How stakeholder engagement has led us to reconsider definitions of rigour in systematic reviews

Abstract: As a methodology designed to inform policy and practice decisions, it is particularly important to ensure that systematic reviews are shaped by those who will use them. There is a broad range of approaches for engagement of the potential users of reviews that aim to elicit their priorities and needs and incorporate these into the review design. This incorporation of their priorities and needs can create a tension between their calls for locally-specific, often rapidly-produced evidence syntheses for policy needs and the production of unbiased, generalisable, globally-relevant systematic reviews. This tension raises the question of what is a ‘gold standard’ review. This commentary aims to address head on this often undiscussed key challenge with regard to stakeholder involvement in systematic reviews: that responding to stakeholders can mean reconsidering what makes a review rigorous. The commentary proposes a new model to address these tensions that combines the production of public-good reviews, with stakeholder-driven syntheses. In this, it presents the approach taken by our team in [Anonymised] to achieve two different but complementary outputs: (i) ‘public goods’, namely comprehensive and generalisable systematic reviews of the evidence available for and accessible to a global audience, and (ii) locally-focussed, stakeholder-driven, pragmatically-produced syntheses for decision-making at a policy level. The designed approach incorporates balancing the formal requirements of full, published systematic reviews with engagement of national and international decision-makers. It also accommodates space to move from stakeholder engagement to co-production, where stakeholders are engaged to such an extent that they become partners in the production of the review. These approaches are integrated into the traditional steps for producing a systematic review with implications as to what constitutes a gold standard approach to synthesising evidence

Preoperative Atrial Fibrillation/Flutter Impact on Risk-Adjusted Repeat Aortic Intervention Patients[PROTOCOL]

Aim: Impacts of pre-operative atrial fibrillation or flutter (AF/AFL) upon repeat aortic valve replacement (r-AVR) patients’ risk-adjusted short-term outcomes is unknown.Methods: From 2005-2018, New York State AF/AFL versus non-AF/AFL adults’ risk-adjusted r-AVR outcomes were compared. Primary endpoints included the Society of Thoracic Surgeons’ 30-day operative mortality or major morbidity (MM) composite and 30-day readmission (READMIT); the MM sub-components were secondary endpoints. Multivariable logistic regression models evaluated AF/AFL impact upon these endpoints while holding other factors constant.Results: Of 36,783 adults initially undergoing aortic valve replacement, 334 subsequently underwent r-AVR. Within this r-AVR group, 42.4% of repeat surgical (r-SAVR) patients had AF/AFL; 50.4% of repeat transcatheter (viv-TAVR) patients had AF/AFL. R-SAVR AF/AFL patients were older and had more comorbidities than those without AF/AFL. Viv-TAVR AF/AFL patients were similar to those without AF/AFL except for lower rates of chronic obstructive pulmonary disease. Comparing risk-adjusted r-AVR outcomes, AF/AFL did not impact MM [odds ratio (OR), 95% confidence interval (CI): 1.23, 0.66-2.28, P = 0.512] or READMIT (OR, 95%CI: 1.15, 0.60-2.19, P = 0.681). Black race (OR, 95%CI: 2.89, 1.01-8.32, P = 0.049) and Elixhauser mortality score (OR, 95%CI: 1.07, 1.04-1.10, P < 0.0001) predicted MM risk. Cerebrovascular disease (OR, 95%CI: 2.54, 1.23-5.25, P = 0.012) predicted READMIT risk, while viv-TAVR was protective compared to r-SAVR (OR, 95%CI: 0.44, 0.21-0.91, P = 0.027).Conclusion: AF/AFL was not associated with risk-adjusted short-term r-AVR outcomes. Black race, Elixhauser mortality score, and cerebrovascular disease predicted adverse outcomes

Developing indicators and measures of high-quality for Australian general practice

Background: Rising health costs and health inequity are major challenges in Australia, as internationally. Strong primary health care is well evidenced to address these challenges. Primary Health Networks (PHNs) work with general practices to collect data and support quality improvement; however, there is no consensus regarding what defines high quality. This paper describes the development of an evidence-based suite of indicators and measures of high-quality general practice for the Australian context. Methods: We reviewed the literature to develop a suitable framework and revise quality assurance measures currently in use, then reviewed these in three workshops with general practitioners, practice managers, nurses, consumers and PHN staff in western Sydney. We used a descriptive qualitative research approach to analyse the data. Results: A total of 125 evidence-based indicators were agreed to be relevant, and 80 were deemed both relevant and feasible. These were arranged across a framework based on the Quadruple Aim, and include structure, process and outcome measures. Conclusions: The agreed suite of indicators and measures will be further validated in collaboration with PHNs across Australia. This work has the potential to inform health systems innovation both nationally and internationally

Reflections on mentoring experiences for evidence-informed decision-making in South Africa and Malawi

Abstract: This article is based on the consensus that the availability and utilisation of research enhances policy discussions. The article reflects on the experiences within one approach: capacity building through mentoring. The UJ-BCURE programme aimed to increase the capacity of decisionmakers to use evidence in decision-making via mentoring models. Mentoring is described as an interactive, facilitated process that promotes learning. The features of the models that have contributed to the programme’s success are orientation workshops with mentees combined with participatory, needs-led, and flexible approaches. UJBCURE experiences are relevant to the field of evidence-informed decision-making in an African government context

Protocol for a Delphi consensus study to select indicators of high-quality general practice to achieve Quality Equity and Systems Transformation in Primary Health Care (QUEST-PHC) in Australia.

BackgroundHigh-quality general practice has been demonstrated to provide cost-effective, equitable health care and improve health outcomes. Yet there is currently not a set of agreed comprehensive indicators in Australia. We have developed 79 evidence-based indicators and their corresponding 129 measures of high-quality general practice. This study aims to achieve consensus on relevant and feasible indicators and measures for the Australian context.MethodsThis Delphi consensus study, approved by WSU Human Research Ethics Committee, consists of three rounds of online survey with general practice experts including general practitioners, practice nurses and primary health network staff. The identified indicators and measures are grouped under an attribute framework aligned with the Quadruple Aim, and further grouped under structures, processes and outcomes according to the Donabedian framework. Participants will rate each indicator and measure for relevance and feasibility, and provide comments and recommendations of additional indicators or measures. In the last round, participants will also be asked their views on the implementation of a quality indicator tool. Each indicator and measure will require ≥70% agreement in both relevance and feasibility to achieve consensus. Aggregated ratings will be statistically analysed for response rates, level of agreement, medians, interquartile ranges and group rankings. Qualitative responses will be analysed thematically using a mixed inductive and deductive approach.DiscussionThis protocol will add to the current knowledge of the translation of performance guidelines into quality practice across complex clinical settings and in a variety of different contexts in Australian general practice. The Delphi technique is appropriate to develop consensus between the diverse experts because of its ability to offer anonymity to other participants and minimise bias. Findings will contribute to the design of an assessment tool of high-quality general practice that would enable future primary health care reforms in Australia

Predictors and risk-adjusted outcomes of new-onset postoperative atrial fibrillation in repeat surgical and valve-in-valve transcatheter aortic valve replacement

Aim: New-onset postoperative atrial fibrillation/flutter (POAF/AFL) complications have not been well studied for repeat aortic valve replacements (r-AVR); this study identified risk factors predisposing to POAF/AFL and POAF/AFL’s effect upon risk-adjusted outcomes.Methods: Using New York State’s Statewide Planning and Research Cooperative System records (2005-2018), multivariable forward selection models identified risks predictive of POAF/AFL. To identify POAF/AFL’s impact upon risk-adjusted mortality/morbidity (MM) and 30-day readmission (READMIT), forward selection logistic regression models applied Firth bias correction to address data sparsity.Results: Of the 242 r-AVR patients, 147 underwent repeat surgical aortic valve replacements (r-SAVR) and 95 underwent valve-in-valve transcatheter aortic valve replacements (ViV-TAVR); 39.46% of r-SAVR and 43.16% of ViV-TAVR patients had POAF/AFL. R-SAVR patients with POAF/AFL were older (69.7 ± 11.1 vs. 56.7 ± 13.2 years, P < 0.01) compared to R-SAVR patients without POAF/AFL. Multivariable models identified an enhanced POAF/AFL risk for elderly (OR: 1.05, 95%CI: 1.03-1.07, P < 0.01) and cerebral vascular disease (OR: 2.18, 95%CI: 1.05-4.55, P = 0.04) patients. Bivariately, POAF/AFL was associated with READMIT, but not MM. Correspondingly, multivariable models found POAF/AFL increased READMIT (OR: 3.12, 95%CI: 1.46-6.65, P < 0.01), but not MM. However, black race (OR: 4.97, 95%CI: 1.61-15.37, P < 0.01) and Elixhauser score (OR: 1.05, 95%CI: 1.02-1.08, P < 0.01) increased risk for MM.Conclusion: More common in older and cerebrovascular disease patients, 41% of r-AVR patients with POAF/AFL had increased READMIT risk; thus, future investigations should focus on improving POAF/AF r-AVR patients’ post-discharge continuity of care