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At least 631 records · Page 35Linked to original sources

PubMed2006

Effectiveness of hip protectors for preventing hip fractures in elderly people: systematic review.

OBJECTIVES: To present the updated results of systematic review of the current evidence for the effectiveness of hip protectors from reports of completed randomised trials, and to explore the evolution of that evidence. DESIGN: Systematic review with meta-analysis. DATA SOURCES: Cochrane Bone, Joint, and Muscle Trauma Group trials register (January 2005), Cochrane central register of controlled trials (Cochrane Library Issue 1, 2005), Medline (1966 to January 2005), Embase (1988 to January 2005), and CINAHL (1982 to December 2004). Other databases and reference lists of relevant articles were searched and some trialists were contacted. REVIEW METHODS: Randomised or quasirandomised controlled trials reporting the incidence of hip fractures, pelvic fractures, and other fractures in elderly people offered hip protectors compared with a control group that was not. RESULTS: Outcomes for fracture were available from 14 randomised and quasirandomised trials. Pooling of data from 11 trials carried out in nursing or residential care settings, including six cluster randomised studies, showed evidence of a marginally statistically significant reduction in incidence of hip fracture (relative risk 0.77, 95% confidence interval 0.62 to 0.97). Pooling of data from three individually randomised trials of 5135 community dwelling participants showed no reduction in hip fracture incidence with provision of hip protectors (1.16, 0.85 to 1.59). No evidence was found of any significant effect of hip protectors on incidence of pelvic or other fractures. No important adverse effects of hip protectors were reported, but compliance, particularly in the long term, was poor. CONCLUSIONS: On the basis of early reports of randomised trials, hip protectors were advocated. Accumulating evidence indicates that hip protectors are an ineffective intervention for those living at home and that their effectiveness in an institutional setting is uncertain.

Aged↗

PubMed1999

Recommendations for future studies: a systematic review of educational interventions in primary care settings.

Systematic reviews are an important part of the current move towards evidence-based practice. Independent reviewers use a variety of search strategies to identify and assess relevant articles in the field of concern. Criteria for quality must be agreed and articles evaluated accordingly. This study systematically reviewed educational interventions targeting physicians in primary care (excluding hospital clinic and academic settings) to determine their effectiveness in changing behaviour and to investigate whether studies gave information about the resource implications of the interventions described and their rationale for choosing a particular target group. Studies in English, French, or German language journals were included. The review applied the criteria of the Cochrane Collaboration for methodological quality of studies (but was not conducted under the auspices of the Cochrane Collaboration). The results showed that relatively few studies had occurred in primary care compared with academic and hospital clinic settings. Many articles did not fit the criteria for rigour of method, and those that did were very heterogeneous in method and target group. Only two studies assessed resource implications, and one study also calculated economic benefits. The review suggests that future studies should either target geographical areas or doctors with an identifiable learning need associated with patient outcome, and that studies should be evaluated on their 'intention to educate'. Evaluations of educational initiatives need to describe the resource implications versus measurable benefits of the intervention to make their studies useful to policymakers and planners of educational provision.

Education, Medical, Graduate↗

PubMed2002

Systematic reviews of the literature: the overview and meta-analysis.

Systematic reviews in the form of overviews or meta-analyses offer a solution for busy practitioners who have difficulty keeping abreast of current literature. Because systematic reviews can condense numerous studies into reliable and valid summaries of the best available evidence for a specific clinical problem, they offer significant benefit to busy clinicians. This article has summarized the major features and advantages of systematic reviews. It has distinguished those features that attempt to increase the usefulness of reviews by limiting bias, and it provided a summary of important questions clinicians can use to appraise such reviews critically. With this knowledge, clinicians should be able to use the literature more appropriately and in a timely fashion.

Dental Research↗

PubMed2006

Heroin maintenance treatment for chronic heroin-dependent individuals: a Cochrane systematic review of effectiveness.

The provision of prescribed heroin to chronic heroin-dependent individuals failing other treatments has been supported during the last 70 years on the ground that the first goal of interventions on drug users is to keep them in treatment to protect them from criminal activities and to promote social integration. To assess heroin prescription effectiveness, we conducted a Cochrane systematic review of all relevant randomized controlled trials. We searched MEDLINE, EMBASE, CINAHL, and the Cochrane Library and contacted leading researchers for ongoing studies. We found 19 eligible studies, of which 4 met our inclusion criteria (577 patients). In 1 study, patients in the heroin arm remained in treatment longer than those in the methadone arm (n = 96, RR = 2.82, 95% CI = 1.70-4.68); in 2 studies, there was no difference; and in 1 study, patients given heroin left the study earlier than those given methadone (n = 235, RR = 0.79, 95% CI = 0.68-0.90). Heroin was more effective than methadone in refraining people from using street heroin in 2 studies (n = 96, RR = 1.10, 95% CI = 0.79-1.53; n = 51, RR = 0.33, 95% CI = 0.15-0.72). In 1 study, heroin reduced the risk of being charged (RR = 0.32, 95% CI = 0.14-0.78); 2 studies showed no difference, and another 2 studies adopted a multidomain outcome enclosing criminal offense and social functioning and found improvements with heroin + methadone over methadone only. It is unclear if heroin attracts people in treatment; those in treatment use less street heroin and are likely to have less criminal activities. This review systematizes and compares studies showing some inconsistencies between their aims, their adopted outcomes, and their conclusions drawn from results.

Chronic Disease↗

PubMed2006

Risk assessment scales for pressure ulcer prevention: a systematic review.

AIM: This paper reports a systematic review conducted to determine the effectiveness of the use of risk assessment scales for pressure ulcer prevention in clinical practice, degree of validation of risk assessment scales, and effectiveness of risk assessment scales as indicators of risk of developing a pressure ulcer. BACKGROUND: Pressure ulcers are an important health problem. The best strategy to avoid them is prevention. There are several risk assessment scales for pressure ulcer prevention which complement nurses' clinical judgement. However, some of these have not undergone proper validation. METHOD: A systematic bibliographical review was conducted, based on a search of 14 databases in four languages using the keywords pressure ulcer or pressure sore or decubitus ulcer and risk assessment. Reports of clinical trials or prospective studies of validation were included in the review. FINDINGS: Thirty-three studies were included in the review, three on clinical effectiveness and the rest on scale validation. There is no decrease in pressure ulcer incidence was found which might be attributed to use of an assessment scale. However, the use of scales increases the intensity and effectiveness of prevention interventions. The Braden Scale shows optimal validation and the best sensitivity/specificity balance (57.1%/67.5%, respectively); its score is a good pressure ulcer risk predictor (odds ratio = 4.08, CI 95% = 2.56-6.48). The Norton Scale has reasonable scores for sensitivity (46.8%), specificity (61.8%) and risk prediction (OR = 2.16, CI 95% = 1.03-4.54). The Waterlow Scale offers a high sensitivity score (82.4%), but low specificity (27.4%); with a good risk prediction score (OR = 2.05, CI 95% = 1.11-3.76). Nurses' clinical judgement (only considered in three studies) gives moderate scores for sensitivity (50.6%) and specificity (60.1%), but is not a good pressure ulcer risk predictor (OR = 1.69, CI 95% = 0.76-3.75). CONCLUSION: There is no evidence that the use of risk assessment scales decreases pressure ulcer incidence. The Braden Scale offers the best balance between sensitivity and specificity and the best risk estimate. Both the Braden and Norton Scales are more accurate than nurses' clinical judgement in predicting pressure ulcer risk.

Aged↗

PubMed2001

Nursing management of chest drains: a systematic review.

The aim of this systematic review was to summarise the best available evidence relating to the nursing management of chest drains. Studies included were those involving hospital patients with a chest drain in situ. A comprehensive and systematic search of the literature was undertaken that included all major databases. Methodological quality was assessed using a developed checklist. The randomised controlled trial (RCT) design was rarely used and therefore evidence was summarised using a narrative discussion. Studies using other methods were also assessed for inclusion in this narrative summary. The findings of this review highlight the lack of research on most aspects of the nursing management of patients with chest drains in situ. RCTs suggest that chest drains remain patent with or without stripping and milking of tubes, but that the total drainage was greater from manipulated tubes. There is little evidence relating to other aspects of chest drain management such as dressing of insertion site, actions following accidental disconnection and tube removal. There is therefore a need for rigorous research in many areas of the nursing management of chest drains, particularly with subjects under the age of 18 years.

Chest Tubes↗

PubMed2005

Spinal cord stimulation for chronic back and leg pain and failed back surgery syndrome: a systematic review and analysis of prognostic factors.

STUDY DESIGN: Systematic review. OBJECTIVES: To assess efficacy and safety of spinal cord stimulation in patients with chronic leg and back pain and failed back surgery syndrome and to examine prognostic factors that predict spinal cord stimulation outcome. SUMMARY OF BACKGROUND DATA: A previous systematic review of spinal cord stimulation in patients with chronic back and leg pain and failed back surgery syndrome by Turner et al in 1995 identified 39 case studies and no controlled studies. METHODS: A number of electronic databases were searched through January 2002. Citation searching of included papers was undertaken, and gray literature was sought through contact with clinical experts. No language restrictions were applied. All controlled and noncontrolled study designs were included. Study selection was carried out independently by two reviewers. Prognostic factors (age, sex, duration of pain, time post surgery, follow-up duration, publication year, data collection year, indication, data collection country, study setting, and quality score) responsible for pain relief outcome across case series were examined using univariate and multivariate metaregression. RESULTS: One randomized controlled trial, one cohort study, and 72 case studies were included. The randomized controlled trial reported a significant benefit (P = 0.047) in the proportion of patients with failed back surgery syndrome reporting 50% or more pain relief with spinal cord stimulation (37.5%) compared with patients undergoing back reoperation (11.5%). There was evidence of substantial statistical heterogeneity (P < 0.0001) in the level of pain relief following spinal cord stimulation reported across case series studies. The four principal prognostic factors found to be predictive of increased level of pain relief with spinal cord stimulation were poor study quality score, short follow-up duration, multicenter (versus single center) studies, and the inclusion of patients with failed back surgery syndrome (versus chronic back and leg pain). Overall, 43% of patients with chronic back and leg pain/failed back surgery syndrome experienced one or more complications following a spinal cord stimulation implant, although no major adverse events were reported. CONCLUSIONS: Despite an increase in the number of studies over the last 10 years, the level of evidence for the efficacy of spinal cord stimulation in chronic back and leg pain/failed back surgery syndrome remains "moderate." Prognostic factors found to be predictive of the level of pain relief following spinal cord stimulation were study quality, follow-up duration, study setting, and patient indication.

Back Pain↗

PubMed2005

The quality of nifedipine studies used to assess tocolytic efficacy: a systematic review.

OBJECTIVE: To assess the quality of studies of nifedipine used to treat spontaneous preterm labor. DESIGN: A systematic review of study quality using a novel validity assessment tool, examining method-specific and topic-specific items in the domains of selection, performance and measurement biases. DATA SOURCES: Medline (1996-2003), EMBASE (1996-2003), BIOSIS (1993-2003), Current Contents (1995-2003), DERWENT DRUGFILE (1983-2003), Cochrane Database of Systematic Reviews. Bibliographies of existing meta-analyses and systematic reviews of nifedipine as a tocolytic. METHODS OF STUDY SELECTION: Forty-five studies evaluating the effectiveness of nifedipine were identified. DATA EXTRACTION: Each study was assessed for 40 method-specific and topic-specific items of quality in duplicate using piloted data extraction forms. Disagreements between assessors were settled by consensus/arbitration. DATA SYNTHESIS: Very few of the studies complied with adequacy criteria of quality for either method-specific or topic-specific items. There was no improvement in quality over time. The quality of method-specific items was significantly poorer when compared with topic-specific items of quality overall (P<0.0001) and in the domains of selection bias (P<0.0001) and performance bias (P<0.0001). CONCLUSION: Studies of the effectiveness of nifedipine as a tocolytic are of poorer quality with respect to method-specific items than topic-specific items. These deficiencies should be highlighted in meta-analyses or systematic reviews which measure efficacy and should influence the generation of guideline statements or recommendations for the use of nifedipine as a tocolytic. A large randomized trial fulfilling the quality items is necessary to assess the real efficacy of nifedipine in preterm labor.

Female↗

PubMedDate not supplied

[Scientific evidence on labor duration from systematic reviews].

OBJECTIVE: We examined the evidence of systematic reviews in the Cochrane Library on interventions that influence the duration of labor. MATERIAL AND METHODS: Of the 208 Cochrane Pregnancy and Childbirth systematic reviews, 69 deal with labor and birth of which 20 address the effect of intrapartum interventions. We analyzed the reviews with respect to those interventions that affected the duration of birth. RESULTS: Six reviews, related to 5 interventions (amniotomy, epidural analgesia, continuous support, amnioinfusion, and maternal position), reported a significant effect on the duration of labor. Six found no significant effect on labor duration. The remaining eight reviews did not assess the effect of the intervention on labor duration. DISCUSSION: Interventions that have a significant influence on labor duration may interact with each other. Therefore, perinatal databases should ascertain not only if but also when an intervention has been performed.

Adult↗

PubMed2004

Use of systematic reviews in the development of new provincial public health policies in Ontario.

OBJECTIVES: The study determined whether the results of recently completed systematic reviews evaluating the effectiveness of public health interventions were used in the development of new provincial policies for public health practice. METHODS: This telephone survey included all members from five review groups who updated the Ontario Mandatory Health Programs and Services guidelines for Public Health in 2000. Independent variables included characteristics of the systematic reviews, organization, and the individual. Outcomes included the use of the reviews in developing new policies and the extent to which the reviews led to new recommendations for practice. Descriptive summaries as well as multiple linear regression were conducted. RESULTS: Eighty-five percent of decision-makers agreed to participate in the study. Ninety-six percent of respondents reported that the systematic reviews played a part in developing the new guidelines, while 47 percent indicated that the reviews contributed a great deal to the development of new recommendations for practice. The multiple linear regression model explained 42 percent of the variation in use of the reviews for developing new recommendations for practice. Significant predictor variables included the importance of the reviews in comparison to other sources of information and relevance of the reviews to the policy decisions. CONCLUSION: Public health decision-makers in Ontario have very positive perceptions of the usefulness of systematic reviews in policy development. Therefore, ongoing efforts to promote the usefulness and relevance of systematic reviews to public health decision-makers should remain a priority for health services researchers.

Cross-Sectional Studies↗

PubMed2006

Managing anterior cruciate ligament deficiency in the skeletally immature individual: a systematic review of the literature.

OBJECTIVE: To perform a systematic review of the literature to answer whether early ACL reconstruction for a skeletally immature individuals result in improved outcome compared with nonsurgical treatment or delaying the reconstruction until skeletal maturity in the pediatric athlete. DATA SOURCES: Articles were restricted to the English language, and 6 databases were searched (MEDLINE, CINAHL, EMBASE, ACP Journal Club, Cochrane Central Register of Controlled Trials, and the Cochrane Database of Systematic Reviews). The following keywords were used: anterior cruciate ligament, ACL, child, immature, pediatric, pediatric, and young. SELECTION CRITERIA: All studies examining the ACL reconstruction in skeletally immature individuals, including citations describing complications. Excluded were articles looking at ACL repairs and ACL avulsion injuries. All types of study design, including review articles, were included. Comparative studies were reviewed in detail and analyzed qualitatively. DATA EXTRACTION AND SYNTHESIS: A total of 615 articles were identified. Sixty-six articles met the inclusion and exclusion criteria. There were no articles with levels of evidence better than level III. The majority of the articles represented case series and reviews with expert opinion. RESULTS: There were 7 articles that provided comparisons between surgical and nonsurgical treatment in order to answer the question. CONCLUSIONS: The study designs are inadequate to answer the question of whether early or delayed ACL reconstruction results in the best possible outcome in skeletally immature individuals. Future prospective studies are required to answer the question adequately. A proposed algorithm was described to deal with the question.

Adolescent↗

PubMed2005

Systemic therapy for advanced uterine sarcoma: a systematic review of the literature.

OBJECTIVE: To conduct a systematic review of the literature regarding the systemic treatment of advanced uterine sarcoma and provide an evidence-based summary of the available literature. METHODS: MEDLINE, EMBASE, and the Cochrane Library databases were searched. "Uterine sarcoma," "leiomyosarcoma," "mixed mesodermal tumor," "chemotherapy," and "systemic therapy" were combined with the search terms for study designs. RESULTS: Three randomized controlled trials and 24 prospective phase II trials were included in the systematic review. In a randomized trial of doxorubicin versus doxorubicin plus cyclophosphamide for advanced or recurrent uterine sarcoma, doxorubicin produced an overall response rate (RR) of 19% and median survival of 11.6 months, which was similar to the response with combination chemotherapy (RR 19%, median survival 10.9 months). A randomized trial comparing ifosfamide plus cisplatin versus ifosfamide alone in mixed mesodermal tumors showed a significant improvement in RR and progression-free survival with the combination compared with ifosfamide alone, however, the combination was associated with increased toxicity including death. A randomized trial comparing doxorubicin to doxorubicin with dacarbazine in women with advanced or recurrent uterine sarcoma demonstrated a significantly higher RR with the combination (P < 0.05), but no significant difference in survival. CONCLUSIONS: Offering palliative chemotherapy to patients with advanced, unresectable uterine sarcoma who are symptomatic from this disease is a reasonable decision. Doxorubicin is an option for women with advanced uterine sarcoma. The combination of cisplatinum and ifosfamide is also an option for women with metastatic mixed mesodermal tumors; however, this combination is associated with significant toxicity when compared to ifosfamide alone.

Clinical Trials, Phase II as Topic↗

PubMed2001

Discontinuation of antihypertensive drugs due to adverse events: a systematic review and meta-analysis.

We conducted a systematic review of randomized, controlled, monotherapy trials since 1990 of oral antihypertensive agents in patients with essential hypertension. Our objective was to quantify the frequency of discontinuation of antihypertensive agents due to adverse events from a meta-analysis of the studies. A total of 190 studies met inclusion criteria. The highest frequency of discontinuations due to adverse events (DAEs) occurred with calcium channel blockers (6.7%) and alpha-adrenergic blockers (6.0%); the lowest with diuretics and angiotensin receptor blockers (each 3.1%). Only in calcium channel blocker studies was the frequency of DAEs greater in treated patients than in patients receiving placebo, but the difference was not significant. This systematic review suggests that the frequency of DAEs in monotherapy antihypertensive trials varies across drug classes and should be considered when choosing drugs for patients with essential hypertension.

Antihypertensive Agents↗

PubMedDate not supplied

[Volume and health outcomes: an overview of systematic reviews].

BACKGROUND: Improving quality and effectiveness of health care is one of the priorities of health policies. Hospital or physician volume of activity may be a measurable variable with a relevant impact on effectiveness of health care. There are several studies and systematic reviews evaluating the association between volume and outcome of health care. The aim of this review is to identify: areas, clinical conditions or interventions (prevention, diagnostic, therapeutic, surgical or clinical) for which an association between volume and outcome has been investigated; those for which an association between volume and outcome has been proved METHODS: Overview of systematic reviews and Health Technology Assessment reports; search of MEDLINE, EMBASE, The Cochrane Library, Web sites of Health Technology Assessment, other HTA Agencies, National guideline Clearinghouse, National Health Care quality tools (1995-february 2005). For each studied area results are described separately for each review due to the heterogeneity of outcomes, volume thresholds and results reported. No metanalysis has been conducted. Completeness of reporting of the systematic reviews has been evaluated using the QUOROM statement. For each review we evaluated the number of studies included and the proportion of studies with statistically significant results (p < 0,05). As far as in-hospital mortality is concerned, the different areas have been classified in the following groups: Strong evidence ofpositive association: areas with > or =10 studies included in the reviews, and high prevalence (> or =50%) of positive studies (p <0. 05) in the majority of reviews. Weak evidence of association: areas with 5 to 9 studies included in the reviews and high prevalence (> or =50%) of positive studies (p <0.05) in the majority of reviews. Weak evidence of lack of association: areas with 5 to 9 studies included in the reviews and high prevalence (>50%) of not statistically significant studies (p >0.05) in the majority of reviews. No suficient evidence of association: areas with less than 5 studies included in the reviews. No evidence of association: areas with > or =10 studies included in the reviews, and high prevalence (>50%) of not statistically significant studies (p >0.05) in the majority of reviews. The same literature search was then applied to identify primary studies published in each considered area following the most recent systematic review published. RESULTS AND DISCUSSION: We identified 21 systematic reviews and included 11 of them analysing 46 different areas. The majority of studies evaluate the effect of specific surgical procedures; the main outcomes considered are hospital mortality and 5 year survival for cancers. Considering in-hospital mortalilty as outcome, in 11 areas there is strong evidence ofassociation between volume of activity and outcome: abdominalaortic aneurysm (unruptured), percutaneous transluminal coronary angioplasty knee arthroplasty coronary artery bypass, surgery for oesophageal and pancreatic cancer, surgery for prostate cancer, colecistectomy, carotid endarterectomy, myocardial infarction, neonatal intensive care. It is never possible however to identify a unique volume threshold. For some of these areas, particularly coronary angioplasty and coronary artery bypass, there are many new studies published following the last systematic review; some specific aspects are being investigated such as the role of temporal changes in the association, the effect of different risk adjustment procedures and the separate role of physician or hospital volume. In some cases, for example knee arthroplasty in-hospital mortality could be an inadequate outcome on which judging the strength of association, in fact, the few studies evaluating other outcomes such as complications provide inconsistent results. For a range of areas the evidence of association is weak: AIDS, appendicectomy, cardiac catheterization, surgery for breast, lung, stomach cancer, hernia repair, hip fracture, hysterectomy and injuries. As far as AIDS is concerned, the few number of studies found is probably due to the lack of studies published after the introduction of effective therapies. All the included studies show an evidence of association between volume and in-hospital mortality. In no case we found weak evidence of lack of association while we identified three conditions for which the number of studies included in the reviews together with the prevalence of non significant studies do suggest lack of association; these are abdominal aortic aneurysm (ruptured), hip arthroplasty and surgery for colorectal cancer. In the case of hip arthroplasty as well, inhospital mortality could be an inadequate outcome, but only one old study found a positive association with risk of complications. Eventually there is a group of areas (n=22) for which there is not enough evidence to draw conclusions about the association between volume and outcome due to a small number of studies. In some cases, such as transplants, this could be due to the low rate of events; in this case all the few published studies show positive results. There are some limitations which should be taken into account in the interpretation of these results: despite the overall good completeness of reporting of the included reviews, the majority of studies included in the reviews themselves are cross-sectional studies representing a very weak study design to evaluate causality of the investigated association. Moreover the methodology of risk adjustment applied is heterogenous among studies and it is difficult to know the extent to which this can affect the observed results. It is eventually necessary to consider the possible occurrence of publication bias which could lead to an overestimation of the positive effect of volume on health care outcomes attributable to the lack of publication of negative studies. CONCLUSIONS: In some areas the evidence seems strong enough to guide health care organizational choices, although it is not possible to identify well defined volume thresholds. In other areas, particularly for non surgical conditions, where there is not enough evidence, it seems necessary to conduct proper epidemiological studies. Also the evaluation of effectiveness of using volume as an instrument of health policy requires further research. Taking into account the rapid and continuing process of technology development, the definition of standard and prerequisite volumes of care should be specific of each temporal period and health care system. It is therefore a dynamic process requiring a continuous review of the available evidence. In the area of evidence based public health, the limited available evidence should not impair the choice of actions based on limited evidence, but rather it should lead to the application of thefew available evidence on one side and to the planning of proper research in the areas of lack of evidence.

Evidence-Based Medicine↗

PubMed1999

Biofeedback or pelvic floor muscle exercises for female genuine stress incontinence: a meta-analysis of trials identified in a systematic review.

OBJECTIVE: To test, by meta-analysis, the conclusion of a systematic review that biofeedback was no more effective than pelvic floor muscle exercises alone for the treatment of female genuine stress urinary incontinence. MATERIALS AND METHODS: Data extracted from the five trials identified in the systematic review were subjected to pooled analysis of odds ratios for the outcome of 'cure'. RESULTS: The odds ratio for biofeedback combined with pelvic floor muscle exercises, compared with pelvic floor muscle exercises alone, leading to cure was 2.1 (95% confidence interval 0.99-4.4). CONCLUSIONS: Biofeedback may be an important adjunct to pelvic floor muscle exercises alone in the treatment of female genuine stress urinary incontinence. A quantitative statistical analysis of the studies identified leads to different conclusions from those in the systematic review.

Biofeedback, Psychology↗

PubMed2002

Systematic reviews in rehabilitation for stroke: issues and approaches to addressing them.

OBJECTIVES: To describe the problems encountered when undertaking systematic reviews of rehabilitation and to give advice to reviewers about ways of addressing these issues. BACKGROUND: Evidence-based practice has become established as a way of linking clinical practice with research evidence. The most robust evidence is usually considered to be that from randomized controlled trials, and from systematic reviews of these trials. However, most reviews have focused on drug and surgical interventions, and few reviews have been produced in the field of rehabilitation. This may be due to the unique difficulties that are posed by reviews in this area. EXPERIENCE OF SYSTEMATIC REVIEWS IN APHASIA: We describe the challenges that occurred when carrying out systematic reviews of speech and language therapy for aphasia following stroke, and of ways to deliver rehabilitation services to people who have suffered a stroke. Issues arose at all stages of the reviews and included: using expertise; planning the review; defining the health care problem, patients, outcomes and interventions of interest; searching for, interpreting and synthesizing the results of the studies identified; and deriving implications from the review. Suggestions made to address these challenges include: developing a suitable team of reviewers; using inclusive and broad criteria for inclusion of trials to a review; developing appropriate search strategies; and using caution in arriving at conclusions. It is important to be explicit about decisions made during the review process concerning how to handle the challenges. Practical advice about carrying out reviews in the field of stroke rehabilitation is likely to be helpful to reviewers of other rehabilitative interventions. There are likely to be relatively few studies available for such reviews, and limitations in drawing specific practical conclusions. Such undertakings are, however, useful in setting the agenda for further research.

Humans↗

PubMed1997

Quantitative synthesis in systematic reviews.

The final common pathway for most systematic reviews is a statistical summary of the data, or meta-analysis. The complex methods used in meta-analyses should always be complemented by clinical acumen and common sense in designing the protocol of a systematic review, deciding which data can be combined, and determining whether data should be combined. Both continuous and binary data can be pooled. Most meta-analyses summarize data from randomized trials, but other applications, such as the evaluation of diagnostic test performance and observational studies, have also been developed. The statistical methods of meta-analysis aim at evaluating the diversity (heterogeneity) among the results of different studies, exploring and explaining observed heterogeneity, and estimating a common pooled effect with increased precision. Fixed-effects models assume that an intervention has a single true effect, whereas random-effects models assume that an effect may vary across studies. Meta-regression analyses, by using each study rather than each patient as a unit of observation, can help to evaluate the effect of individual variables on the magnitude of an observed effect and thus may sometimes explain why study results differ. It is also important to assess the robustness of conclusions through sensitivity analyses and a formal evaluation of potential sources of bias, including publication bias and the effect of the quality of the studies on the observed effect.

Bias↗

PubMed2002

Systematic review of cost effectiveness studies of telemedicine interventions.

OBJECTIVES: To systematically review cost benefit studies of telemedicine. DESIGN: Systematic review of English language, peer reviewed journal articles. DATA SOURCES: Searches of Medline, Embase, ISI citation indexes, and database of Telemedicine Information Exchange. STUDIES SELECTED: 55 of 612 identified articles that presented actual cost benefit data. MAIN OUTCOME MEASURES: Scientific quality of reports assessed by use of an established instrument for adjudicating on the quality of economic analyses. RESULTS: 557 articles without cost data categorised by topic. 55 articles with data initially categorised by cost variables employed in the study and conclusions. Only 24/55 (44%) studies met quality criteria justifying inclusion in a quality review. 20/24 (83%) restricted to simple cost comparisons. No study used cost utility analysis, the conventional means of establishing the "value for money" that a therapeutic intervention represents. Only 7/24 (29%) studies attempted to explore the level of utilisation that would be needed for telemedicine services to compare favourably with traditionally organised health care. None addressed this question in sufficient detail to adequately answer it. 15/24 (62.5%) of articles reviewed here provided no details of sensitivity analysis, a method all economic analyses should incorporate. CONCLUSION: There is no good evidence that telemedicine is a cost effective means of delivering health care.

Cost-Benefit Analysis↗