Evidence process

STEP ONE

Search

For the evidence synthesis, we performed a comprehensive search for published systematic reviews and randomized controlled trials (RCTs) using the Cochrane Library, Embase, Ovid MEDLINE and PsycINFO databases.^⁶ A search strategy was developed for each of the scoping questions (Annex 3). Details of the search strategies can be found in the GRADE (Grading of Recommendations Assessment, Development and Evaluation) tables^⁷ and evidence profiles appended to these guidelines, which are available at http://www.who.int/ageing/health-systems/icope.

STEP TWO

Screening

Identified references were exported to reference manager software and duplicates were identified and deleted. References were screened first by title and abstract and then by full text to identify systematic reviews and RCTs. Details of the search process and the number of records retrieved and assessed for eligibility are presented in a PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) flow diagram for each PICO (population, intervention, comparison, outcome) question in the relevant GRADE evidence profile documents.

STEP THREE

Eligibility

Systematic reviews that reported the methodological quality assessment of included RCTs were eligible for inclusion. Of the 32 included systematic reviews, 20 were published between 2011 and 2015 and were updated with newer RCTs identified in consultation with guideline development group (GDG) members. The remaining 12 systematic reviews were published before 2011, and were updated with new RCTs identified from the search strategies during screening.

STEP FOUR

Quality assessment of included studies

The AMSTAR appraisal tool was used on each included systematic review to provide an indication of review conduct quality (see Fig. 3). No review was excluded based on the cut-off points in the AMSTAR tool as there is no score recommended for separating high- from low-quality reviews.

Fig. 3

Assessment of systematic review quality using the 11 questions of the AMSTAR checklist tool.

STEP FIVE

Meta-analysis

Where new trials were identified and included comparable interventions and outcomes, meta-analysis was conducted either as an update to the analyses contained in a previous review, or as a de novo meta-analysis. Review Manager 5 (RevMan 5) software was used to calculate mean differences and standardized mean differences between intervention and control groups. Relative risks or odds ratios were presented for categorical outcomes.

STEP SIX

GRADE assessment

The meta-analysed results were exported to the GRADE profiler software for evidence grading work.^⁸ The evidence was graded as very low, low, moderate, or high, based on the limitations of the included studies, specifically in terms of inconsistency, indirectness, imprecision and publication bias. Except for one Cochrane review, none of the included systematic reviews performed GRADE assessments. Therefore, for each meta-analysis, we conducted an independent assessment of the quality of results using GRADE profiler software.

Footnotes

See:

—: Cochrane Library (http://www.cochranelibrary.com/cochrane-database-of-systematic-reviews)
—: Embase (http://www.elsevier.com/solutions/embase-biomedical-research)
—: Ovid MEDLINE (http://ovid.com/site/catalog/databases/901.jsp)
—: PsycINFO (http://www.apa.org/pubs/databases/psycinfo/index.aspx)

Guyatt G, Oxman AD, Akl EA, Kunz R, Vist G, Brozek J et al. GRADE guidelines: 1. Introduction – GRADE evidence profiles and summary of findings tables. J Clin Epidemiol. 2011;64(4):383–94. doi:10.1016/j.jclinepi.2010.04.026. [PubMed: 21195583] [CrossRef]

GRADE’s software for summary of findings tables, health technology assessment and guidelines [website]. Hamilton (ON): McMaster University and Evidence Prime; 2015 (http://gradepro.org, accessed 11 September 2017).

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Annex 4Evidence process