Judith Streak Gomersall

Conducting systematic reviews of economic evaluations.

Background:In 2012, a working group was established to review and enhance the Joanna Briggs Institute (JBI) guidance for conducting systematic review of evidence from economic evaluations addressing a question(s) about health intervention cost-effectiveness. Objectives:The objective is to present the outcomes of the working group. Methods:The group conducted three activities to inform the new guidance: review of literature on the utility/futility of systematic reviews of economic evaluations and consideration of its implications for updating the existing methodology; assessment of the critical appraisal tool in the existing guidance against criteria that promotes validity in economic evaluation research and two other commonly used tools; and a workshop. Results:The debate in the literature on the limitations/value of systematic review of economic evidence cautions that systematic reviews of economic evaluation evidence are unlikely to generate one size fits all answers to questions about the cost-effectiveness of interventions and their comparators. Informed by this finding, the working group adjusted the framing of the objectives definition in the existing JBI methodology. The shift is away from defining the objective as to determine one cost-effectiveness measure toward summarizing study estimates of cost-effectiveness and informed by consideration of the included study characteristics (patient, setting, intervention component, etc.), identifying conditions conducive to lowering costs and maximizing health benefits. The existing critical appraisal tool was included in the new guidance. The new guidance includes the recommendation that a tool designed specifically for the purpose of appraising model-based studies be used together with the generic appraisal tool for economic evaluations assessment to evaluate model-based evaluations. The guidance produced by the group offers reviewers guidance for each step of the systematic review process, which are the same steps followed in JBI reviews of other types of evidence. Discussion:The updated JBI guidance will be useful for researchers wanting to synthesize evidence about economic questions, either as stand-alone reviews or part of comprehensive or mixed method evidence reviews. Although the updated methodology produced by the work of the working group has improved the JBI guidance for systematic reviews of economic evaluations, there are areas where further work is required. These include adjusting the critical appraisal tool to separate out questions addressing intervention cost and effectiveness measurement; providing more explicit guidance for assessing generalizability of findings; and offering a more robust method for evidence synthesis that facilitates achieving the more ambitious review objectives.

Factors determining quality of care in family planning services in Africa: A systematic review of mixed evidence

Background Improving use of family planning services is key to improving maternal health in Africa, and provision of quality of care in family planning services is critical to support higher levels of contraceptive uptake. The objective of this systematic review was to synthesize the available evidence on factors determining the quality of care in family planning services in Africa. Methods Quantitative and qualitative studies undertaken in Africa, published in English, in grey and commercial literature, between 1990 and 2015 were considered. Methodological quality of included studies was assessed using standardized tools. Findings from the quantitative studies were summarized using narrative and tables. Client satisfaction was used to assess the quality of care in family planning services in the quantitative component of the review. Meta-aggregation was used to synthesize the qualitative study findings. Results From 4334 records, 11 studies (eight quantitative, three qualitative) met the review eligibility criteria. The review found that quality of care was influenced by client, provider and facility factors, and structural and process aspects of the facilities. Client’s waiting time, provider competency, provision/prescription of injectable methods, maintaining privacy and confidentiality were the most commonly identified process factors. The quality of stock inventory was the most commonly identified structural factor. The quality of care was also positively associated with privately-owned facilities. The qualitative synthesis revealed additional factors including access related factors such as ‘pre-requisites to be fulfilled by the clients and cost of services, provider workload, and providers’ behaviour. Conclusion There is limited evidence on factors determining quality of care in family planning services in Africa that shows quality of care is influenced by multiple factors. The evidence suggests that lowering access barriers and avoiding unnecessary pre-requisites for taking contraceptive methods are important to improve the quality of care in family planning services. Strategies to improve provider behavior and competency are important. Moreover, strategies that minimize client waiting time and ensure client confidentiality should be implemented to ensure quality of care in family planning services. However, no strong evidence based conclusions and recommendations may be drawn from the evidence. Future studies are needed to identify the most important factors associated with quality of care in family planning services in a wider range of African countries.

Prevalence and Characteristics of Overweight and Obesity in Indigenous Australian Children: A Systematic Review

ABSTRACT Evidence-based profiling of obesity and overweight in Indigenous Australian children has been poor. This study systematically reviewed evidence of the prevalence and patterns of obesity/overweight, with respect to gender, age, remoteness, and birth weight, in Indigenous Australian children, 0–18 years (PROSPERO CRD42014007626). Study quality and risk of bias were assessed. Twenty-five publications (21 studies) met inclusion criteria, with large variations in prevalence for obesity or overweight (11 to 54%) reported. A high degree of heterogeneity in study design was observed, few studies (6/21) were representative of the target population, and few appropriately recruited Indigenous children (8/21). Variability in study design, conduct, and small sample sizes mean that it is not possible to derive a single estimate for prevalence although two high-quality studies indicate at least one in four Indigenous Australian children are overweight or obese. Four of six studies reporting on gender, found overweight/obesity higher in girls and eight studies reporting on overweight/obesity by age suggest prevalence increases with age with one high quality large national study reporting total overweight/obesity as 22.4% of children aged 2–4 years, 27.5% of those aged 5–9, 38.5% aged 10–14, and 36.3% aged 15–17. Three of four studies, reporting obesity/overweight by region, found lower rates for children living in more remote areas than urban areas.

Systematic review to inform prevention and management of chronic disease for Indigenous Australians: overview and priorities

Objective: To describe the main characteristics of systematic reviews addressing questions of chronic disease and related risk factors for Indigenous Australians.

The CREATE Critical Appraisal Tool: Establishing The Validity, Reliability And Feasibility Of A Tool To Appraise Research From Aboriginal And Torres Strait Islander Perspective

Abstract presented at the Global Evidence Summit: Using evidence. Improving lives, 13-16 September 2017, Cape Town, South Africa

What Indigenous Australian clients value about primary health care: a systematic review of qualitative evidence

Objective: To synthesise client perceptions of the unique characteristics and value of care provided in Aboriginal Community Controlled Health Organisations (ACCHOs) compared to mainstream/general practitioner services, and implications for improving access to quality, appropriate primary health care for Indigenous Australians.

Factors determining quality of care in family planning services in Africa: a systematic review protocol.

REVIEW OBJECTIVE AND QUESTIONS The objective of this systematic review is to identify and synthesize the best available quantitative and qualitative evidence to understand the factors determining quality of care in family planning services in Africa.The review question for the quantitative component of the review is:What factors, including facility, provider and client characteristics, are associated with quality of care in family planning services in Africa?The review question for the qualitative component of the review is:What are client and provider experiences and/or perceptions of factors that affect quality of care in family planning services in Africa?

Effectiveness of offloading methods in preventing primary diabetic foot ulcers in adults with diabetes: a systematic review.

BackgroundThe incidence of foot ulceration related to diabetes is increasing. Many foot care professionals recommend offloading measures as part of management strategies for modulating excess pressure to prevent development of diabetic foot ulcers (DFUs). These measures may include padding, insoles/orthotic devices and footwear. There is a lack of evidence-based guidance on the effectiveness of the different offloading options for preventing primary ulceration in those with diabetes. ObjectivesTo identify, critically appraise and synthesize the best available evidence on methods of offloading to prevent the development, and reduce the risk, of primary foot ulceration in adults with diabetes.The question addressed by the review was: what is the effectiveness of methods of offloading in preventing primary DFUs in adults with diabetes? Inclusion criteria Types of participantsAdults 18 years and older with diabetes mellitus, regardless of age, gender, ethnicity, duration or type of diabetes, with no history of DFUs and in any clinical setting will be included. Types of interventions and comparatorsInterventions will include all external methods of offloading. All comparators will be considered. Studies that utilize interventions not considered usual practice in the prevention of DFUs will be excluded. OutcomesThe primary outcome will be primary foot ulceration. The secondary outcome will be indications of changes in plantar pressure. Types of studiesThis review will consider all quantitative study designs. Search strategyA three-step strategy for published and unpublished literature will be used. Fourteen databases will be searched for studies in English up to November 2013. Data extractionThe JBI-MAStARI extraction tool was used to extract relevant data. Data synthesisResults were summarized using narrative and tables. ResultsThree studies which examined the effectiveness of four different offloading interventions met the inclusion criteria. There is limited evidence that use of a footwear system (prototype shoe plus polyurethane or cork insole) may prevent a break in the skin; use of customized rigid orthotic devices may contribute to a reduction in the grade and number of calluses; and a manufactured shoe plus customized insole may reduce plantar pressure and therefore reduce the potential risk of skin ulceration. ConclusionThere is limited and low-quality evidence that in a population of adults with diabetes with no history of DFU, the use of footwear with customized or prefabricated orthotic devices may provide some reduction in plantar pressure and therefore help to prevent a primary DFU. There is a lack of evidence on the relative effectiveness of different offloading options.

Health care worker hand hygiene in the pediatric special care unit at Mulago National Referral Hospital in Uganda: a best practice implementation project.

Introduction:The hands of a health care worker are a common vehicle of pathogen transmission in hospital settings. Health care worker hand hygiene is therefore critical for patients’ well being. Whilst failure of health care workers to comply with the best hand hygiene practice is a problem in all health care settings, issues of lack of access to adequate cleaning equipment and in some cases even running water make practicing good hand hygiene particularly difficult in low-resource developing country settings. This study reports an audit and feedback project that focused on the hand hygiene of the health care worker in the pediatric special care unit of the Mulago National Referral Hospital, which is a low-resource setting in Uganda. Objective:To improve hand hygiene among health care workers in the pediatric special care unit and thereby contribute to reducing transmission of health care worker-associated pathogens. Methods:The Joanna Briggs Institute three-phase Practical Application of Clinical Evidence System audit and feedback tool for promoting evidence utilization and change in health care was used. In phase one of the project, stakeholders were engaged and seven evidence-based audit criteria were developed. A baseline audit was then conducted. In phase two, barriers underpinning areas of noncompliance found in the baseline audit were identified and three strategies – education, reminders and provision of hand cleaning equipment – were implemented to overcome them. In phase three, a follow-up audit was conducted. Results:Compliance with best practice hygiene was found to be poor in the baseline audit for all but one of the audit criteria. Following the implementation of the strategies, hand hygiene improved. The compliance rate increased substantially across all criteria. Staff education achieved 100%, whilst criterion 4 increased to 70%. However, use of alcohol-based hand-rub for hand hygiene only improved to 66%, and for six of the seven audit criteria, compliance remained below 74%. Conclusion:The project provides another example of how audit can be used as a tool to improve health practice, even in a low-resource setting. At the same time, it showed how difficult it is to achieve compliance with best hand hygiene practice in a low-resource hospital. The project highlights the importance of continued education/awareness raising on the importance of good hand hygiene practice as well as investment in infrastructure and cleaning supplies for achieving and sustaining good hand hygiene among workers in a low-resource hospital setting. A key contribution of the project was the legacy it left in the form of knowledge about how to use audit and feedback as a tool to promote the best practice. A similar project has been implemented in the maternity ward at the hospital and further audits are planned.

the effectiveness of surgical versus conservative treatment for symptomatic unilateral spondylolysis of the lumbar spine in athletes: a systematic review

Background Spondylolysis is a common cause of low back pain in athletes. Historically, spondylolysis injuries were thought to be mostly bilateral; however advances in lumbar spine imaging have shown that in certain athlete groups, unilateral spondylolysis is highly prevalent. It remains unclear whether athletes with unilateral spondylolysis who undergo surgical repair are able to return to sports as effectively or faster than if they had conservative treatment. Objectives To determine the effectiveness of surgical fixation performed after a trial period of conservative management, compared to the effectiveness of conservative management only for unilateral spondylolysis in athletes. Inclusion criteria Types of participants Athletes with symptomatic unilateral spondylolysis of the lumbar spine. Types of intervention(s) Surgical interventions which attempted a direct repair of the pars interarticularis, compared to conservative management. Types of studies Experimental and epidemiological study designs were considered for inclusion. The majority of the studies reviewed consisted of descriptive epidemiological study designs including case series, individual case reports and descriptive cross sectional studies. Types of outcomes The primary outcome of interest in this review was the ability to return to sport. The effectiveness of surgery on pain and overall function were secondary outcomes of interest. Search strategy A three‐step search strategy that aimed to find both published and unpublished studies was utilized. The search was limited to studies published in the English language between 1 January 1970 and 1 September 2013. Methodological quality The studies were critically appraised using one of the standardized critical appraisal instruments from The Joanna Briggs Institute. Data collection Details describing each study and results on effectiveness in promoting the outcomes of interest were extracted from papers included in the review using the standardized data extraction tool from The Joanna Briggs Institute. Data synthesis Due to heterogeneity in the included studies, the results for similar outcome measures were not pooled in statistical meta‐analysis. A narrative and tabular format was used to synthesize the results of identified and included studies. Results Five studies reporting results for the outcomes of interest were critically appraised and included in the review. One study was a quasi‐experimental design, while the other four were case series studies. Due to the paucity of data, studies were included regardless of whether their participants were exclusively athletes with unilateral spondylolysis or adults (athletes and non‐athletes) with unilateral and bilateral spondylolysis. Sub‐group analysis was used to distinguish the findings for the main participant group of interest, namely athletes with unilateral spondylolysis. Conclusions The limited evidence on the effectiveness of surgical treatment versus conservative treatment for unilateral spondylolysis in athletes does not allow any conclusions to be drawn about the relative effectiveness of surgery versus conservative treatment for facilitating rapid return to sport or a high level of post injury sporting level/performance. It does suggest, however, that for adult athletes for whom conservative treatment has not been successful, surgery is likely to enable return to sport, reduce pain and promote overall function. Implication for practice Adult athletes who have failed conservative treatment who suffer pain and compromised functionality (including inability to play regular sport) can consider surgery to reduce their pain, increase their function and enable return to sport (Grade B). It does however remain unclear as to what level of sport they will be able to return to post surgery (Grade B). Implications for research A prospective case series design focused specifically on unilateral spondylolysis is required. Future research needs to be more specific in identifying athletes and the specific sports they participate in. More clarity is a also required when describing return to sport as an outcome measure.