systematic review and meta analysis klp 6

8/19/2019 Systematic Review and Meta Analysis Klp 6

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Systematic Review and Meta Analysis

Presented by :

Arind Vicha P 1506785740

yah Prabanin!r"m 1506705001

#atimah etiniaty 15067861$5

P%nisah 1506786781

Siti &h%di'ah Parind"ri 15067055$5


2/20

• (itle : Systematic review %) the a**licati%n %) the*lan+d%+st"dy+act meth%d t% im*r%ve ,"ality inhealthcare

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http://dx.doi.org/10.1136/bmjqs-2013-001862http://dx.doi.org/10.1136/bmjqs-2013-001862http://dx.doi.org/10.1136/bmjqs-2013-001862http://dx.doi.org/10.1136/bmjqs-2013-001862http://dx.doi.org/10.1136/bmjqs-2013-001862


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TITLE1. Title : Identify the report as a

systematic review, meta-analysis, orboth.

Systematic review of the application ofthe plan–do–stdy–act method to

improve !ality in healthcare


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"#ST$"%T&. Strctred smmary : 'rovide a strctred smmary incldin(, as applicable:bac)(rond* ob+ectives* data sorces* stdy eli(ibility criteria, participants, andinterventions* stdy appraisal and synthesis methods* reslts* limitations*conclsions and implications of )ey ndin(s* systematic review re(istrationnmber.#ac)(rond Plan+d%+st"dy+act -PSA3 cycles *r%vide a str"ct"re )%r iterative

testin! %) chan!es t% im*r%ve ,"ality %) systems (he meth%d is widely acce*ted in

healthcare im*r%vement; h%wever there is little %verarchin! eval"ati%n %) h%w themeth%d is a**lied (his *a*er *r%*%ses a the%retical )ramew%r& )%r assessin! the,"ality %) a**licati%n %) PSA cycles and e/*l%res the c%nsistency with which themeth%d has been a**lied in *eer2reviewed literat"re a!ainst this )ramew%r&

ethods vidence and %chrane databases were searched by threeinde*endent reviewers >m*irical st"dies were incl"ded that re*%rted a**licati%n %)the PSA meth%d in healthcare A**licati%n %) PSA cycles was assessed a!ainst &ey

)eat"res %) the meth%d? incl"din! d%c"mentati%n characteristics? "se %) iterativecycles? *redicti%n2based testin! %) chan!e? initial small2scale testin! and "se %) data%ver time Reslts 7 %) 40 individ"al articles identi@ed met the incl"si%n criteria ) the 7articles? 47 d%c"mented PSA cycles in s"Bcient detail )%r )"ll analysis a!ainst thewh%le )ramew%r& Many %) these st"dies re*%rted a**licati%n %) the PSA meth%dthat )ailed t% acc%rd with *rimary )eat"res %) the meth%d Cess than $0D -14.73)"lly d%c"mented the a**licati%n %) a se,"ence %) iterative cycles #"rtherm%re? alac& %) adherence t% the n%ti%n %) small2scale chan!e is a**arent and %nly 15D-7.473 re*%rted the "se %) ,"antitative data at m%nthly %r m%re )re,"ent dataintervals t% in)%rm *r%!ressi%n %) cycles

iscssion (% *r%!ress the devel%*ment %) the science %) im*r%vement? a !reater"nderstandin! %) the "se %) im*r%vement meth%ds? incl"din! PSA? is essential t%draw reliable c%ncl"si%ns ab%"t their eEectiveness (his w%"ld be s"**%rted by thedevel%*ment %) systematic and ri!%r%"s standards )%r the a**licati%n and re*%rtin!%) PSAs


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I/T$0%TI0/2. $ationale : escribe the rationale for the review in the conte3t of

what is already )nown.n recent

years? ,"ality im*r%vement -3 meth%ds s"ch as *lan+s%+st"dy+act-PSA3 cycles have been "sed in an attem*t t% drive s"ch im*r%vements (hemeth%d is widely "sed in healthcare im*r%vement; h%wever there is little

%verarchin! eval"ati%n %) h%w the meth%d is a**lied

es*ite increased investment in research int% the im*r%vement %) healthcare?evidence %) eEective interventi%ns remains mi/ed? with many systematicreviews c%ncl"din! that s"ch interventi%nsare %nly eEective in s*eci@c settin!s

I/T$0%TI0/

4. 0b+ectives : 'rovide an e3plicit statement of !estions bein(addressed with reference to participants, interventions, comparisons,

otcomes, and stdy desi(n 5'I%0S6.

(his review e/amines the a**licati%n %) PSA cycles as determined by these*rinci*le )eat"res %) the PSA meth%d described ab%ve Fe rec%!nise that a

n"mber %) health and research related c%nte/t"al )act%rs may aEect a**licati%n%) the meth%d b"t these )act%rs are bey%nd the sc%*e %) this review (he reviewintends t% im*r%ve the "nderstandin! %) whether the PSA meth%d is bein!"sed and re*%rted in line with the literat"re in)%rmed criteria and there)%rein)%rm the inter*retati%n %) st"dies that have "sed PSA cycles t% )acilitateiterative devel%*ment %) an interventi%n


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ET70S8. 'rotocol and re(istration: Indicate if a review protocol e3ists, if andwhere it can be accessed 5e.(., 9eb address6, and, if available, providere(istration information incldin( re(istration nmber.

ata c%llecti%n *r%cess and st"dy selecti%n ata were c%llected and tab"latedinde*endently by M(? M and < in a manner !"ided by the %chrane =andb%%&

ET70S. Eli(ibility criteria : Specify stdy characteristics 5e.(., 'I%0S, len(th offollow;p6 and report characteristics 5e.(., years considered, lan(a(e,pblication stats6 sed as criteria for eli(ibility, (ivin( rationale.

>li!ibility was decided inde*endently? in a standardised manner anddisa!reements were res%lved by c%nsens"s ) an abstract was n%t available

)r%m the database? the )"ll2te/t re)erence was accessed ncl"si%n criteria )%rarticles were as )%ll%ws: *"blished in *eer2reviewed '%"rnal; describes PSAmeth%d bein! a**lied t% im*r%ve ,"ality in a healthcare settin!; *"blished in>n!lish >dit%rial letters? c%n)erence abstracts? %*ini%n and a"dit articles weree/cl"ded )r%m the st"dy selecti%n


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ET70S; 185 t% *resent3? ritish lite ->M>S P"blishin!?*swich? Massach"setts? GSA3? the =ealth Mana!ement n)%rmati%n %ns%rti"m-=M3? M>C )r%m P"bMed -150 t% *resent3 and Psych


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ET70S>. Stdy selection: State the process for selectin( stdies 5i.e.,screenin(, eli(ibility, inclded in systematic review, and, if applicable,inclded in the meta;analysis6.

ncl"si%n criteria )%r articles were as )%ll%ws: *"blished in *eer2reviewed '%"rnal;describes PSA meth%d bein! a**lied t% im*r%ve ,"ality in a healthcare settin!;

*"blished in >n!lish >dit%rial letters? c%n)erence abstracts? %*ini%n and a"ditarticles were e/cl"ded )r%m the st"dy selecti%n

ET70S

1?. ata collection process : escribe method of data e3traction fromreports 5e.(., piloted forms, independently, in dplicate6 and anyprocesses for obtainin( and conrmin( data from investi(ators.

ata were c%llected and tab"lated inde*endently by M(? M and < in a

manner !"ided by the %chrane =andb%%& >li!ibility was decidedinde*endently? in a standardised manner and disa!reements were res%lved byc%nsens"s ) an abstract was n%t available )r%m the database? the )"ll2te/tre)erence was accessed


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ET70S11. ata items: List and dene all variables for which datawere so(ht 5e.(., 'I%0S, fndin( sorces6 and any

assmptions and simplications made.

A the%retical )ramew%r& was c%nstr"cted by c%m*artmentalisin! the&ey )eat"res %) the PSA meth%d int% %bservable variables )%r

eval"ati%n -table $3 (his )ramew%r& was devel%*ed in acc%rdance withrec%mmendati%ns )%r PSA "se cited in the literat"re? describin! the%ri!ins and the%ry %) the meth%d #ace validity %) the )ramew%r& wasachieved thr%"!h disc"ssi%n am%n! a"th%rs? with )acilitat%rs and atl%cal research meetin!s ata were c%llected re!ardin! a**licati%n %) the PSA meth%d in line

with the the%retical )ramew%r& ther data c%llected incl"ded @rsta"th%r? year %) *"blicati%n? c%"ntry? area %) healthcare? "se %) PSA %rPA termin%l%!y? and "se %) M# %r #GS as s"**%rtin! )ramew%r&s


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ET70S1&. $is) of bias in individal stdies : escribe methods sed for assessin( ris)of bias of individal stdies 5incldin( specication of whether this was done atthe stdy or otcome level6, and how this information is to be sed in any datasynthesis.

(he *resent review aimed t% assess the re*%rted a**licati%n %) the PSAmeth%d and the res"lts %) individ"al st"dies were n%t analysed in this review

ET70S12. Smmary measres: State the principal smmary measres 5e.(., ris) ratio,

di@erence in means6.


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ET70S14. Synthesis of reslts: escribe the methods of handlin( data and combinin(reslts of stdies, if done, incldin( measres of consistency 5e.(., I&6 for eachmeta;analysis.

A systematic narrative review was c%nd"cted in adherence t% the Pre)erredRe*%rtin! tems )%r Systematic Reviews and Meta2Analyses -PRSMA3 statementAll st"dies "sed a )%rm %) ,"alitative and ,"antitative data t% assess cyclesSt"dies were cate!%rised acc%rdin! t% )%"r ty*es %) re*%rtin! ,"antitative data:re!"lar -nJ153? three %r m%re data *%ints with c%nsistent time intervals; n%n2re!"lar -nJ163? be)%re and a)ter %r *er PSA cycle; sin!le data *%int -nJ83? asin!le data *%int a)ter PSA cycle-s3; and n% ,"antitative data re*%rted -nJ83

) the 15 articles that "sed re!"lar data? %nly 7 "sed m%nthly %r m%re )re,"entdata intervals -see %nline s"**lementary @!"re S )%r )"ll )re,"ency %) re!"lar,"antitative data re*%rtin!3 leven incl"ded analysis %)data "sin! in)erential statistical tests -@ve %) these st"dies c%llected is%lateddata? si/ inv%lved c%ntin"%"s data c%llecti%n3 ) the ei!ht articles that did n%t

re*%rt any ,"antitative data? tw% re*%rted that ,"antitative analyses had ta&en*lace b"t did n%t *resent the @ndin!s and si/ described the "se %) ,"alitative)eedbac& %nly -%ne n%n2re!"lar? @ve sin!le data *%int3 "alitative data were!athered thr%"!h a ran!e %) mechanisms )r%m in)%rmal staE %r *atient)eedbac& t% str"ct"red )%c"s


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ET70S18. $is) of bias across stdies: Specify any assessment of ris) of bias that maya@ect the cmlative evidence 5e.(., pblication bias, selective reportin( withinstdies6.

es*ite %"r review bein! )%c"sed %n re*%rted a**licati%n? rather than s"ccess

%) interventi%ns? it may still be *%ssible that *"blicati%n bias aEected the res"lts%) this st"dy Research that "sed PSA meth%d%l%!y? b"t did n%t yields"ccess)"l res"lts? may be less li&ely t% !et *"blished than re*%rts %) s"ccess)"lPSA interventi%ns

ET70S1. "dditional analyses: escribe methods of additional analyses 5e.(.,

sensitivity or sb(rop analyses, meta-re(ression6, if done, indicatin( whichwere pre;specied.

Rati%s were "sed t% analyses the res"lts re!ardin! the ma'%rity %) variables? andmean sc%res re!ardin! data ass%ciated with len!th %) st"dy? len!th %) PSA cycle

and sam*le siKe were als% "sed )%r analysis ata were analysed inde*endently byM( and M iscre*ancies -which %cc"rred in less than D %) data items3 wereres%lved by c%nsens"s


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$ESLTS1


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$ESLTS1=. Stdy characteristics: Cor each stdy, present characteristics for which datawere e3tracted 5e.(., stdy siDe, 'I%0S, follow-p period6 and provide thecitations.

%ontry of stdy (he retrieved articles describe st"dies c%nd"cted in the GSA -nJ463?the GL -nJ13? anada -nJ3 A"stralia -nJ3? the


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$ESLTS1>. $is) of bias within stdies: 'resent data on ris) of bias of each stdy and, ifavailable, any otcome level assessment 5see item 1&6.

(he *resent review aimed t% assess the re*%rted a**licati%n %) the PSA meth%d and theres"lts %) individ"al st"dies were n%t analysed in this review

$ESLTS&?. $eslts of individal stdies: Cor all otcomes considered 5benets orharms6, present, for each stdy: 5a6 simple smmary data for each intervention(rop 5b6 e@ect estimates and condence intervals, ideally with a forest plot. (% s"**%rt systematic re*%rtin! and enc%"ra!e a**r%*riate "sa!e? we s"!!est thatre*%rtin! !"idelines be *r%d"ced )%r "sers %) the PSA meth%d t% increase trans*arency ast% the iss"es that were enc%"ntered and h%w they were res%lved Fhile PSA is anal%!%"st% a scienti@c meth%d? it a**ears t% be rarely "sed %r re*%rted with scienti@c ri!%"r? whichin t"rn? inhibits *erce*ti%ns %) PSA as a scienti@c meth%d S"ch !"idelines are essential t%increase the scienti@c le!itimacy%) the PSA meth%d as well as t% im*r%ve scienti@c ri!%"r %r a**licati%n and re*%rtin!Alth%"!h the SGR> !"idelines ma&e re)erence t% the *%tential "se %) PSA cycles?)"rther s"**%rt t% "sers and teachers? and *"blicati%n %) this im*r%vement meth%d seems

necessary %nsistent re*%rtin! %) PSA str"ct"re w%"ld all%w meta2eval"ati%n andsystematic reviews t% )"rther b"ild the &n%wled!e %) h%w t% "se s"ch meth%ds eEectivelyand the *rinci*les t% a**ly t% increase chances %) s"ccessThese reslts s((est that the fll benets of the 'S" method wold probablynot have been realised in these stdies. 9ithot an iterative approach, learnin(from one cycle is not sed to inform the ne3t cycle, and therefore it is nli)elythat interventions will be adapted and optimised for se in a particlar settin(.Crthermore, lar(e-scale cycles ris) si(nicant resorce investment in aninterventionthat has not been tested and optimised within that environment andris) prodcin( falseF ne(atives


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$ESLTS&1. Synthesis of reslts: 'resent reslts of each meta-analysis done, incldin(

condence intervals and measres of consistency.

$ESLTS&&. $is) of bias across stdies: 'resent reslts of any assessment of ris) of biasacross stdies 5see Item 186.


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$ESLTS&2. "dditional analysis: Aive reslts of additional analyses, if done 5e.(.,

sensitivity or sb(rop analyses, meta-re(ression Gsee Item 1H6.

IS%SSI0/&4. Smmary of evidence: SmmariDe the main ndin(s incldin( the stren(th ofevidence for each main otcome* consider their relevance to )ey (rops 5e.(.,healthcare providers, sers, and policy ma)ers6.

verall these res"lts dem%nstrate *%%r c%m*liance with &ey *rinci*les %) the PSAmeth%d? s"!!estin! that it is n%t bein! "sed %*timally (he increasin! trend in "sin! PSA-as %**%sed t% HPAI3 cycles in recent years? h%wever? d%es seem t% have beenacc%m*anied by an increase in c%m*liance with s%me &ey *rinci*les? s"ch as "se %)iterative cycles emin! was ca"ti%"s %ver the "se %) the HPAI termin%l%!y and warnedit re)erred t% an e/*licitly diEerent *r%cess? re)errin! t% a ,"ality c%ntr%l circle )%r dealin!with )a"lts within a system? rather than the PSA *r%cess? which was intended )%r iterativelearnin! and im*r%vement %) a *r%d"ct %r a *r%cess (his s"btle diEerence in

termin%l%!ies may hel* t% e/*lain the better c%m*liance with &ey meth%d%l%!ical*rinci*lesin st"dies that re)er t% the meth%d as HPSAI


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LIIT"TI0/&8. isc"ss limitati%ns at st"dy and %"tc%me level -e!? ris& %) bias3? and at review2level-e!? inc%m*lete retrieval %) identi@ed research? re*%rtin! bias3

%0/%LSI0/S&. Pr%vide a !eneral inter*retati%n %) the res"lts in the c%nte/t %) %ther evidence? andim*licati%ns )%r )"t"re research

(he )act that %nly *eer2reviewed *"blicati%ns were assessed in this st"dy means thatres"lts may be aEected by *"blicati%n bias (his is antici*ated b%th in terms %) what isacce*ted )%r *"blicati%n b"t als% the level and ty*e %) detail that is re,"ested and all%wedin ty*ical *"blicati%ns -e!? be)%re and a)ter st"dies are m%re c%mm%n than *resentin! data%ver time and this may ma&e these ty*es %) st"dies easier t% *"blish3 (h%"!h w%r&may be easier t% *"blish n%w thr%"!h recent chan!es in *"blicati%n !"idelines? $7 *%ssible*"blicati%n %"tlets c%ntin"e t% be relatively limited

(here is varied a**licati%n and re*%rtin! %) PSAs and lac& %) c%m*liance with the*rinci*les that "nder*in its desi!n as a *ra!matic scienti@c meth%d (he varied *ractice

c%m*r%mises its eEectiveness as a meth%d )%r im*r%vement and ca"ti%ns a!ainst st"diesthat view %r PSA as a Hblac& b%/I interventi%n (here is an "r!ent need )%r !reaterscienti@c ri!%"r in the a**licati%n and re*%rtin! %) these meth%ds t% advance the"nderstandin! %) the science %) im*r%vement and eBcacy %) the PSA meth%d

(he PSA meth%d sh%"ld be a**lied with !reater c%nsistency and with !reater acc%rdancet% !"idelines *r%vided by )%"nders and c%mmentat%rs


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C/I/A&


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systematic review and meta analysis klp 6

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