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Presentation of Findings Prepared for: The Agency for Healthcare Research and Quality (AHRQ) Training Modules for Systemat...
Systematic Review Process Overview
<ul><li>To understand the goals of presenting systematic review data in tables that summarize data across studies </li></u...
<ul><li>Once the evidence tables are completed, there is an enormous (sometimes overwhelming) amount of data yet to synthe...
<ul><li>Even studies meeting the same inclusion criteria can vary. </li></ul><ul><ul><li>Clinical heterogeneity — variatio...
<ul><li>Nonquantitative synthesis using tables that summarize data across studies </li></ul><ul><li>Use of evidence maps t...
<ul><li>Population:  primary populations of interest are followed by subpopulations </li></ul><ul><li>Intervention:  hiera...
<ul><li>Evidence tables are the first step to summarization, but each evidence table represents the data in only one study...
<ul><li>Combine data from multiple studies to illustrate trends in the data </li></ul><ul><li>May be focused on describing...
<ul><li>Simplified entry (one row) for each study  </li></ul><ul><li>Table columns may include, for example: </li></ul><ul...
Example: Summary Table of Study Characteristics <ul><li>A basic summary table is the “study characteristics” table.  </li>...
Example: Summary Table as High-Level Map  Chung M, et al. AHRQ Evidence Report/Technology Assessment No. 183. Available at...
Example: Summary Table of Study Characteristics Balk EM, et al.  Ann Intern Med  2003;139:670-82. Reprinted with permissio...
Visual Presentation of Available Comparisons Ip S, et al. AHRQ Evidence Report/Technology Assessment No. 124.  Available a...
Example: Summary Table of Prevalence Findings <ul><li>Summary tables can be specialized for different types of questions. ...
Example: Summary Table for Randomized Controlled Trials <ul><li>Summary tables can be specialized for different subgroups ...
Example:  Summary Table for Cohort Studies Wang C, et al. AHRQ Evidence Report/Technology Assessment No. 94. Available at:...
Example: Presentation of Harms Data <ul><li>Summary tables can be specialized for different subgroups of the literature. <...
Example: Presentation of Data by Outcome and Age Chung M, et al. AHRQ Evidence Report/Technology Assessment No. 183. Avail...
Example: Presentation of Patient-Reported Outcomes <ul><li>Summary tables can be specialized for different types of outcom...
<ul><li>Are a succinct graphical presentation of available studies to address key questions along variables of interest </...
Example: Evidence Map Terasawa T, et al.  Ann Intern Med  2009;151:556-65. Reprinted with permission from the American Col...
A Second Approach to an Evidence Map Raman G, et al. AHRQ Technology Assessment No. GEND1206. Available at:  http://www.cm...
Forest Plot Without Summary Favors Wide-Area Circumferential Ablation Favors Pulmonary Vein Isolation Ip S, et al. AHRQ Co...
Summary Matrix Wang C, et al. AHRQ Evidence Report/Technology Assessment No. 94. Available at:  http://www.ahrq.gov/downlo...
<ul><li>Summary tables and evidence maps provide key information on study characteristics and study findings. Through tabl...
<ul><li>Agency for Healthcare Research and Quality. Methods reference guide for effectiveness and comparative effectivenes...
<ul><li>Hartmann KE, McPheeters ML, Biller DH, et al.  Treatment of Overactive Bladder in Women . Evidence Report/Technolo...
<ul><li>Ip S, Terasawa T, Balk EM, et al.  Comparative Effectiveness of Radiofrequency Catheter Ablation for Atrial Fibril...
<ul><li>Terasawa T, Dvorak T, Ip S, et al. Systematic review: charged-particle radiation therapy for cancer.  Ann Intern M...
<ul><li>This presentation was prepared by Melissa L. McPheeters, Ph.D., M.P.H., and Jeff Seroogy, B.S., members of the Van...
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Presentation of Findings

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Presentation of Findings

  1. 1. Presentation of Findings Prepared for: The Agency for Healthcare Research and Quality (AHRQ) Training Modules for Systematic Reviews Methods Guide www.ahrq.gov
  2. 2. Systematic Review Process Overview
  3. 3. <ul><li>To understand the goals of presenting systematic review data in tables that summarize data across studies </li></ul><ul><li>To become familiar with approaches to graphical presentations of findings not synthesized through statistical or meta-analytic techniques </li></ul>Learning Objectives
  4. 4. <ul><li>Once the evidence tables are completed, there is an enormous (sometimes overwhelming) amount of data yet to synthesize. </li></ul><ul><li>Various types of heterogeneity may preclude a quantitative synthesis (e.g., meta-analysis). </li></ul><ul><li>Synthesizing heterogeneous studies by using tables (nonquantitative synthesis) can capture underlying similarities to support conclusions. </li></ul><ul><li>Making sense of the data requires good tabular presentation, in addition to clear organization and writing of the text. </li></ul>Organizing and Reporting Findings
  5. 5. <ul><li>Even studies meeting the same inclusion criteria can vary. </li></ul><ul><ul><li>Clinical heterogeneity — variation in the study population, interventions, and outcomes </li></ul></ul><ul><ul><li>Methodological heterogeneity — variation in study design </li></ul></ul><ul><ul><li>Statistical heterogeneity — variation in observed treatment effect (for trials) </li></ul></ul><ul><li>Many factors can contribute to variation in seemingly similar studies. </li></ul><ul><ul><li>Some examples are evolving diagnostic criteria, evolving diseases, differences in baseline characteristics, and differences in care. </li></ul></ul><ul><li>Not all studies can (or should) be combined statistically. </li></ul><ul><ul><li>Various statistical models are useful for identifying the level of heterogeneity between studies. </li></ul></ul>Why Not Meta-analysis? AHRQ . Methods reference guide for effectiveness and comparative effectiveness reviews . Version 1.0. Available at: http://effectivehealthcare.ahrq.gov/repFiles/2007_10DraftMethodsGuide.pdf.
  6. 6. <ul><li>Nonquantitative synthesis using tables that summarize data across studies </li></ul><ul><li>Use of evidence maps to provide an overview of the data </li></ul>Solution
  7. 7. <ul><li>Population: primary populations of interest are followed by subpopulations </li></ul><ul><li>Intervention: hierarchy of interventions may reflect most common to least common </li></ul><ul><li>Comparator: where multiple comparisons are made, one might present the more “usual” decision first </li></ul><ul><li>Outcome: a hierarchy of outcomes may reflect higher to lower acuity or target outcomes followed by collateral ones; harms are generally presented last </li></ul><ul><li>Timing: short term generally precedes long term </li></ul><ul><li>Setting: an intervention may be available in various settings (e.g., inpatient or outpatient) </li></ul>PICOTS
  8. 8. <ul><li>Evidence tables are the first step to summarization, but each evidence table represents the data in only one study. </li></ul><ul><li>Incorporating multiple studies into a single table allows entire subsets of the literature to be summarized and compared (e.g., by key question or study design). </li></ul><ul><li>Summary tables and evidence maps are two approaches with which information about individual studies and results are combined. </li></ul><ul><li>Authors should use caution when deciding which evidence to summarize so as not to introduce a biased perspective. </li></ul>Combining Studies
  9. 9. <ul><li>Combine data from multiple studies to illustrate trends in the data </li></ul><ul><li>May be focused on describing study characteristics, results, or both </li></ul><ul><li>Can be designed to include characteristics of all included studies </li></ul><ul><ul><li>Examples: funding sources, assessment method, country of study </li></ul></ul><ul><li>Can be designed for subsets of included studies </li></ul><ul><ul><li>Examples: summary tables for randomized controlled trials, prevalence studies, harms/side effects, outcomes for specific treatments </li></ul></ul>Summary Tables (I)
  10. 10. <ul><li>Simplified entry (one row) for each study </li></ul><ul><li>Table columns may include, for example: </li></ul><ul><ul><li>PICOTS (may be listed in table title or headers) </li></ul></ul><ul><ul><li>Methodological quality </li></ul></ul><ul><ul><li>Applicability </li></ul></ul><ul><ul><li>Study size (weight) </li></ul></ul><ul><ul><li>Magnitude of effect </li></ul></ul><ul><li>A single study may be represented in multiple summary tables (e.g., different outcomes) </li></ul>Summary Tables (II) PICOTS = population, intervention, comparator, outcomes, timing, and setting
  11. 11. Example: Summary Table of Study Characteristics <ul><li>A basic summary table is the “study characteristics” table. </li></ul><ul><li>The overall summary provides an overview of the state of the available studies in the literature. </li></ul>Hartmann KE, et al. AHRQ Evidence Report/Technology Assessment No. 187. Available at: http://www.ahrq.gov/downloads/pub/evidence/pdf/ bladder/bladder.pdf.
  12. 12. Example: Summary Table as High-Level Map Chung M, et al. AHRQ Evidence Report/Technology Assessment No. 183. Available at: http://www.ahrq.gov/downloads/pub/evidence/pdf/vitadcal/vitadcal.pdf.
  13. 13. Example: Summary Table of Study Characteristics Balk EM, et al. Ann Intern Med 2003;139:670-82. Reprinted with permission from the American College of Physicians.
  14. 14. Visual Presentation of Available Comparisons Ip S, et al. AHRQ Evidence Report/Technology Assessment No. 124. Available at: http://www.ahrq.gov/downloads/pub/evidence/pdf/rhinoupdate/rhinoup.pdf.
  15. 15. Example: Summary Table of Prevalence Findings <ul><li>Summary tables can be specialized for different types of questions. </li></ul>Hartmann KE, et al. AHRQ Evidence Report/Technology Assessment No. 187. Available at: http://www.ahrq.gov/ downloads/pub/evidence/ pdf/ bladder/bladder.pdf.
  16. 16. Example: Summary Table for Randomized Controlled Trials <ul><li>Summary tables can be specialized for different subgroups of the literature. </li></ul>Hartmann KE, et al. AHRQ Evidence Report/Technology Assessment No. 187. Available at: http://www.ahrq.gov/ downloads/pub/evidence/pdf/bladder/bladder.pdf.
  17. 17. Example: Summary Table for Cohort Studies Wang C, et al. AHRQ Evidence Report/Technology Assessment No. 94. Available at: http://www.ahrq.gov/downloads/pub/evidence/pdf/o3cardio/o3cardio.pdf.
  18. 18. Example: Presentation of Harms Data <ul><li>Summary tables can be specialized for different subgroups of the literature. </li></ul>Hartmann KE, et al. AHRQ Evidence Report/Technology Assessment No. 187. Available at: http://www.ahrq.gov/ downloads/pub/evidence/ pdf/ bladder/bladder.pdf.
  19. 19. Example: Presentation of Data by Outcome and Age Chung M, et al. AHRQ Evidence Report/Technology Assessment No. 183. Available at: http://www.ahrq.gov/downloads/pub/evidence/pdf/vitadcal/vitadcal.pdf.
  20. 20. Example: Presentation of Patient-Reported Outcomes <ul><li>Summary tables can be specialized for different types of outcomes. </li></ul>Hartmann KE, et al. AHRQ Evidence Report/Technology Assessment No. 187. Available at: http://www.ahrq.gov/ downloads/pub/evidence/ pdf/ bladder/bladder.pdf.
  21. 21. <ul><li>Are a succinct graphical presentation of available studies to address key questions along variables of interest </li></ul><ul><ul><li>Results of outcomes typically not included </li></ul></ul><ul><li>Can help to identify comparisons with sufficient evidence for analysis </li></ul><ul><li>Can help to guide readers in knowing what comparisons and outcomes are available in the report </li></ul><ul><li>Can help to identify evidence gaps </li></ul>Evidence Maps
  22. 22. Example: Evidence Map Terasawa T, et al. Ann Intern Med 2009;151:556-65. Reprinted with permission from the American College of Physicians.
  23. 23. A Second Approach to an Evidence Map Raman G, et al. AHRQ Technology Assessment No. GEND1206. Available at: http://www.cms.gov/determinationprocess/downloads/id61TA.pdf. Dt: time (to stable dose) INR: international normalized ratio mean dose: mean maintenance dose
  24. 24. Forest Plot Without Summary Favors Wide-Area Circumferential Ablation Favors Pulmonary Vein Isolation Ip S, et al. AHRQ Comparative Effectiveness Review No. 15. Available at: http://www.effectivehealthcare.ahrq.gov/ehc/products/51/114/2009_0623RadiofrequencyFinal.pdf.
  25. 25. Summary Matrix Wang C, et al. AHRQ Evidence Report/Technology Assessment No. 94. Available at: http://www.ahrq.gov/downloads/pub/evidence/pdf/o3cardio/o3cardio.pdf.
  26. 26. <ul><li>Summary tables and evidence maps provide key information on study characteristics and study findings. Through table and graphical formats, respectively </li></ul><ul><li>Properly constructed summary tables: </li></ul><ul><ul><li>Effectively convey results </li></ul></ul><ul><ul><li>Provide an overview of the literature in a given field </li></ul></ul><ul><ul><li>Enable the reader to grasp results for subsets of the literature </li></ul></ul>Key Messages
  27. 27. <ul><li>Agency for Healthcare Research and Quality. Methods reference guide for effectiveness and comparative effectiveness reviews. Version 1.0. Rockville, MD: Agency for Healthcare Research and Quality, Draft Posted October 2007. Chapter 2, Finding evidence. Available at: http://effectivehealthcare.ahrq.gov/repFiles/ 2007_10DraftMethodsGuide.pdf. </li></ul><ul><li>Balk EM, Lau J, Goudas LC, et al. Effects of statins on nonlipid serum markers associated with cardiovascular disease. Ann Intern Med 2003;139:670-82. </li></ul><ul><li>Chung M, Balk EM, Brendel M, et al. Vitamin D and Calcium: A Systematic Review of Health Outcomes. Evidence Report/Technology Assessment No. 183. (Prepared by Tufts–New England Medical Center Evidence-based Practice Center under Contract No. HHSA 290-2007-10055-I). Rockville, MD: Agency for Healthcare Research and Quality, August 2009. AHRQ Publication No. 09-E015. Available at: http://www.ahrq.gov/downloads/pub/ evidence/pdf/vitadcal/vitadcal.pdf. </li></ul>References (I)
  28. 28. <ul><li>Hartmann KE, McPheeters ML, Biller DH, et al. Treatment of Overactive Bladder in Women . Evidence Report/Technology Assessment No. 187 (Prepared by Vanderbilt University Evidence-based Practice Center under Contract No. 290-2007-10065-I). Rockville, MD: Agency for Healthcare Research and Quality, August 2009. AHRQ Publication No. 09-E017. Available at: http://www.ahrq.gov/downloads/pub/evidence/pdf/bladder/ bladder.pdf. </li></ul><ul><li>Ip S, Fu L, Balk E, et al. Update on Acute Bacterial Rhinosinusitis . Evidence Report/Technology Assessment No. 124. (Prepared by Tufts – New England Medical Center Evidence-based Practice Center under Contract No. 290-02-0022). Rockville, MD: Agency for Healthcare Research and Quality, June 2005. AHRQ Publication No. 05-E020-2. Available at: http://www.ahrq.gov/downloads/pub/ evidence/pdf/rhinoupdate/rhinoup.pdf . </li></ul>References (II)
  29. 29. <ul><li>Ip S, Terasawa T, Balk EM, et al. Comparative Effectiveness of Radiofrequency Catheter Ablation for Atrial Fibrillation . Comparative Effectiveness Review No. 15 (Prepared by Tufts –New England Medical Center Evidence-based Practice Center under Contract No. 290-02-0022). Rockville, MD: Agency for Healthcare Research and Quality, July 2009. AHRQ Pub. No. 09-EHC015-EF. Available at: http://www.effectivehealthcare.ahrq.gov/ ehc/products/51/114/2009_0623RadiofrequencyFinal.pdf. </li></ul><ul><li>Raman G, Trikalinos TA, Zintzaras E, et al. Reviews of Selected Pharmacogenetic Tests for Non-Cancer and Cancer Conditions . Technology Assessment No. GEND1206 (Prepared by Tufts – New England Medical Center Evidence-based Practice Center under Contract No. 290-02-0022). Rockville, MD: Agency for Healthcare Research and Quality, November 2008. Available at: http://www.cms.gov/determinationprocess/downloads/id61TA.pdf. </li></ul>References (III)
  30. 30. <ul><li>Terasawa T, Dvorak T, Ip S, et al. Systematic review: charged-particle radiation therapy for cancer. Ann Intern Med 2009;151:556-65. </li></ul><ul><li>Wang C, Chung M, Balk E, et al. Effects of Omega-3 Fatty Acids on Cardiovascular Disease. Evidence Report/Technology Assessment No. 94 (Prepared by Tufts –New England Medical Center Evidence-based Practice Center under Contract No. 209-02-0022). Rockville, MD: Agency for Healthcare Research and Quality, March 2004. AHRQ Publication No. 04-E009-2. Available at: http://www.ahrq.gov/downloads/pub/evidence/pdf/o3cardio/o3cardio.pdf. </li></ul>References (IV)
  31. 31. <ul><li>This presentation was prepared by Melissa L. McPheeters, Ph.D., M.P.H., and Jeff Seroogy, B.S., members of the Vanderbilt University Evidence-based Practice Center, and Joseph Lau, M.D., and Thomas Trikalinos, M.D., Ph.D., members of the Tufts Medical Center Evidence-based Practice Center. </li></ul><ul><li>The information in this module is currently not included in Version 1.0 of the Methods Guide for Comparative Effectiveness Reviews (available at: http://www.effectivehealthcare.ahrq.gov/ehc/ products/60/294/2009_0805_principles1.pdf). </li></ul>Authors

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