A clinician's perspective on rating the strength of evidence in a systematic review

A critical overview of systematic reviews and meta-analyses of extracorporeal shockwave therapy for knee osteoarthritis

Knee Osteoarthritis (KOA) has become a serious health issue for elderly patients. Several systematic reviews (SRs) and Meta-Analyses (MAs) have reported extracorporeal shockwave therapy (ESWT) has widely been used in the treatment of KOA. This overview aims to summarize and evaluate the available evidence for the efficacy of ESWT for KOA. Eight databases were searched from inception to December 4, 2022. The methodological quality of the included SRs/MAs was assessed by Assessing the Methodological Quality of Systematic Reviews 2 (AMSTAR 2) and the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) tool was used to assess the quality of the included studies in terms of outcome indicators. Eight SRs/MAs were finally included in this study. The results of the methodological quality of the included SRs/MAs were generally unsatisfactory. The limitations were a lack of explaining the reasons for selection, a list of excluded literature, reporting bias assessment, and reporting the potential sources of conflict of interest. A total of 49 outcome indicators were assessed by using the GRADE tool. Only 3 items were assessed as moderate quality and the remaining indicators were rated as low and very low. Limitations were the most common downgraded factors. ESWT is regarded as a safe and therapeutically effective non-pharmacological method for the treatment of KOA. However, the reliability of the results is affected by the generally low methodological and evidential quality of the included SRs/MAs. Future researchers should improve the quality of original studies and SRs/MAs to provide a higher level of evidence-based medical evidence.

Meta-analyses using real-world data to generate clinical and epidemiological evidence: a systematic literature review of existing recommendations

OBJECTIVES

To identify existing guidelines, key recommendations, and existing limitations regarding the evaluation and use of real-world evidence (RWE) in meta-analyses (MAs) to generate clinical and epidemiological evidence: a systematic review of existing recommendations.

METHODS

A literature search was performed in April 2017 in MEDLINE and Embase using the Ovid platform, the Cochrane Library, and other sources. No specific inclusion and exclusion criteria were applied, and no restrictions in timeframe, language, or geographical scope were imposed.

RESULTS

The search strategy identified 1681 citations; 12 references were included in this review. Recommendations within the literature regarding the use of RWE in MAs are: (1) it may be useful to extract and analyze adjusted results because confounding is expected; (2) testing heterogeneity in the MA of RWE is important as it may minimize the potential for bias and generate hypotheses for future research; (3) limiting a search ≤2 bibliographic databases when conducting MAs of RWE will not provide a thorough summary of existing literature; and (4) the Meta-analysis Of Observational Studies in Epidemiology (MOOSE) checklist is a 35-item checklist developed to allow for more standardized reporting of MAs of RWE and address their limitations.

LIMITATIONS

(1) No formal guidelines were found regarding the use of RWE in MAs; (2) no consensus was found on a preferred instrument for the assessment of RWE; and (3) critical appraisal of RWE is often omitted from Health Technology Assessment submissions.

CONCLUSIONS

The inclusion of RWE in MAs may facilitate the confirmation of conclusions drawn from randomized controlled trials and, thus, reassure decision-makers that findings can be extrapolated to real-world populations. However, qualitative and quantitative bias may co-exist in MAs of RWE. Reviewers should select the most appropriate tools that match the study designs identified in a particular systematic review.

Decision making about healthcare-related tests and diagnostic test strategies. Paper 3: a systematic review shows limitations in most tools designed to assess quality and develop recommendations

OBJECTIVES

The objective of this study was to identify and describe critical appraisal tools designed for assessing the quality of evidence (QoE) and/or strength of recommendations (SoRs) related to health care-related tests and diagnostic strategies (HCTDSs).

STUDY DESIGN AND SETTING

We conducted a systematic review to identify tools applied in guidelines, methodological articles, and systematic reviews to assess HCTDS.

RESULTS

We screened 5,534 titles and abstracts, 1,004 full-text articles, and abstracted data from 330 references. We identified 29 tools and 14 modifications of existing tools for assessing QoE and SoR. Twenty-three out of 29 tools acknowledge the importance of assessing the QoE and SoR separately, but in 8, the SoR is based solely on QoE. When making decisions about the use of tests, patient values and preferences and impact on resource utilization were considered in 6 and 8 tools, respectively. There is also confusion about the terminology that describes the various factors that influence the QoE and SoR.

CONCLUSION

Although at least one approach includes all relevant criteria for assessing QoE and determining SoR, more detailed guidance about how to operationalize these assessments and make related judgments will be beneficial. There is a need for a better description of the framework for using evidence to make decisions and develop recommendations about HCTDS.

An evidence-based systematic review of frequency lowering in hearing aids for school-age children with hearing loss

PURPOSE

We developed 1 clinical question for this review, which addressed the comparison of hearing aids using frequency lowering compared to conventional processing amplification for outcomes of audibility, speech recognition, speech and language, and self- or parent-report for children with hearing loss.

METHOD

We systematically searched 26 databases for studies addressing a clinical question and meeting all inclusion criteria. We evaluated studies for methodological quality and reported or calculated effect sizes when possible.

RESULTS

The literature search resulted in the inclusion of 5 studies. We implemented several different frequency-lowering strategies across studies; 2 studies used nonlinear frequency compression, 2 used frequency transposition, and 1 used frequency compression with dynamic consonant boost.

CONCLUSIONS

Whereas methodological limitations of the included studies preclude the formulation of strong conclusions, findings were generally positive across frequency-lowering strategies and outcomes. Additional high-quality research is needed in this area.

An evidence-based systematic review of directional microphones and digital noise reduction hearing aids in school-age children with hearing loss

PURPOSE

The purpose of this evidence-based systematic review was to evaluate the efficacy of digital noise reduction and directional microphones for outcome measures of audibility, speech recognition, speech and language, and self- or parent-report in pediatric hearing aid users.

METHOD

The authors searched 26 databases for experimental studies published after 1980 addressing one or more clinical questions and meeting all inclusion criteria. The authors evaluated studies for methodological quality and reported or calculated p values and effect sizes when possible.

RESULTS

A systematic search of the literature resulted in the inclusion of 4 digital noise reduction and 7 directional microphone studies (in 9 journal articles) that addressed speech recognition, speech and language, and/or self- or parent-report outcomes. No digital noise reduction or directional microphone studies addressed audibility outcomes.

CONCLUSIONS

On the basis of a moderate level of evidence, digital noise reduction was not found to improve or degrade speech understanding. Additional research is needed before conclusions can be drawn regarding the impact of digital noise reduction on important speech, language, hearing, and satisfaction outcomes. Moderate evidence also indicates that directional microphones resulted in improved speech recognition in controlled optimal settings; however, additional research is needed to determine the effectiveness of directional microphones in actual everyday listening environments.

An evidence-based systematic review of amplitude compression in hearing aids for school-age children with hearing loss

PURPOSE

Two clinical questions were developed: one addressing the comparison of linear amplification with compression limiting to linear amplification with peak clipping, and the second comparing wide dynamic range compression with linear amplification for outcomes of audibility, speech recognition, speech and language, and self- or parent report in children with hearing loss.

METHOD

Twenty-six databases were systematically searched for studies addressing a clinical question and meeting all inclusion criteria. Studies were evaluated for methodological quality, and effect sizes were reported or calculated when possible.

RESULTS

The literature search resulted in the inclusion of 8 studies. All 8 studies included comparisons of wide dynamic range compression to linear amplification, and 2 of the 8 studies provided comparisons of compression limiting versus peak clipping.

CONCLUSIONS

Moderate evidence from the included studies demonstrated that audibility was improved and speech recognition was either maintained or improved with wide dynamic range compression as compared with linear amplification. No significant differences were observed between compression limiting and peak clipping on outcomes (i.e., speech recognition and self-/parent report) reported across the 2 studies. Preference ratings appear to be influenced by participant characteristics and environmental factors. Further research is needed before conclusions can confidently be drawn.