- Email: [email protected]
April 2012
JOGNN
SPECIAL REPORT
Current Resources for Evidence-Based Practice March/April 2012 Cathy L. Emeis
Correspondence Cathy L. Emeis, CNM, PhD, School of Nursing, 3455 SW US Veterans Hospital Rd. Oregon Health & Science University, Portland, OR 97239-2941. [email protected]
P
Cathy Emeis, PhD, CNM, is an assistant professor in the School of Nursing at Oregon Health & Science University, Portland, OR.
Evidence-based practice relies on the availability of the highest level of clinical evidence. The sheer volume of published studies available to the contemporary clinician can be overwhelming. Although a number of resources, such as this column, are available to organize and summarize clinical evidence, clinicians are often uncertain about the differences in types of reviews when conducting a search for clinical information. For instance, what is the difference between an integrative review and a systematic review or between a metasynthesis and a meta-analyses? Can qualitative research be included in a systematic review? How do these types of methods inform evidencebased practice?
ublished simultaneously in the Journal of Midwifery & Women’s Health 2012; 57(2).
A Review of Reviews: Systematic, Integrative, Meta-Analyses, and Metasynthesis
Meta-analyses are statistical methods to summarize research findings by combining the results of several or many quantitative studies. Metaanalyses may be included with systematic reviews or included with only select studies. Metasynthesis is a technique that combines the findings from several or many qualitative studies. In contrast, integrative reviews are narrative summaries of original research for a given subject. The reviewer uses analytic reasoning to integrate findings and summarize conclusions, typically including studies using diverse research methods. In an integrative review, findings from experimental and nonexperimental research are included. Knafl and Whitmore (2005) noted that an integrative review has the potential to play a greater role in evidence-based practice in nursing because an integrative review allows for the inclusion of findings from diverse methods of analysis as well as varied perspectives on a phenomenon. Integrative reviews are generally conducted by individuals or panels with expertise in the given topic. Integrative reviews conducted by panels are more likely to use a process of checks and balances to reduce the risk of selection bias of studies included in the review (Brown, 2012). Reviewers usually make a priori decisions regarding the range of publication years and the types of studies that will be sought in the literature. Analysis of studies ideally results in conclusions that summarize the findings of the individual studies and synthesize the conclusions for relevance to clinical practice, research, or policy. A well-conducted integrative review may serve as the background for the design of evidencebased protocols and assist the clinician to understand a topic from a variety of dimensions.
The author reports no conflict of interest or relevant financial relationships.
The overarching goal of systematic reviews is to reach conclusions for prespecified questions or objectives through a systematic analysis of several or many studies (Brown, 2012). A single study, regardless of how well it was designed and conducted, is rarely sufficient to answer a clinical question. Systematic reviews are particularly valuable for bringing together a number of separate studies and synthesizing the results. Systematic reviews rely on a process for identification of primary studies relevant to a selected topic. After identified studies have undergone a systematic appraisal, each study is assigned a quality rating (Greenhalgh, 1997). Appraising studies for quality is a hallmark of the systematic review process. Next, data are synthesized and summarized, and the findings interpreted. Authors of systematic reviews within the Cochrane Collaboration commit to updating reviews periodically as new studies emerge (Levin, 2001).
http://jognn.awhonn.org
C 2012 AWHONN, the Association of Women’s Health, Obstetric and Neonatal Nurses
Systematic and integrative reviews are strengthened by adherence to standardized methods that help to ensure rigor and quality. Knowledge of these methods can assist clinicians to access and interpret evidence to inform their practice. Although different in approach, both methods are
275
SPECIAL REPORT
Current Resources for Evidence-Based Practice March/April 2012
important tools for consumers, clinicians, scientists, and policy makers.
REFERENCES Brown, S. (2012). Evidence-based nursing. Sudbury, MA: Jones and Bartlett. Greenhalgh, T. (1997). How to read a paper: Papers that summarise other papers (systematic reviews and meta-analyses). British Medical Journal, 315, 672–675.
Updated Systematic Reviews in CSDR: Pregnancy and Birth
r r r r
Knafl, K., & Whitmore, R. (2005). The integrative review: Updated methodology. Journal of Advanced Nursing, 52, 546–553. Levin, A. (2001). The Cochrane collaboration. Annals of Internal
r
Medicine, 135, 309–312.
From Cochrane Database of Systematic Reviews (CDSR) Issue 11, 2011 New Systematic Reviews in CDSR: Pregnancy and Birth
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Analgesia for amniocentesis or chorionic villus sampling Antenatal breastfeeding education for increasing breastfeeding duration Mind–body interventions during pregnancy for preventing or treating women’s anxiety Mother and baby units for schizophrenia Risk scoring systems for predicting preterm birth with the aim of reducing associated adverse outcomes
New Systematic Reviews in CDSR: Women’s Health
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r r r
Adjuvant gonadotropin-releasing hormone analogues for the prevention of chemotherapy induced premature ovarian failure in premenopausal women Compression stockings for the initial treatment of varicose veins in patients without venous ulceration Mechanical dilatation of the cervix at nonlabor cesarean section for reducing postoperative morbidity Quadriphasic versus monophasic oral contraceptives for contraception
New Systematic Reviews in CDSR: Neonatal
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Low versus high hemoglobin concentration threshold for blood transfusion for preventing morbidity and mortality in very low-birthweight infants
New Systematic Reviews in CDSR: Clinical Practice
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276
Effectiveness of external inspection of compliance with standards in improving health care organization behavior, health care professional behavior, or patient outcomes
Active versus expectant management for women in the third stage of labor Interventions for leg cramps in pregnancy Nitric oxide donors for the treatment of preterm labor Pneumococcal vaccination during pregnancy for preventing infant infection Prophylactic oral betamimetics for reducing preterm birth in women with a twin pregnancy
Updated Systematic Reviews in CDSR: Women’s Health
r r r r r r r
Antioxidants for male subfertility Antiretroviral therapy for prevention of HIV transmission in HIV-discordant couples Exercise interventions for smoking cessation Interventions to reduce hemorrhage during myomectomy for fibroids Intraperitoneal chemotherapy for the initial management of primary epithelial ovarian cancer Medical methods for first trimester abortion Triphasic versus monophasic oral contraceptives for contraception
Updated Systematic Reviews in CDSR: Neonatal
r r r r
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Continuous nasogastric milk feeding versus intermittent bolus milk feeding for premature infants less than 1500 grams One dose per day compared to multiple doses per day of gentamicin for treatment of suspected or proven sepsis in neonates Oral immunoglobulin for the prevention of rotavirus infection in low-birth-weight infants Patient isolation measures for infants with candida colonization or infection for preventing or reducing transmission of candida in neonatal units Probiotics for the prevention of pediatric antibiotic-associated diarrhea
Cochrane Reviews are available by subscription to The Cochrane Library, and review abstracts are available without charge. See http://www.thecochranelibrary.com
From Database of Abstracts of Reviews of Effects (DARE) Recent Abstract Entries Assessing Quality of Systematic Reviews: Pregnancy and Birth
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JOGNN, 41, 275-280; 2012. DOI: 10.1111/j.1552-6909.2012.01343.x
Effect of antenatal peer support on breastfeeding initiation: a systematic review
http://jognn.awhonn.org
SPECIAL REPORT
Emeis, C. L.
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Novel biomarkers for the prediction of spontaneous preterm birth phenotype: a systematic review and meta-analysis The efficacy of hypnosis as an intervention for labor and delivery pain: a comprehensive methodological review The risk of preterm birth following treatment for precancerous changes in the cervix: a systematic review and meta-analysis Treatment of abnormal vaginal flora in early pregnancy with clindamycin for the prevention of spontaneous preterm birth: a systematic review and meta-analysis Validity of two case finding questions to detect postnatal depression: a review of diagnostic test accuracy
Recent Abstract Entries Assessing Quality of Systematic Reviews: Women’s Health
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A systematic review assessing the effectiveness of interventions to improve persistence with antiresorptive therapy in women at high risk of clinical fracture A systematic review of interventions by health care professionals on community-dwelling postmenopausal women with osteoporosis A systematic review of randomized controlled trials of interventions promoting effective condom use Effectiveness of photodynamic therapy for mammary and extramammary Paget’s disease: a state of the science review Effect of radiotherapy after breast-conserving surgery on 10-year recurrence and 15-year breast cancer death: meta-analysis of individual patient data for 10801 women in 17 randomized trials GnRH antagonists are safer than agonists: an update of a Cochrane review Radiochemotherapy versus radiotherapy in locally advanced cervical cancer: a metaanalysis School-linked sexual health services for young people (SSHYP): a survey and systematic review concerning current models, effectiveness, cost-effectiveness, and research opportunities Screening for cervical cancer: a systematic evidence review for the U.S. preventive services task force Systematic comparison of radical vaginal trachelectomy and radical hysterectomy in the treatment of early-stage cervical cancer
JOGNN 2012; Vol. 41, Issue 2
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Systematic review of the effect of external beam radiation therapy to the breast on axillary recurrence after negative sentinel lymph node biopsy Systematic review of the efficacy and safety of using mesh in surgery for uterine or vaginal vault prolapse
DARE abstracts are available without charge at http://www.crd.york.ac.uk/crdweb/
Evidence-Based Reviews From Other Sources Featured Review: Mozurkewich, E. L., Chilimigras, J. L., Berman, D. R., Perni, U. C., Romero, V. C., King, V. J., & Keeton, K. L. (2011). Methods of induction of labour: A systematic review. BMC Pregnancy Childbirth, 11(84), 1–19. doi:10.1186/14712393-11-84 The purpose of this systematic review was to summarize the best available evidence for women with a viable fetus requiring induction of labor in the third trimester of pregnancy. The authors noted that the incidence of induction of labor has increased significantly over the past decade. Once the decision to induce labor has been made, selection of the method for induction of labor must be made. In this review pharmacologic, mechanical, investigational, and complementary and alternative methods were assessed for efficacy and potential harms. When possible, each method was compared to placebo as well as with other methods using a prespecified hierarchy utilized in a series of Cochrane reviews of induction of labor. Search methods involved a MEDLINE and Cochrane Library search for relevant search terms between 1980 and November 2010. A total of 46 full-text articles were retained and assessed for quality and strength of evidence. Primary outcomes for this review included vaginal delivery not achieved within 24 hr, uterine hyperstimulation with fetal heart rate (FHR) changes, cesarean, serious neonatal morbidity or neonatal death, and serious maternal morbidity or death. Secondary outcomes included, but were not limited to, need for oxytocin augmentation, epidural anesthesia, postpartum hemorrhage, maternal and neonatal infection, and maternal satisfaction data. The authors were able to summarize primary outcomes when available with far fewer studies, offering the ability to analyze secondary outcomes. Of all pharmacological methods, vaginal or cervical prostaglandin E2 (PGE2) use was the method
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consistently associated with likelihood of vaginal delivery within 24 hr when compared to placebo. Prostaglandin E2 was associated with increased likelihood of uterine hyperstimulation (with and without FHR changes) without changing the overall risk for cesarean. Vaginal misoprostol was associated with increased likelihood of vaginal delivery when compared to vaginal and cervical prostaglandin E2 and decreased likelihood of cesarean when compared to intravenous oxytocin but was associated with more uterine contractile abnormalities. Intravenous oxytocin was found to be more effective than expectant management or placebo, but when compared to vaginal or cervical PGE2, intravenous oxytocin was less likely to result in vaginal delivery within 24 hr and was associated with more cesareans than cervical PGE2. Oral misoprostol was associated with fewer cesareans when compared with placebo or vaginal PGE2. When comparing oral versus vaginal misoprostol, fewer contractile abnormalities, but increased need for oxytocin augmentation were found with the oral route of administration of misoprostol. Overall, mechanical methods were associated with less uterine hyperstimulation but were associated with an increased risk for infectious complications (maternal and neonatal) in an included systematic review. Membrane sweeping appeared to have the most efficacy among nonpharmacologic methods by reducing postterm gestations without contributing to clinically significant harms. There was not sufficient evidence to consider sexual intercourse and nipple stimulation beneficial or safe. This review included several investigational drugs (mifepristone, corticosteroids, relaxin, hyaluronidase, and isosorbide mononitrate) with hyaluronidase showing the most promise. In one small study, hyaluronidase reduced the need for oxytocin augmentation and cesarean. Overall, the grade of recommendation for investigational drugs as well as complementary and alternative methods (castor oil, acupuncture, breast stimulation, sexual intercourse, homeopathic meds, and hypnosis) was weak. Comment: This review used the preestablished hierarchy for reviews of induction of labor from the Cochrane library; therefore, each method was compared to the method above it on the list, potentially limiting the types of comparisons. Most studies were not of sufficient size to assess for rare adverse events. The table summarizing the quality of evidence by type of induction method, the strength of evidence grade, and the balance
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of benefits and harms for the type of method is a useful reference for clinicians. Featured Review: Raval, A. D., Hunter, T., Stuckey, B., Hart, R. J. (2011). Statins for women with polycystic ovary syndrome not actively trying to conceive. Cochrane Database of Systematic Reviews (10). CD008565. The purpose of this systematic review was to examine and assess the efficacy and safety of statin use in women with polycystic ovary syndrome (PCOS) who are not actively trying to conceive. The authors noted the clinical and biochemical complexity of PCOS, which is estimated to affect 5% to 10% of women of reproductive age. Women with this endocrine abnormality exhibit a range of adverse effects including obesity, hypertension, insulin resistance, gestational diabetes, type 2 diabetes mellitus, menstrual irregularity, and dyslipidemia. Despite little evidence of increased cardiovascular events later in life, women with PCOS are at increased risk for coronary atherosclerosis and arterial stiffness. The primary outcomes measured were resumption of menstrual regularity and spontaneous ovulation. Secondary outcomes included improvement of lipid profile, inflammatory markers, body mass index, waist–hip ratio and waist circumference, markers for diabetes, and symptoms and markers of hyperandrogenicity. Four randomized controlled trials met the criteria for inclusion, and 244 women with PCOS received simvastatin (two trials with 184 women randomized) or atorvastatin (two trials with 60 women randomized). Although there was no good evidence that statins improved the primary outcomes of interest (menstrual regularity and spontaneous ovulation), statins were effective in reducing testosterone levels (alone and with oral contraceptive pills), improving total cholesterol levels, low-density lipoprotein levels, and triglyceride levels. There were no beneficial effects on high density lipoproteins, high-sensitive Creactive protein, or fasting insulin. Reduction in serum testosterone levels was seen (with and without concurrent use of oral contraceptives) without improvement in hirsutism or acne. Comment: A limited number of available studies combined with relatively short treatment periods (6–12 weeks) limit the benefits of statin use in these studies of women with PCOS to improvement of dyslipidemia without demonstrable improvement of menstrual or ovulatory dysfunction. More studies are needed to determine the long-term effects
JOGNN, 41, 275-280; 2012. DOI: 10.1111/j.1552-6909.2012.01343.x
http://jognn.awhonn.org
SPECIAL REPORT
Emeis, C. L.
of statin use, although reported side effects in the included studies were mild to moderate. Despite the anticipated improvement in dyslipidemia in the women receiving statins, data regarding the longterm cardiovascular risk profile of women with PCOS are needed to better understand the efficacy of statin treatment in health outcomes that extend beyond lab values. Featured Review: Conde-Agudelo, A., Belizan, ´ J. M., & Diaz-Rossello, J. (2011). Kangaroo mother care to reduce morbidity and mortality in low birthweight infants. Cochrane Database of Systematic Reviews (10). CD002771. In this updated systematic review, the authors sought to determine if there was evidence to support the use of kangaroo mother care (KMC) as an alternative to conventional neonatal care for low-birth-weight (LBW) infants before or after the initial stabilization period. Conventional neonatal care for LBW infants is highly dependent on resources (human and financial) that are often limited in low and middle income countries. Kangaroo mother care is theorized to reduce neonatal morbidity and mortality by maintaining the infant’s body temperature and nutritional state and providing the main source of stimulation. For the purposes of this review the traditional definition of KMC was used (defined as skin-to-skin contact between mother and newborn, frequent and exclusive/nearly exclusive breastfeeding, early discharge from hospital care). Sixteen studies with a total of 2,518 infants met the inclusion criteria. The majority of studies (14) evaluated KMC in LBW infants after stabilization. Kangaroo mother care was associated with a reduction in risk of mortality at either discharge or 40 to 41 weeks postmenstrual age in seven trials with 1,614 infants (typical risk ratio [RR] 0.60, 95% Confidence Interval [CI] 0.39, 0.93). Nosocomial infection, hypothermia, and length of hospital stay were also reduced in the KMC infants compared to conventional neonatal care. Only one small study examining early onset of KMC compared to late onset of KMC met inclusion criteria. This study found that early onset of KMC was associated with a significant reduction in weight loss from birth to 48 hr after birth, without significant difference in morbidity, mortality, breastfeeding rates at 4 weeks, or readmission to the hospital. Comment: This updated systematic review provides compelling evidence that KMC is associated with reduced mortality and morbidity in LBW infants in middle- and low-income settings.
JOGNN 2012; Vol. 41, Issue 2
This current review, which includes 12 additional trials as well as data from individual studies of meta-analyses, differs from two previous systematic reviews of KMC by the primary author. In the previous reviews (2000 and 2003), there was not sufficient evidence to recommend routine use of KMC in LBW infants. The results of this systematic review justify the need for further studies of KMC in developed countries including evaluation of cost-effectiveness and long-term outcomes.
Recent Evidence-Based Reviews: Pregnancy and Birth
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Abou-Nassar, K., Carrier, M., Ramsay, T., & Rodger, M. A. (2011). The association between antiphospholipid antibodies and placenta mediated complications: A systematic review and meta-analysis. Thrombosis Research, 128, 77–85. Audibert, F., Gagnon, A., Genetics Committee of the Society of Obstetricians and Gynaecologists of Canada, & Prenatal Diagnosis Committee of the Canadian College of Medical, Geneticists. (2011). Prenatal screening for and diagnosis of aneuploidy in twin pregnancies. Clinical practice guideline no. 262. Journal of Obstetrics & Gynaecology Canada, 33, 754–767. Bruinsma, F. J., & Quinn, M. A. (2011). The risk of preterm birth following treatment for precancerous changes in the cervix: A systematic review and meta-analysis. BJOG: An International Journal of Obstetrics & Gynaecology, 118, 1031–1041. Chitayat, D., Langlois, S., Wilson, R. D., Genetics Committee of the Society of Obstetricians and Gynaecologists of Canada, & Prenatal Diagnosis Committee of the Canadian College of Medical, Geneticists. (2011). Prenatal screening for fetal aneuploidy in singleton pregnancies. Clinical practice guideline no. 261. Journal of Obstetrics & Gynaecology Canada, 33, 736–750. Conde-Agudelo, A., Papageorghiou, A. T., Kennedy, S. H., & Villar, J. (2011). Novel biomarkers for the prediction of the spontaneous preterm birth phenotype: A systematic review and meta-analysis. BJOG: An International Journal of Obstetrics & Gynaecology, 118, 1042–1054. Han, Z., Lutsiv, O., Mulla, S., Rosen, A., Beyene, J., McDonald, S. D., & Knowledge Synthesis Group. (2011). Low gestational weight gain and the risk of preterm birth and low birthweight: a systematic review and
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meta-analyses. Acta Obstetricia et Gynecologica Scandinavica, 90, 935–954. Hillman, S. C., Morris, R. K., & Kilby, M. D. (2011). Co-twin prognosis after single fetal death: A systematic review and metaanalysis. Obstetrics & Gynecology, 118, 928– 940.
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Amir, E., Seruga, B., Niraula, S., Carlsson, L., & Ocana, A. (2011). Toxicity of adjuvant endocrine therapy in postmenopausal breast cancer patients: A systematic review and meta-analysis. Journal of the National Cancer Institute, 103, 1299–1309. Bahn, R. S., Burch, H. B., Cooper, D. S., Garber, J. R., Greenlee, M. C., Klein, I., . . . Laurberg, P. (2011). Hyperthyroidism and other causes of thyrotoxicosis: Management guidelines of the American Thyroid Association and American Association of Clinical Endocrinologists. Endocrine Practice, 17, 456– 520. Holt, K., Grindlay, K., Taskier, M., & Grossman, D. (2011). Unintended pregnancy and contraceptive use among women in the U.S. military: A systematic literature review. Military Medicine, 176, 1056–1064. Operario, D., Underhill, K., Chuong, C., & Cluver, L. (2011). HIV infection and sexual risk behaviour among youth who have experienced orphanhood: Systematic review and
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meta-analysis. Journal of the International AIDS Society, 14, 25. Reid, A., de Klerk, N., & Musk, A. W. (2011). Does exposure to asbestos cause ovarian cancer? A systematic literature review and meta-analysis. Cancer Epidemiology, Biomarkers & Prevention, 20, 1287– 1295. Zhou, W.-B., Liu, X.-A., Dai, J.-C., & Wang, S. (2011). Meta-analysis of sentinel lymph node biopsy at the time of prophylactic mastectomy of the breast. Canadian Journal of Surgery, 54, 300–306.
Recent Evidence-Based Reviews: Neonatal
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Karakosta, P., Chatzi, L., Plana, E., Margioris, A., Castanas, E., & Kogevinas, M. (2011). Leptin levels in cord blood and anthropometric measures at birth: A systematic review and meta-analysis. Paediatric and Perinatal Epidemiology, 25, 150–163. Philipps, L. H., Santhakumaran, S., Gale, C., Prior, E., Logan, K. M., Hyde, M. J., & Modi, N. (2011). The diabetic pregnancy and offspring BMI in childhood: A systematic review and meta-analysis. Diabetologia, 54, 1957– 1966. Samra, H. A., McGrath, J. M., & Wehbe, M. (2011). An integrated review of developmental outcomes and late-preterm birth. Journal of Obstetric, Gynecologic, & Neonatal Nursing, 40, 399–411.
http://jognn.awhonn.org
SPECIAL REPORT
Current Resources for Evidence-Based Practice March/April 2012 Cathy L. Emeis
Correspondence Cathy L. Emeis, CNM, PhD, School of Nursing, 3455 SW US Veterans Hospital Rd. Oregon Health & Science University, Portland, OR 97239-2941. [email protected]
P
Cathy Emeis, PhD, CNM, is an assistant professor in the School of Nursing at Oregon Health & Science University, Portland, OR.
Evidence-based practice relies on the availability of the highest level of clinical evidence. The sheer volume of published studies available to the contemporary clinician can be overwhelming. Although a number of resources, such as this column, are available to organize and summarize clinical evidence, clinicians are often uncertain about the differences in types of reviews when conducting a search for clinical information. For instance, what is the difference between an integrative review and a systematic review or between a metasynthesis and a meta-analyses? Can qualitative research be included in a systematic review? How do these types of methods inform evidencebased practice?
ublished simultaneously in the Journal of Midwifery & Women’s Health 2012; 57(2).
A Review of Reviews: Systematic, Integrative, Meta-Analyses, and Metasynthesis
Meta-analyses are statistical methods to summarize research findings by combining the results of several or many quantitative studies. Metaanalyses may be included with systematic reviews or included with only select studies. Metasynthesis is a technique that combines the findings from several or many qualitative studies. In contrast, integrative reviews are narrative summaries of original research for a given subject. The reviewer uses analytic reasoning to integrate findings and summarize conclusions, typically including studies using diverse research methods. In an integrative review, findings from experimental and nonexperimental research are included. Knafl and Whitmore (2005) noted that an integrative review has the potential to play a greater role in evidence-based practice in nursing because an integrative review allows for the inclusion of findings from diverse methods of analysis as well as varied perspectives on a phenomenon. Integrative reviews are generally conducted by individuals or panels with expertise in the given topic. Integrative reviews conducted by panels are more likely to use a process of checks and balances to reduce the risk of selection bias of studies included in the review (Brown, 2012). Reviewers usually make a priori decisions regarding the range of publication years and the types of studies that will be sought in the literature. Analysis of studies ideally results in conclusions that summarize the findings of the individual studies and synthesize the conclusions for relevance to clinical practice, research, or policy. A well-conducted integrative review may serve as the background for the design of evidencebased protocols and assist the clinician to understand a topic from a variety of dimensions.
The author reports no conflict of interest or relevant financial relationships.
The overarching goal of systematic reviews is to reach conclusions for prespecified questions or objectives through a systematic analysis of several or many studies (Brown, 2012). A single study, regardless of how well it was designed and conducted, is rarely sufficient to answer a clinical question. Systematic reviews are particularly valuable for bringing together a number of separate studies and synthesizing the results. Systematic reviews rely on a process for identification of primary studies relevant to a selected topic. After identified studies have undergone a systematic appraisal, each study is assigned a quality rating (Greenhalgh, 1997). Appraising studies for quality is a hallmark of the systematic review process. Next, data are synthesized and summarized, and the findings interpreted. Authors of systematic reviews within the Cochrane Collaboration commit to updating reviews periodically as new studies emerge (Levin, 2001).
http://jognn.awhonn.org
C 2012 AWHONN, the Association of Women’s Health, Obstetric and Neonatal Nurses
Systematic and integrative reviews are strengthened by adherence to standardized methods that help to ensure rigor and quality. Knowledge of these methods can assist clinicians to access and interpret evidence to inform their practice. Although different in approach, both methods are
275
SPECIAL REPORT
Current Resources for Evidence-Based Practice March/April 2012
important tools for consumers, clinicians, scientists, and policy makers.
REFERENCES Brown, S. (2012). Evidence-based nursing. Sudbury, MA: Jones and Bartlett. Greenhalgh, T. (1997). How to read a paper: Papers that summarise other papers (systematic reviews and meta-analyses). British Medical Journal, 315, 672–675.
Updated Systematic Reviews in CSDR: Pregnancy and Birth
r r r r
Knafl, K., & Whitmore, R. (2005). The integrative review: Updated methodology. Journal of Advanced Nursing, 52, 546–553. Levin, A. (2001). The Cochrane collaboration. Annals of Internal
r
Medicine, 135, 309–312.
From Cochrane Database of Systematic Reviews (CDSR) Issue 11, 2011 New Systematic Reviews in CDSR: Pregnancy and Birth
r r r r r
Analgesia for amniocentesis or chorionic villus sampling Antenatal breastfeeding education for increasing breastfeeding duration Mind–body interventions during pregnancy for preventing or treating women’s anxiety Mother and baby units for schizophrenia Risk scoring systems for predicting preterm birth with the aim of reducing associated adverse outcomes
New Systematic Reviews in CDSR: Women’s Health
r
r r r
Adjuvant gonadotropin-releasing hormone analogues for the prevention of chemotherapy induced premature ovarian failure in premenopausal women Compression stockings for the initial treatment of varicose veins in patients without venous ulceration Mechanical dilatation of the cervix at nonlabor cesarean section for reducing postoperative morbidity Quadriphasic versus monophasic oral contraceptives for contraception
New Systematic Reviews in CDSR: Neonatal
r
Low versus high hemoglobin concentration threshold for blood transfusion for preventing morbidity and mortality in very low-birthweight infants
New Systematic Reviews in CDSR: Clinical Practice
r
276
Effectiveness of external inspection of compliance with standards in improving health care organization behavior, health care professional behavior, or patient outcomes
Active versus expectant management for women in the third stage of labor Interventions for leg cramps in pregnancy Nitric oxide donors for the treatment of preterm labor Pneumococcal vaccination during pregnancy for preventing infant infection Prophylactic oral betamimetics for reducing preterm birth in women with a twin pregnancy
Updated Systematic Reviews in CDSR: Women’s Health
r r r r r r r
Antioxidants for male subfertility Antiretroviral therapy for prevention of HIV transmission in HIV-discordant couples Exercise interventions for smoking cessation Interventions to reduce hemorrhage during myomectomy for fibroids Intraperitoneal chemotherapy for the initial management of primary epithelial ovarian cancer Medical methods for first trimester abortion Triphasic versus monophasic oral contraceptives for contraception
Updated Systematic Reviews in CDSR: Neonatal
r r r r
r
Continuous nasogastric milk feeding versus intermittent bolus milk feeding for premature infants less than 1500 grams One dose per day compared to multiple doses per day of gentamicin for treatment of suspected or proven sepsis in neonates Oral immunoglobulin for the prevention of rotavirus infection in low-birth-weight infants Patient isolation measures for infants with candida colonization or infection for preventing or reducing transmission of candida in neonatal units Probiotics for the prevention of pediatric antibiotic-associated diarrhea
Cochrane Reviews are available by subscription to The Cochrane Library, and review abstracts are available without charge. See http://www.thecochranelibrary.com
From Database of Abstracts of Reviews of Effects (DARE) Recent Abstract Entries Assessing Quality of Systematic Reviews: Pregnancy and Birth
r
JOGNN, 41, 275-280; 2012. DOI: 10.1111/j.1552-6909.2012.01343.x
Effect of antenatal peer support on breastfeeding initiation: a systematic review
http://jognn.awhonn.org
SPECIAL REPORT
Emeis, C. L.
r r r r
r
Novel biomarkers for the prediction of spontaneous preterm birth phenotype: a systematic review and meta-analysis The efficacy of hypnosis as an intervention for labor and delivery pain: a comprehensive methodological review The risk of preterm birth following treatment for precancerous changes in the cervix: a systematic review and meta-analysis Treatment of abnormal vaginal flora in early pregnancy with clindamycin for the prevention of spontaneous preterm birth: a systematic review and meta-analysis Validity of two case finding questions to detect postnatal depression: a review of diagnostic test accuracy
Recent Abstract Entries Assessing Quality of Systematic Reviews: Women’s Health
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A systematic review assessing the effectiveness of interventions to improve persistence with antiresorptive therapy in women at high risk of clinical fracture A systematic review of interventions by health care professionals on community-dwelling postmenopausal women with osteoporosis A systematic review of randomized controlled trials of interventions promoting effective condom use Effectiveness of photodynamic therapy for mammary and extramammary Paget’s disease: a state of the science review Effect of radiotherapy after breast-conserving surgery on 10-year recurrence and 15-year breast cancer death: meta-analysis of individual patient data for 10801 women in 17 randomized trials GnRH antagonists are safer than agonists: an update of a Cochrane review Radiochemotherapy versus radiotherapy in locally advanced cervical cancer: a metaanalysis School-linked sexual health services for young people (SSHYP): a survey and systematic review concerning current models, effectiveness, cost-effectiveness, and research opportunities Screening for cervical cancer: a systematic evidence review for the U.S. preventive services task force Systematic comparison of radical vaginal trachelectomy and radical hysterectomy in the treatment of early-stage cervical cancer
JOGNN 2012; Vol. 41, Issue 2
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Systematic review of the effect of external beam radiation therapy to the breast on axillary recurrence after negative sentinel lymph node biopsy Systematic review of the efficacy and safety of using mesh in surgery for uterine or vaginal vault prolapse
DARE abstracts are available without charge at http://www.crd.york.ac.uk/crdweb/
Evidence-Based Reviews From Other Sources Featured Review: Mozurkewich, E. L., Chilimigras, J. L., Berman, D. R., Perni, U. C., Romero, V. C., King, V. J., & Keeton, K. L. (2011). Methods of induction of labour: A systematic review. BMC Pregnancy Childbirth, 11(84), 1–19. doi:10.1186/14712393-11-84 The purpose of this systematic review was to summarize the best available evidence for women with a viable fetus requiring induction of labor in the third trimester of pregnancy. The authors noted that the incidence of induction of labor has increased significantly over the past decade. Once the decision to induce labor has been made, selection of the method for induction of labor must be made. In this review pharmacologic, mechanical, investigational, and complementary and alternative methods were assessed for efficacy and potential harms. When possible, each method was compared to placebo as well as with other methods using a prespecified hierarchy utilized in a series of Cochrane reviews of induction of labor. Search methods involved a MEDLINE and Cochrane Library search for relevant search terms between 1980 and November 2010. A total of 46 full-text articles were retained and assessed for quality and strength of evidence. Primary outcomes for this review included vaginal delivery not achieved within 24 hr, uterine hyperstimulation with fetal heart rate (FHR) changes, cesarean, serious neonatal morbidity or neonatal death, and serious maternal morbidity or death. Secondary outcomes included, but were not limited to, need for oxytocin augmentation, epidural anesthesia, postpartum hemorrhage, maternal and neonatal infection, and maternal satisfaction data. The authors were able to summarize primary outcomes when available with far fewer studies, offering the ability to analyze secondary outcomes. Of all pharmacological methods, vaginal or cervical prostaglandin E2 (PGE2) use was the method
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consistently associated with likelihood of vaginal delivery within 24 hr when compared to placebo. Prostaglandin E2 was associated with increased likelihood of uterine hyperstimulation (with and without FHR changes) without changing the overall risk for cesarean. Vaginal misoprostol was associated with increased likelihood of vaginal delivery when compared to vaginal and cervical prostaglandin E2 and decreased likelihood of cesarean when compared to intravenous oxytocin but was associated with more uterine contractile abnormalities. Intravenous oxytocin was found to be more effective than expectant management or placebo, but when compared to vaginal or cervical PGE2, intravenous oxytocin was less likely to result in vaginal delivery within 24 hr and was associated with more cesareans than cervical PGE2. Oral misoprostol was associated with fewer cesareans when compared with placebo or vaginal PGE2. When comparing oral versus vaginal misoprostol, fewer contractile abnormalities, but increased need for oxytocin augmentation were found with the oral route of administration of misoprostol. Overall, mechanical methods were associated with less uterine hyperstimulation but were associated with an increased risk for infectious complications (maternal and neonatal) in an included systematic review. Membrane sweeping appeared to have the most efficacy among nonpharmacologic methods by reducing postterm gestations without contributing to clinically significant harms. There was not sufficient evidence to consider sexual intercourse and nipple stimulation beneficial or safe. This review included several investigational drugs (mifepristone, corticosteroids, relaxin, hyaluronidase, and isosorbide mononitrate) with hyaluronidase showing the most promise. In one small study, hyaluronidase reduced the need for oxytocin augmentation and cesarean. Overall, the grade of recommendation for investigational drugs as well as complementary and alternative methods (castor oil, acupuncture, breast stimulation, sexual intercourse, homeopathic meds, and hypnosis) was weak. Comment: This review used the preestablished hierarchy for reviews of induction of labor from the Cochrane library; therefore, each method was compared to the method above it on the list, potentially limiting the types of comparisons. Most studies were not of sufficient size to assess for rare adverse events. The table summarizing the quality of evidence by type of induction method, the strength of evidence grade, and the balance
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of benefits and harms for the type of method is a useful reference for clinicians. Featured Review: Raval, A. D., Hunter, T., Stuckey, B., Hart, R. J. (2011). Statins for women with polycystic ovary syndrome not actively trying to conceive. Cochrane Database of Systematic Reviews (10). CD008565. The purpose of this systematic review was to examine and assess the efficacy and safety of statin use in women with polycystic ovary syndrome (PCOS) who are not actively trying to conceive. The authors noted the clinical and biochemical complexity of PCOS, which is estimated to affect 5% to 10% of women of reproductive age. Women with this endocrine abnormality exhibit a range of adverse effects including obesity, hypertension, insulin resistance, gestational diabetes, type 2 diabetes mellitus, menstrual irregularity, and dyslipidemia. Despite little evidence of increased cardiovascular events later in life, women with PCOS are at increased risk for coronary atherosclerosis and arterial stiffness. The primary outcomes measured were resumption of menstrual regularity and spontaneous ovulation. Secondary outcomes included improvement of lipid profile, inflammatory markers, body mass index, waist–hip ratio and waist circumference, markers for diabetes, and symptoms and markers of hyperandrogenicity. Four randomized controlled trials met the criteria for inclusion, and 244 women with PCOS received simvastatin (two trials with 184 women randomized) or atorvastatin (two trials with 60 women randomized). Although there was no good evidence that statins improved the primary outcomes of interest (menstrual regularity and spontaneous ovulation), statins were effective in reducing testosterone levels (alone and with oral contraceptive pills), improving total cholesterol levels, low-density lipoprotein levels, and triglyceride levels. There were no beneficial effects on high density lipoproteins, high-sensitive Creactive protein, or fasting insulin. Reduction in serum testosterone levels was seen (with and without concurrent use of oral contraceptives) without improvement in hirsutism or acne. Comment: A limited number of available studies combined with relatively short treatment periods (6–12 weeks) limit the benefits of statin use in these studies of women with PCOS to improvement of dyslipidemia without demonstrable improvement of menstrual or ovulatory dysfunction. More studies are needed to determine the long-term effects
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Emeis, C. L.
of statin use, although reported side effects in the included studies were mild to moderate. Despite the anticipated improvement in dyslipidemia in the women receiving statins, data regarding the longterm cardiovascular risk profile of women with PCOS are needed to better understand the efficacy of statin treatment in health outcomes that extend beyond lab values. Featured Review: Conde-Agudelo, A., Belizan, ´ J. M., & Diaz-Rossello, J. (2011). Kangaroo mother care to reduce morbidity and mortality in low birthweight infants. Cochrane Database of Systematic Reviews (10). CD002771. In this updated systematic review, the authors sought to determine if there was evidence to support the use of kangaroo mother care (KMC) as an alternative to conventional neonatal care for low-birth-weight (LBW) infants before or after the initial stabilization period. Conventional neonatal care for LBW infants is highly dependent on resources (human and financial) that are often limited in low and middle income countries. Kangaroo mother care is theorized to reduce neonatal morbidity and mortality by maintaining the infant’s body temperature and nutritional state and providing the main source of stimulation. For the purposes of this review the traditional definition of KMC was used (defined as skin-to-skin contact between mother and newborn, frequent and exclusive/nearly exclusive breastfeeding, early discharge from hospital care). Sixteen studies with a total of 2,518 infants met the inclusion criteria. The majority of studies (14) evaluated KMC in LBW infants after stabilization. Kangaroo mother care was associated with a reduction in risk of mortality at either discharge or 40 to 41 weeks postmenstrual age in seven trials with 1,614 infants (typical risk ratio [RR] 0.60, 95% Confidence Interval [CI] 0.39, 0.93). Nosocomial infection, hypothermia, and length of hospital stay were also reduced in the KMC infants compared to conventional neonatal care. Only one small study examining early onset of KMC compared to late onset of KMC met inclusion criteria. This study found that early onset of KMC was associated with a significant reduction in weight loss from birth to 48 hr after birth, without significant difference in morbidity, mortality, breastfeeding rates at 4 weeks, or readmission to the hospital. Comment: This updated systematic review provides compelling evidence that KMC is associated with reduced mortality and morbidity in LBW infants in middle- and low-income settings.
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This current review, which includes 12 additional trials as well as data from individual studies of meta-analyses, differs from two previous systematic reviews of KMC by the primary author. In the previous reviews (2000 and 2003), there was not sufficient evidence to recommend routine use of KMC in LBW infants. The results of this systematic review justify the need for further studies of KMC in developed countries including evaluation of cost-effectiveness and long-term outcomes.
Recent Evidence-Based Reviews: Pregnancy and Birth
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Abou-Nassar, K., Carrier, M., Ramsay, T., & Rodger, M. A. (2011). The association between antiphospholipid antibodies and placenta mediated complications: A systematic review and meta-analysis. Thrombosis Research, 128, 77–85. Audibert, F., Gagnon, A., Genetics Committee of the Society of Obstetricians and Gynaecologists of Canada, & Prenatal Diagnosis Committee of the Canadian College of Medical, Geneticists. (2011). Prenatal screening for and diagnosis of aneuploidy in twin pregnancies. Clinical practice guideline no. 262. Journal of Obstetrics & Gynaecology Canada, 33, 754–767. Bruinsma, F. J., & Quinn, M. A. (2011). The risk of preterm birth following treatment for precancerous changes in the cervix: A systematic review and meta-analysis. BJOG: An International Journal of Obstetrics & Gynaecology, 118, 1031–1041. Chitayat, D., Langlois, S., Wilson, R. D., Genetics Committee of the Society of Obstetricians and Gynaecologists of Canada, & Prenatal Diagnosis Committee of the Canadian College of Medical, Geneticists. (2011). Prenatal screening for fetal aneuploidy in singleton pregnancies. Clinical practice guideline no. 261. Journal of Obstetrics & Gynaecology Canada, 33, 736–750. Conde-Agudelo, A., Papageorghiou, A. T., Kennedy, S. H., & Villar, J. (2011). Novel biomarkers for the prediction of the spontaneous preterm birth phenotype: A systematic review and meta-analysis. BJOG: An International Journal of Obstetrics & Gynaecology, 118, 1042–1054. Han, Z., Lutsiv, O., Mulla, S., Rosen, A., Beyene, J., McDonald, S. D., & Knowledge Synthesis Group. (2011). Low gestational weight gain and the risk of preterm birth and low birthweight: a systematic review and
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meta-analyses. Acta Obstetricia et Gynecologica Scandinavica, 90, 935–954. Hillman, S. C., Morris, R. K., & Kilby, M. D. (2011). Co-twin prognosis after single fetal death: A systematic review and metaanalysis. Obstetrics & Gynecology, 118, 928– 940.
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Amir, E., Seruga, B., Niraula, S., Carlsson, L., & Ocana, A. (2011). Toxicity of adjuvant endocrine therapy in postmenopausal breast cancer patients: A systematic review and meta-analysis. Journal of the National Cancer Institute, 103, 1299–1309. Bahn, R. S., Burch, H. B., Cooper, D. S., Garber, J. R., Greenlee, M. C., Klein, I., . . . Laurberg, P. (2011). Hyperthyroidism and other causes of thyrotoxicosis: Management guidelines of the American Thyroid Association and American Association of Clinical Endocrinologists. Endocrine Practice, 17, 456– 520. Holt, K., Grindlay, K., Taskier, M., & Grossman, D. (2011). Unintended pregnancy and contraceptive use among women in the U.S. military: A systematic literature review. Military Medicine, 176, 1056–1064. Operario, D., Underhill, K., Chuong, C., & Cluver, L. (2011). HIV infection and sexual risk behaviour among youth who have experienced orphanhood: Systematic review and
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meta-analysis. Journal of the International AIDS Society, 14, 25. Reid, A., de Klerk, N., & Musk, A. W. (2011). Does exposure to asbestos cause ovarian cancer? A systematic literature review and meta-analysis. Cancer Epidemiology, Biomarkers & Prevention, 20, 1287– 1295. Zhou, W.-B., Liu, X.-A., Dai, J.-C., & Wang, S. (2011). Meta-analysis of sentinel lymph node biopsy at the time of prophylactic mastectomy of the breast. Canadian Journal of Surgery, 54, 300–306.
Recent Evidence-Based Reviews: Neonatal
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Karakosta, P., Chatzi, L., Plana, E., Margioris, A., Castanas, E., & Kogevinas, M. (2011). Leptin levels in cord blood and anthropometric measures at birth: A systematic review and meta-analysis. Paediatric and Perinatal Epidemiology, 25, 150–163. Philipps, L. H., Santhakumaran, S., Gale, C., Prior, E., Logan, K. M., Hyde, M. J., & Modi, N. (2011). The diabetic pregnancy and offspring BMI in childhood: A systematic review and meta-analysis. Diabetologia, 54, 1957– 1966. Samra, H. A., McGrath, J. M., & Wehbe, M. (2011). An integrated review of developmental outcomes and late-preterm birth. Journal of Obstetric, Gynecologic, & Neonatal Nursing, 40, 399–411.
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