A Guide to Understanding Meta-analysis

Journal Article Evidence-Based Practices in Health Care: Social Work Possibilities Get access Joan Levy Zlotnik, Joan Levy Zlotnik Search for other works by this author on: Oxford Academic PubMed Google Scholar Colleen Galambos Colleen Galambos Search for other works by this author on: Oxford Academic PubMed Google Scholar Health & Social Work, Volume 29, Issue 4, November 2004, Pages 259–261, https://doi.org/10.1093/hsw/29.4.259 Published: 01 November 2004

Background: Research competencies across nurses’ career stages have not been adequately explored. Yet, research skills to appraise, synthesize, and implement research findings are required for evidence-based practice. Purpose: To explore the literature on registered nurse research competencies; to identify core competencies (i.e., knowledge, skills, and attitudes), research capacity-building activities, strategies and recommendations to strengthen nurses’ research capacity; and to propose a conceptual developmental framework of nurse research competencies. Methods: As part of a larger project titled “Health Services Researcher Pathway”, with the consultation of a health sciences librarian, we conducted an integrative literature review drawing on relevant publications. The PubMed (Medline), CINAHL, Web of Science and ProQuest Dissertations and Theses databases were searched from 2000 to 2012. From the revealed publications (n=1012), only 22 articles were relevant to nurse research competencies. Findings: The key themes cited in the literature reviewed include models and partnerships for building and developing competencies for research production (rather than utilization), and educational strategies and recommendations for interventions to provide confidence in evidence-based practice including research utilization and in clinical decision-making. According to the five-step evidence-based practice model (i.e., formation of answerable research questions, literature search and retrieval of the best available evidence, critical appraisal of the evidence, application of research findings into practice, and evaluation of performance based on the outcomes), we propose a framework for a nurse researcher pathway that may contribute to two research competency streams: for research users and research producers. The important area of research users is open for further research, since scarce literature exists. Conclusions: The proposed conceptual developmental framework for a nurse researcher pathway includes essential steps toward evidence-based practice in healthcare that have implications at the micro-level (nurse), meso-level (organization), and macro-level (society). Our work continues to pilot and refine a nurse researcher pathway and its associated competencies.

Evidence-based Practice Journal Club: How We Do It

More knowledge is needed regarding the complex factors and perceptions that enable the implementation of change in health care. The study aimed to examine the enabling factors and barriers encountered in the implementation of improvements in health care in order to achieve patient-centred care (PCC) and to study if there was a correlation in the extent the improvements were perceived to be implemented and the preconditions that were considered to affect them. Using a mixed method design, data were gathered via a questionnaire and individual interviews with health care personnel, clinic managers, and first-line managers. The data collection and analyses were based on the framework for Promoting Action on Research Implementation in Health Services (PARiHS). Correlations between PCC improvements and preconditions for improvements were performed. A high level of involvement, knowledge, and adequate resources were considered important to achieve an implementation of PCC with joint responsibility. Leadership and management need to be explicit and promote continuous follow-up and feedback. Preconditions for improvement had a linear correlation with the perceived level of implementation. Knowledge-related preconditions had greatest impact on implementation. The PARiHS framework was appropriate to use since the three components of evidence, context, and facilitation present different important preconditions in the implementation process. Evidence was the highest rated contributor since evidence-based practices in health care are necessary. It is vital that the important role of the context and facilitators is acknowledged in the implementation process to enable a successful implementation of change. There is a need to incorporate a clear strategy involving all levels in the organization. Furthermore, leaders play an important role in the implementation by facilitating communication and support and by having trust in facilitators and health care personnel. The results are applicable to other interventions implementing change in health care.

BackgroundMiddle managers are in a unique position to promote the implementation of evidence-based practices (EBPs) in healthcare organizations, yet knowledge of middle managers’ role in implementation and determinants (e.g., individual-, organizational-, and system-level factors) which influence their role remains fractured, spanning decades and disciplines. To synthesize understanding, we undertook a systematic review of studies of middle managers’ role in healthcare EBP implementation and determinants of that role.MethodsWe searched MEDLINE/PubMed and Business Source Complete (Ebsco) for literature on middle managers’ role in healthcare EBP implementation and its determinants. We abstracted data from records that met inclusion criteria (i.e., written in English, peer-reviewed, and reporting either a protocol or results of an empirical study) into a matrix for analysis. We summarized categorical variables using descriptive statistics. To analyze qualitative data, we used a priori codes and then allowed additional themes to emerge.ResultsOne hundred five records, spanning across several countries and healthcare settings and relating to a range of EBPs, met our inclusion criteria. Studies of middle managers’ role in healthcare EBP implementation and its determinants substantially increased from 1996 to 2015. Results from included studies suggest that middle managers shape implementation climate in addition to fulfilling the four roles hypothesized in extant theory of middle managers’ role in implementation. However, extant studies offered little understanding of determinants of middle managers’ role.ConclusionsOur findings suggest that middle managers may play an important role in facilitating EBP implementation. Included studies offered little understanding regarding the relative importance of various roles, potential moderators of the relationship between middle managers’ roles and EBP implementation, or determinants of middle managers’ role in EBP implementation. Future studies should seek to understand determinants and moderators of middle managers’ role. Clearer understanding may facilitate the translation of evidence into practice.

Editorial: Introduction to Special Section on Evidence-Based Practices for Persons With Intellectual and Developmental Disabilities

Integrating evidence-based practice (EBP) into nursing is critical for improving clinical outcomes, yet adoption remains limited due to ongoing individual and organizational barriers. The EBP Scholars Program was developed to overcome barriers and foster a culture of evidence-based nursing practice within a pediatric healthcare system. Launched in 2007 during the organization's Magnet journey, the program is grounded in scientific, educational, and implementation science principles. Selected through a competitive application process, scholars engage in a seven-month structured curriculum grounded in the 8 A's Model of EBP. Learning outcomes are evaluated using pre- and post-program scores on the Evidence-Based Practice Knowledge Assessment Questionnaire (EBP-KAQ). The program has enrolled 147 participants and graduated 124. On average, participants increased their EBP knowledge by 15.7%. Scholar-led projects have led to over 40 policy updates, new care guidelines, and measurable quality and safety improvements. Graduates have produced 43 posters, 18 podium presentations, and 9 peer-reviewed publications. The EBP Scholars Program offers a scalable model for embedding EBP in healthcare. Through strategic leadership, interdisciplinary collaboration, and structured mentorship, it has advanced evidence-based care, professional development, and a culture of continuous improvement.

Individualized or personalized medicine has become a buzzword in the academic as well as public debate surrounding health care. The word personalized is appealing and transports the message of a new medicine evoking hopes for patients and physicians. However, personalized medicine is not necessarily about persons - it’s about subgroups and the more refined nosology of modern medicine which is based on much more profound knowledge on the pathological processes. To identify benefits and harms for these subgroups implicates several methodological issues, which I investigated in my PhD thesis. Subgroup analyses in randomized clinical trials (RCT) can have important impact on patient care if their results are true. However, most subgroup analyses have been shown to be false with detrimental effects on patients’ health. To investigate the planning of subgroup analyses in protocols of RCTs and the agreement with corresponding full journal publications, we established a cohort of RCT protocols and subsequent full journal publications. Protocols were approved between 2000 and 2003 by six research ethics committees in Switzerland, Germany, and Canada. We included 894 protocols of RCTs involving patients; 515 subsequent full journal publications were identified. About a third of protocols planned one or more subgroup analyses, but of those, only a small fraction (< 10%) provided a clear hypothesis for at least one subgroup analysis, and only a third planned an appropriate statistical test for interaction. 515 of 894 (58%) studies were published as journal article; of those, almost 50% reported at least one subgroup analysis. In 33% of all publications reporting subgroup analyses, authors stated that subgroup analyses were pre-specified but this was not supported by a third of the corresponding protocols. Furthermore, in those 86 publications in which authors claimed a subgroup effect, only 42% corresponding protocols reported a planned subgroup analysis. More than one third of statements in RCT publications about subgroup pre-specification had no documentation in the corresponding protocols. We conclude that subgroup analyses are insufficiently described in RCT protocols and investigators rarely specify the anticipated direction of subgroup effects. Credibility of claimed subgroup effects cannot be judged without access to RCT protocols. In statistical analysis, categorizing an inherently continuous predictor (e.g. age) raises several critical methodological issues. This problem also applies to investigation of interaction between e.g. treatment assignment and a continuous predictor in RCTs – e.g. do older patients benefit from a certain therapy compared to younger patients? We applied the new multivariable fractional polynomial interaction (MFPI) approach to investigate interaction between continuous patient baseline characteristics and the allocated treatment in an individual patient data meta-analysis of 3 RCTs (N=2299) from the intensive care field. In all included RCTs, patients requiring mechanical ventilation were randomized into two treatment groups: higher versus lower positive end expiratory pressure (PEEP) ventilation strategy. For each study, we used MFPI to calculate a continuous treatment effect function for four baseline characteristics and 3 outcomes. These functions were plotted with a 95% point wise confidence interval: 1. For each study separately, 2. For all studies combined (averaged function using a fixed effect model). This novel approach allows assessing whether treatment effects interact with continuous baseline patient characteristics and avoids categorisation-based subgroup analyses. These interaction analyses are exploratory in nature. However, they may help to foster future research using the MFPI approach to improve interaction analyses of continuous predictors in randomized trials and individual patient data meta-analyses.

Cox regression and Kaplan-Meier estimations are often needed in clinical research and this requires access to individual patient data (IPD). However, IPD cannot always be shared because of privacy or proprietary restrictions, which complicates the making of such estimations. We propose a method that generates pseudodata replacing the IPD by only sharing non-disclosive aggregates such as IPD marginal moments and a correlation matrix. Such aggregates are collected by a central computer and input as parameters to a Gaussian copula (GC) that generates the pseudodata. Survival inferences are computed on the pseudodata as if it were the IPD. Using practical examples we demonstrate the utility of the method, via the amount of IPD inferential content recoverable by the GC. We compare GC to a summary-based meta-analysis and an IPD bootstrap distributed across several centers. Other pseudodata approaches are also considered. In the empirical results, GC approximates the utility of the IPD bootstrap although it might yield more conservative inferences and it might have limitations in subgroup analyses. Overall, GC avoids many legal problems related to IPD privacy or property while enabling approximation of common IPD survival analyses otherwise difficult to conduct. Sharing more IPD aggregates than is currently practiced could facilitate "second purpose"-research and relax concerns regarding IPD access.

This article summarizes recent research on the effectiveness of efforts to implement evidence-based health care. The authors conclude that the evidence in support of single interventions being effective in bringing about practitioner change is weak at best. The authors give examples and evaluative comments on more complex organizational and systemic interventions that are aimed at changing clinical practice, and discuss some of the barriers to their application.

The Foucauldian concepts of governmentality and pastoral power have been used to explain the way health professionals internalise evidence-based practices in health care generally and clinical networks more specifically. However, we know little about the work, practices and process involved in developing and implementing an ‘evidence-based governmentality’ outside the West, particularly in Low and Middle Income Counties (LMICs), where governmentality often has a different transnational character. We explain the development and implementation of a Western transnational evidence-based governmentality in a clinical network in Kenya, using a decentred analytical approach. We highlight the essential work of medical professional ‘pastors’, with experience of both health care in Kenya and evidence-based medicine in Western High-Income Countries, in transposing this governmentality into health care in a LMIC in a way improving clinical care.

Effects of radiotherapy and of differences in the extent of surgery for early breast cancer on local recurrence and 15-year survival: an overview of the randomised trials

Combining individual patient data from multiple trials require specific modelling techniques in order to provide accurate predictions

Incorporating evidence-based healthcare practice would improve patients' response and safety and make patients partners in current healthcare practice. This partnership is certain to offer patients the opportunity to guide safety initiatives through data access by clinicians and encourage evidence-based healthcare while alleviating potential medical errors. In this paper, we promote a collaborative model that integrates interrelated concepts for responsive healthcare services that target patient-centred healthcare--with healthcare providers and relevant stakeholders in the loop. The implementation strategies for fulfilling the desired healthcare outcomes as well as design implications are also provided. The model is expected to offer transformative impact that would drive our weak healthcare system for improved healthcare and complement the huge dearth in healthcare services. The outcome is shared prosperity and health, and a mainstream of the people into healthcare decision making for informed policy planning and implementation.

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