life (standardised mean difference (SMD) 0.15, 95% confidence interval (CI) 0.05 to 0.26; 11 studies; 2687 participants), and leads to an increase in patient-physician communication (SMD 0.36, 95% CI 0.21 to 0.52; 5 studies; 658 participants), diagnosis and notation (risk ratio (RR) 1.73, 95% CI 1.44 to 2.08; 21 studies; 7223 participants), and disease control (RR 1.25, 95% CI 1.10 to 1.41; 14 studies; 2806 participants). The intervention probably makes little or no difference for general health perceptions (SMD 0.04, 95% CI -0.17 to 0.24; 2 studies, 552 participants; low-certainty evidence), social functioning (SMD 0.02, 95% CI -0.06 to 0.09; 15 studies; 2632 participants; moderate-certainty evidence), and pain (SMD 0.00, 95% CI -0.09 to 0.08; 9 studies; 2386 participants; moderate-certainty evidence). We are uncertain about the effect of PROMs feedback on physical functioning (14 studies; 2788 participants) and mental functioning (34 studies; 7782 participants), as well as fatigue (4 studies; 741 participants), as the certainty of the evidence was very low. We did not find studies reporting on adverse effects defined as distress following or related to PROM completion.

AUTHORS' CONCLUSIONS

PROM feedback probably produces moderate improvements in communication between healthcare professionals and patients as well as in diagnosis and notation, and disease control, and small improvements to quality of life. Our confidence in the effects is limited by the risk of bias, heterogeneity and small number of trials conducted to assess outcomes of interest. It is unclear whether   many of these improvements are clinically meaningful or sustainable in the long term. There is a need for more high-quality studies in this area, particularly studies which employ cluster designs and utilise techniques to maintain allocation concealment.

Framework for the development and evaluation of complex interventions: gap analysis, workshop and consultation-informed update

BACKGROUND

The Medical Research Council published the second edition of its framework in 2006 on developing and evaluating complex interventions. Since then, there have been considerable developments in the field of complex intervention research. The objective of this project was to update the framework in the light of these developments. The framework aims to help research teams prioritise research questions and design, and conduct research with an appropriate choice of methods, rather than to provide detailed guidance on the use of specific methods.

METHODS

There were four stages to the update: (1) gap analysis to identify developments in the methods and practice since the previous framework was published; (2) an expert workshop of 36 participants to discuss the topics identified in the gap analysis; (3) an open consultation process to seek comments on a first draft of the new framework; and (4) findings from the previous stages were used to redraft the framework, and final expert review was obtained. The process was overseen by a Scientific Advisory Group representing the range of relevant National Institute for Health Research and Medical Research Council research investments.

RESULTS

Key changes to the previous framework include (1) an updated definition of complex interventions, highlighting the dynamic relationship between the intervention and its context; (2) an emphasis on the use of diverse research perspectives: efficacy, effectiveness, theory-based and systems perspectives; (3) a focus on the usefulness of evidence as the basis for determining research perspective and questions; (4) an increased focus on interventions developed outside research teams, for example changes in policy or health services delivery; and (5) the identification of six 'core elements' that should guide all phases of complex intervention research: consider context; develop, refine and test programme theory; engage stakeholders; identify key uncertainties; refine the intervention; and economic considerations. We divide the research process into four phases: development, feasibility, evaluation and implementation. For each phase we provide a concise summary of recent developments, key points to address and signposts to further reading. We also present case studies to illustrate the points being made throughout.

LIMITATIONS

The framework aims to help research teams prioritise research questions and design and conduct research with an appropriate choice of methods, rather than to provide detailed guidance on the use of specific methods. In many of the areas of innovation that we highlight, such as the use of systems approaches, there are still only a few practical examples. We refer to more specific and detailed guidance where available and note where promising approaches require further development.

CONCLUSIONS

This new framework incorporates developments in complex intervention research published since the previous edition was written in 2006. As well as taking account of established practice and recent refinements, we draw attention to new approaches and place greater emphasis on economic considerations in complex intervention research. We have introduced a new emphasis on the importance of context and the value of understanding interventions as 'events in systems' that produce effects through interactions with features of the contexts in which they are implemented. The framework adopts a pluralist approach, encouraging researchers and research funders to adopt diverse research perspectives and to select research questions and methods pragmatically, with the aim of providing evidence that is useful to decision-makers.

FUTURE WORK

We call for further work to develop relevant methods and provide examples in practice. The use of this framework should be monitored and the move should be made to a more fluid resource in the future, for example a web-based format that can be frequently updated to incorporate new material and links to emerging resources.

FUNDING

This project was jointly funded by the Medical Research Council (MRC) and the National Institute for Health Research (Department of Health and Social Care 73514).

The Building Blocks of Implementation Frameworks and Models in Primary Care: A Narrative Review

Background: Our aim is to identify the core building blocks of existing implementation frameworks and models, which can be used as a basis to further develop a framework for the implementation of complex interventions within primary care practices. Within the field of implementation science, various frameworks, and models exist to support the uptake of research findings and evidence-based practices. However, these frameworks and models often are not sufficiently actionable or targeted for use by intervention designers. The objective of this research is to map the similarities and differences of various frameworks and models, in order to find key constructs that form the foundation of an implementation framework or model that is to be developed.

Methods: A narrative review was conducted, searching for papers that describe a framework or model for implementation by means of various search terms, and a snowball approach. The core phases, components, or other elements of each framework or model are extracted and listed. We analyze the similarities and differences between the frameworks and models and elaborate on their core building blocks. These core building blocks form the basis of an overarching model that we will develop based upon this review and put into practice.

Results: A total of 28 implementation frameworks and models are included in our analysis. Throughout 15 process models, a total of 67 phases, steps or requirements are extracted and throughout 17 determinant frameworks a total of 90 components, constructs, or elements are extracted and listed into an Excel file. They are bundled and categorized using NVivo 12© and synthesized into three core phases and three core components of an implementation process as common elements of most implementation frameworks or models. The core phases are a development phase, a translation phase, and a sustainment phase. The core components are the intended change, the context, and implementation strategies.

Discussion: We have identified the core building blocks of an implementation framework or model, which can be synthesized in three core phases and three core components. These will be the foundation for further research that aims to develop a new model that will guide and support intervention designers to develop and implement complex interventions, while taking account contextual factors.

Intensive therapy for moderate established rheumatoid arthritis: the TITRATE research programme

Background

Rheumatoid arthritis is a major inflammatory disorder and causes substantial disability. Treatment goals span minimising disease activity, achieving remission and decreasing disability. In active rheumatoid arthritis, intensive management achieves these goals. As many patients with established rheumatoid arthritis have moderate disease activity, the TITRATE (Treatment Intensities and Targets in Rheumatoid Arthritis ThErapy) programme assessed the benefits of intensive management.

Objectives

To (1) define how to deliver intensive therapy in moderate established rheumatoid arthritis; (2) establish its clinical effectiveness and cost-effectiveness in a trial; and (3) evaluate evidence supporting intensive management in observational studies and completed trials.

Design

Observational studies, secondary analyses of completed trials and systematic reviews assessed existing evidence about intensive management. Qualitative research, patient workshops and systematic reviews defined how to deliver it. The trial assessed its clinical effectiveness and cost-effectiveness in moderate established rheumatoid arthritis.

Setting

Observational studies (in three London centres) involved 3167 patients. These were supplemented by secondary analyses of three previously completed trials (in centres across all English regions), involving 668 patients. Qualitative studies assessed expectations (nine patients in four London centres) and experiences of intensive management (15 patients in 10 centres across England). The main clinical trial enrolled 335 patients with diverse socioeconomic deprivation and ethnicity (in 39 centres across all English regions).

Participants

Patients with established moderately active rheumatoid arthritis receiving conventional disease-modifying drugs.

Interventions

Intensive management used combinations of conventional disease-modifying drugs, biologics (particularly tumour necrosis factor inhibitors) and depot steroid injections; nurses saw patients monthly, adjusted treatment and provided supportive person-centred psychoeducation. Control patients received standard care.

Main outcome measures

Disease Activity Score for 28 joints based on the erythrocyte sedimentation rate (DAS28-ESR)-categorised patients (active to remission). Remission (DAS28-ESR < 2.60) was the treatment target. Other outcomes included fatigue (measured on a 100-mm visual analogue scale), disability (as measured on the Health Assessment Questionnaire), harms and resource use for economic assessments.

Results

Evaluation of existing evidence for intensive rheumatoid arthritis management showed the following. First, in observational studies, DAS28-ESR scores decreased over 10–20 years, whereas remissions and treatment intensities increased. Second, in systematic reviews of published trials, all intensive management strategies increased remissions. Finally, patients with high disability scores had fewer remissions. Qualitative studies of rheumatoid arthritis patients, workshops and systematic reviews helped develop an intensive management pathway. A 2-day training session for rheumatology practitioners explained its use, including motivational interviewing techniques and patient handbooks. The trial screened 459 patients and randomised 335 patients (168 patients received intensive management and 167 patients received standard care). A total of 303 patients provided 12-month outcome data. Intention-to-treat analysis showed intensive management increased DAS28-ESR 12-month remissions, compared with standard care (32% vs. 18%, odds ratio 2.17, 95% confidence interval 1.28 to 3.68; p = 0.004), and reduced fatigue [mean difference –18, 95% confidence interval –24 to –11 (scale 0–100); p < 0.001]. Disability (as measured on the Health Assessment Questionnaire) decreased when intensive management patients achieved remission (difference –0.40, 95% confidence interval –0.57 to –0.22) and these differences were considered clinically relevant. However, in all intensive management patients reductions in the Health Assessment Questionnaire scores were less marked (difference –0.1, 95% confidence interval –0.2 to 0.0). The numbers of serious adverse events (intensive management n = 15 vs. standard care n = 11) and other adverse events (intensive management n = 114 vs. standard care n = 151) were similar. Economic analysis showed that the base-case incremental cost-effectiveness ratio was £43,972 from NHS and Personal Social Services cost perspectives. The probability of meeting a willingness-to-pay threshold of £30,000 was 17%. The incremental cost-effectiveness ratio decreased to £29,363 after including patients’ personal costs and lost working time, corresponding to a 50% probability that intensive management is cost-effective at English willingness-to-pay thresholds. Analysing trial baseline predictors showed that remission predictors comprised baseline DAS28-ESR, disability scores and body mass index. A 6-month extension study (involving 95 intensive management patients) showed fewer remissions by 18 months, although more sustained remissions were more likley to persist. Qualitative research in trial completers showed that intensive management was acceptable and treatment support from specialist nurses was beneficial.

Limitations

The main limitations comprised (1) using single time point remissions rather than sustained responses, (2) uncertainty about benefits of different aspects of intensive management and differences in its delivery across centres, (3) doubts about optimal treatment of patients unresponsive to intensive management and (4) the lack of formal international definitions of ‘intensive management’.

Conclusion

The benefits of intensive management need to be set against its additional costs. These were relatively high. Not all patients benefited. Patients with high pretreatment physical disability or who were substantially overweight usually did not achieve remission.

Future work

Further research should (1) identify the most effective components of the intervention, (2) consider its most cost-effective delivery and (3) identify alternative strategies for patients not responding to intensive management.

Trial registration

Current Controlled Trials ISRCTN70160382.

Funding

This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 9, No. 8. See the NIHR Journals Library website for further project information.

PROTOCOL: Community-based interventions for initiating early end-of-life conversations in nonterminally Ill adults: a systematic review

This systematic review aims to answer the following research questions: (1) What are the existing community-based interventions for initiating advance care planning (ACP) conversations and quality end-of-life (EoL) planning behaviours in nonterminally ill adults internationally? (2) What are the effects of community-based interventions on the initiation of ACP conversations and EoL planning behaviours of nonterminally ill adults in the community?

Feasibility and Process Evaluation of a Need-Supportive Physical Activity Program in Aged Care Workers: The Activity for Well-Being Project

The need to undertake pilot testing and evaluation of novel health promotion programs has become increasingly apparent for the purpose of understanding the true effects of complex interventions and for testing and refining behavioral theories that these interventions are informed by. A mixed-methods process evaluation and feasibility study was undertaken for a need-supportive physical activity program that was piloted in a single-group pre–post study. The piloted program was designed to support participant needs of autonomy, competence, and relatedness through evidence-based and theory-informed behavior change strategies including a motivational interviewing style appointment, education on self-management tools (i.e., pedometers, goal setting, action and coping planning, a customized website for goal setting and self-monitoring), and self-determined methods of regulating physical activity intensity [affect, rating of perceived exertion (RPE), and self-pacing]. The program aimed to positively impact physical activity behavior, psychological well-being, and associated motivational processes. Reach, adoption, fidelity, context, change and performance objectives, and feasibility of the program were evaluated using information from survey respondents from the target population (n = 118) and implementing staff (n = 6); questionnaires from pilot study participants (n = 21); and individual semi-structured interviews with a combination of pilot study participants, non-participants, and implementing staff (n = 19). Process evaluation of the Activity for Well-Being program found that the reach of the program was moderate but adoption was low. The use of self-management tools and self-determined methods of regulating physical activity intensity appeared to be feasible. The website had mixed responses and low engagement. The element of having a support person elicited a strong positive response in the program participant interviews. Involving local implementing staff more directly into the delivery of the intervention could have potentially improved reach, adoption, and feasibility of the program.

Reduction in saturated fat intake for cardiovascular disease

BACKGROUND

Reducing saturated fat reduces serum cholesterol, but effects on other intermediate outcomes may be less clear. Additionally, it is unclear whether the energy from saturated fats eliminated from the diet are more helpfully replaced by polyunsaturated fats, monounsaturated fats, carbohydrate or protein.

OBJECTIVES

To assess the effect of reducing saturated fat intake and replacing it with carbohydrate (CHO), polyunsaturated (PUFA), monounsaturated fat (MUFA) and/or protein on mortality and cardiovascular morbidity, using all available randomised clinical trials.

SEARCH METHODS

We updated our searches of the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (Ovid) and Embase (Ovid) on 15 October 2019, and searched Clinicaltrials.gov and WHO International Clinical Trials Registry Platform (ICTRP) on 17 October 2019.

SELECTION CRITERIA

Included trials fulfilled the following criteria: 1) randomised; 2) intention to reduce saturated fat intake OR intention to alter dietary fats and achieving a reduction in saturated fat; 3) compared with higher saturated fat intake or usual diet; 4) not multifactorial; 5) in adult humans with or without cardiovascular disease (but not acutely ill, pregnant or breastfeeding); 6) intervention duration at least 24 months; 7) mortality or cardiovascular morbidity data available.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed inclusion, extracted study data and assessed risk of bias. We performed random-effects meta-analyses, meta-regression, subgrouping, sensitivity analyses, funnel plots and GRADE assessment.

MAIN RESULTS

We included 15 randomised controlled trials (RCTs) (16 comparisons, 56,675 participants), that used a variety of interventions from providing all food to advice on reducing saturated fat. The included long-term trials suggested that reducing dietary saturated fat reduced the risk of combined cardiovascular events by 17% (risk ratio (RR) 0.83; 95% confidence interval (CI) 0.70 to 0.98, 12 trials, 53,758 participants of whom 8% had a cardiovascular event, I² = 67%, GRADE moderate-quality evidence). Meta-regression suggested that greater reductions in saturated fat (reflected in greater reductions in serum cholesterol) resulted in greater reductions in risk of CVD events, explaining most heterogeneity between trials. The number needed to treat for an additional beneficial outcome (NNTB) was 56 in primary prevention trials, so 56 people need to reduce their saturated fat intake for ~four years for one person to avoid experiencing a CVD event. In secondary prevention trials, the NNTB was 53. Subgrouping did not suggest significant differences between replacement of saturated fat calories with polyunsaturated fat or carbohydrate, and data on replacement with monounsaturated fat and protein was very limited. We found little or no effect of reducing saturated fat on all-cause mortality (RR 0.96; 95% CI 0.90 to 1.03; 11 trials, 55,858 participants) or cardiovascular mortality (RR 0.95; 95% CI 0.80 to 1.12, 10 trials, 53,421 participants), both with GRADE moderate-quality evidence. There was little or no effect of reducing saturated fats on non-fatal myocardial infarction (RR 0.97, 95% CI 0.87 to 1.07) or CHD mortality (RR 0.97, 95% CI 0.82 to 1.16, both low-quality evidence), but effects on total (fatal or non-fatal) myocardial infarction, stroke and CHD events (fatal or non-fatal) were all unclear as the evidence was of very low quality. There was little or no effect on cancer mortality, cancer diagnoses, diabetes diagnosis, HDL cholesterol, serum triglycerides or blood pressure, and small reductions in weight, serum total cholesterol, LDL cholesterol and BMI. There was no evidence of harmful effects of reducing saturated fat intakes.

AUTHORS' CONCLUSIONS

The findings of this updated review suggest that reducing saturated fat intake for at least two years causes a potentially important reduction in combined cardiovascular events. Replacing the energy from saturated fat with polyunsaturated fat or carbohydrate appear to be useful strategies, while effects of replacement with monounsaturated fat are unclear. The reduction in combined cardiovascular events resulting from reducing saturated fat did not alter by study duration, sex or baseline level of cardiovascular risk, but greater reduction in saturated fat caused greater reductions in cardiovascular events.

Personally tailored activities for improving psychosocial outcomes for people with dementia in community settings

BACKGROUND

People with dementia living in the community, that is in their own homes, are often not engaged in meaningful activities. Activities tailored to their individual interests and preferences might be one approach to improve quality of life and reduce challenging behaviour.

OBJECTIVES

To assess the effects of personally tailored activities on psychosocial outcomes for people with dementia living in the community and their caregivers. To describe the components of the interventions. To describe conditions which enhance the effectiveness of personally tailored activities in this setting.

SEARCH METHODS

We searched ALOIS: the Cochrane Dementia and Cognitive Improvement Group's Specialized Register on 11 September 2019 using the terms: activity OR activities OR occupation* OR "psychosocial intervention" OR "non-pharmacological intervention" OR "personally-tailored" OR "individually-tailored" OR individual OR meaning OR involvement OR engagement OR occupational OR personhood OR "person-centred" OR identity OR Montessori OR community OR ambulatory OR "home care" OR "geriatric day hospital" OR "day care" OR "behavioural and psychological symptoms of dementia" OR "BPSD" OR "neuropsychiatric symptoms" OR "challenging behaviour" OR "quality of life" OR depression. ALOIS contains records of clinical trials identified from monthly searches of a number of major healthcare databases, numerous trial registries and grey literature sources.

SELECTION CRITERIA

We included randomised controlled trials and quasi-experimental trials including a control group offering personally tailored activities. All interventions comprised an assessment of the participant's present or past interests in, or preferences for, particular activities for all participants as a basis for an individual activity plan. We did not include interventions offering a single activity (e.g. music or reminiscence) or activities that were not tailored to the individual's interests or preferences. Control groups received usual care or an active control intervention.

DATA COLLECTION AND ANALYSIS

Two review authors independently checked the articles for inclusion, extracted data, and assessed the methodological quality of all included studies. We assessed the risk of selection bias, performance bias, attrition bias, and detection bias. In case of missing information, we contacted the study authors.

MAIN RESULTS

We included five randomised controlled trials (four parallel-group studies and one cross-over study), in which a total of 262 participants completed the studies. The number of participants ranged from 30 to 160. The mean age of the participants ranged from 71 to 83 years, and mean Mini-Mental State Examination (MMSE) scores ranged from 11 to 24. One study enrolled predominantly male veterans; in the other studies the proportion of female participants ranged from 40% to 60%. Informal caregivers were mainly spouses. In four studies family caregivers were trained to deliver personally tailored activities based on an individual assessment of interests and preferences of the people with dementia, and in one study such activities were offered directly to the participants. The selection of activities was performed with different methods. Two studies compared personally tailored activities with an attention control group, and three studies with usual care. Duration of follow-up ranged from two weeks to four months. We found low-certainty evidence indicating that personally tailored activities may reduce challenging behaviour (standardised mean difference (SMD) -0.44, 95% confidence interval (CI) -0.77 to -0.10; I² = 44%; 4 studies; 305 participants) and may slightly improve quality of life (based on the rating of family caregivers). For the secondary outcomes depression (two studies), affect (one study), passivity (one study), and engagement (two studies), we found low-certainty evidence that personally tailored activities may have little or no effect. We found low-certainty evidence that personally tailored activities may slightly improve caregiver distress (two studies) and may have little or no effect on caregiver burden (MD -0.62, 95% CI -3.08 to 1.83; I² = 0%; 3 studies; 246 participants), caregivers' quality of life, and caregiver depression. None of the studies assessed adverse effects, and no information about adverse effects was reported in any study.

AUTHORS' CONCLUSIONS

Offering personally tailored activities to people with dementia living in the community may be one approach for reducing challenging behaviour and may also slightly improve the quality of life of people with dementia. Given the low certainty of the evidence, these results should be interpreted with caution. For depression and affect of people with dementia, as well as caregivers' quality of life and burden, we found no clear benefits of personally tailored activities.

Evaluating the role of surgical sterilisation in canine rabies control: A systematic review of impact and outcomes

Current recommendations for the elimination of canine-mediated human rabies focus on mass dog vaccination as the most feasible and cost-effective strategy. However, attempts to control rabies are often combined with canine surgical sterilisation programmes. The added value of sterilisation is widely debated. A systematic review was undertaken to compare the outcomes and impact of vaccination and sterilisation programmes with vaccination only programmes. A systematic search of three electronic databases (CAB Abstracts, Medline and Global Health) and grey literature was performed. From 8696 abstracts found, 5554 unique studies were identified, and 16 studies met the inclusion criteria. Eight described vaccination only programmes and eight described vaccination and sterilisation programmes. Indicators of impact measured were dog bites and/or doses of post-exposure prophylaxis administered; numbers of dog and/or human rabies cases; dog population demographic changes; changes in health and welfare of dogs, and indicators related to human behaviour change. The studies were contextually very diverse, programmes being implemented were complex, and there was variation in measurement and reporting of key indicators. Therefore, it was difficult to compare the two types of intervention, and impossible to make an evaluation of the role of sterilisation, using this evidence. Given the large number of vaccination and sterilisation programmes conducted globally, the lack of studies available for review highlights a gap in data collection or reporting, essential for impact assessment. There are several knowledge gaps concerning the impact of the sterilisation component alone, as well as subsequent effects on rabies transmission and control. Prospective studies comparing the outcomes and impact of the two interventions would be required in order to establish any additional contribution of sterilisation, as well as the underlying mechanisms driving any changes. In the absence of such evidence, the priority for rabies control objectives should be implementation of mass vaccination, as currently recommended by the World Health Organisation.

Variations of mixed methods reviews approaches: A case study

Conducting mixed methods reviews is challenging. The aim of this article is to describe a range of rationales for and approaches to mixed methods reviews, with a particular focus on one research group. A case study was conducted to describe the mixed methods review process used at the Department of Health and Social Care Reviews Facility in England. The case study used document analysis. A total of 30 mixed methods reviews were identified and analyzed. The analysis revealed five key dimensions on which the reviews varied: review questions and purposes of the mixed methods questions, types of evidence and sources, reasons for using a mixed methods approach, synthesis methods and designs, and integration strategies. The questions in the included reviews addressed stakeholders' views, and intervention processes and/or intervention effectiveness. The mixed methods questions addressed four different purposes: comparing findings, identifying critical intervention features, quantifying effects, and making recommendations. Five main sources of evidence were used: formal evidence from primary studies, informal evidence, policy documents, systematic reviews, and work with stakeholders. Twelve reasons for conducting mixed methods reviews were identified: completeness, contextual understanding, credibility, different research questions, diversity of views, enhancement, explanation, process, triangulation, utility, development of a framework, and identification of promising interventions. Each review employed one or several integration strategies for comparing findings, connecting phases and/or assimilating data. It is hoped that the information garnered from this study will provide useful insights into mixed method review diversity and trigger new ideas for conducting this type of review.

Self-management programmes for cirrhosis: A systematic review

BACKGROUND AND AIMS

Liver cirrhosis severely decreases patients' quality of life. Since self-management programmes have improved quality of life and reduce hospital admissions in other chronic diseases, they have been suggested to decrease liver cirrhosis burden.

METHODS

We performed a systematic review and meta-analysis to evaluate the clinical impact of self-management programmes in patients with liver cirrhosis, which followed the Preferred Reporting for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Primary outcomes include health-related quality of life (HRQOL) and hospitalisation. We searched MEDLINE, CENTRAL, Embase, CINAHL, PsycINFO and two trial registers to July 2017.

RESULTS

We identified four randomised trials (299 patients) all rated at a high risk of bias. No difference was demonstrated for HRQOL (standardised mean difference -0.01, 95% CI: -0.48 to 0.46) and hospitalisation days (incidence rate ratio 1.6, 95% CI: 0.5-4.8). For secondary outcomes, one study found a statistically significant improvement in patient knowledge (mean difference (MD) 3.68, 95% CI: 2.11-5.25) while another study found an increase in model for end-stage liver disease scores (MD 2.8, 95% CI: 0.6-4.9) in the self-management group. No statistical difference was found for the other secondary outcomes (self-efficacy, psychological health outcomes, healthcare utilisation, mortality). Overall, the quality of the evidence was low. The content of self-management programmes varied across studies with little overlap.

CONCLUSIONS

The current literature indicates that there is no evidence of a benefit of self-management programmes for people with cirrhosis.

RELEVANCE TO CLINICAL PRACTICE

Practitioners should use self-management programmes with caution when delivering care to patients living with cirrhosis. Further research is required to determine what are the key features in a complex intervention like self-management. This review offers a preliminary framework for clinicians to develop a new self-management programme with key features of effective self-management interventions from established models.

Implementation of geriatric assessment in oncology settings: A systematic realist review

Older adults with cancer are more likely to have worse clinical outcomes than their younger counterparts, and shared decision-making can be difficult, due to both complexity from adverse ageing and under-representation in clinical trials. Geriatric assessment (GA) has been increasingly recognised as a predictive and prehabilitative tool for older adults with cancer. However, GA has been notoriously difficult to implement in oncological settings due to workforce, economic, logistical, and practical barriers. We aimed to review the heterogenous literature on implementation of GA in oncology settings to understand the different implementation context configurations of GA and the mechanisms they trigger to enable successful implementation. A systematic realist review was undertaken in two stages: i) systematic searches with structured data extraction combined with iterative key stakeholder consultations to develop programme theories for implementing GA in oncology settings; ii) synthesis to refine programme theories. Medline, Embase, PsycInfo, Cochrane Library, CINAHL, Web of Science, Scopus, ASSIA, Epistemonikos, JBI Database of Systematic Reviews and Implementation Reports, DARE and Health Technology Assessment were searched. Four programme theories were developed from 53 included articles and 20 key stakeholder consultations addressing the major barriers of GA implementation in oncology practice: time (leveraging non-specialists), funding (creating favourable health economics), practicalities (establishing the use of GA in cancer care), and managing limited resources. We demonstrate that a whole system approach is required to improve the implementation of GA in cancer settings. This review will help inform policy decisions regarding implementation of GA and provide a basis for further implementation research.

Application of the intervention Complexity Assessment Tool for Systematic Reviews within a Cochrane review: an illustrative case study

Background: The intervention Complexity Assessment Tool for Systematic Reviews (iCAT_SR) has been developed to facilitate detailed assessments of intervention complexity in systematic reviews. Worked examples of the tool's application are needed to promote its use and refinement. The aim of this case study was to apply the iCAT_SR to a subset of 20 studies included in a Cochrane review of interventions aimed at improving appropriate polypharmacy in older people. Methods: Interventions were assessed independently by two authors using the six core iCAT_SR dimensions: (1) 'Target organisational levels/categories'; (2) 'Target behaviour/actions'; (3) 'Active intervention components'; (4) 'Degree of tailoring'; (5) 'Level of skill required by intervention deliverers'; (6) 'Level of skill required by intervention recipients'. Attempts were made to apply four optional dimensions: 'Interaction between intervention components'; 'Context/setting'; 'Recipient/provider factors'; 'Nature of causal pathway'. Inter-rater reliability was assessed using Cohen's Kappa coefficient. Disagreements were resolved by consensus discussion. The findings are presented narratively. Results: Assessments involving the core iCAT_SR dimensions showed limited consistency in intervention complexity across included studies, even when categorised according to clinical setting. Interventions were delivered across various organisational levels and categories (i.e. healthcare professionals and patients) and typically comprised multiple components. Intermediate skill levels were required by those delivering and receiving the interventions across all studies. A lack of detail in study reports precluded application of the iCAT_SR's optional dimensions. The inter-rater reliability was substantial (Cohen's Kappa = 0.75) Conclusions: This study describes the application of the iCAT_SR to studies included in a Cochrane systematic review. Future intervention studies need to ensure more detailed reporting of interventions, context and the causal pathways underlying intervention effects to allow a more holistic understanding of intervention complexity and facilitate replication in other settings. The experience gained has helped to refine the original guidance document relating to the application of iCAT_SR.

Social and Structural Determinants of Household Support for ART Adherence in Low- and Middle-Income Countries: A Systematic Review

Adherence to HIV antiretroviral therapy (ART) is a crucial factor in health outcomes for people living with HIV (PLWH). Interventions to support ART adherence are increasingly focused on the household as a source of social support. This review aims to examine the social and structural determinants of support for ART adherence within households and families in low- and middle-income countries (LMICs). The review methodology followed the recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. Seven databases were searched for peer-reviewed literature. The terms searched thematically covered (1) ART adherence, (2) household and family and (3) support and care. Thirty-three studies conducted in 15 LMICs were selected and a mixed methods synthesis was undertaken. Social and structural determinants affected the type, quality and amount of support for PLWH of all ages, which affected PLWH's ART adherence. Gender norms affected the type of support that household members give to PLWH. Education moderated household support for ART adherence through literacy and language skills. Cultural context, religious beliefs, and social norms reinforced or undermined household support for ART adherence. Stigma affected disclosure, generated secrecy around giving medication and impeded access to support from the community. Supporting PLWH exacerbated economic hardship for household members. Health system dysfunction negatively impacted trust and communication between household members and health professionals. Intersecting social and structural determinants particularly affected the care given by household members who were older, female, with little education and low socioeconomic status. Household members were able to overcome some of these barriers when they received support themselves. Household interventions to support PLWH's ART adherence should take structural factors into account to have maximum impact.

Reduction in saturated fat intake for cardiovascular disease

BACKGROUND

Reducing saturated fat reduces serum cholesterol, but effects on other intermediate outcomes may be less clear. Additionally, it is unclear whether the energy from saturated fats eliminated from the diet are more helpfully replaced by polyunsaturated fats, monounsaturated fats, carbohydrate or protein.

OBJECTIVES

To assess the effect of reducing saturated fat intake and replacing it with carbohydrate (CHO), polyunsaturated (PUFA), monounsaturated fat (MUFA) and/or protein on mortality and cardiovascular morbidity, using all available randomised clinical trials.

SEARCH METHODS

We updated our searches of the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (Ovid) and Embase (Ovid) on 15 October 2019, and searched Clinicaltrials.gov and WHO International Clinical Trials Registry Platform (ICTRP) on 17 October 2019.

SELECTION CRITERIA

Included trials fulfilled the following criteria: 1) randomised; 2) intention to reduce saturated fat intake OR intention to alter dietary fats and achieving a reduction in saturated fat; 3) compared with higher saturated fat intake or usual diet; 4) not multifactorial; 5) in adult humans with or without cardiovascular disease (but not acutely ill, pregnant or breastfeeding); 6) intervention duration at least 24 months; 7) mortality or cardiovascular morbidity data available.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed inclusion, extracted study data and assessed risk of bias. We performed random-effects meta-analyses, meta-regression, subgrouping, sensitivity analyses, funnel plots and GRADE assessment.

MAIN RESULTS

We included 15 randomised controlled trials (RCTs) (16 comparisons, ~59,000 participants), that used a variety of interventions from providing all food to advice on reducing saturated fat. The included long-term trials suggested that reducing dietary saturated fat reduced the risk of combined cardiovascular events by 21% (risk ratio (RR) 0.79; 95% confidence interval (CI) 0.66 to 0.93, 11 trials, 53,300 participants of whom 8% had a cardiovascular event, I² = 65%, GRADE moderate-quality evidence). Meta-regression suggested that greater reductions in saturated fat (reflected in greater reductions in serum cholesterol) resulted in greater reductions in risk of CVD events, explaining most heterogeneity between trials. The number needed to treat for an additional beneficial outcome (NNTB) was 56 in primary prevention trials, so 56 people need to reduce their saturated fat intake for ~four years for one person to avoid experiencing a CVD event. In secondary prevention trials, the NNTB was 32. Subgrouping did not suggest significant differences between replacement of saturated fat calories with polyunsaturated fat or carbohydrate, and data on replacement with monounsaturated fat and protein was very limited. We found little or no effect of reducing saturated fat on all-cause mortality (RR 0.96; 95% CI 0.90 to 1.03; 11 trials, 55,858 participants) or cardiovascular mortality (RR 0.95; 95% CI 0.80 to 1.12, 10 trials, 53,421 participants), both with GRADE moderate-quality evidence. There was little or no effect of reducing saturated fats on non-fatal myocardial infarction (RR 0.97, 95% CI 0.87 to 1.07) or CHD mortality (RR 0.97, 95% CI 0.82 to 1.16, both low-quality evidence), but effects on total (fatal or non-fatal) myocardial infarction, stroke and CHD events (fatal or non-fatal) were all unclear as the evidence was of very low quality. There was little or no effect on cancer mortality, cancer diagnoses, diabetes diagnosis, HDL cholesterol, serum triglycerides or blood pressure, and small reductions in weight, serum total cholesterol, LDL cholesterol and BMI. There was no evidence of harmful effects of reducing saturated fat intakes.

AUTHORS' CONCLUSIONS

The findings of this updated review suggest that reducing saturated fat intake for at least two years causes a potentially important reduction in combined cardiovascular events. Replacing the energy from saturated fat with polyunsaturated fat or carbohydrate appear to be useful strategies, while effects of replacement with monounsaturated fat are unclear. The reduction in combined cardiovascular events resulting from reducing saturated fat did not alter by study duration, sex or baseline level of cardiovascular risk, but greater reduction in saturated fat caused greater reductions in cardiovascular events.

Assessing the Effectiveness of Complex Interventions to Meet the Needs of VA Stakeholders: Experience of the Department of Veterans Affairs Evidence Synthesis Program

Complex health care interventions involve multiple distinct elements that contribute to their functioning. Conducting systematic reviews of complex interventions has substantial challenges. Although methodological guidance exists, less is known about the practical strategies and approaches undertaken by systematic review groups to navigate common challenges and enhance impacts of systematic review findings.

Developing a framework to inform scale-up success for population health interventions: a critical interpretive synthesis of the literature

Background

Population health interventions (PHIs) have the potential to improve the health of large populations by systematically addressing underlying conditions of poor health outcomes (i.e., social determinants of health) and reducing health inequities. Scaling-up may be one means of enhancing the impact of effective PHIs. However, not all scale-up attempts have been successful. In an attempt to help guide the process of successful scale-up of a PHI, we look to the organizational readiness for change theory for a new perspective on how we may better understand the scale-up pathway. Using the change theory, our goal was to develop the foundations of an evidence-based, theory-informed framework for a PHI, through a critical examination of various PHI scale-up experiences documented in the literature.

Methods

We conducted a multi-step, critical interpretive synthesis (CIS) to gather and examine insights from scale-up experiences detailed in peer-reviewed and grey literatures, with a focus on PHIs from a variety of global settings. The CIS included iterative cycles of systematic searching, sampling, data extraction, critiquing, interpreting, coding, reflecting, and synthesizing. Theories relevant to innovations, complexity, and organizational readiness guided our analysis and synthesis.

Results

We retained and examined twenty different PHI scale-up experiences, which were extracted from 77 documents (47 peer-reviewed, 30 grey literature) published between 1995 and 2013. Overall, we identified three phases (i.e., Groundwork, Implementing Scale-up, and Sustaining Scale-up), 11 actions, and four key components (i.e., PHI, context, capacity, stakeholders) pertinent to the scale-up process. Our guiding theories provided explanatory power to various aspects of the scale-up process and to scale-up success, and an alternative perspective to the assessment of scale-up readiness for a PHI.

Conclusion

Our synthesis provided the foundations of the Scale-up Readiness Assessment Framework. Our theoretically-informed and rigorous synthesis methodology permitted identification of disparate processes involved in the successful scale-up of a PHI. Our findings complement the guidance and resources currently available, and offer an added perspective to assessing scale-up readiness for a PHI.

The development of complex and controversial innovations. Genetically modified mosquitoes for malaria eradication

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Using the example of mosquitoes that are genetically modified for malaria eradication through gene drive methods, a scientifically complex ‘living technology’, we show how complexity, uncertainty and risk can propel NPD processes towards a linear sequence of stages.

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Although the need to control risks associated with gene drive technology imposes linearity to the NPD process, there are possibilities for deviation from a structured sequence of stages. This is due to the effects of feedback loops in the wider system of evidence creation and learning at the population and governance levels, which cumulatively impact on acceptance of the innovation.

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The NPD and adoption processes involved in the use of gene drive technology are closely intertwined, and the endpoint for R&D and beginning of ‘mainstream’ adoption and diffusion are unclear.

When there is significant uncertainty in an innovation project, research literature suggests that strictly sequencing actions and stages may not be an appropriate mode of project management. We use a longitudinal process approach and qualitative system dynamics modelling to study the development of genetically modified (GM) mosquitoes for malaria eradication in an African country. Our data were collected in real time, from early scientific research to deployment of the first prototype mosquitoes in the field. The 'gene drive' technology for modifying the mosquitoes is highly complex and controversial due to risks associated with its characteristics as a living, self-replicating technology. We show that in this case the innovation journey is linear and highly structured, but also embedded within a wider system of adoption that displays emergent behaviour. Although the need to control risks associated with the technology imposes a linearity to the NPD process, there are possibilities for deviation from a more structured sequence of stages. This arises from the effects of feedback loops in the wider system of evidence creation and learning at the population and governance levels, which cumulatively impact on acceptance of the innovation. The NPD and adoption processes are therefore closely intertwined, meaning that the endpoint for R&D and beginning of 'mainstream' adoption and diffusion are unclear. A key challenge for those responsible for NPD and its regulation is to plan for the adoption of the technology while simultaneously conducting its scientific and technical development.

Efficacy of theory-informed workplace physical activity interventions: a systematic literature review with meta-analyses

This review aimed to assess the efficacy of workplace physical activity interventions; compare the efficacy of those that were and were not informed by behaviour change theory, and outline the effectiveness of different intervention components. A search was undertaken in Medline, Embase, PsycINFO, Ovid Emcare (previously CINAHL) and SportDiscus. Randomised, non-randomised and cluster-controlled trials with objectively measured physical activity and/or measured or predicted maximal oxygen uptake (VO_2max) as outcomes were included in the review (83 papers from 79 trials). Random-effects meta-analyses of mean differences were undertaken. Workplace physical activity programmes demonstrated positive overall intervention effects for daily step counts (814.01 steps/day; CI: 446.36, 1181.67; p < 0.01; i² = 88%) and measured VO_2max (2.53 ml kg^-1 min^-1; CI: 1.69, 3.36; p < 0.01; i² = 0%) with no sub-group differences between theory- and non-theory informed interventions. Significant sub-group differences were present for predicted VO_2max (p < 0.01), with a positive intervention effect for non-theory informed studies (2.11 ml.kg^-1 min^-1; CI: 1.20, 3.02; p < 0.01; i² = 78%) but not theory-informed studies (-0.63 ml kg^-1 min^-1; CI: -1.55, 0.30; p = 0.18; i² = 0%). Longer-term follow-ups ranged from 24 weeks to 13 years, with significant positive effects for measured VO_2max (2.84 ml kg^-1 min^-1; CI: 1.41, 4.27; p < 0.01; i² = 0%). Effective intervention components included the combination of self-monitoring with a goal, and exercise sessions onsite or nearby. The findings of this review were limited by the number and quality of theory-informed studies presenting some outcomes, and confounding issues in complex interventions. Future researchers should consider rigorous testing of outcomes of theory-informed workplace physical activity interventions and incorporate longer follow-ups.

Criteria for describing and evaluating training interventions in healthcare professions - CRe-DEPTH

BACKGROUND

Descriptions of training intervention in healthcare include a lot of vagueness, leaving the reader in doubt about the intervention and the true value of the reported effects. A set of reporting criteria to improve the transparency and comprehensiveness in reporting training interventions in healthcare is recommended.

OBJECTIVE

This study aimed to develop and content validate a set of reporting criteria for the development and evaluation of training interventions for healthcare professionals.

METHOD

The set of criteria was developed along three stages: (1) a literature review, (2) the design of the criteria, and (3) a Delphi and consensus meeting process with ten experts from different professional disciplines.

RESULTS

The Criteria for Reporting on Development and Evaluation of Professional Training interventions in Healthcare (CRe-DEPTH) set was systematically developed and consisted of 12 items representing four categories: (1) development of the training, (2) characteristics of the training, (3) characteristics of the providers, and (4) assessment of the training outcomes. Each item has a detailed description to support its unambiguous interpretation.

CONCLUSIONS

The developed CRe-DEPTH reporting criteria guide high quality development, evaluation and reporting for complex training interventions, while preserving the flexibility to incorporate various teaching content or teaching methods. The Cre-DEPTH criteria will allow for detailed reporting on the training, its developmental process, as well as on the rationale for underlying choices, and will avoid non-reporting of training details.

A systematic review examining whether community-based self-management programs for older adults with chronic conditions actively engage participants and teach them patient-oriented self-management strategies

OBJECTIVE

To identify whether community-based Self-Management Programs (SMPs) actively engaged, or taught, individuals patient-oriented strategies; and whether having these attributes led to significant differences in outcomes.

METHODS

This systematic review included randomized controlled trials (RCTs)and cluster RCTs reporting on community-based SMPs with a group component for older adults with chronic conditions. The ways SMPS actively engaged participants and whether they taught patient-oriented strategies were analyzed. All study outcomes were reported.

RESULTS

The 31 included studies demonstrated community-based SMP programs actively engaged participants and provided strategies to improve health behaviour or care of their condition. Few included strategies to help manage the impact of conditions on their everyday lives. Seventy-nine percent of studies reported significant differences; variations in sample sizes and outcomes made it difficult to conclude whether having these attributes led to significant differences.

CONCLUSION

SMPs are not supporting older adults to use strategies to address the impact of conditions on their everyday lives, addressing the needs of older adults with multiple conditions, nor assessing outcomes that align with the strategies taught.

PRACTICE IMPLICATIONS

Health-care providers delivering SMPs to older adults need to tailor programs to the needs of older adults and assess whether participants are using strategies being proposed.

Identifying and resolving the frustrations of reviewing the improvement literature: The experiences of two improvement researchers

Background and aims

Summarising quality improvement (QI) research through systematic literature review has great potential to improve patient care. However, heterogeneous terminology, poor definition of QI concepts and overlap with other scientific fields can make it hard to identify and extract data from relevant literature. This report examines the compromises and pragmatic decisions that undertaking literature review in the field of QI requires and the authors propose recommendations for literature review authors in similar fields.

Methods

Two authors (EJ and JF) provide a reflective account of their experiences of conducting a systematic literature review in the field of QI. They draw on wider literature to justify the decisions they made and propose recommendations to improve the literature review process. A third collaborator, (WC) co-created the paper challenging author’s EJ and JF views and perceptions of the problems and solutions of conducting a review of literature in QI.

Results

Two main challenges were identified when conducting a review in QI. These were defining QI and selecting QI studies. Strategies to overcome these problems include: select a multi-disciplinary authorship team; review the literature to identify published QI search strategies, QI definitions and QI taxonomies; Contact experts in related fields to clarify whether a paper meets inclusion criteria; keep a reflective account of decision making; submit the protocol to a peer reviewed journal for publication.

Conclusions

The QI community should work together as a whole to create a scientific field with a shared vision of QI to enable accurate identification of QI literature. Our recommendations could be helpful for systematic reviewers wishing to evaluate complex interventions in both QI and related fields.

Pay for performance for hospitals

BACKGROUND

Pay-for-Performance (P4P) is a payment model that rewards health care providers for meeting pre-defined targets for quality indicators or efficacy parameters to increase the quality or efficacy of care.

OBJECTIVES

Our objective was to assess the impact of P4P for in-hospital delivered health care on the quality of care, resource use and equity. Our objective was not only to answer the question whether P4P works in general (simple perspective) but to provide a comprehensive and detailed overview of P4P with a focus on analyzing the intervention components, the context factors and their interrelation (more complex perspective).

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, three other databases and two trial registers on 27 June 2018. In addition, we searched conference proceedings, gray literature and web pages of relevant health care institutions, contacted experts in the field, conducted cited reference searches and performed cross-checks of included references and systematic reviews on the same topic.

SELECTION CRITERIA

We included randomized trials, cluster randomized trials, non-randomized clustered trials, controlled before-after studies, interrupted time series and repeated measures studies that analyzed hospitals, hospital units or groups of hospitals and that compared any kind of P4P to a basic payment scheme (e.g. capitation) without P4P. Studies had to analyze at least one of the following outcomes to be eligible: patient outcomes; quality of care; utilization, coverage or access; resource use, costs and cost shifting; healthcare provider outcomes; equity; adverse effects or harms.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened all citations for inclusion, extracted study data and assessed risk of bias for each included study. Study characteristics were extracted by one reviewer and verified by a second.We did not perform meta-analysis because the included studies were too heterogenous regarding hospital characteristics, the design of the P4P programs and study design. Instead we present a structured narrative synthesis considering the complexity as well as the context/setting of the intervention. We assessed the certainty of evidence using the GRADE approach and present the results narratively in 'Summary of findings' tables.

MAIN RESULTS

We included 27 studies (20 CBA, 7 ITS) on six different P4P programs. Studies analyzed between 10 and 4267 centers. All P4P programs targeted acute or emergency physical conditions and compared a capitation-based payment scheme without P4P to the same capitation-based payment scheme combined with a P4P add-on. Two P4P program used rewards or penalties; one used first rewards and than penalties; two used penalties only and one used rewards only. Four P4P programs were established and evaluated in the USA, one in England and one in France.Most studies showed no difference or a very small effect in favor of the P4P program. The impact of each P4P program was as follows.Premier Hospital Quality Incentive Demonstration Program: It is uncertain whether this program, which used rewards for some hospitals and penalties for others, has an impact on mortality, adverse clinical events, quality of care, equity or resource use as the certainty of the evidence was very low.Value-Based Purchasing Program: It is uncertain whether this program, which used rewards for some hospitals and penalties for others, has an impact on mortality, adverse clinical events or quality of care as the certainty of the evidence was very low. Equity and resource use outcomes were not reported in the studies, which evaluated this program.Non-payment for Hospital-Acquired Conditions Program: It is uncertain whether this penalty-based program has an impact on adverse clinical events as the certainty of the evidence was very low. Mortality, quality of care, equity and resource use outcomes were not reported in the studies, which evaluated this program.Hospital Readmissions Reduction Program: None of the studies that examined this penalty-based program reported mortality, adverse clinical events, quality of care (process quality score), equity or resource use outcomes.Advancing Quality Program: It is uncertain whether this reward-/penalty-based program has an impact on mortality as the certainty of the evidence was very low. Adverse clinical events, quality of care, equity and resource use outcomes were not reported in any study.Financial Incentive to Quality Improvement Program: It is uncertain whether this reward-based program has an impact on quality of care, as the certainty of the evidence was very low. Mortality, adverse clinical events, equity and resource use outcomes were not reported in any study.Subgroup analysis (analysis of modifying design and context factors)Analysis of P4P design factors provides some hints that non-payments compared to additional payments and payments for quality attainment (e.g. falling below specified mortality threshold) compared to quality improvement (e.g. reduction of mortality by specified percent points within one year) may have a stronger impact on performance.

AUTHORS' CONCLUSIONS

It is uncertain whether P4P, compared to capitation-based payments without P4P for hospitals, has an impact on patient outcomes, quality of care, equity or resource use as the certainty of the evidence was very low (or we found no studies on the outcome) for all P4P programs. The effects on patient outcomes of P4P in hospitals were at most small, regardless of design factors and context/setting. It seems that with additional payments only small short-term but non-sustainable effects can be achieved. Non-payments seem to be slightly more effective than bonuses and payments for quality attainment seem to be slightly more effective than payments for quality improvement.

The development of implementation management instruments for a new complex stroke caregiver intervention based on systematic stakeholder and risk analyses

BACKGROUND

Stakeholders are important contributors in the implementation of a complex public health intervention. During the development phase of an implementation, alongside careful design of its components and investing in the exploration of the dynamic multi-stakeholder stroke rehabilitation setting, it is essential to assess possible implementation risks. Systematic stakeholder and risk analyses can guide the exploration process and enable teams involved in complex interventions to develop context-tailored implementation management instruments.

PURPOSE

To develop instruments that facilitate the implementation of the complex stroke caregiver intervention project in the real-life support system.

METHODS

Systematic stakeholder and risk analyses were conducted composing five activities. Project stakeholders were identified, classified and assessed using a top-down approach, while implementation risks were identified and assessed by applying a bottom-up approach. Data were collected through interviews and focus groups.

RESULTS

Based on the knowledge provided by the stakeholders, two context-tailored implementation management instruments were designed with a top-down approach: (1) a comprehensive 'stakeholder-risk atlas' providing individual stakeholder information, such as role, access, contribution, power and interest, expectations, perceived risks and specific engagement activities and (2) an overall 'project implementation strategy' concentrating on communication, transparency, network building and professionalism.

CONCLUSION

Complex interventions will benefit from early and comprehensive stakeholder and risk analyses. The early involvement of stakeholders, with their insightful knowledge, enables the research team to develop context-tailored implementation management instruments. Instruments will support the team during implementation and may impact positively on the outcome of the intervention. Knowledge can be obtained by combining top-down and bottom-up working approaches.

Effects of community health worker interventions on socioeconomic inequities in maternal and newborn health in low-income and middle-income countries: a mixed-methods systematic review

Introduction

Community health worker (CHW) interventions are promoted to improve maternal and newborn health in low-income and middle-income countries. We reviewed the evidence on their effectiveness in reducing socioeconomic inequities in maternal and newborn health outcomes, how they achieve these effects, and contextual processes that shape these effects.

Methods

We conducted a mixed-methods systematic review of quantitative and qualitative studies published between 1996 and 2017 in Medline, Embase, Web of Science and Scopus databases. We included studies examining the effects of CHW interventions in low-income and middle-income countries on maternal and newborn health outcomes across socioeconomic groups (wealth, occupation, education, class, caste or tribe and religion). We then conducted a narrative synthesis of evidence.

Results

We identified 1919 articles, of which 22 met the inclusion criteria. CHWs facilitated four types of interventions: home visits, community-based groups, cash transfers or combinations of these. Four studies found that CHWs providing home visits or facilitating women’s groups had equitable coverage. Four others found that home visits and cash transfer interventions had inequitable coverage. Five studies reported equitable effects of CHW interventions on antenatal care, skilled birth attendance and/or essential newborn care. One study found that a CHW home visit intervention did not reduce wealth inequities in skilled birth attendance. A study of women’s groups reported greater reductions in neonatal mortality among lower compared with higher socioeconomic groups. Equity was most improved when CHWs had relevant support for assisting women to improve health practices and access health care within community contexts.

Conclusion

While current evidence remains limited, particularly for mortality, existing studies suggest that CHW interventions involving home visits, cash transfers, participatory women’s groups or multiple components can improve equity in maternal and newborn health. Future mixed-methods research should explore intervention strategies and contextual processes shaping such effects on equity to optimise these efforts.

Development of a program theory for clinical pathways in hospitals: protocol for a realist review

BACKGROUND

Despite the increased utilization of clinical pathways (CPWs) as a strategy to improve patient and system outcomes in hospitals, there remain ongoing challenges with their conceptualization, implementation, and evaluation. Theories that explain how CPWs work in hospitals are lacking, making it difficult to identify important factors for sustaining changes arising from CPWs implemented in hospitals. The objective of this realist review is to develop a program theory for CPWs in hospitals.

METHODS

This is a protocol for a realist review. The review will use a six-step iterative process to develop a program theory for CPWs in hospitals: (1) development of a preliminary program theory; (2) search strategy and literature search; (3) study selection and appraisal; (4) data extraction; (5) data analysis and synthesis; and (6) stakeholder engagement. In addition to searching the gray literature and contacting authors, we will search electronic databases such as MEDLINE, NHSEED, CINAHL EBSCO, HMIC, and PsycINFO. Studies will be included based on their ability to provide data that test some aspect of the program theory. Two independent reviewers will select, screen, and extract data related to the program theory from all relevant sources. A realist logic of analysis will be used to identify all context-mechanism-outcome heuristics that explains how CPWs implemented in hospitals translates to better health system outcomes.

DISCUSSION

Overall, the review aims to develop a program theory for CPWs in hospitals and to explore how, why, to what extent, and in what contexts does the implementation of CPWs in hospitals contribute to better health system outcomes. As a result, the review will provide a theoretical framework of how CPWs work in hospitals.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42018103220.

The Consensus on Exercise Reporting Template (CERT) in a systematic review of exercise-based rehabilitation effectiveness: completeness of reporting, rater agreement, and utility

BACKGROUND

Rehabilitation interventions are diverse - making decisions about pooling data in meta-analyses challenging. Intervention reporting templates such as the Consensus on Exercise Reporting Template (CERT) may help reviewers document intervention variability.

AIM

To assess inter-rater agreement and utility of CERT used to assess completeness of reporting of one rehabilitation exercise intervention: pelvic floor muscle training (PFMT).

DESIGN

A non-experimental agreement study.

SETTING

Update of the Cochrane systematic review comparing different approaches to PFMT for urinary incontinence in women.

POPULATION

Two PFMT arms from 21 newly identified trials.

METHODS

Five raters independently used CERT to assess sufficiency of reporting of each arm (experimental PFMT and control PFMT) of each trial. One rater, PFMT non-expert, rated all trials. Four raters, all PFMT experts, assessed a mutually exclusive subgroup of the trials. In addition to rating sufficiency - "Yes" compared to No" or "Uncertain" - raters also reported on CERT utility. Expert ratings were used to determine the proportion of CERT items rated as sufficiently reported. Rater agreement was estimated using coefficient kappa and McNemar's test.

RESULTS

The range of CERT items rated as sufficiently reported was 0 to 15 of 19 items, and the mean for both trial arms was 5.5. For agreement, 11 of 19 items had sufficient data to estimate coefficient kappa and only 3 of 11 had a kappa >0.4 (moderate agreement). From the 12 of 19 items for which McNemar's test could be performed, five had evidence that PFMT experts more often rated the reporting as sufficient than the non-expert. Raters reported the CERT template was comprehensive but not complete and needed contextualizing for PFMT.

CONCLUSIONS

Completeness of reporting was poor for this example of a rehabilitation exercise intervention, and equally poor in both trial arms. Inter-rater agreement of completeness of reporting was also poor. Using a data extraction tool with poor rater-agreement may add unnecessary burden in a review. However, using a data extraction tool that enables assessment of intervention homogeneity has benefits in making decisions about which data to pool or not.

CLINICAL REHABILITATION IMPACT

Researchers reporting clinical trials must pay more attention to completeness of rehabilitation exercise reporting.

Quality improvement strategies to prevent falls in older adults: a systematic review and network meta-analysis

BACKGROUND

Falls are a common occurrence and the most effective quality improvement (QI) strategies remain unclear.

METHODS

We conducted a systematic review and network meta-analysis (NMA) to elucidate effective quality improvement (QI) strategies for falls prevention. Multiple databases were searched (inception-April 2017). We included randomised controlled trials (RCTs) of falls prevention QI strategies for participants aged ≥65 years. Two investigators screened titles and abstracts, full-text articles, conducted data abstraction and appraised risk of bias independently.

RESULTS

A total of 126 RCTs including 84,307 participants were included after screening 10,650 titles and abstracts and 1210 full-text articles. NMA including 29 RCTs and 26,326 patients found that team changes was statistically superior in reducing the risk of injurious falls relative to usual care (odds ratio [OR] 0.57 [0.33 to 0.99]; absolute risk difference [ARD] -0.11 [95% CI, -0.18 to -0.002]). NMA for the outcome of number of fallers including 61 RCTs and 40 128 patients found that combined case management, patient reminders and staff education (OR 0.18 [0.07 to 0.47]; ARD -0.27 [95% CI, -0.33 to -0.15]) and combined case management and patient reminders (OR, 0.36 [0.13 to 0.97]; ARD -0.19 [95% CI, -0.30 to -0.01]) were both statistically superior compared to usual care.

CONCLUSIONS

Team changes may reduce risk of injurious falls and a combination of case management, patient reminders, and staff education, as well as case management and patient reminders may reduce risk of falls. Our results can be tailored to decision-maker preferences and availability of resources.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO (CRD42013004151).

Supporting implementation of Cochrane methods in complex communication reviews: resources developed and lessons learned for editorial practice and policy

Every healthcare encounter involves some form of communication and there is growing recognition that effective health communication is central to the delivery of safe, high-quality healthcare. Conversely, poor communication has a range of adverse consequences for those receiving healthcare and the systems delivering care, including elevated patient safety risks. Increasing understanding and documentation of the key role that good communication plays in healthcare design and delivery has meant there is growing demand from policy-makers and other decision-makers for evidence on the effects of health communication interventions - that is, how best to communicate. While systematic reviews of such interventions are fundamental to building this evidence base, such interventions and reviews are often highly complex and pose considerable challenges for authors and editors. In this paper, we describe our experience as a Cochrane editorial group identifying common issues in reviews of communication interventions and developing resources to support authors to better meet these challenges. Our analysis found that issues typically fell into one or more of the following three stages of the review process: understanding and applying systematic review methods (e.g. selecting outcomes for analysis); reporting the review's methods (e.g. describing key decisions made in conducting the review); and interpreting the findings (e.g. incorporating quality of the evidence into findings of the review). We also found that common issues reflected both practical difficulties (such as the typically large size of reviews and disparate measures for outcomes) and conceptual challenges (for instance, the difficulties of identifying comparisons). While extensive advice for Cochrane systematic reviewers exists, this standardised advice does not cover all of the issues emerging for complex communication reviews. In response, we therefore developed a collection of resources, both general and targeted to specific methodological issues. Here, we describe the types of resources developed and the aims of these, the rationale for why we needed to fill specific gaps in existing advice, and reflect on the lessons for future editorial practice, policies and research in relation to the implementation of Cochrane review methods in the area of health communication.

Implications of a complexity perspective for systematic reviews and guideline development in health decision making

There is growing interest in the potential for complex systems perspectives in evaluation. This reflects a move away from interest in linear chains of cause-and-effect, towards considering health as an outcome of interlinked elements within a connected whole. Although systems-based approaches have a long history, their concrete implications for health decisions are still being assessed. Similarly, the implications of systems perspectives for the conduct of systematic reviews require further consideration. Such reviews underpin decisions about the implementation of effective interventions, and are a crucial part of the development of guidelines. Although they are tried and tested as a means of synthesising evidence on the effectiveness of interventions, their applicability to the synthesis of evidence about complex interventions and complex systems requires further investigation. This paper, one of a series of papers commissioned by the WHO, sets out the concrete methodological implications of a complexity perspective for the conduct of systematic reviews. It focuses on how review questions can be framed within a complexity perspective, and on the implications for the evidence that is reviewed. It proposes criteria which can be used to determine whether or not a complexity perspective will add value to a review or an evidence-based guideline, and describes how to operationalise key aspects of complexity as concrete research questions. Finally, it shows how these questions map onto specific types of evidence, with a focus on the role of qualitative and quantitative evidence, and other types of information.

Harnessing Energies, Resolving Tensions: Acknowledging a Dual Heritage for Qualitative Evidence Synthesis

Qualitative evidence synthesis (QES) encompasses more than 20 methods for synthesizing qualitative accounts of research phenomena documenting real-life contexts. However, tensions frequently arise from the different heritages that shape QES methodology: namely, systematic reviews of effectiveness and primary qualitative research. Methodological innovations either derive from each heritage or are stimulated when both are in juxtaposition; it is important to broker a rapprochement. This article draws on practical experience from a range of syntheses and methodological development work conducted with the Cochrane Qualitative and Implementation Methods Group. The legacy of both heritages is briefly characterized. Three stages of the QES process offer exemplars: searching/sampling, quality assessment, and data synthesis. Rather than an antagonistic clash of research paradigms, this dual heritage offers an opportunity to harness the collective energies of both paradigms. Future methodological research is needed to identify further applications by which this dual heritage might be optimally harnessed.

Lack of transparency in reporting narrative synthesis of quantitative data: a methodological assessment of systematic reviews

OBJECTIVE

To assess the adequacy of reporting and conduct of narrative synthesis of quantitative data (NS) in reviews evaluating the effectiveness of public health interventions.

STUDY DESIGN AND SETTING

A retrospective comparison of a 20% (n = 474/2,372) random sample of public health systematic reviews from the McMaster Health Evidence database (January 2010-October 2015) to establish the proportion of reviews using NS. From those reviews using NS, 30% (n = 75/251) were randomly selected and data were extracted for detailed assessment of: reporting NS methods, management and investigation of heterogeneity, transparency of data presentation, and assessment of robustness of the synthesis.

RESULTS

Most reviews used NS (56%, n = 251/446); meta-analysis was the primary method of synthesis for 44%. In the detailed assessment of NS, 95% (n = 71/75) did not describe NS methods; 43% (n = 32) did not provide transparent links between the synthesis data and the synthesis reported in the text; of 14 reviews that identified heterogeneity in direction of effect, only one investigated the heterogeneity; and 36% (n = 27) did not reflect on limitations of the synthesis.

CONCLUSION

NS methods are rarely reported in systematic reviews of public health interventions and many NS reviews lack transparency in how the data are presented and the conclusions are reached. This threatens the validity of much of the evidence synthesis used to support public health. Improved guidance on reporting and conduct of NS will contribute to improved utility of NS systematic reviews.

Sound therapy (using amplification devices and/or sound generators) for tinnitus

BACKGROUND

Tinnitus affects 10% to 15% of the adult population, with about 20% of these experiencing symptoms that negatively affect quality of life. In England alone there are an estimated ¾ million general practice consultations every year where the primary complaint is tinnitus, equating to a major burden on healthcare services. Clinical management strategies include education and advice, relaxation therapy, tinnitus retraining therapy (TRT), cognitive behavioural therapy (CBT), sound enrichment using ear-level sound generators or hearing aids, and drug therapies to manage co-morbid symptoms such as insomnia, anxiety or depression. Hearing aids, sound generators and combination devices (amplification and sound generation within one device) are a component of many tinnitus management programmes and together with information and advice are a first line of management in audiology departments for someone who has tinnitus.

OBJECTIVES

To assess the effects of sound therapy (using amplification devices and/or sound generators) for tinnitus in adults.

SEARCH METHODS

The Cochrane ENT Information Specialist searched the Cochrane ENT Register; Central Register of Controlled Trials (CENTRAL, via the Cochrane Register of Studies); Ovid MEDLINE; Ovid Embase; CINAHL; Web of Science; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials. The date of the search was 23 July 2018.

SELECTION CRITERIA

Randomised controlled trials (RCTs) recruiting adults with acute or chronic subjective idiopathic tinnitus. We included studies where the intervention involved hearing aids, sound generators or combination hearing aids and compared them to waiting list control, placebo or education/information only with no device. We also included studies comparing hearing aids to sound generators, combination hearing aids to hearing aids, and combination hearing aids to sound generators.

DATA COLLECTION AND ANALYSIS

We used the standard methodological procedures expected by Cochrane. Our primary outcomes were tinnitus symptom severity as measured as a global score on multi-item tinnitus questionnaire and significant adverse effects as indicated by an increase in self-reported tinnitus loudness. Our secondary outcomes were depressive symptoms, symptoms of generalised anxiety, health-related quality of life and adverse effects associated with wearing the device such as pain, discomfort, tenderness or skin irritation, or ear infections. We used GRADE to assess the quality of evidence for each outcome; this is indicated in italics.

MAIN RESULTS

This review included eight studies (with a total of 590 participants). Seven studies investigated the effects of hearing aids, four combination hearing aids and three sound generators. Seven studies were parallel-group RCTs and one had a cross-over design. In general, risk of bias was unclear due to lack of detail about sequence generation and allocation concealment. There was also little or no use of blinding.No data for our outcomes were available for any of our three main comparisons (comparing hearing aids, sound generators and combination devices with a waiting list control group, placebo or education/information only). Data for our additional comparisons (comparing these devices with each other) were also few, with limited potential for data pooling.Hearing aid only versus sound generator device onlyOne study compared patients fitted with sound generators versus those fitted with hearing aids and found no difference between them in their effects on our primary outcome, tinnitus symptom severity measured with the Tinnitus Handicap Inventory (THI) at 3, 6 or 12 months (low-quality evidence). The use of both types of device was associated with a clinically significant reduction in tinnitus symptom severity.Combination hearing aid versus hearing aid onlyThree studies compared combination hearing aids with hearing aids and measured tinnitus symptom severity using the THI or Tinnitus Functional Index. When we pooled the data we found no difference between them (standardised mean difference -0.15, 95% confidence interval -0.52 to 0.22; three studies; 114 participants) (low-quality evidence). The use of both types of device was again associated with a clinically significant reduction in tinnitus symptom severity.Adverse effects were not assessed in any of the included studies.None of the studies measured the secondary outcomes of depressive symptoms or depression, anxiety symptoms or generalised anxiety, or health-related quality of life as measured by a validated instrument, nor the newly developed core outcomes tinnitus intrusiveness, ability to ignore, concentration, quality of sleep and sense of control.

AUTHORS' CONCLUSIONS

There is no evidence to support the superiority of sound therapy for tinnitus over waiting list control, placebo or education/information with no device. There is insufficient evidence to support the superiority or inferiority of any of the sound therapy options (hearing aid, sound generator or combination hearing aid) over each other. The quality of evidence for the reported outcomes, assessed using GRADE, was low. Using a combination device, hearing aid or sound generator might result in little or no difference in tinnitus symptom severity.Future research into the effectiveness of sound therapy in patients with tinnitus should use rigorous methodology. Randomisation and blinding should be of the highest quality, given the subjective nature of tinnitus and the strong likelihood of a placebo response. The CONSORT statement should be used in the design and reporting of future studies. We also recommend the use of validated, patient-centred outcome measures for research in the field of tinnitus.

Interventions for behaviour change and self-management in stroke secondary prevention: protocol for an overview of reviews

BACKGROUND

Stroke secondary prevention guidelines recommend medication prescription and adherence, active education and behavioural counselling regarding lifestyle risk factors. To impact on recurrent vascular events, positive behaviour/s must be adopted and sustained as a lifestyle choice, requiring theoretically informed behaviour change and self-management interventions. A growing number of systematic reviews have addressed complex interventions in stroke secondary prevention. Differing terminology, inclusion criteria and overlap of studies between reviews makes the mechanism/s that affect positive change difficult to identify or replicate clinically. Adopting a two-phase approach, this overview will firstly comprehensively summarise systematic reviews in this area and secondly identify and synthesise primary studies in these reviews which provide person-centred, theoretically informed interventions for stroke secondary prevention.

METHODS

An overview of reviews will be conducted using a systematic search strategy across the Cochrane Database of Systematic Reviews, PubMed and Epistomonikas.

INCLUSION CRITERIA

systematic reviews where the population comprises individuals post-stroke or TIA and where data relating to person-centred risk reduction are synthesised for evidence of efficacy when compared to standard care or no intervention. Primary outcomes of interest include mortality, recurrent stroke and other cardiovascular events. In phase 1, two reviewers will independently (1) assess the eligibility of identified reviews for inclusion; (2) rate the quality of included reviews using the ROBIS tool; (3) identify unique primary studies and overlap between reviews; (4) summarise the published evidence supporting person-centred behavioural change and self-management interventions in stroke secondary prevention and (5) identify evidence gaps in this field. In phase 2, two independent reviewers will (1) examine person-centred, primary studies in each review using the Template for Intervention Description and Replication (TIDieR checklist), itemising, where present, theoretical frameworks underpinning interventions; (2) group studies employing theoretically informed interventions by the intervention delivered and by the outcomes reported (3) apply GRADE quality of evidence for each intervention by outcome/s identified from theoretically informed primary studies. Disagreement between reviewers at each process stage will be discussed and a third reviewer consulted.

DISCUSSION

This overview will comprehensively bring together the best available evidence supporting person-centred, stroke secondary prevention strategies in an accessible format, identifying current knowledge gaps.