Cluster Randomised Trials in Cochrane Reviews: Evaluation of Methodological and Reporting Practice

Interventions for improving health literacy among older people: a systematic review

BACKGROUND

Health literacy(HL) is defined as the degree to which individuals have the capacity to obtain process and understand basic health information and services required for making appropriate health decisions. Effective interventions to improve older people's HL have become increasingly important. The purpose of this study is to conduct a review of interventions aimed at enhancing the HL of older people.

METHODOLOGY

Relevant information was gathered from various databases including PubMed, Scopus, Cochrane Library, Science Direct, and Web of Science. Additionally, a manual search of related journals and Google Scholar, a search of the reference lists of selected articles, and a search of unpublished sources were also conducted up to 30 August 2024. Reporting quality assessment was performed using CONSORT: 2010, JBI Critical Appraisal Checklist for Quasi-Experimental Studies, and "Quality Assessment Criteria for Survey Research Reports".

RESULTS

A total of 21 articles were included in this study. The interventions conducted in high-income countries were found to be more effective compared to those conducted in middle and low-income countries. Furthermore, interventions carried out at the community level were more effective than those performed in nursing homes. Educational interventions were more effective than lifestyle modification interventions, and interventions carried out in a single dimension were more effective than multidimensional interventions. Additionally, interventions that utilized technology were found to be more effective.

CONCLUSION

Based on the findings, community-based interventions that encompass a one-dimensional approach, incorporating the use of technology and considering the duration of the intervention, are more recommended.

Waist circumference as a parameter in school-based interventions to prevent overweight and obesity - a systematic review and meta-analysis

BACKGROUND

Preventing childhood obesity remains an important public health issue worldwide. Since visceral fat in particular is understood as an important risk factor for many chronic diseases, waist circumference is recommended as a measurement parameter for global obesity surveillance. This systematic review and meta-analysis focused on waist circumference as an outcome parameter for studies of school-based interventions to prevent overweight and obesity.

METHODS

A systematic literature search was conducted at the end of 2019 in nine data bases, including Medline and Embase, in order to identify relevant studies evaluating interventions in schools aimed at preventing obesity. Eligibility criteria admitted randomised and non-randomised controlled trials. After screening titles, abstracts and full texts, the data of the identified studies were systematically extracted. Risk of bias was assessed according to study type with the appropriate Cochrane Risk of Bias Tool. The review gives a qualitative overview over all included studies structured by extracted data. Separate meta-analyses were done for the outcome mean difference in change in waist circumference, measured in cm or reported as z-score value, using an inverse variance random-effects model due to study design.

RESULTS

A total of 2421 publications were screened based on titles, abstracts and full texts. Complemented by results of a former systematic literature search 44 studies were identified for inclusion, comprising a total of 39.837 participants (age range: 6 to 18 years). Nearly half of the studies were conducted in Europe, two-thirds combined diet and exercise-based interventions. Likewise two thirds of the studies were conducted as cluster-randomised trials. Most of the reported effects favoured the experimental groups, indicating the basic effectiveness of school-based measures. Based on reported data, only one third of the studies could be included in the meta-analyses. For the difference in mean change of the outcome parameter waist circumference measured in cm (95% CI), we found a pooled effect estimate of -0.95 (-1.87; -0.46). For the difference in mean change of the outcome parameter waist circumference reported as z-score value (95% CI), the pooled effect estimate was -0.10 (-0.15; -0.05). Both effect estimates were in favour of the experimental group. The overall effect sizes were small with a p-value < 0.05.

CONCLUSIONS

Pooled effect estimates were small but in favour of the experimental groups. The same applies to the majority of the effects reported in the included studies. The included cluster of randomised controlled trials demonstrated an especially sound methodological standard. The possibility of achieving larger effects in studies of preventive interventions and health promotion is limited. Schools can only realise their full potential in preventing overweight and obesity in children and adolescents if they are accompanied by measures in other areas of the obesogenic environment.

Identification of application and interpretation errors that can occur in pairwise meta-analyses in systematic reviews of interventions: a systematic review

OBJECTIVES

To generate a bank of items describing application and interpretation errors that can arise in pairwise meta-analyses in systematic reviews of interventions.

STUDY DESIGN AND SETTING

MEDLINE, Embase, and Scopus were searched to identify studies describing types of errors in meta-analyses. Descriptions of errors and supporting quotes were extracted by multiple authors. Errors were reviewed at team meetings to determine if they should be excluded, reworded, or combined with other errors, and were categorized into broad categories of errors and subcategories within.

RESULTS

Fifty articles met our inclusion criteria, leading to the identification of 139 errors. We identified 25 errors covering data extraction/manipulation, 74 covering statistical analyses, and 40 covering interpretation. Many of the statistical analysis errors related to the meta-analysis model (eg, using a two-stage strategy to determine whether to select a fixed or random-effects model) and statistical heterogeneity (eg, not undertaking an assessment for statistical heterogeneity).

CONCLUSION

We generated a comprehensive bank of possible errors that can arise in the application and interpretation of meta-analyses in systematic reviews of interventions. This item bank of errors provides the foundation for developing a checklist to help peer reviewers detect statistical errors.

Non-medical interventions to enhance return to work for people with cancer

BACKGROUND

People with cancer are 1.4 times more likely to be unemployed than people without a cancer diagnosis. Therefore, it is important to investigate whether programmes to enhance the return-to-work (RTW) process for people who have been diagnosed with cancer are effective. This is an update of a Cochrane review first published in 2011 and updated in 2015.

OBJECTIVES

To evaluate the effectiveness of non-medical interventions aimed at enhancing return to work (RTW) in people with cancer compared to alternative programmes including usual care or no intervention.

SEARCH METHODS

We searched CENTRAL (the Cochrane Library), MEDLINE, Embase, CINAHL, PsycINFO and three trial registers up to 18 August 2021. We also examined the reference lists of included studies and selected reviews, and contacted authors of relevant studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and cluster-RCTs on the effectiveness of psycho-educational, vocational, physical or multidisciplinary interventions enhancing RTW in people with cancer. The primary outcome was RTW measured as either RTW rate or sick leave duration measured at 12 months' follow-up. The secondary outcome was quality of life (QoL).

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed RCTs for inclusion, extracted data and rated certainty of the evidence using GRADE. We pooled study results judged to be clinically homogeneous in different comparisons reporting risk ratios (RRs) with 95% confidence intervals (CIs) for RTW and mean differences (MD) or standardised mean differences (SMD) with 95% CIs for QoL.

MAIN RESULTS

We included 15 RCTs involving 1477 people with cancer with 19 evaluations because of multiple treatment groups. In this update, we added eight new RCTs and excluded seven RCTs from the previous versions of this review that were aimed at medical interventions. All included RCTs were conducted in high-income countries, and most were aimed at people with breast cancer (nine RCTs) or prostate cancer (two RCTs). Risk of bias We judged nine RCTs at low risk of bias and six at high risk of bias. The most common type of bias was a lack of blinding (9/15 RCTs). Psycho-educational interventions We found four RCTs comparing psycho-educational interventions including patient education and patient counselling versus care as usual. Psycho-educational interventions probably result in little to no difference in RTW compared to care as usual (RR 1.09, 95% CI 0.96 to 1.24; 4 RCTs, 512 participants; moderate-certainty evidence). This means that in the intervention and control groups, approximately 625 per 1000 participants may have returned to work. The psycho-educational interventions may result in little to no difference in QoL compared to care as usual (MD 1.47, 95% CI -2.38 to 5.32; 1 RCT, 124 participants; low-certainty evidence). Vocational interventions We found one RCT comparing vocational intervention versus care as usual. The evidence was very uncertain about the effect of a vocational intervention on RTW compared to care as usual (RR 0.94, 95% CI 0.78 to 1.13; 1 RCT, 34 participants; very low-certainty evidence). The study did not report QoL. Physical interventions Four RCTs compared a physical intervention programme versus care as usual. These physical intervention programmes included walking, yoga or physical exercise. Physical interventions likely increase RTW compared to care as usual (RR 1.23, 95% CI 1.08 to 1.39; 4 RCTs, 434 participants; moderate-certainty evidence). This means that in the intervention group probably 677 to 871 per 1000 participants RTW compared to 627 per 1000 in the control group (thus, 50 to 244 participants more RTW). Physical interventions may result in little to no difference in QoL compared to care as usual (SMD -0.01, 95% CI -0.33 to 0.32; 1 RCT, 173 participants; low-certainty evidence). The SMD translates back to a 1.8-point difference (95% CI -7.54 to 3.97) on the European Organisation for Research and Treatment of Cancer Quality of life Questionnaire Core 30 (EORTC QLQ-C30). Multidisciplinary interventions Six RCTs compared multidisciplinary interventions (vocational counselling, patient education, patient counselling, physical exercises) to care as usual. Multidisciplinary interventions likely increase RTW compared to care as usual (RR 1.23, 95% CI 1.09 to 1.33; 6 RCTs, 497 participants; moderate-certainty evidence). This means that in the intervention group probably 694 to 844 per 1000 participants RTW compared to 625 per 1000 in the control group (thus, 69 to 217 participants more RTW). Multidisciplinary interventions may result in little to no difference in QoL compared to care as usual (SMD 0.07, 95% CI -0.14 to 0.28; 3 RCTs, 378 participants; low-certainty evidence). The SMD translates back to a 1.4-point difference (95% CI -2.58 to 5.36) on the EORTC QLQ-C30.

AUTHORS' CONCLUSIONS

Physical interventions (four RCTs) and multidisciplinary interventions (six RCTs) likely increase RTW of people with cancer. Psycho-educational interventions (four RCTs) probably result in little to no difference in RTW, while the evidence from vocational interventions (one RCT) is very uncertain. Psycho-educational, physical or multidisciplinary interventions may result in little to no difference in QoL. Future research on enhancing RTW in people with cancer involving multidisciplinary interventions encompassing a physical, psycho-educational and vocational component is needed, and be preferably tailored to the needs of the patient.

Effectiveness of Exercise Interventions for Preventing Neck Pain: A Systematic Review With Meta-analysis of Randomized Controlled Trials

OBJECTIVE: To update the evidence on the effectiveness of exercise interventions to prevent episodes of neck pain. DESIGN: Systematic review with meta-analysis. LITERATURE SEARCH: MEDLINE, Embase, CENTRAL, CINAHL, SPORTDiscus, PEDro, and trial registries from inception to December 2, 2022. Forward and backward citation searches. STUDY SELECTION CRITERIA: Randomized controlled trials (RCTs) that enrolled adults without neck pain at baseline and compared exercise interventions to no intervention, placebo/sham, attention control, or minimal intervention. Military populations and astronauts were excluded. DATA SYNTHESIS: Random-effects meta-analysis. Risk of bias was assessed using the Cochrane RoB 2 tool. The certainty of evidence was judged according to the GRADE approach. RESULTS: Of 4703 records screened, 5 trials (1722 participants at baseline) were included and eligible for meta-analysis. Most (80%) participants were office workers. Risk of bias was rated as some concerns for 2 trials and high for 3 trials. There was moderate-certainty evidence that exercise interventions probably reduce the risk of a new episode of neck pain (OR, 0.49; 95% confidence interval: 0.31, 0.76) compared to no or minimal intervention in the short-term (≤12 months). The results were not robust to sensitivity analyses for missing outcome data. CONCLUSION: There was moderate-certainty evidence supporting exercise interventions for reducing the risk for an episode of neck pain in the next 12 months. The clinical significance of the effect is unclear. J Orthop Sports Phys Ther 2023;53(10):1-16. Epub: 8 September 2023. doi:10.2519/jospt.2023.12063.

Effectiveness of brief alcohol interventions for pregnant women: a systematic literature review and meta-analysis

BACKGROUND

Prenatal alcohol exposure (PAE) can result in a range of adverse neonatal outcomes, including Fetal Alcohol Spectrum Disorder (FASD). This systematic review and meta-analysis sought to investigate the effectiveness of brief interventions (BIs) in eliminating or reducing 1) alcohol consumption during pregnancy; and 2) PAE-related adverse neonatal outcomes; and 3) cost-effectiveness of BIs.

METHOD

We conducted a systematic literature search for original controlled studies (randomized control trials (RCTs); quasi-experimental) in any setting, published from 1987 to 2021. The comparison group was no/minimal intervention, where a measure of alcohol consumption was reported. Studies were critically appraised using the Centre for Evidence-based Medicine Oxford critical appraisal tool for RCTs (1). The certainty in the evidence for each outcome was assessed using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) (2). Meta-analysis of continuous and binary estimates of effect-size for similar outcome measures for BIs versus control groups were pooled and reported as mean difference (MD) Hedges' g and odds ratios (ORs), respectively.

RESULTS

In total, 26 studies, all from high income countries, met inclusion criteria. Alcohol abstinence outcome available in 12 studies (n = 2620) found modest effects in favor of BIs conditions by increasing the odds of abstinence by 56% (OR = 1.56, 95% confidence interval (CI) = 1.15-2.13, I² = 46.75%; p = 0.04). BIs effects for reduction in mean drinks/week (Cohen's d = - 0.21, 95%CI = - 0.78 to 0.36; p = 0.08) and AUDIT scores (g = 0.10, 95%CI = - 0.06 to 0.26; p = 0.17) were not statistically significant. Among seven studies (n = 740) reporting neonatal outcomes, BI receipt was associated with a modest and significant reduction in preterm birth (OR = 0.67, 95% CI = 0.46-0.98, I² = 0.00%; p = 0.58). No statistically significant differences were observed for mean birthweight or lower likelihood of low birth weight (LBW). Certainty in the evidence was rated as 'low'. No eligible studies were found on cost-effectiveness of BIs.

CONCLUSION

BIs are moderately effective in increasing abstinence during pregnancy and preventing preterm birth. More studies on the effectiveness of BIs are needed from low- and middle-income countries, as well as with younger mothers and with a broader range of ethnic groups.

Influential methods reports for group-randomized trials and related designs

BACKGROUND

This article identifies the most influential methods reports for group-randomized trials and related designs published through 2020. Many interventions are delivered to participants in real or virtual groups or in groups defined by a shared interventionist so that there is an expectation for positive correlation among observations taken on participants in the same group. These interventions are typically evaluated using a group- or cluster-randomized trial, an individually randomized group treatment trial, or a stepped wedge group- or cluster-randomized trial. These trials face methodological issues beyond those encountered in the more familiar individually randomized controlled trial.

METHODS

PubMed was searched to identify candidate methods reports; that search was supplemented by reports known to the author. Candidate reports were reviewed by the author to include only those focused on the designs of interest. Citation counts and the relative citation ratio, a new bibliometric tool developed at the National Institutes of Health, were used to identify influential reports. The relative citation ratio measures influence at the article level by comparing the citation rate of the reference article to the citation rates of the articles cited by other articles that also cite the reference article.

RESULTS

In total, 1043 reports were identified that were published through 2020. However, 55 were deemed to be the most influential based on their relative citation ratio or their citation count using criteria specific to each of the three designs, with 32 group-randomized trial reports, 7 individually randomized group treatment trial reports, and 16 stepped wedge group-randomized trial reports. Many of the influential reports were early publications that drew attention to the issues that distinguish these designs from the more familiar individually randomized controlled trial. Others were textbooks that covered a wide range of issues for these designs. Others were "first reports" on analytic methods appropriate for a specific type of data (e.g. binary data, ordinal data), for features commonly encountered in these studies (e.g. unequal cluster size, attrition), or for important variations in study design (e.g. repeated measures, cohort versus cross-section). Many presented methods for sample size calculations. Others described how these designs could be applied to a new area (e.g. dissemination and implementation research). Among the reports with the highest relative citation ratios were the CONSORT statements for each design.

CONCLUSIONS

Collectively, the influential reports address topics of great interest to investigators who might consider using one of these designs and need guidance on selecting the most appropriate design for their research question and on the best methods for design, analysis, and sample size.

Evaluation of the Swedish school-based program "tobacco-free DUO" in a cluster randomized controlled trial (TOPAS study). Results at 2-year follow-up

Friends' and parents' tobacco use are strong predictors of tobacco uptake among adolescents, however the effectiveness of interventions based on public commitments and agreements to remain tobacco-free are not established. Here, we evaluated the effectiveness of the school-based Swedish program Tobacco-Free Duo (T-Duo) in preventing adolescents from initiating tobacco use (TOPAS study). T-Duo is a multi-component intervention witha formal agreement between a student and an adult partner to remain tobacco-free during the entire 3-year study period as core component. The standardized educational component of the same program was used as comparator (control). Primary outcome was the probability to "remain a non-user" of i) cigarettes and secondary outcomes ii) other types of tobacco at second (21-month) follow-up. Analysis was conducted according to Intention To Treat. In total 1776 adolescents (51% female) aged 12-13 in grade 7 from 34 participating high schools in Sweden were included at baseline in 2018, of which 1489 were retained after 21 months. The Risk Ratio (RR) of not having tried cigarettes 21-months after initiation of the intervention was 1.03(CI 0.98-1.08), Bayes Factor(BF) = 0.93, Absolute Risk Difference(ARD) = 3.1%. Similar associations were found for never smoked a whole cigarette and never use of other tobacco/nicotine products. There was a minimal reduction of tobacco use initiation among Swedish adolescents assigned to a multi-component intervention (T-Duo) compared to those assigned to standardized classroom education after 2 schoolyears. However, for most outcomes' findings were inconclusive and not reliably different from zero. Trial registration: ISRCTN5285808 (doi:https://doi.org/10.1186/ISRCTN52858080); Study protocol: DERR1-https://doi.org/10.2196/21100. Registration: Current Controlled Trials ISRCTN52858080 Date: January 4, 2019, retrospectively registered. Protocol: Galanti, M.R., Pulkki-Brännström, A.-M., Nilsson, M., 2020. Tobacco-free duo adult-child contract for prevention of tobacco use among adolescents and parents: protocol for a mixed-design evaluation. JMIR Res. Protoc. 9, e21100. doi:10.2196/21100.

Mass drug administration for malaria

BACKGROUND

Studies evaluating mass drug administration (MDA) in malarious areas have shown reductions in malaria immediately following the intervention. However, these effects vary by endemicity and are not sustained. Since the 2013 version of this Cochrane Review on this topic, additional studies have been published.

OBJECTIVES

Primary objectives To assess the sustained effect of MDA with antimalarial drugs on: - the reduction in malaria transmission in moderate- to high-transmission settings; - the interruption of transmission in very low- to low-transmission settings. Secondary objective To summarize the risk of drug-associated adverse effects following MDA.

SEARCH METHODS

We searched several trial registries, citation databases, conference proceedings, and reference lists for relevant articles up to 11 February 2021. We also communicated with researchers to identify additional published and unpublished studies.

SELECTION CRITERIA

Randomized controlled trials (RCTs) and non-randomized studies comparing MDA to no MDA with balanced co-interventions across study arms and at least two geographically distinct sites per study arm.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for eligibility and extracted data. We calculated relative risk (RR) and rate ratios with corresponding 95% confidence intervals (CIs) to compare prevalence and incidence, respectively, in MDA compared to no-MDA groups. We stratified analyses by malaria transmission and by malaria species. For cluster-randomized controlled trials (cRCTs), we adjusted standard errors using the intracluster correlation coefficient. We assessed the certainty of the evidence using the GRADE approach. For non-randomized controlled before-and-after (CBA) studies, we summarized the data using difference-in-differences (DiD) analyses.

MAIN RESULTS

Thirteen studies met our criteria for inclusion. Ten were cRCTs and three were CBAs. Cluster-randomized controlled trials Moderate- to high-endemicity areas (prevalence ≥ 10%) We included data from two studies conducted in The Gambia and Zambia.  At one to three months after MDA, the Plasmodium falciparum (hereafter, P falciparum) parasitaemia prevalence estimates may be higher compared to control but the CIs included no effect (RR 1.76, 95% CI 0.58 to 5.36; Zambia study; low-certainty evidence); parasitaemia incidence was probably lower (RR 0.61, 95% CI 0.40 to 0.92; The Gambia study; moderate-certainty evidence); and confirmed malaria illness incidence may be substantially lower,  but the CIs included no effect (rate ratio 0.41, 95% CI 0.04 to 4.42; Zambia study; low-certainty evidence).  At four to six months after MDA, MDA showed little or no effect on P falciparum parasitaemia prevalence (RR 1.18, 95% CI 0.89 to 1.56; The Gambia study; moderate-certainty evidence) and, no persisting effect was demonstrated with parasitaemia incidence (rate ratio 0.91, 95% CI 0.55 to 1.50; The Gambia study). Very low- to low-endemicity areas (prevalence < 10%) Seven studies from Cambodia, Laos, Myanmar (two studies), Vietnam, Zambia, and Zanzibar evaluated the effects of multiple rounds of MDA on P falciparum. Immediately following MDA (less than one month after MDA), parasitaemia prevalence was reduced (RR 0.12, 95% CI 0.03 to 0.52; one study; low-certainty evidence). At one to three months after MDA, there was a reduction in both parasitaemia incidence (rate ratio 0.37, 95% CI 0.21 to 0.55; 1 study; moderate-certainty evidence) and prevalence (RR 0.25, 95% CI 0.15 to 0.41; 7 studies; low-certainty evidence). For confirmed malaria incidence, absolute rates were low, and it is uncertain whether MDA had an effect on this outcome (rate ratio 0.58, 95% CI 0.12 to 2.73; 2 studies; very low-certainty evidence).  For P falciparum prevalence, the relative differences declined over time, from RR 0.63 (95% CI 0.36 to 1.12; 4 studies) at four to six months after MDA, to RR 0.86 (95% CI 0.55 to 1.36; 5 studies) at 7 to 12 months after MDA. Longer-term prevalence estimates showed overall low absolute risks, and relative effect estimates of the effect of MDA on prevalence varied from RR 0.82 (95% CI 0.20 to 3.34) at 13 to 18 months after MDA, to RR 1.25 (95% CI 0.25 to 6.31) at 31 to 36 months after MDA in one study. Five studies from Cambodia, Laos, Myanmar (2 studies), and Vietnam evaluated the effect of MDA on Plasmodium vivax (hereafter, P vivax). One month following MDA, P vivax prevalence was lower (RR 0.18, 95% CI 0.08 to 0.40; 1 study; low-certainty evidence). At one to three months after MDA, there was a reduction in P vivax prevalence (RR 0.15, 95% CI 0.10 to 0.24; 5 studies; low-certainty evidence). The immediate reduction on P vivax prevalence was not sustained over time, from RR 0.78 (95% CI 0.63 to 0.95; 4 studies) at four to six months after MDA, to RR 1.12 (95% CI 0.94 to 1.32; 5 studies) at 7 to 12 months after MDA. One of the studies in Myanmar provided estimates of longer-term effects, where overall absolute risks were low, ranging from RR 0.81 (95% CI 0.44 to 1.48) at 13 to 18 months after MDA, to RR 1.20 (95% CI 0.44 to 3.29) at 31 to 36 months after MDA. Non-randomized studies Three CBA studies were conducted in moderate- to high-transmission areas in Burkina Faso, Kenya, and Nigeria. There was a reduction in P falciparum parasitaemia prevalence in MDA groups compared to control groups during MDA (DiD range: -15.8 to -61.4 percentage points), but the effect varied at one to three months after MDA (DiD range: 14.9 to -41.1 percentage points).  AUTHORS' CONCLUSIONS: In moderate- to high-transmission settings, no studies reported important effects on P falciparum parasitaemia prevalence within six months after MDA. In very low- to low-transmission settings, parasitaemia prevalence and incidence were reduced initially for up to three months for both P falciparum and P vivax; longer-term data did not demonstrate an effect after four months, but absolute risks in both intervention and control groups were low. No studies provided evidence of interruption of malaria transmission.

Development of a checklist to detect errors in meta-analyses in systematic reviews of interventions: study protocol

Background : Systematic reviews underpin clinical practice and policies that guide healthcare decisions. A core component of many systematic reviews is meta-analysis, which is a statistical synthesis of results across studies. Errors in the conduct and interpretation of meta-analysis can lead to incorrect conclusions regarding the benefits and harms of interventions; and studies have shown that these errors are common. Enabling peer reviewers to better detect errors in meta-analysis through the use of a checklist provides an opportunity for these errors to be rectified before publication. To our knowledge, no such checklist exists. Objective : To develop and evaluate a checklist to detect errors in pairwise meta-analyses in systematic reviews of interventions. Methods : We will undertake a four-step process to develop the checklist. First, we will undertake a systematic review of studies that have evaluated errors in the conduct and interpretation of meta-analysis to generate a bank of items to consider for the checklist. Second, we will undertake a survey of systematic review methodologists and statisticians to seek their views on which items, of the bank of items generated in step 1, are most important to include in the checklist. Third, we will hold a virtual meeting to agree upon which items to include in the checklist. Fourth, before finalising the checklist, we will pilot with editors and peer reviewers of journals. Conclusion : The developed checklist is intended to help journal editors and peer reviewers identify errors in the application and interpretation of meta-analyses in systematic reviews. Fewer errors in the conduct and improved interpretation will lead to more accurate review findings and conclusions to inform clinical practice.

Smoking-Cessation Interventions in Appalachia: A Systematic Review and Meta-Analysis

CONTEXT

Appalachia, a socioeconomically disadvantaged rural region in the eastern U.S., has one of the nation's highest prevalence rates of smoking and some of the poorest health outcomes. Effective interventions that lower smoking rates in Appalachia have great potential to reduce health disparities and preventable illness; however, a better understanding of effective interventions is needed.

EVIDENCE ACQUISITION

This review included trials that evaluated the impact of smoking-cessation programs among populations living in Appalachia. The search was carried out on October 9, 2018 and comprised the Cochrane Central Register of Controlled Trials, Medline, Embase, and Scopus for academic journal articles published in English, with no date restrictions. After preliminary screening, potentially relevant full-text articles were independently reviewed by the authors with a Cohen's κ of 0.72, leading to the final inclusion of 9 articles.

EVIDENCE SYNTHESIS

Eligible studies were assessed qualitatively for heterogeneity and risk of bias. Six of the 9 included studies had extractable data related to dichotomous smoking status and reported a measure of association suitable for inclusion in a meta-analysis. For those 6 studies, the pooled RR and pooled OR were estimated using random effects models, with an I² index demonstrating substantial heterogeneity. A funnel plot of the 6 trials appeared relatively symmetric.

CONCLUSIONS

Participation in smoking-cessation interventions increased the probability of smoking abstinence among Appalachian smokers by an estimated 2.33 times (pooled RR=2.33, 95% CI=1.03, 5.25, p=0.04). Given the low number of studies, their substantial heterogeneity, and high risk of bias, the evidence of the effectiveness of smoking-cessation interventions in Appalachia must be interpreted with caution.

Essential Ingredients and Innovations in the Design and Analysis of Group-Randomized Trials

This article reviews the essential ingredients and innovations in the design and analysis of group-randomized trials. The methods literature for these trials has grown steadily since they were introduced to the biomedical research community in the late 1970s, and we summarize those developments. We review, in addition to the group-randomized trial, methods for two closely related designs, the individually randomized group treatment trial and the stepped-wedge group-randomized trial. After describing the essential ingredients for these designs, we review the most important developments in the evolution of their methods using a new bibliometric tool developed at the National Institutes of Health. We then discuss the questions to be considered when selecting from among these designs or selecting the traditional randomized controlled trial. We close with a review of current methods for the analysis of data from these designs, a case study to illustrate each design, and a brief summary.

Larviciding to prevent malaria transmission

BACKGROUND

Larviciding refers to the regular application of chemical or microbial insecticides to water bodies or water containers to kill the aquatic immature forms of the mosquito (the larvae and pupae).

OBJECTIVES

To summarize research evidence evaluating whether larviciding with chemical or microbial insecticides prevents malaria transmission.

SEARCH METHODS

We searched the Cochrane Infectious Diseases Group Specialized Register; the Cochrane Central Register of Controlled Trials (CENTRAL), published in the Cochrane Library; MEDLINE; Embase; CAB Abstracts; LILACS; the World Health Organization International Clinical Trials Registry Platform (WHO ICTRP); ClinicalTrials.gov; and the ISRCTN registry up to 6 June 2019.

SELECTION CRITERIA

We included cluster-randomized controlled trials (cRCTs), interrupted time series (ITS), randomized cross-over studies, non-randomized cross-over studies, and controlled before-and-after studies (CBAs) that compared larviciding with no larviciding.

DATA COLLECTION AND ANALYSIS

We independently assessed trials for eligibility and risk of bias, and extracted data. We assessed the certainty of evidence using the GRADE approach.

MAIN RESULTS

Four studies (one cRCT, two CBAs, and one non-randomized cross-over design) met the inclusion criteria. All used ground application of larvicides (people hand-delivering larvicides); one evaluated chemical and three evaluated microbial agents. Studies were carried out in The Gambia, Tanzania, Kenya, and Sri Lanka. Three studies were conducted in areas where mosquito aquatic habitats were less extensive (< 1 km²), and one where habitats were more extensive (> 1 km²; a cross-over study from The Gambia).For aquatic habitats of less than 1 km², one cRCT randomized eight villages in Sri Lanka to evaluate chemical larviciding using insect growth regulator; and two CBA studies undertaken in Kenya and Tanzania evaluated microbial larvicides. In the cRCT, larviciding across all villages was associated with lower malaria incidence (rate ratio 0.24, 4649 participants, low-certainty evidence) and parasite prevalence (risk ratio (RR) 0.26, 5897 participants, low-certainty evidence) compared to no larviciding. The two CBA studies reported lower malaria prevalence during the intervention period (parasite prevalence RR 0.79, 95% confidence interval (CI) 0.71 to 0.89; 70,902 participants; low-certainty evidence). The Kenyan study also reported a reduction in the incidence of new malaria cases (RR 0.62, 95% CI 0.38 to 1.01; 720 participants; very low-certainty evidence).For aquatic habitats of more than 1 km², the non-randomized cross-over trial using microbial larvicides did not detect an effect for malaria incidence (RR 1.58, 95% CI 0.94 to 2.65; 4226 participants), or parasite prevalence (RR 1.15, 95% CI 0.41 to 3.20; 3547 participants); both were very low-certainty evidence. The Gambia trial also reported the mean haemoglobin level, and there was no difference across the four comparisons (mean difference -0.13, 95% CI -0.40 to 0.13; 3586 participants).We were unable to summarize or pool entomological outcomes due to unreported and missing data.

AUTHORS' CONCLUSIONS

Most controlled studies on larviciding have been performed with microbial agents. Ground larviciding for non-extensive larval habitats may have an effect on malaria transmission, and we do not know if there is an effect in large-scale aquatic habitats. We found no studies using larviciding application techniques that could cover large aquatic habitats, such as aerial spraying using aircraft.

Impact of health service interventions on acute hospital use in community-dwelling persons with dementia: A systematic literature review and meta-analysis

Background

Persons with dementia have twice the acute hospital use as older persons without dementia. In addition to straining overburdened healthcare systems, acute hospital use impacts patient and caregiver quality of life and is associated with increased risk of adverse outcomes including death. Reducing avoidable acute hospital use in persons with dementia is thus a global healthcare priority. However, evidence regarding the impact of health service interventions as defined by the Effective Practice and Organization of Care Cochrane Group on acute hospital use is scant and inconclusive. The aim of this systematic review and meta-analysis was to synthesize available evidence on the impact of health service interventions on acute hospital use in community-dwelling persons with dementia compared to usual care.

Methods

Data Sources: MEDLINE, EMBASE, CINAHL and Cochrane CENTRAL (from 01/1995 to 08/2017). Study eligibility criteria: Randomised controlled trials measuring the impact of health service interventions on acute hospital use (proportion and mean number of emergency department visits and hospitalisations, mean number of hospital days, measured at 12 months, and at longest follow-up) in community-dwelling persons with dementia, compared to usual care. Study selection, appraisal and synthesis methods: Reviewers independently identified studies, extracted data, and assessed the risk of bias, with the Cochrane risk of bias tool. Authors of relevant trials were queried about unpublished data. Random effects model was used for meta-analyses. Effect heterogeneity was assessed through prediction intervals, and explored using sub-group analyses.

Findings

Seventeen trials provided data on 4,549 persons. Unpublished data were obtained for 13 trials, representing 65% of synthesized data. Most interventions included a case management or a self-management component. None of the outcome comparisons provided conclusive evidence supporting the hypothesis that these interventions would lead to a decrease in acute hospital use. Furthermore, prediction intervals indicated possible and important increased service use associated with these interventions, such as emergency department visits, hospital admissions, and hospital days. Subgroup analyses did not favour any type of intervention. A limitation of this study is the inclusion of any type of health service intervention, which may have increased the observed heterogeneity.

Conclusion

Despite a comprehensive systematic review and meta-analysis, including predominantly unpublished data, no health service intervention beyond usual care was found to reduce acute hospital use in community-dwelling persons with dementia. An important increase in service use may be associated with these interventions. Further research is urgently needed to identify effective interventions for this vulnerable population to limit rising acute hospital use, associated costs and adverse outcomes. Systematic review registration PROSPERO CRD42016046444.

Effectiveness of conservative urinary incontinence management among female nursing home residents-A cluster RCT

BACKGROUND

Guideline-compliant conservative management of urinary incontinence (UI) is the first step of the initial management for UI and is recommended for long-term care in older persons. Recent studies have focused on the effects of guideline-compliant UI management. However, most of these studies were tested in another setting than nursing homes and were not focused on conservative management.

AIMS

To measure the effectiveness of 29 evidence-based nursing recommendations regarding the conservative management of UI in Austrian nursing homes.

METHODS

The study is a cluster randomized intervention trial with institution as the unit of randomization. Twelve nursing homes in two Austrian provinces (Styria, Carinthia) were randomly allocated to the intervention group (IG) and control group (CG). Data were collected from participating residents over a three-month period. The intervention consisted of the implementation of recommendations for the conservative management of UI among female nursing home residents. The primary outcome variable was the daily UI experienced by the participating residents.

RESULTS

Residents in the (IG n = 216) had a lower risk (OR = 0.14, p = 0.02) of experiencing daily UI and were less likely to receive absorbent products (OR = 0.01, p = 0.01) than residents in the CG (n = 165). Residents in the IG (OR = 5.16, p = 0.00) were five times more likely to receive recommended interventions (e.g., bladder training) than residents in the CG.

CONCLUSION

Introducing guideline-compliant management into nursing practice can increase the likelihood of evidence-based interventions for the conservative management of UI. The intervention in this study targeted on nurses/nurse managers and can be recommended for the nursing home setting.

Insecticide-treated nets for preventing malaria

BACKGROUND

A previous version of this Cochrane Review identified that insecticide-treated nets (ITNs) are effective at reducing child mortality, parasite prevalence, and uncomplicated and severe malaria episodes. Insecticide-treated nets have since become a core intervention for malaria control and have contributed greatly to the dramatic decline in disease incidence and malaria-related deaths seen since the turn of the millennium. However, this time period has also seen a rise in resistance to pyrethroids (the insecticide used in ITNs), raising questions over whether the evidence from trials conducted before resistance became widespread can be applied to estimate the impact of ITNs on malaria transmission today.

OBJECTIVES

The primary objective of this review was to assess the impact of ITNs on mortality and malaria morbidity, incorporating any evidence published since the previous update into new and existing analyses, and assessing the certainty of the resulting evidence using GRADE.

SEARCH METHODS

We searched the Cochrane Infectious Diseases Group Specialized Register, the Cochrane Central Register of Controlled Trials (CENTRAL) published in the Cochrane Library, MEDLINE, Embase, LILACS, the World Health Organization (WHO) International Clinical Trials Registry Platform, ClinicalTrials.gov, and the ISRCTN registry for new trials published since 2004 and up to 18 April 2018.

SELECTION CRITERIA

We included individual randomized controlled trials (RCTs) and cluster RCTs comparing bed nets or curtains treated with a synthetic pyrethroid insecticide at a minimum target impregnation dose recommended by the WHO with no nets or untreated nets.

DATA COLLECTION AND ANALYSIS

One review author assessed the identified trials for eligibility and risk of bias, and extracted data. We compared intervention and control data using risk ratios (RRs), rate ratios, and mean differences, and presented all results with their associated 95% confidence intervals (CIs). We assessed the certainty of evidence using the GRADE approach. We drew on evidence from a meta-analysis of entomological outcomes stratified by insecticide resistance from 2014 to inform the GRADE assessments.

MAIN RESULTS

Our updated search identified three new trials. A total of 23 trials met the inclusion criteria, enrolling more than 275,793 adults and children. The included studies were conducted between 1987 and 2001.ITN versus no netsInsecticide-treated nets reduce child mortality from all causes by 17% compared to no nets (rate ratio 0.83, 95% CI 0.77 to 0.89; 5 trials, 200,833 participants, high-certainty evidence). This corresponds to a saving of 5.6 lives (95% CI 3.6 to 7.6) each year for every 1000 children protected with ITNs. Insecticide-treated nets also reduce the incidence of uncomplicated episodes of Plasmodium falciparum malaria by almost a half (rate ratio 0.55, 95% CI 0.48 to 0.64; 5 trials, 35,551 participants, high-certainty evidence) and probably reduce the incidence of uncomplicated episodes of Plasmodium vivax malaria (risk ratio (RR) 0.61, 95% CI 0.48 to 0.77; 2 trials, 10,967 participants, moderate-certainty evidence).Insecticide-treated nets were also shown to reduce the prevalence of P falciparum malaria by 17% compared to no nets (RR 0.83, 95% CI 0.71 to 0.98; 6 trials, 18,809 participants, high-certainty evidence) but may have little or no effect on the prevalence of P vivax malaria (RR 1.00, 95% CI 0.75 to 1.34; 2 trials, 10,967 participants, low-certainty evidence). A 44% reduction in the incidence of severe malaria episodes was seen in the ITN group (rate ratio 0.56, 95% CI 0.38 to 0.82; 2 trials, 31,173 participants, high-certainty evidence), as well as an increase in mean haemoglobin (expressed as mean packed cell volume) compared to the no-net group (mean difference 1.29, 95% CI 0.42 to 2.16; 5 trials, 11,489 participants, high-certainty evidence).ITN versus untreated netsInsecticide-treated nets probably reduce child mortality from all causes by a third compared to untreated nets (rate ratio 0.67, 95% CI 0.36 to 1.23; 2 trials, 25,389 participants, moderate-certainty evidence). This corresponds to a saving of 3.5 lives (95% CI -2.4 to 6.8) each year for every 1000 children protected with ITNs. Insecticide-treated nets also reduce the incidence of uncomplicated P falciparum malaria episodes (rate ratio 0.58, 95% CI 0.44 to 0.78; 5 trials, 2036 participants, high-certainty evidence) and may also reduce the incidence of uncomplicated P vixax malaria episodes (rate ratio 0.73, 95% CI 0.51 to 1.05; 3 trials, 1535 participants, low-certainty evidence).Use of an ITN probably reduces P falciparum prevalence by one-tenth in comparison to use of untreated nets (RR 0.91, 95% CI 0.78 to 1.05; 3 trials, 2,259 participants, moderate-certainty evidence). However, based on the current evidence it is unclear whether or not ITNs impact on P vivax prevalence (1 trial, 350 participants, very low certainty evidence) or mean packed cell volume (2 trials, 1,909 participants, low certainty evidence).

AUTHORS' CONCLUSIONS

Although there is some evidence that insecticide resistance frequency has some effects on mosquito mortality, it is unclear how quantitatively important this is. It appeared insufficient to downgrade the strong evidence of benefit on mortality and malaria illness from the trials conducted earlier.

Completeness of Human Papilloma Virus Vaccination: A Systematic Review

PROBLEM

It has been reported that some adolescents and young women who started taking human papillomavirus (HPV) vaccination are not completing all three doses. The aim of this study was to systematically review intervention studies on HPV vaccination completion.

ELIGIBILITY CRITERIA

Intervention studies with a comparison group that assessed HPV vaccination completion rate as the primary outcome variable in adolescents and adults younger than 26years of age, and published in English from 2006 to 2016, were eligible for review.

SAMPLE

Five studies from a literature search of CINAHL, EMBASE, PsycARTICLES, PubMed, SCOPUS, and Web of Science databases were included in this review.

RESULTS

The overall quality of the reviewed studies was moderate, and the studies have mainly been conducted in a high-income country. Intervention strategies were DVD-based education on HPV and reminders that were delivered via either electronic or non-electronic methods. Some studies used fixed type of electronic reminders. Others chose preference-based electronic reminders, allowing participants to select one or two delivery options from e-mail, text message, automated telephone message, or Facebook message. Non-electronic reminders were letters sent by standard mail.

CONCLUSIONS

The rates of HPV vaccination completeness increased with the interventions. However, the completeness rate of HPV vaccination remained unsatisfactory and lower than its initiation rate.

IMPLICATIONS

Educational and reminder interventions for HPV vaccination could contribute to HPV vaccination completion. However, this review highlights the need for more high-quality studies to identify the best way to promote vaccination completion.

Flaws in the application and interpretation of statistical analyses in systematic reviews of therapeutic interventions were common: a cross-sectional analysis

OBJECTIVES

The objective of the study was to investigate the application and interpretation of statistical analyses in a cross-section of systematic reviews (SRs) of therapeutic interventions, without restriction by journal, clinical condition, or specialty.

STUDY DESIGN AND SETTING

We evaluated a random sample of SRs assembled previously, which were indexed in MEDLINE® during February 2014, focused on a treatment or prevention question, and reported at least one meta-analysis. The reported statistical methods used in each SR were extracted from articles and online appendices by one author, with a 20% random sample extracted in duplicate.

RESULTS

We evaluated 110 SRs; 78/110 (71%) were non-Cochrane SRs and 55/110 (50%) investigated a pharmacological intervention. The SRs presented a median of 13 (interquartile range: 5-27) meta-analytic effects. When considering the index (primary or first reported) meta-analysis of each SR, just over half (62/110 [56%]) used the random-effects model, but few (5/62 [8%]) interpreted the meta-analytic effect correctly (as the average of the intervention effects across all studies). A statistical test for funnel plot asymmetry was reported in 17/110 (15%) SRs; however, in only 4/17 (24%) did the test include the recommended number of at least 10 studies of varying size. Subgroup analyses accompanied 42/110 (38%) index meta-analyses, but findings were not interpreted with respect to a test for interaction in 29/42 (69%) cases, and the issue of potential confounding in the subgroup analyses was not raised in any SR.

CONCLUSIONS

There is scope for improvement in the application and interpretation of statistical analyses in SRs of therapeutic interventions. The involvement of statisticians on the SR team and establishment of partnerships between researchers with specialist expertise in SR methods and journal editors may help overcome these shortcomings.

Citations for Randomized Controlled Trials in Sepsis Literature: The Halo Effect Caused by Journal Impact Factor

Citations for randomized controlled trials (RCT) are important for the dissemination of study results. However, predictors of citations for RCTs have not been investigated. The study aimed to investigate the predictors of citations for RCTs in sepsis literature. RCTs that investigated the efficacy of treatment strategies on clinical outcomes in sepsis patients were included, and publication dates were restricted to the period from 2000 to 2016. Risk of bias was assessed using the Cochrane handbook for systematic reviews and interventions. A multivariable linear regression model was built to investigate the independent variables associated with total citations. In total, 160 RCTs met our inclusion criteria and were included for analysis. The median of total citations was 28.5 (IQR: 6-76). The journal impact factor (IF) for articles was 6.312 (IQR: 3.143-7.214). The dependent variable was transformed by the square root to improve normality and meet the assumption of homoscedasticity. The journal IF (coefficient: 0.2; 95% CI: 0.16, 0.25) was independently associated with total citations. Large samples were associated with more total citations (coefficient: 0.0026; 95% CI: 0.0013, 0.0039). The study demonstrated that the journal IF was a major determinant of the RCT's total citation number.