CE Professional Case Management Vol. 14, No. 2, 76 81 Copyright 2009 Wolters Kluwer Health Lippincott Williams & Wilkins Evidenced-Based Case Management Practice, Part 1 The Systematic Review Terry Throckmorton, PhD, RN, and Pamela E. Windle, MS, RN, NE-BC, CPAN, CAPA ABSTRACT Objectives: This article aims to (1) describe the steps in the development of a systematic review, (2) discuss the use of systematic reviews in developing an evidence base for case management practice, and (3) present listings of agencies that provide systematic reviews on clinical topics and resources to evaluate systematic reviews for application to practice. Primary Practice Settings: Evidence-based practice is mandated for all healthcare professionals regardless of setting. For nonacademic settings, a lack of library resources may make this mandate difficult to accomplish. Systematic reviews are available through agency Web sites and, therefore, are accessible to anyone with Internet access. Findings/Conclusions: Evidence-based practice supports professionalism, patient safety, and quality care. However, most case managers, have heavy workloads and limited time to complete literature reviews adequate to provide a basis for clinical decision making. For that reason, systematic reviews are developed and published by a variety of professional groups, including clinicians, academics, researchers, and library systems. This article focuses on the systematic review and includes definitions, a comparison of types of reviews, the process for completing systematic reviews, sources of systematic reviews, and tools used to critique them. Implications for Case Management Practice: Systematic reviews can be helpful tools to allow busy case managers to provide the safest and most effective care to their patients. They can support the development of guidelines specific to case management such as transitioning care to other institutions or to the patient s home, management of the patient in the community, and prevention of recidivism or unplanned return to an acute care setting. Key Words: case management, critical appraisal, evidence-based practice, research, sources of evidence, systematic review This article is Part 1 of a two-part series designed to provide information on sources of evidence for incorporation into practice. Part 1 describes the systematic review, how it is conducted, tools to critique reviews, and how they can be used to support practice. Part 2 will address meta-analysis, how the process differs from systematic review, how to evaluate a meta-analysis, and how to use the evidence in practice. Evidence-based practice (EBP) has been with us in various forms and degrees throughout the history of our profession. Over the last 10 20 years, a very refined comprehensive approach to establishing an evidence base for clinical practice has evolved. Healthcare, and certainly case management, has moved from the original few reference citations supporting practices to the more formal research utilization process, and then to the current comprehensive evidence-based approach to supporting practice decisions. As the process has developed, the required skills and the volume of work have also escalated. Each of us as practicing clinicians, case managers, educators, practitioners, and managers should be knowledgeable of the process involved in EBP and the skills required. This article addresses the systematic review, one aspect of EBP that, when available for a specific topic, can save case managers and other healthcare professionals a significant amount of time and work. The authors have no conflict of interest. Address correspondence to Terry Throckmorton, PhD, RN, The Methodist Hospital, 6565 Fannin, MGJH 11.018, Houston, TX 77030 (TAThrockmorton@ tmhs.org). 76 Professional Case Management March/April 2009
EVIDENCE-BASED PRACTICE Evidence-based practice is the conscientious, deliberate, and judicious use of the best available evidence (Sackett, Rosenberg, Gray, Haynes, & Richardson, 1996) in conjunction with clinical experience and patient preference to make decisions about patient care (American Psychological Association, 2006; Gambrill, 2003; Gilgun, 2006; Ingersoll, 2000). As the definition implies, best evidence means that the clinician actually knows what evidence exists and what portion of the evidence represents the best available evidence. Obviously, reviewing the literature for all available studies and critiquing them to determine the best current approach requires a time commitment that most case managers do not have. This process also often requires levels of expertise in research and statistical analysis that clinicians may not have acquired. In its best form, the process also includes analysis of any available unpublished research. The solution for accomplishing EBP for most areas of practice, including case management, is to utilize systematic reviews of research. TYPES OF REVIEWS A systematic review is the use of scientific methods to assemble, critically appraise, and synthesize pertinent studies that address a specific clinical question (Pai et al., 2004; Sweet & Moynihan, 2007). Systematic reviews, one of the higher levels of evidence, are very different from the standard literature reviews that have served us in the past. Literature reviews, sometimes called narrative reviews, are often developed to provide evidence around a specific variable for a research study or as a basis for designing a process improvement or similar project. Narrative reviews may or may not be biased toward the proposed intervention the investigator planned to study. There is often a critique of the study designs and an effort to define what has not been covered in previous research. Unlike systematic reviews, standard literature reviews do not usually have stringent criteria for (1) what types of studies are included and (2) rigorous evaluation of the validity and reliability of the measurement and outcomes. There may or may not be bias in the presentation of the studies. There is usually not a significant effort to determine what unpublished evidence is available and what those studies indicate. Occasionally, studies presented at professional meetings are included in the review. See Table 1 for definitions of terms used in this article. Systematic reviews can be classified as investigations in themselves, with a stated methodology and collection of data for analysis. They involve an exhaustive review of the literature for specific types of studies outlined in explicit selection criteria. Each article is critiqued using standard critique guidelines, and conclusions are drawn about the validity of the data and the applicability of the findings to practice. Systematic reviews are divided into two types: qualitative and quantitative or meta-analysis (Cook et al., 1997; Duke University Medical Library, 2004). Qualitative systematic reviews are summaries of all the studies found on a well-defined topic along with an evaluation of the scientific merit of the studies. Quantitative reviews or meta-analyses are systematic reviews in which the results of multiple studies are TABLE 1 Definitions Terms Evidence-based practice Narrative or descriptive review Systematic or qualitative review Meta-analysis or quantitative review Critical appraisal Definitions Evidence-based practice is the conscientious, deliberate, and judicious use of the best available evidence (Sackett et al., 1996) in conjunction with clinical experience and patient preference to make decisions about patient care (American Psychological Association, 2006; Gambrill, 2003; Gilgun, 2006; Ingersoll, 2000). Narrative reviews are literature summaries related to a specific topic that are most frequently completed to support a research study or project. There may or may not be a critique of the included articles, and there is often no description of the search strategy. A systematic review is the use of scientific methods to assemble, critically appraise, and synthesize pertinent studies that address a specific clinical question (Pai et al., 2004; Sweet & Moynihan, 2007). Systematic reviews may also be called qualitative reviews (Cook, Mulrow, & Haynes, 1997). Quantitative reviews or meta-analyses are systematic reviews in which the results of multiple studies are pooled and analyzed as though they were one study (Cook et al., 1997; Sackett et al., 1996). Critical appraisal is the systematic review of a research study using standard criteria to determine its scientific merit. Vol. 14/No. 2 Professional Case Management 77
Evidence-based practice is the conscientious, deliberate, and judicious use of the best available evidence in conjunction with clinical experience and patient preference to make decisions about patient care. pooled and analyzed as though they were one study. These three types of reviews narrative, qualitative systematic, and quantitative systematic may also be called reviews, overviews, and meta-analysis by some experts (Centre for Evidence-Based Dentistry, 2008; Sackett et al., 1996). Case managers can use the systematic reviews to provide a broader base of evidence on which to base practice and make decisions. For example, The Cochrane Library of Systematic Reviews includes a review on transitioning patients to a nurse-led step-down unit before transitioning home and another manuscript on day centers for patients with mental illness. The available reviews may support a specific process for transitioning care but more often will support nursing interventions that improve the quality of care for patients transitioned to different levels inside and outside of the care system. HOW IS ASYSTEMATIC REVIEW CONDUCTED? Step 1: Determining Whether the Review Is Necessary and Feasible Researchers who decide to undertake a systematic review begin by sharing their idea with the subject and methodology experts. Experts in this area can provide advice about the worth and feasibility of the topic. Surveying the systematic review sources is also important to ensure that the proposed work has not already been done. A general survey of the available literature will allow the investigator to estimate need and feasibility. If there is no research available, then the systematic review is not feasible. Before progressing any further, the investigator may want to consider where the review will be published. Each organization that maintains a library of systematic reviews has requirements for how the review is to be conducted and the format for how the report is to be written. The Cochrane Library (Oxman, 1995) is probably the best known and has published its manual on its Web site. Step 2: Formulating the Research Question The criteria for the question are similar to those for any evidence-based literature search: population or medical problem, specific intervention of interest, comparison group, outcome of interest, and specific study design. Each criterion should be clearly defined. An example would be as follows: Population: Patients being transferred from hospital to nursing home Intervention: Use of a standard format for handoff from nursing home to Emergency Medical Transport to hospital Comparison Group: Standard reporting process Outcome: Reduction in errors related to incomplete reporting Study Design randomized controlled trials Step 3: Selecting a Study Protocol There are multiple approaches to designing the protocol for the systematic review, most of which are defined by the organization for which the review will be done. Investigators who are not working with a specific systematic review collective can still adopt the format of one of the groups such as the Cochrane Collaboration (http://www.cochrane.org/). The investigator should be aware of the time commitment and the cost of conducting a systematic review. Most reviews commonly last from 6 to 18 months. Costs include the investigator s time, photocopying, interlibrary loans, and possibly long-distance phone calls to speak with the authors of unpublished studies. In this technological age of e-mail and the Internet, photocopying and phone expenses may be diminished, but some costs should be expected. Step 4: Determining a Search Strategy and the Extent of the Search Initially, the investigator should determine what disciplines are likely to have published literature related to the topic and whether there are any previously completed reviews. Then the related search drives are identified. The criteria for the question are expanded to determine inclusion and exclusion criteria. In other words, how terms must be defined, what is acceptable as a treatment, and how the outcomes should be measured. In addition to standard search drives, citation indexes can be used to identify the authors who are repeatedly cited by other researchers. These studies are usually the baseline or landmark studies related to your topic. Other approaches that may be used are manual searches of journal index pages and searches of the reference lists in articles already selected for the review. Finally, unpublished studies can be obtained from the abstracts presented at conferences. The abstracts of many professional associations are published on their Web sites or in their journals. The authors can be contacted for the details of the studies. 78 Professional Case Management March/April 2009
TABLE 2 Samples Critical Appraisal Skills Program Centre for Evidence Based Medicine AHRQ Systems to Rate the Strength of Scientific Evidence Summary Systematic Review Critical Appraisal Worksheet Pediatric Critical Care Web site University of Glasgow Evaluation of systematic reviews of treatment or prevention interventions Netting the Evidence Duke University Medical Library http://www.phru.nhs.uk/pages/phd/resources.htm http://www.cebm.net/?o 1016 http://www.ahrq.gov/clinic/epcsums/strengthsum.htm http://www.uphs.upenn.edu/medicine/education/residents/ curriculum/journalclub/pdf s/systematic_review.pdf; http://pennhealth.com/search/search.aspx?uphs_st=health&col= inter&q=systematic+review+critical+appraisal+worksheet http://pedsccm.org/ebjournal_resources.php http://www.gla.ac.uk/departments/generalpracticeprimarycare/ evidencebasedpractice/checklists/#d.en.19536 http://ebn.bmj.com/cgi/reprint/4/4/100.pdf http://www.shef.ac.uk/scharr/ir/netting/appraising.htm http://www.mclibrary.duke.edu/training/pdaformat/overviewpda.html Step 5: Matching References With the Criteria for Inclusion This process eliminates those that do not measure up, analyzing the validity of the results and ranking the articles according to value. It facilitates the investigator s effort to provide the best available evidence on a specific, precisely defined topic. Step 6: Organizing and Writing the Review Readers who hope to use the systematic review will expect that the final document includes a description of each step and the process used to accomplish it. The readers can then estimate the rigor of the review and better assess the validity of the completed review for their purposes. See Table 2 for sources of appraisal instruments. Uses and Availability Obviously, systematic reviews constitute a significant investment in terms of time, expense, and expertise. For the busy case manager with large caseloads for follow-up who has very little time to complete the well-designed and executed literature searches, current systematic reviews are great finds. Systematic reviews may provide an overview of research related to community care of patients with chronic disease or of independent nursing functions that may enhance the patient s transition from hospital or interim care to home. For example, the TABLE 3 Systematic Review Sources The Cochrane Collaboration BMJ Systematic Reviews in Health Care National Guidelines Clearinghouse Agency for Healthcare Research and Quality PubMed Clinical Queries Joanna Briggs Institute Health Information Research Unit Task Force on Community Preventive Services Centre for Evidence Based Medicine Clinical Evidence Health Links, University of Washington MD Consult Nursing Best Practice Guidelines http://www.cochrane.org/ www.bmj.com http://www.guideline.gov/ http://www.ahrq.gov/clinic/epcix.htm http://www.ncbi.nlm.nih.gov/entrez/query/static/clinical.shtml http://www.joannabriggs.edu.au/pubs/systematic_reviews.php http://hiru.mcmaster.ca/epc/projects.asp http://www.thecommunityguide.org/ http://www.cebm.net/?o 1016 http://www.library.ualberta.ca/databases/databaseinfo/index.cfm?id 3119 http://healthlinks.washington.edu/ebp http://www.library.ualberta.ca/databases/databaseinfo/index.cfm?id 101 http://www.rnao.org/page.asp?pageid 861&SiteNodeID 133&BL_ExpandID &AA_Shell Vol. 14/No. 2 Professional Case Management 79
(As) with any new approach, patient preferences must be considered. The best case management process can be very ineffective or inefficient if the process does not work well with your population or institution or is not accepted by management. Cochrane Database of Systematic Reviews includes a systematic review on telephone follow-up of patients discharged home and one on home-based versus center-based physical activity programs in older adults. Currently, the majority of the systematic reviews are disease management focused with a much smaller number related to healthcare process. However, many of the clinical systematic reviews can be used by case managers to determine the optimum route for patients to take through the system and into the community on the basis of the current best evidence for disease management and rehabilitation. Issues related to transition of care from home, through the varied outpatient and inpatient points, and back to home have long been recognized by nurses, but have only recently received general recognition as a necessary focus for caregivers. As the research in this area begins to accumulate, researchers may decide that a systematic review is necessary. In the interim, case managers are in an excellent position to collaborate with nurse investigators to design and conduct the research needed to support practice and safeguard the patient. SOURCES OF SYSTEMATIC REVIEWS Sources of systematic reviews have incrementally increased as the demand for EBP has grown. Some of these sources are listed in Table 3. Each of these Web sites was accessed on December 10, 2008. Most of the sources are Web based and easily accessible to case managers in any setting with computer access. Commercial search drives, such as Nursing Reference Center, Dynamed, Clinical Evidence, Up to Date, and MD Consult are available by subscription. Just as sources of systematic reviews have increased, so have Web sites with criteria for the evaluation of systematic reviews. Because there are many individuals and organizations conducting systematic reviews with varying degrees of rigor, evaluation of the validity of the review is an important step before applying the results to changes in practice. A sampling of these Web sites is listed in Table 2. All Web sites were accessed on December 10, 2008. SUMMARY Systematic reviews, clearly, can be helpful for busy case managers in their attempt to plan the most current and safest care for their patients. However, as with any other tool, there is an inherent responsibility in case management to evaluate the validity of the resulting recommendations. In addition, case managers will want to compare the populations included in the research for similarity with the ones with which they are working. Finally, as with any new approach, patient preferences must be considered. The best case management process can be very ineffective or inefficient if the process does not work well with your population or institution or is not accepted by management. Patients make decisions about their healthcare on the basis of circumstances or preferences that may not have been considered in the research for the systematic review. Case managers and clinical nurses are in the best position to understand the bases for patients decisions and to adjust best practices to meet the needs of patients. A systematic review identifying best processes in discharging patients to the next continuum of care or transferring to the next level of care, when available, might reveal some differences in the processes and provide helpful suggestions that may result in improved options for the case manager and interdisciplinary team in making the transition. Systematic reviews about the efficacy of specific types of community resources may assist the case manager in determining referrals, the need for follow-up evaluation of the program, and the criteria to use in evaluating it. REFERENCES American Psychological Association. (2006). APA presidential task force on evidence based practice. Washington, DC: Author. Centre for Evidence-Based Dentistry. (2008). Systematic reviews. Retrieved December 10, 2008, from http:// www.cebd.org/ index.aspx?o 1059 Cochrane Database of Systematic Reviews. (2008, 4th Quarter). Retrieved December 10, 2008, from http://www.cochrane.org/ Cook, D. J., Mulrow, C. D., & Haynes, R. B. (1997). Systematic reviews: Synthesis of best evidence for clinical decisions. Academia and Clinic, 126(5), 376 380. Duke University Medical Library. (2004). Evaluating a systematic review article. Retrieved December 10, 2008, from http://www.mclibrary.duke.edu/training/ pdaformat/overviewpda.html 80 Professional Case Management March/April 2009
Gambrill, E. (2003). Evidence-based practice: Implications for knowledge development and use in social work. In A. Rosen & E. Proctor (Eds.), Developing practice guidelines for social work intervention (pp. 37 58). New York: Columbia University Press. Gilgun, J. (2006). The four cornerstones of qualitative research. Qualitative Health Research, 16(3), 436 443. Ingersoll, G. L. (2000). Evidence-based nursing: What it is and what it isn t. Nursing Outlook, 48(4), 151 152. Oxman, A. (Ed). (1995). Preparing and maintaining systematic reviews. In Cochrane Collaboration handbook, section VI. Oxford, UK: Cochrane Collaboration. Pai, M., McCulloch, M., Gorman, J., Pai, N., Enanoria, W., Kennedy, G., et al. (2004). Systematic reviews and meta-analyses: An illustrated step-by-step guide. The National Medical Journal of India, 17(2), 86 95. Sackett, D. L., Rosenberg, W. M. C., Gray, J. A. M., Haynes, R. B., & Richardson, W. S. (1996). Evidence based medicine: What it is and what it isn t. British Medical Journal, 312, 71 72. Retrieved from http:// bmj.bmjjournals.com/cgi/content/full/312/7023/71 Sweet, M., & Moynihan, R. (2007). Improving population health: The uses of systematic reviews. Retrieved February 12, 2009, from http://www.milbank.org/ reports Terry Throckmorton, PhD, RN, is an experienced researcher and has served on several institutional review boards and scientific review committees. She has served for two terms as institutional review board vice chair for a large oncology center. She is a nurse scientist for a large medical center hospital system and has taught research and statistics at Texas Woman s University. Pamela E. Windle, MS, RN, NE-BC, CPAN, CAPA, is an experienced perianesthesia nurse manager, has conducted several research studies in her department, is very active with nursing professional organizations, and is an ASPAN past president. She has been the JoPAN research columnist and is currently the coeditor for the second edition of Nursing PeriAnesthesia Core Curriculum book. Vol. 14/No. 2 Professional Case Management 81