Use of quality assessment tools in systematic reviews was varied and inconsistent

OBJECTIVES To assess the use of quality assessment tools among a cross-section of systematic reviews (SRs) and to further evaluate whether quality was used as a parameter in the decision to include primary studies within subsequent meta-analysis. STUDY DESIGN AND SETTING We searched PubMed for SRs (interventional, observational, and diagnostic) published in Core Clinical Journals between January 1 and March 31, 2014. RESULTS Three hundred nine SRs were identified. Quality assessment was undertaken in 222 (71.8%) with isolated use of the Cochrane risk of bias tool (26.1%, n = 58) and the Newcastle-Ottawa Scale (15.3%, n = 34) most common. A threshold level of primary study quality for subsequent meta-analysis was used in 12.9% (40 of 309) of reviews. Overall, fifty-four combinations of quality assessment tools were identified with a similar preponderance of tools used among observational and interventional reviews. Multiple tools were used in 11.7% (n = 36) of SRs overall. CONCLUSION We found that quality assessment tools were used in a majority of SRs; however, a threshold level of quality for meta-analysis was stipulated in just 12.9% (n = 40). This cross-sectional analysis provides further evidence of the need for more active or intuitive editorial processes to enhance the reporting of SRs.

A systematic review of glomerular hyperfiltration assessment and definition in the medical literature.

BACKGROUND AND OBJECTIVES Evaluation of glomerular hyperfiltration (GH) is difficult; the variable reported definitions impede comparisons between studies. A clear and universal definition of GH would help in comparing results of trials aimed at reducing GH. This study assessed how GH is measured and defined in the literature. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Three databases (Embase, MEDLINE, CINAHL) were systematically searched using the terms "hyperfiltration" or "glomerular hyperfiltration". All studies reporting a GH threshold or studying the effect of a high GFR in a continuous manner against another outcome of interest were included. RESULTS The literature search was performed from November 2012 to February 2013 and updated in August 2014. From 2013 retrieved studies, 405 studies were included. Threshold use to define GH was reported in 55.6% of studies. Of these, 88.4% used a single threshold and 11.6% used numerous thresholds adapted to participant sex or age. In 29.8% of the studies, the choice of a GH threshold was not based on a control group or literature references. After 2004, the use of GH threshold use increased (P<0.001), but the use of a control group to precisely define that GH threshold decreased significantly (P<0.001); the threshold did not differ among pediatric, adult, or mixed-age studies. The GH threshold ranged from 90.7 to 175 ml/min per 1.73 m(2) (median, 135 ml/min per 1.73 m(2)). CONCLUSION Thirty percent of studies did not justify the choice of threshold values. The decrease of GFR in the elderly was rarely considered in defining GH. From a methodologic point of view, an age- and sex-matched control group should be used to define a GH threshold.

Hepatitis C in HIV-infected individuals: a systematic review and meta-analysis of estimated prevalence in Africa.

INTRODUCTION Although hepatitis C virus (HCV) screening is recommended for all HIV-infected patients initiating antiretroviral therapy, data on epidemiologic characteristics of HCV infection in resource-limited settings are scarce. METHODS We searched PubMed and EMBASE for studies assessing the prevalence of HCV infection among HIV-infected individuals in Africa and extracted data on laboratory methods used. Prevalence estimates from individual studies were combined for each country using random-effects meta-analysis. The importance of study design, population and setting as well as type of test (anti-HCV antibody tests and polymerase chain reactions) was examined with meta-regression. RESULTS Three randomized controlled trials, 28 cohort studies and 121 cross-sectional analyses with 108,180 HIV-infected individuals from 35 countries were included. The majority of data came from outpatient populations (55%), followed by blood donors (15%) and pregnant women (14%). Based on estimates from 159 study populations, anti-HCV positivity prevalence ranged between 3.3% (95% confidence interval (CI) 1.8-4.7) in Southern Africa and 42.3% (95% CI 4.1-80.5) in North Africa. Study design, type of setting and age distribution did not influence this prevalence significantly. The prevalence of replicating HCV infection, estimated from data of 29 cohorts, was 2.0% (95% CI 1.5-2.6). Ten studies from nine countries reported the HCV genotype of 74 samples, 53% were genotype 1, 24% genotype 2, 14% genotype 4 and 9% genotypes 3, 5 or 6. CONCLUSIONS The prevalence of anti-HCV antibodies is high in HIV-infected patients in Africa, but replicating HCV infection is rare and varies widely across countries.

A Framework for Realistic and Systematic Multicast Performance Evaluation

Previous multicast research often makes commonly accepted but unverifed assumptions on network topologies and group member distribution in simulation studies. In this paper, we propose a framework to systematically evaluate multicast performance for different protocols. We identify a series of metrics, and carry out extensive simulation studies on these metrics with different topological models and group member distributions for three case studies. Our simulation results indicate that realistic topology and group membership models are crucial to accurate multicast performance evaluation. These results can provide guidance for multicast researchers to perform realistic simulations, and facilitate the design and development of multicast protocols.

For-profit business safety interventions: A systematic, descriptive review of the literature

The purpose of this research was to determine if principles from organizational theory could be used as a framework to compare and contrast safety interventions developed by for-profit industry for the time period 1986–1996. A literature search of electronic databases and manual search of journals and local university libraries' book stacks was conducted for safety interventions developed by for-profit businesses. To maintain a constant regulatory environment, the business sectors of nuclear power, aviation and non-profits were excluded. Safety intervention evaluations were screened for scientific merit. Leavitt's model from organization theory was updated to include safety climate and renamed the Updated Leavitt's Model. In all, 8000 safety citations were retrieved, 525 met the inclusion criteria, 255 met the organizational safety intervention criteria, and 50 met the scientific merit criteria. Most came from non-public health journals. These 50 were categorized by the Updated Leavitt's Model according to where within the organizational structure the intervention took place. Evidence tables were constructed for descriptive comparison. The interventions clustered in the areas of social structure, safety climate, the interaction between social structure and participants, and the interaction between technology and participants. No interventions were found in the interactions between social structure and technology, goals and technology, or participants and goals. Despite the scientific merit criteria, many still had significant study design weaknesses. Five interventions tested for statistical significance but none of the interventions commented on the power of their study. Empiric studies based on safety climate theorems had the most rigorous designs. There was an attempt in these studies to address randomization amongst subjects to avoid bias. This work highlights the utility of using the Updated Leavitt's Model, a model from organizational theory, as a framework when comparing safety interventions. This work also highlights the need for better study design of future trials of safety interventions. ^

Design and implementation of a clinical dashboard

In a large health care system, the importance of accurate information as feedback mechanisms about its performance is necessary on many levels from the senior level management to service level managers for valid decision-making purposes. The implementation of dashboards is one way to remedy the problem of data overload by providing up-to-date, accurate, and concise information. As this health care system seeks to have an organized, systematic review mechanism in place, dashboards are being created in a variety of the hospital service departments to monitor performance indicators. The Infection Control Administration of this health care system is one that does not currently utilize a dashboard but seeks to implement one. ^ The purpose of this project is to research and design a clinical dashboard for the Infection Control Administration. The intent is that the implementation and usefulness of the clinical dashboard translates into improvement in the measurement of health care quality.^

The association between diabetes and hepatitis C: A systematic review of epidemiological evidence

Background. Several studies have proposed a link between type 2 Diabetes mellitus (DM2) and Hepatitis C infection (HCV) with conflicting results. Since DM2 and HCV have high prevalence, establishing a link between the two may guide further studies aimed at DM2 prevention. A systematic review was conducted to estimate the magnitude and direction of association between DM2 and HCV. Temporality was assessed from cohort studies and case-control studies where such information was available. ^ Methods. MEDLINE searches were conducted for studies that provided risk estimates and fulfill criteria regarding the definition of exposure (HCV) and outcomes (DM2). HCV was defined in terms of method of diagnosis, laboratory technique and method of data collection; DM2 was defined in terms of the classification [World Health Organization (WHO) and American Diabetes Association (ADA)] 1-3 used for diagnosis, laboratory technique and method of data collection. Standardized searches and data abstraction for construction of tables was performed. Unadjusted or adjusted measures of association for individual studies were obtained or calculated from the full text of the studies. Template designed by Dr. David Ramsey. ^ Results. Forty-six studies out of one hundred and nine potentially eligible articles finally met the inclusion and exclusion criteria and were classified separately based on the study design as cross-sectional (twenty four), case-control (fifteen) or cohort studies (seven). The cohort studies showed a three-fold high (confidence interval 1.66–6.29) occurrence of DM2 in individuals with HCV compared to those who were unexposed to HCV and cross sectional studies had a summary odds ratio of 2.53 (1.96, 3.25). In case control studies, the summary odds ratio for studies done in subjects with DM2 was 3.61 (1.93, 6.74); in HCV, it was 2.30 (1.56, 3.38); and all fifteen studies, together, yielded an odds ratio of 2.60 (1.82, 3.73). ^ Conclusion. The above results support the hypothesis that there is an association between DM and HCV. The temporal relationship evident from cohort studies and proposed pathogenic mechanisms also suggest that HCV predisposes patients to development of DM2. Further cohort or prospective studies are needed, however, to determine whether treatment of HCV infections prevents development of DM2.^

A systematic review of community-based participatory research interventions in pediatric and adolescent populations

Background. Community-based participatory research (CBPR) is a collaborative approach to research actively involving community members in all aspects of the research process. CBPR is not a new research method, but an approach that has gained increased attention in the field of public health over the last several years. Recognition of the inequalities in health status associated with social and environmental factors have led to calls for a renewed focus on ecological approaches to research. Ecological approaches acknowledge that the health of the community is dependent on an interaction between behavioral and environmental factors affecting the entire population. While many published studies document the benefits of CBPR in difficult-to-reach populations and describe successful implementation of this approach in adult populations, relatively few studies have been conducted in child and adolescent populations. Given that children and adolescents are particularly sensitive to the effects of their physical environments and may also be distrustful of outsiders, ecological approaches involving the community as partners, such as CBPR, may be especially useful in this population. ^ Objective. This thesis reviews published studies using a community-based participatory research approach in children and adolescents to assess the appropriateness of this approach in this population. ^ Method. Studies using CBPR in youth populations were identified using Medline and other Internet searches through both MeSH heading and text-word searches. ^ Results. A total of 16 studies were identified and analyzed for this review. Nine of the sixteen studies were experimental or quasi-experimental design, with Asthma being the most commonly studied disease. ^ Conclusions. While many studies using CBPR were not conducted with the level of scientific rigor typically found in clinical trial research, the studies reviewed each contributed to a greater understanding of the problems they investigated. Furthermore, interventional studies provided lasting benefits to communities under study above what would be found in studies using more traditional research approaches. While CBPR may not be appropriate for all research situations due to the time and resources required, we conclude that is a useful approach and should be considered when conducting community-based research for pediatric and adolescent populations.^

A systematic review of economic evaluations for interventions of cardiovascular diseases

Background. Cardiovascular disease (CVD) exhibits the most striking public health significance due to its high prevalence and mortality as well as huge economic burdens all over the world, especially in industrialized countries. Major risk factors of CVDs have been the targets of population-wide prevention in the United States. Economic evaluations provide structured information in regard to the efficiency of resource utilization which can inform decisions of resource allocation. The main purpose of this review is to investigate the pattern of study design of economic evaluations for interventions of CVDs. ^ Methods. Primary journal articles published during 2003-2008 were systematically retrieved via relevant keywords from Medline, NHS Economic Evaluation Database (NHS EED) and EBSCO Academic Search Complete. Only full economic evaluations for narrowly defined CVD interventions were included for this review. The methodological data of interest were extracted from the eligible articles and reorganized in Microsoft Access database. Chi-square tests in SPSS were used to analyze the associations between pairs of categorical data. ^ Results. One hundred and twenty eligible articles were reviewed after two steps of literature selection with explicit inclusion and exclusion criteria. Descriptive statistics were reported regarding the evaluated interventions, outcome measures, unit costing and cost reports. The chi-square test of the association between prevention level of intervention and category of time horizon showed no statistical significance. The chi-square test showed that sponsor type was significantly associated with whether new or standard intervention being concluded as more cost effective. ^ Conclusions. Tertiary prevention and medication interventions are the major interests for economic evaluators. The majority of the evaluations were claimed from either a provider’s or a payer’s perspective. Almost all evaluations adopted gross costing strategy for unit cost data rather than micro costing. EQ-5D is the most commonly used instrument for subjective outcome measurement. More than half of the evaluations used decision analytic modeling techniques. The lack of consistency in study design standards in published evaluations appears in several aspects. Prevention level of intervention is not likely to be a factor for evaluators to decide whether to design an evaluation in a lifetime horizon or not. Published evaluations sponsored by industry are more likely to conclude that new intervention is more cost effective than standard intervention.^

Plasma homocysteine levels and Alzheimer's Disease: A systematic review

Objective. To systematically review studies published in English on the relationship between plasma total homocysteine (Hcy) levels and the clinical and/or postmortem diagnosis of Alzheimer's disease (AD) in subjects who are over 60 years old.^ Method. Medline, PubMed, PsycINFO and Academic Search Premier, were searched by using the keywords "homocysteine", "Alzheimer disease" and "dementia", and "cognitive disorders". In addition, relevant articles in PubMed using the "related articles" link and by cross-referencing were identified. The study design, study setting and study population, sample size, the diagnostic criteria of the National Institute of Neurological and Communicative Disorders and Stroke (NINCDS) and the Alzheimer's Disease and Related Disorders Association (ADRDA), and description of how Hcy levels were measured or defined had to have been clearly stated. Empirical investigations reporting quantitative data on the epidemiology of the relationship between plasma total Hcy (exposure factor) and AD (outcome) were included in the systematic review.^ Results. A total of 7 studies, which included a total of 2,989 subjects, out of 388 potential articles met the inclusion criteria: four case control and three cohort studies were identified. All 7 studies had association statistics, such as the odds ratio (OR), the relative rates (RR), and the hazard ratio (HR) of AD, examined using multivariate and logistic regression analyses. Three case - comparison studies: Clarke et al. (1998) (OR: 4.5, 95% CI.: 2.2 - 9.2); McIlroy et al. (2002) (OR: 2.9, 95% CI.: 1.00–8.1); Quadri et al. (2004) (OR: 3.7, 95% CI.: 1.1 - 13.1), and two cohort studies: Seshadri et al. (2002) (RR: 1.8, 95% CI.: 1.3 - 2.5); Ravaglia et al. (2005) (HR: 2.1, 95% CI.: 1.7 - 3.8) found a significant association between serum total Hcy and AD. One case-comparison study, Miller et al. (2002) (OR: 2.2, 95% C.I.: 0.3 -16), and one cohort study, Luchsinger et al. (2004) (HR: 1.4, 95% C.I.: 0.7 - 2.3) failed to reject H0.^ Conclusions. The purpose of this review is to provide a thorough analysis of studies that examined the relationship between Hcy levels and AD. Five studies showed a positive statistically significant association between elevated total Hcy values and AD but the association was not statistically significant in two studies. Further research is needed in order to establish evidence of the strong, consistent association between serum total Hcy and AD as well as the presence of the appropriate temporal relationship. To answer these questions, it is important to conduct more prospective studies that examine the occurrence of AD in individuals with and without elevated Hcy values at baseline. In addition, the international standardization of measurements and cut-off points for plasma Hcy levels across laboratories is a critical issue to be addressed for the conduct of future studies on the topic.^

A systematic review of literature on socioeconomic disparities in the prevalence of dental caries

Dental caries, also known as tooth decay, are a disease of the oral cavity that affects the tooth structure and leads to the occurrence of cavities in teeth. Dental caries are one of the leading chronic diseases in the population and are very common in childhood. If not treated appropriately, dental caries have debilitating effect on the oral and general health of individuals. ^ Objectives. The aims of this review are to (1) analyze and elucidate the relationship between the social and economic determinants of health like income, education and race/ethnicity and the prevalence of dental caries and (2) identify and understand the pathways/underlying causes through which these factors affect the occurrence of dental caries. This review will provide a foundation for formulation of better oral health policies in future by identifying the key socio-economic factors and pathways affecting the prevalence of dental caries. Knowledge about these socioeconomic factors could be incorporated in the design of future policies and interventions to achieve greater benefits.^ Methods. This review includes information from all pertinent articles, reviews, surveys, reports, peer reviewed literature and web sources that were published after 2000. The selection criterion includes literature focusing on individuals between the ages of 1 to 65 years, and individuals from different subgroups of community based on income, education and race/ethnicity. The analyses of literature include identifying if a relationship between income/education/race and the prevalence of dental caries exists by comparing the prevalence of dental caries in different socio-economic groups. Also included in this review are articles that are relevant to the mechanisms/pathways through which income/education/race affect the prevalence of dental caries.^ Results. Analyses of available literature suggests that disparities in the prevalence of dental caries may be attributed to differences in income, education and race/ethnicity. Higher prevalence of dental caries was observed in African-American and Mexican-American individuals, and in people with low income and low education. The leading pathways through which the socioeconomic factors affect the prevalence of dental caries are the lack of access to dental care, lack of awareness about good oral hygiene beliefs and habits, oral health, inability to afford dental care, lack of social support to maintain oral health and lack of dental insurance.^ Conclusion. Disparities in the prevalence of dental caries exist in various socio-economic groups. The relationship between socio-economic factors and dental caries prevalence should be considered in the development of future policies and interventions that are aimed at reducing the prevalence of dental caries and enhancing oral health status.^

Errors in the administration of medication in inpatient hospitals: A systematic review of the research literature on commercial computerized physician order entry systems

Errors in the administration of medication represent a significant loss of medical resources and pose life altering or life threatening risks to patients. This paper considered the question, what impact do Computerized Physician Order Entry (CPOE) systems have on medication errors in the hospital inpatient environment? Previous reviews have examined evidence of the impact of CPOE on medication errors, but have come to ambiguous conclusions as to the impact of CPOE and decision support systems (DSS). Forty-three papers were identified. Thirty-one demonstrated a significant reduction in prescribing error rates for all or some drug types; decreases in minor errors were most often reported. Several studies reported increases in the rate of duplicate orders and failures to remove contraindicated drugs, often attributed to inappropriate design or to an inability to operate the system properly. The evidence on the effectiveness of CPOE to reduce errors in medication administration is compelling though it is limited by modest study sample sizes and designs. ^

Biomedical informatics applications for epilepsy management: A systematic review

Epilepsy is a very complex disease which can have a variety of etiologies, co-morbidities, and a long list of psychosocial factors4. Clinical management of epilepsy patients typically includes serological tests, EEG's, and imaging studies to determine the single best antiepileptic drug (AED). Self-management is a vital component of achieving optimal health when living with a chronic disease. For patients with epilepsy self-management includes any necessary actions to control seizures and cope with any subsequent effects of the condition9; including aspects of treatment, seizure, and lifestyle. The use of computer-based applications can allow for more effective use of clinic visits and ultimately enhance the patient-provider relationship through focused discussion of determinants affecting self-management. ^ The purpose of this study is to conduct a systematic literature review on informatics application in epilepsy self-management in an effort to describe current evidence for informatics applications and decision support as an adjunct to successful clinical management of epilepsy. Each publication was analyzed for the type of study design utilized. ^ A total of 68 publications were included and categorized by the study design used, development stage, and clinical domain. Descriptive study designs comprised of three-fourths of the publications and indicate an underwhelming use of prospective studies. The vast majority of prospective studies also focused on clinician use to increase knowledge in treating patients with epilepsy. ^ Due to the chronic nature of epilepsy and the difficulty that both clinicians and patients can experience in managing epilepsy, more prospective studies are needed to evaluate applications that can effectively increase management activities. Within the last two decades of epilepsy research, management studies have employed the use of biomedical informatics applications. While the use of computer applications to manage epilepsy has increased, more progress is needed.^

Treatment modalities of female Operation Iraqi Freedom/Operation Enduring Freedom Veterans with posttraumatic stress disorder: A systematic review of the literature

Objective. To review professional literature regarding treatment modalities of post-traumatic stress disorder (PTSD) amongst female Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF) veterans, to assess the efficacy of these treatment options, and to summarize implications of the findings from this literature. Design. Systematic review of published literature. Data sources. Medline, Pubmed, Psycinfo. Review Methods. Articles selected for the literature review pertain to the treatment options of female OIF or OEF veterans who have a diagnosis of PTSD. In addition, other relevant articles, such as articles that discuss the prevalence of the problem, access to care, and similar treatment modalities for PTSD in other war settings, were selected for background information for the review. Results. The search strategy identified 1,305 potential journal articles, taken from thorough searches in Medline, Pubmed, and Psycinfo. These articles were then imported into Refworks. Following final screening, there were 18 articles included in the systematic review and 28 articles used as background information. The remaining articles were excluded following screening of abstract and/or full text of articles. Treatment modalities presented in these trials include: Exposure Therapy (average of 68% reduction in PTSD symptoms), Imagery Rehearsal Therapy (23% reduction), Body-Oriented Therapy (57% reduction), Electroconvulsive Therapy (35% reduction), Holographic Reprocessing (47% reduction), a self-defense training program (13% reduction), Cognitive Behavioral Therapy (65% reduction) and a variety of pharmacotherapies (antipsychotics at 81% reduction, sympatholytic drug at 100% reduction). Outcomes of the studies included in this systematic review were measured by using personal assessment of whether there was a reduction in symptoms of PTSD, based on the results in each study. Conclusion. Overall, all of the treatment modalities investigated in the systematic review proved to be somewhat effective in relieving the burden of symptoms of PTSD amongst female veterans of OIF/OEF. In addition to pharmacotherapy, which had the highest reduction in PTSD symptoms, both the Exposure Therapy and the Cognitive Behavioral Therapy techniques proved to have the most positive results. As all of the therapies had a positive effect on this population, to some degree, a study needs to be done in the future to compare and contrast the efficacy of each therapy intervention when applied to a standardized population.^

Factors associated with contraception use among postpartum or parenting Latina adolescents: A systematic review

Despite advances in effective and long-acting contraceptive methods and the introduction into health care that an initial unplanned pregnancy allows, repeat unplanned pregnancy continues to affect Hispanic adolescents at a rate higher than that of non-Hispanic whites. The current study was undertaken to identify and categorize factors associated with uptake of long acting contraception (implant or intrauterine devices) or consistent use of highly effective methods (injectable DMPA, ring, patch, or pills), among Hispanic/Latina teens who have previously given birth. ^ I searched Ovid Medline, Pubmed, CINAHL, PsychINFO, POPLINE and Scopus, and reference lists for studies in English, ≥1980, of original data from the United States on factors related to initiation, maintenance, or discontinuation of contraceptive methods in postpartum or parenting adolescent females. I then identified articles that specified the inclusion of Hispanics/Latinas in the study population and either reported findings specific to race/ethnicity or used race/ethnicity as an independent variable in analyses of contributing factors. I then extracted data for each study and categorized independent variables as predisposing, enabling, or reinforcing following the PRECEDE model.1 Factors found to be associated with contraception use or non-use were combined to create a logic model of risk. ^ Of 9 eligible studies, one solely addressed initiation; one, initiation and maintenance; two, initiation and discontinuation; three, maintenance; and two, maintenance and discontinuation. There was some overlap in the studies' assessments of maintenance and discontinuation and the author(s) often did not distinguish between the two. Nearly all (k=7) were prospective observational studies with convenience samples and bivariate analyses (k=6). One study was initially a quasi-experimental design but became a prospective cohort due to extremely high attrition. Sociodemographic characteristics and predisposing factors were studied frequently, as were reinforcing factors; enabling factors were discussed infrequently and only in studies involving focus groups or interviews. Due to a paucity of research, a consensus of factors found consistently to influence the contraception behavior of postpartum Latina teens could not be established for the overall population nor for cultural subgroups. Future research is needed that focuses on postpartum/parenting Latina teens, with subgroup identification and differentiation, to determine the prevalent and pertinent predisposing, enabling, and reinforcing factors related to effective contraception initiation and maintenance.^