A survey study identified global research priorities for decreasing maternal mortality

ObjectivesThe aim of this study was to identify and prioritize research gaps to help decrease maternal mortality.Study Design and SettingWe conducted a two-stage survey. We provided participants (Cochrane Collaboration experts) with a list of 319 problem/population, intervention, comparison, and outcome questions built from 178 Cochrane systematic reviews. Questions were classified according to causes of maternal death. Respondents of the first round refined the research questions and prioritized them by eliminating those that were considered of low priority, according to four criteria. They also included additional questions. In the second round, respondents prioritized 62 questions.ResultsThe overall response rates for the first and second rounds were 47% (73 of 155) and 17% (363 of 2,121), respectively. Participants ranked 62 of the research questions as “very relevant.” Approximately 20% of all questions that were identified in Cochrane reviews and two-third of questions of the second round were considered of “very high priority.” More women (235) than men (128) participated in the survey. We did not find statistically significant differences when comparing the groups of very relevant questions by the type of respondent, income, country, and round.ConclusionWe identified research priorities by mapping and improving the understanding of research needs in low- and middle-income settings internationally.     

Prevention and self-management interventions are top priorities for osteoarthritis systematic reviews

ObjectiveTo identify high-priority research questions for osteoarthritis systematic reviews with consideration of health equity and the social determinants of health (SDH).Study Design and SettingWe consulted with experts and conducted a literature search to identify a priority-setting method that could be adapted to address the health equity and SDH. We selected the Global Evidence Mapping priority-setting method, and through consultations and consensus, we adapted the method to meet our objectives. This involves developing an evidence map of the existing systematic reviews on osteoarthritis; conducting one face-to-face workshop with patients and another one with clinicians, researchers, and patients; and conducting an online survey of patients to rank the top 10 research questions. We piloted the adapted method with the Cochrane Musculoskeletal Review Group to set research priorities for osteoarthritis.ResultsOur focus was on systematic reviews: we identified 34 high-priority research questions for osteoarthritis systematic reviews. Prevention and self-management interventions, mainly diet and exercise, are top priorities for osteoarthritis systematic reviews. Evaluation against our predefined objectives showed that this method did prioritize SDH (50% of the research questions considered SDH). There were marked gaps: no high-priority topics were identified for access to care until patients had advanced disease–lifestyle changes once the disease was diagnosed. This method was felt feasible if conducted annually.ConclusionWe confirmed the utility of an adapted priority-setting method that is feasible and considers SDH. Further testing of this method is needed to assess whether considerations of health equity are prioritized and involve disadvantaged groups of the population.     

Development and pilot test of a process to identify research needs from a systematic review

ObjectiveTo ensure appropriate allocation of research funds, we need methods for identifying high-priority research needs. We developed and pilot tested a process to identify needs for primary clinical research using a systematic review in gestational diabetes mellitus.Study Design and SettingWe conducted eight steps: abstract research gaps from a systematic review using the Population, Intervention, Comparison, Outcomes, and Settings (PICOS) framework; solicit feedback from the review authors; translate gaps into researchable questions using the PICOS framework; solicit feedback from multidisciplinary stakeholders at our institution; establish consensus among multidisciplinary external stakeholders on the importance of the research questions using the Delphi method; prioritize outcomes; develop conceptual models to highlight research needs; and evaluate the process.ResultsWe identified 19 research questions. During the Delphi method, external stakeholders established consensus for 16 of these 19 questions (15 with “high” and 1 with “medium” clinical benefit/importance).ConclusionWe pilot tested an eight-step process to identify clinically important research needs. Before wider application of this process, it should be tested using systematic reviews of other diseases. Further evaluation should include assessment of the usefulness of the research needs generated using this process for primary researchers and funders.     

An equity lens can ensure an equity-oriented approach to agenda setting and priority setting of Cochrane Reviews

ObjectivesThis study aimed to develop and pilot an equity lens that could help researchers in developing a more equity-oriented approach toward priority setting and agenda setting in systematic reviews.Study Design and SettingWe developed an equity lens to guide the development and evaluation of a prioritization process and evaluate its outcomes based on the information derived from a discussion workshop and a comparison with the existing literature on the topic. We piloted the process section of the equity lens across the 13 structured priority-setting approaches in the Cochrane Collaboration.ResultsWe devised an equity lens with two checklists: one to guide the process of priority setting (nine questions) and the other to evaluate the outcomes of priority setting (eight questions). Of the nine questions, seven questions were partially addressed by at least one of the prioritization projects. Two questions were not considered in any of them. The prioritization projects did not report sufficient outcome data, thus we could not explore the eight question on evaluating outcomes.ConclusionCurrently, there are few strategies in the Cochrane Collaboration that explicitly address the research priorities of individuals from different sociodemographic groups. The equity lens for priority setting and agenda setting can help project teams to develop a more equity-oriented approach to set a research agenda and/or prioritize research topics. However, further studies are needed to evaluate its impact on the prioritization process.     

A framework for effective collaboration between specialist and broad-spectrum groups for delivering priority Cochrane reviews

ObjectivesWe aimed to develop and pilot a process for joint working between Cochrane Review Groups (specialist-area groups responsible for producing Cochrane reviews) and Cochrane Fields (broad-spectrum interest groups), for identifying high priority review topics and enhancing quality and dissemination of priority reviews.Study Design and SettingWe developed and piloted a framework for collaboration between a Cochrane Review Group (specializing in musculoskeletal injuries) and a Cochrane Field (focusing on health care of older people) for identifying, delivering, and disseminating priority Cochrane intervention reviews using hip fracture rehabilitation as an exemplar. The processes adopted included consultation of members of both the entities, mapping of trials from the Review Group’s Specialized Register, jointly establishing criteria for topic prioritization, identification of researchers, and facilitating provision of expert peer review from the field.ResultsA framework for effective collaboration between a Cochrane Review Group and Cochrane Field for identifying and delivering priority Cochrane Reviews was devised and piloted. Additionally, two new Cochrane reviews, preceded by protocols, were published.ConclusionThe project demonstrated the feasibility and potential benefits of a structured collaboration between a Cochrane Review Group and a Cochrane Field for the identification and production of Cochrane reviews on priority topics.     

Review of mixed treatment comparisons in published systematic reviews shows marked increase since 2009

ObjectivesTo identify and summarize published systematic reviews that report results of meta-analyses that combined direct and indirect comparisons.Study Design and SettingNarrative review of mixed treatment comparisons (MTCs) reported in systematic reviews of health interventions. MEDLINE, MEDLINE In-Process, Embase, CINAHL, DARE, the Cochrane Database of Systematic Reviews, and SIGLE were searched for reviews published up to June 2012 in which a meta-analysis had been conducted that combined direct and indirect comparisons among more than two interventions.ResultsReviews reporting MTCs are difficult to identify when searching major databases. These databases offer no way to identify MTCs, and authors use various names when reporting them. Of the 201 eligible reviews identified, more than three-quarters had been published in full. MTC methods have been used to study a wide range of clinical topics. The reported use of these methods has increased rapidly since 2009, and results from MTCs are commonly used in health policy decisions, through the evidence considered in health technology assessments.ConclusionIn view of the increasing use of MTCs, indexing of this study type in databases and a consensus on terminology and standards for conduct and reporting would be timely.     

Cochrane reviews used more rigorous methods than non-Cochrane reviews: survey of systematic reviews in physiotherapy

ObjectiveTo describe the quality and methods of systematic reviews of physiotherapy interventions, compare Cochrane and non-Cochrane reviews, and establish the interrater reliability of the Overview Quality Assessment Questionnaire (OQAQ) quality assessment tool.Study Design and SettingA survey of 200 published systematic reviews was done. Two independent raters assessed the search strategy, assessment of trial quality, outcomes, pooling, conclusions, and overall quality (OQAQ). The study was carried out in the University research center.ResultsIn these reviews, the five most common databases searched were MEDLINE, EMBASE, Cochrane Library, CINAHL, and Cochrane Review Group Registers. The Cochrane allocation concealment system and Jadad Scale were most frequently used to assess trial quality. Cochrane reviews searched more databases and were more likely to assess trial quality, report dichotomous outcomes for individual trials, and conduct a meta-analysis than non-Cochrane reviews. Non-Cochrane reviews were more likely to conclude that there was a beneficial effect of treatment. Cochrane reviews were of higher quality than non-Cochrane reviews. There has been an increase in the quality of systematic reviews over time. The OQAQ has fair to good interrater reliability.ConclusionThe quality of systematic reviews in physiotherapy is improving, and the use of Cochrane Collaboration procedures appears to improve the methods and quality.     

Converting systematic reviews to Cochrane format: a cross-sectional survey of Australian authors of systematic reviews

Background

Despite the growing reputation and subject coverage of the Cochrane Database of Systematic Reviews, many systematic reviews continue to be published solely in paper-based health care journals. This study was designed to determine why authors choose to publish their systematic reviews outside of the Cochrane Collaboration and if they might be interested in converting their reviews to Cochrane format for publication in the Cochrane Database of Systematic Reviews.

Methods

Cross-sectional survey of Australian primary authors of systematic reviews not published on the Cochrane Database of Systematic Reviews identified from the Database of Abstracts of Reviews of Effectiveness.

Results

We identified 88 systematic reviews from the Database of Abstracts of Reviews of Effectiveness with an Australian as the primary author. We surveyed 52 authors for whom valid contact information was available. The response rate was 88 per cent (46/52). Ten authors replied without completing the survey, leaving 36 valid surveys for analysis. The most frequently cited reasons for not undertaking a Cochrane review were: lack of time (78%), the need to undergo specific Cochrane training (46%), unwillingness to update reviews (36%), difficulties with the Cochrane process (26%) and the review topic already registered with the Cochrane Collaboration (21%). (Percentages based on completed responses to individual questions.) Nearly half the respondents would consider converting their review to Cochrane format. Dedicated time emerged as the most important factor in facilitating the potential conversion process. Other factors included navigating the Cochrane system, assistance with updating and financial support. Eighty-six per cent were willing to have their review converted to Cochrane format by another author.

Conclusion

Time required to complete a Cochrane review and the need for specific training are the primary reasons why some authors publish systematic reviews outside of the Cochrane Collaboration. Encouragingly, almost half of the authors would consider converting their review to Cochrane format. Based on the current number of reviews in the Database of Abstracts of Reviews of Effectiveness, this could result in more than 700 additional Cochrane reviews. Ways of supporting these authors and how to provide dedicated time to convert systematic reviews needs further consideration.

     

Is there a solution to publication bias? Researchers call for changes in dissemination of clinical research results

ObjectivesTo explore opinions of authors of published reports of clinical trials and Cochrane systematic reviews on the causes and methods of preventing publication bias.Study Design and SettingAn online questionnaire was developed and sent to researchers publishing in high-impact or national general medical journals, authors of Cochrane systematic reviews, and a general population of researchers. Open-ended questions about publication bias were qualitatively analyzed. We also held a focus group with experienced researchers and/or Cochrane reviewers.ResultsPublication bias was common: 48 (36%) respondents had own unpublished trials and 40 (30%) admitted selective outcome reporting; but researchers felt strongly that blame rested also with the system that promotes and augments publication bias practices. Qualitative analysis of both survey responses and focus group discussion identified possible ways of reducing publication bias through increased transparency, improvements to trial registries, search engines and databases, enhancement of the role of institutional review boards, positive encouragement of scientists, and policy changes.ConclusionAlthough well aware of the problem, clinical researchers knowingly contribute to problems of selective reporting and nonpublication of trials. They call for changes in current practices of journal-based communication of trial reporting and for systematic evaluation of measures to decrease publication bias.     

Three challenges described for identifying participants with missing data in trials reports,and potential solutions suggested to systematic reviewers

ObjectiveTo categorize the challenges in determining the extent of missing participant data in randomized trials and suggest potential solutions for systematic review authors.Study Design and SettingDuring the process of updating a series of Cochrane systematic reviews on the topic of anticoagulation in patients with cancer, we identified challenges and used an iterative approach to improve, and a consensus process to agree on the challenges identified, and to suggest potential ways of dealing with them. The five systematic reviews included 58 trials and 75 meta-analyses for patient-important dichotomous outcomes with 27,037 randomized participants.ResultsWe identified three categories of challenges: (1) Although systematic reviewers require information about missing data to be reported by outcome, trialists typically report the information by participant; (2) It is not always clear whether the trialists followed up participants in certain categories (e.g., noncompliers), that is, whether some categories of participants did or did not have missing data; (3) It is not always clear how the trialists dealt with missing data in their analysis (e.g., exclusion from the denominator vs. assumptions made for the numerator). We discuss potential solutions for each one of these challenges and suggest further research work.ConclusionCurrent reporting of missing data is often not explicit and transparent, and although our potential solutions to problems of suboptimal reporting may be helpful, reliable and valid characterization of the extent and nature of missing data remains elusive. Reporting of missing data in trials needs further improvement.     

Ensuring relevance for Cochrane reviews: evaluating processes and methods for prioritizing topics for Cochrane reviews

ObjectiveThe purpose of this study was to assess the presence and effectiveness of existing systems of prioritization for Cochrane review topics and to explore methods of improving those systems.Study Design and SettingWe surveyed groups of Cochrane review authors and recorded any evidence of their use of priority-setting processes or policies. To evaluate the effectiveness of the policies we encountered, we assessed them using two frameworks from the literature: “Accountability for Reasonableness” (1) and Sibbald’s 2009 framework (2) for successful priority setting. We then held two workshops with the subject groups to discuss our findings and their implications.ResultsOf the 66 groups surveyed, 29 had a system in place to inform the selection or prioritization of topics for Cochrane reviews. Fifteen groups used a more comprehensive structured approach that eventually resulted in a list of ranked priority titles for authoring, updating, or disseminating Cochrane reviews. Most groups involved researchers, practitioners, and patients in their prioritization processes.ConclusionGroups within The Cochrane Collaboration currently use a range of different priority-setting systems, some of which are more detailed than others. These differences often reflect the nature of The Cochrane Collaboration itself: given the topic breadth, history, and variety of international contexts present in the organization, a single unified system would not always be appropriate. All Cochrane entities, however, should have or develop strategic plans to improve the inclusiveness and transparency of their own prioritization processes, increase the number of finished prioritized reviews, and make more effective use of feedback from end users to increase the likelihood of producing reviews that have positive effects on health outcomes.     

Case study: A patient–clinician collaboration that identified and prioritized evidence gaps and stimulated research development

ObjectiveTo assess the effect of a research prioritization partnership that aimed to influence the research agenda relating to urinary incontinence (UI).Study Design and SettingResearch often neglects important gaps in existing evidence so that decisions must be made about treatments without reliable evidence of their effectiveness. In 2007–2009, a United Kingdom partnership of eight patient and 13 clinician organizations identified and prioritized gaps in the evidence that affect everyday decisions about treatment of UI. The top 10 prioritized research questions were published and reported to research funders in 2009. A year later, new research or funding applications relating to the prioritized topics were identified through reviews of research databases and consultation with funding organizations, elements of the research community, and organizations that participated in the partnership.ResultsSince dissemination of the prioritized topics, five studies are known to have been funded, three in development; five new systematic reviews are under way, one is being updated; five questions are under consideration by a national research commissioning body.ConclusionThe partnership successfully developed and used a methodology for identification and prioritization of research needs through patient–clinician consensus. Prioritization through consensus can be effective in informing the development of clinically useful research.     

An encouraging assessment of methods to inform priorities for updating systematic reviews

ObjectiveTo consider the use of statistical methods that aim to prioritize the updating of a collection of systematic reviews based on preliminary literature searches.Study Design and SettingA new simulation-based method estimating statistical power and the ratio of the weights assigned to the predicted new and old evidence, and the existing Barrowman n approach is considered. Using only information on the numbers of subjects randomized in the “new” trials, these were applied retrospectively, by removing recent studies, to existing systematic reviews from the Cochrane Infectious Diseases Group.ResultsTwelve systematic reviews were included. When the removed studies were reinstated, inferences changed in five of them. These reviews were ranked, in order of update priority, 1, 2, 3, 4, and 11 and 1, 2, 3, 4, and 12 by the Barrowman n and simulation-based power approaches, respectively. The low ranking of one significant meta-analysis by both methods was due to unexpectedly favorable results in the reinstated study.ConclusionThis study demonstrates the feasibility of the use of analytical methods to inform update prioritization strategies. Under conditions of homogeneity, Barrowman's n and simulated power were in close agreement. We encourage further, prospective, evaluation of these methods.     

Systematic reviewers commonly contact study authors but do so with limited rigor

ObjectivesAuthor contact can enhance the quality of systematic reviews. We conducted a systematic review of the practice of author contact in recently published systematic reviews to characterize its prevalence, quality, and results.Study Design and SettingEligible studies were systematic reviews of efficacy published in 2005–2006 in the 25 journals with the highest impact factor publishing systematic reviews in clinical medicine and the Cochrane Library, identified by searching MEDLINE, EMBASE, and the Cochrane Library. Two researchers determined whether and why reviewers contacted authors. To assess the accuracy of the abstracted data, we surveyed reviewers by e-mail.ResultsForty-six (50%) of the 93 eligible systematic reviews published in top journals and 46 (85%) of the 54 eligible Cochrane reviews reported contacting authors of eligible studies. Requests were made most commonly for missing information: 40 (76%) clinical medicine reviews and 45 (98%) Cochrane reviews. One hundred and nine of 147 (74%) reviewers responded to the survey, and reported a higher rate of author contact than apparent from the published record.ConclusionAlthough common, author contact is not a universal feature of systematic reviews published in top journals and the Cochrane Library. The conduct and reporting of author contact purpose, procedures, and results require improvement.     

Development of a framework to identify research gaps from systematic reviews

Objective

Our objective was to develop a framework to identify research gaps from systematic reviews.

Study Design and Setting

We reviewed the practices of (1) evidence-based practice centers (EPCs), and (2) other organizations that conduct evidence syntheses. We developed and pilot tested a framework for identifying research gaps.

Results

Four (33%) EPCs and three (8%) other organizations reported using an explicit framework to determine research gaps. Variations of the PICO (population, intervention, comparison, outcomes) framework were most common. We developed a framework incorporating both the characterization of the gap using PICOS elements (also including setting) and the identification of the reason(s) why the gap exists as (1) insufficient or imprecise information, (2) biased information, (3) inconsistency or unknown consistency, and (4) not the right information. We mapped each of these reasons to concepts from three common evidence-grading systems.

Conclusion

Our framework determines from systematic reviews where the current evidence falls short and why or how the evidence falls short. This explicit identification of research gaps will allow systematic reviews to maximally inform the types of questions that need to be addressed and the types of studies needed to address the research gaps.     

Outcomes in systematic reviews of complex interventions never reached “high” GRADE ratings when compared with those of simple interventions

ObjectivesTo investigate the application of the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach and the quality of evidence ratings in systematic reviews of complex interventions.Study Design and SettingThis study examined all 40 systematic reviews published in three Cochrane Review Groups from 2013 to May 2014: Cochrane Developmental, Psychosocial and Learning Problems Group (CDPLPG); Cochrane Public Health Group (CPHG); and Cochrane Depression, Anxiety, and Neurosis Group (CCDAN). The reviews were coded and classified into “complex” (n = 24) and “simple” (n = 16) intervention review groups based on the predefined complexity dimensions from the extant literature mapped into the PICOTS framework. All the data were analyzed in these two groups to help identify specific patterns of the GRADE ratings in the reviews of complex interventions.ResultsOutcomes of complex intervention reviews had higher proportions of “very low” quality of evidence ratings compared with those of simple intervention reviews (37.5% vs. 9.1% for the primary benefit outcomes) and were more frequently downgraded for inconsistency, performance bias, and study design. None of the outcomes of complex intervention reviews (0%) were given “high” GRADE ratings.ConclusionResults suggest that the GRADE assessment may not adequately describe the evidence base of complex interventions.     

Knowledge for knowledge translation: the role of the Cochrane Collaboration

Knowledge-translation (KT) activities, including continuing education, should be informed by the totality of available research evidence. Systematic reviews are a generic methodology used to synthesize evidence from a broad range of research methods addressing different questions. Over the past decade, there has been a dramatic increase in the availability of systematic reviews that could support KT activities. However, the conduct of systematic reviews is technically challenging, and it is not surprising that the quality of available reviews is variable. In addition, unless attempts are made to update systematic reviews, they rapidly become out of date. The Cochrane Collaboration is a unique, worldwide, not-for-profit organization that aims to help people make well-informed decisions about all forms of health care by preparing, maintaining, and promoting the accessibility of systematic reviews of the effects of health care interventions. Globally, over 13, 000 consumers, clinicians, policymakers, and researchers are involved with The Cochrane Collaboration and have to date produced over 2, 500 systematic reviews that can be used to inform KT activities. The Cochrane Collaboration publishes its reviews quarterly in The Cochrane Library. Cochrane reviews have been used to develop a number of KT-derivative products for professionals, consumers, and policymakers. Whereas most Cochrane Review groups focus on specific clinical areas, the Cochrane Effective Practice and Organisation of Care Group undertakes reviews of interventions to improve health care delivery and health care systems, including reviews of different KT activities. We summarize the activities of The Cochrane Collaboration and how these can contribute to KT activities.     

Economic Evaluation of Prenatal and Postpartum Care in Women With Gestational Diabetes and Hypertensive Disorders of Pregnancy: A Systematic Review

ObjectivesThis study aimed to summarize evidence on the economic outcomes of prenatal and postpartum interventions for the management of gestational diabetes mellitus and hypertensive disorders of pregnancy (HDP), assess the quality of each study, and identify research gaps that may inform future research.MethodsElectronic databases including PubMed/MEDLINE, Embase, the Cochrane Library, and Cochrane Central Register of Controlled Trials were searched from January 1, 2000, to October 1, 2021. Selected studies were included in narrative synthesis and extracted data were presented in narrative and tabular forms. The quality of each study was assessed using the Consolidated Health Economic Evaluation Reporting Standards and Consensus on Health Economic Criteria list.ResultsAmong the 22 studies identified through the systematic review, 19 reported favorable cost-effectiveness of the intervention. For prenatal management of HDP, home blood pressure monitoring was found to be cost-effective compared with in-person visits in improving maternal and neonatal outcomes. For postpartum care, regular screening for hypertension or metabolic syndrome followed by subsequent treatment was found to be cost-effective compared with no screening in women with a history of gestational diabetes mellitus or HDP.ConclusionsExisting economic evaluation studies showed that prenatal home blood pressure monitoring and postpartum screening for hypertension or metabolic syndrome were cost-effective. Nevertheless, limitations in the approach of the current economic evaluations may dampen the quality of the evidence and warrant further investigation.