Dena M. Bravata, MD, MS; Kathryn M. McDonald, MM; Kaveh G. Shojania, MD; Vandana Sundaram, MPH; Douglas K. Owens, MD, MS
Bravata DM, McDonald KM, Shojania KG, Sundaram V, Owens DK. Challenges in Systematic Reviews: Synthesis of Topics Related to the Delivery, Organization, and Financing of Health Care. Ann Intern Med. 2005;142:1056-1065. doi: 10.7326/0003-4819-142-12_Part_2-200506211-00005
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Published: Ann Intern Med. 2005;142(12_Part_2):1056-1065.
Some important health policy topics, such as those related to the delivery, organization, and financing of health care, present substantial challenges to established methods for evidence synthesis. For example, such reviews may ask: What is the effect of for-profit versus not-for-profit delivery of care on patient outcomes? Or, which strategies are the most effective for promoting preventive care? This paper desc ribes innovative methods for synthesizing evidence related to the delivery, organization, and financing of health care. We found 13 systematic reviews on these topics that described novel methodologic approaches. Several of these syntheses used 3 approaches: conceptual frameworks to inform problem formulation, systematic searches that included nontraditional literature sources, and hybrid synthesis methods that included simulations to address key gaps in the literature. As the primary literature on these topics expands, so will opportunities to develop additional novel methods for performing high-quality comprehensive syntheses.
This figure describes 3 stages of evidence synthesis used in a systematic review evaluating reports of information technologies and decision support systems for bioterrorism preparedness and response. The description of the full conceptual framework (24) and results of this systematic review (14) are available elsewhere. Figure modified with permission from reference 24: Bravata DM, McDonald KM, Szeto H, Smith WM, Rydzak C, Owens DK. Med Decis Making, pp. 192-206, copyright 2004 by Society for Medical Decision Making. Reprinted by permission of Sage Publications.
This figure uses influence diagram notation to depict the key decisions of clinicians and public health officials responding to bioterrorism (rectangular decision nodes), to identify the uncertain events affecting these decisions (elliptic chance nodes), and to evaluate the information that is observable by the decision makers at the time they make their decisions. The schematic depicts 3 critical time periods as follows: Time period 1 refers to the interval in which decisions are made by clinicians regarding the events associated with the initial cases; time period 2 refers to the interval in which decisions are made by public health officials regarding the events associated with the initial cases; and time period 3 refers to the interval in which decisions are made by clinicians regarding the events associated with the subsequent cases. The decisions and processes depicted in this figure could be supported by information technologies and decision support systems designed to facilitate bioterrorism preparedness and response. Figure reprinted with permission from reference 24: Bravata DM, McDonald KM, Szeto H, Smith WM, Rydzak C, Owens DK. Med Decis Making, pp. 192-206, copyright 2004 by Society for Medical Decision Making. Reprinted by permission of Sage Publications.
Top. An analytic framework with the linkages between antecedent factors (generally not modifiable), work environment conditions (which can either impede or improve work quality, and are therefore denoted as “demands” or “resources”), and the resultant influence on patient safety and outcomes. Bottom . Conceptual model of patient safety derived from several sources. The research team used these representations to develop a series of research questions focusing on the effects of the 5 categories of working conditions on patient outcomes related to patient safety, rate of medical error, rate of error recognition, and probability of adverse events. For example, one key question of this review was the following: Does the complexity of the plan of care influence whether working conditions affect patient outcomes that are related to patient safety? An asterisk denotes where this key question fits in the conceptual framework.
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