Living systematic reviews in a context of rapidly emerging diseases: challenges and lessons learned

Background

In a context of a rapid emerging disease, like the COVID-19 pandemic, we are confronted with clinical uncertainty, evolving epidemiological setting and lacking evidence. Within the context of such a high-priority topic, living systematic reviews (LSRs) are an important systematic review type characterized through regular updating and permanent surveillance of continuously evolving evidence. However, with the new pandemic-related challenges, the standard LSR methodology had to be adapted.

Objectives

The objective is to discuss certain challenges that occurred when conducting LSRs in a rapidly emerging disease context. In particular, we give insights in the lessons we have learned from the conduct of two COVID-19 LSRs and highlight emerging methodological aspects.

Results

With the evolving knowledge around the virus and its caused disease, we learned that the initial plan for inclusion of study designs, publication types, interventions and comparators, outcomes and the search strategy had to be adapted. The author teams for example had to revise outcome measures or included observational data in addition to evidence from randomized controlled trials, as they provided substantial information on the safety of investigated interventions. For deciding when to update a LSR, additional aspects, such as policy relevance or waiting for important evidence dependent on the individual research question were considered. To avoid biases in the review process, we learned that transparent reporting of any methodological adaptations is highly relevant; between protocol and review, as well as between each review update.

Conclusions

Our experience showed that LSRs are highly suitable in a pandemic context, in particular when facing unexpected methodological and clinical challenges. The research question, study designs and the methodology, should be revisited and critically discussed before each update, to be flexible enough for addressing the pandemic context.

Key messages

Living systematic reviews are highly relevant in a pandemic context, but the methodology and decision when to update the review have to be adapted to respond purposeful to the emerging topic. To avoid biases in the review process, we learned that transparent reporting of any methodological adaptations is highly relevant; between protocol and review, as well as between each review update.

Gender-specific health literacy of individuals with a migrant background: A mixed-method approach

Background

The project “Gender-specific health literacy in individuals with a migrant background (GLIM)” (German Federal Ministry of Education and Research; 01GL1723) aims to provide a comprehensive overview of international research and evidence on aspects of gender and migration related to health literacy. It encompasses primary and secondary research using a mixed-methods approach.

Methods

In a first step, we systematically review the available quantitative and qualitative evidence: in the first quantitative review, we meta-analyse the evidence on gender differences in health literacy of migrants. The second quantitative review assesses the effectiveness of interventions for improving health literacy in female and male migrants. The third review summarises qualitative evidence to assess factors associated with gender and migration that may play a role in the design, delivery, and effectiveness of such interventions. In a second step, we conduct primary research by performing focus group discussions (FGDs) with health care providers who regularly work with different migrant groups in order to explore their perspectives on the challenges and needs of migrants in the German health care system.

Results

To date, we identified 163 relevant references after screening of 17,932 references, for all reviews combined. Various health literacy interventions and measurement tools exist and require critical evaluation. The FGDs yielded hints to factors that a) influence gender differences in the health literacy of migrants (e.g. masculinity norms preventing Mediterranean men from consulting psychotherapists) or b) limit systemic health literacy (e.g. lack of translators).

Conclusions

Results from the FGDs can provide insights into the processes underlying the results of the reviews. However, despite increasing research, summarising the available evidence is highly challenging, as there are no universal definitions of the key concepts health literacy and migrant background.

Key messages

This is an interdisciplinary project, combining quantitative and qualitative evidence to provide maximum value to health policy and decision-making for the health care and health literacy of migrants. Research on gender-, and migration-specific aspects of health literacy is of great importance for the development and delivery of effective interventions for improving migrants’ health literacy.

Gender differences of health literacy in first and second generation migrants: A systematic review

Background

Health literacy, defined as all skills and capabilities that enable a person to access, understand, appraise and apply health information, is a key factor regarding disease management, health outcomes, and health-decision-making. Internationally, migrants have been identified as a high-risk group for limited health literacy. However, it remains unclear if female and male migrants process health information differently. This systematic review aims to analyze gender differences in the health literacy of first and second generation migrants.

Methods

We performed a systematic review according to PRISMA guidelines. We searched OVID (MEDLINE), PsychInfo and CINAHL for original articles providing extractable data on the health literacy of male and/or female migrants. Two reviewers independently reviewed abstracts and full text articles for according to predefined inclusion criteria, including the use of a validated health literacy measurement tool, applying it to first and/or second generation adult migrants. We adapted a data extraction sheet from the Cochrane Collaboration for extracting relevant data. The included studies were evaluated against a standardized set of quality criteria.

Results

Our search yielded 3411 records. We included 48 studies, of which 37 were conducted in the USA and Canada, with 22 focusing Hispanic and Asian immigrants’ functional health literacy; the nine European studies examined a variety of work migrants and refugees using a comprehensive approach (e.g. measured by the HLS-EU-Q47). Thus, a strong heterogeneity in defining and measuring health literacy and in the populations examined can be stated. 15 studies exclusively examined the health literacy of women; none dealt with men only.

Conclusions

The heterogeneity in defining and measuring health literacy in migrants as well as the diversity of the populations studied make it difficult to compare international research in this area. There is a lack of research focusing male migrants.

Key messages

International research on health literacy with gender-specific data on migrants reveals a strong heterogeneity in defining and measuring health literacy. International research on health literacy with gender-specific data on migrants reveals a lack of studies regarding male migrants’ health literacy.

Building bridges takes time: Views of healthcare professionals on health literacy and migration

Background

Health literacy is an output of individual resources and capabilities, situational factors, environmental conditions, and the requirements of the health care system. As migration continues to increase globally, successful interaction between healthcare professionals and migrants can be important for a sustainable and resource-oriented promotion of health literacy. This study aims to explore challenges, needs and applied solutions of healthcare professionals in the interaction with migrants in Germany.

Methods

Five focus group discussions were conducted in Cologne, Germany. Participants were healthcare professionals (n = 30), including general practitioners, medical specialists in inpatient and outpatient care, and nurses. Discussions were audio recorded, transcribed verbatim and analysed by qualitative content analysis.

Preliminary results

Participants reported a lack of time and general uncertainty in dealing with the health literacy-related needs of the target population. Assumptions on discrimination through the health system and restrictive gender roles on the patients’ side were additional key challenges for a successful interaction. To bridge these barriers, some participants reported to invest time even beyond systemic conditions; most wished for professional interpreters or cultural mediators. Participants who themselves were migrants found this helpful for communicating information to patients and improving patients’ confidence in the recommended treatment. Using clinical staff as lay interpreters outside their own treatment situation was rated critical, as it can be associated with a considerable burden due to a further time restriction for their actual tasks.

Conclusions

Preliminary findings reveal that general problems in the health care setting (e.g. time pressure, ensuring patients’ compliance) can occur more intensively in migrant patients. Health professionals require support through the provision of state-funded professional interpreters.

Key messages

Health literacy related challenges become more visible in the context of migration and reveal general issues in the German health system that need to be solved for the benefit of the entire population. Research on health literacy in the context of migration is important in order to ensure the promotion and maintenance of health equally and effectively across populations.

Adjuvant bisphosphonates or RANK-ligand inhibitors for patients with breast cancer and bone metastases: A systematic review and network meta-analysis

Bone-modifying agents like bisphosphonates and receptor activator of nuclear factor kappaβ ligand (RANK-L) inhibitors are used as supportive treatments in breast cancer patients with bone metastases to prevent skeletal-related events (SREs). Due to missing head-to-head comparisons, a network meta-analysis was performed to provide a hierarchy of these therapeutic options. Through a systematic literature search, 21 randomized controlled trials (RCTs) that fulfilled the inclusion criteria were identified. To prevent SREs, the ranking through P-scores showed denosumab (RR: 0.62; 95%CI: 0.50-0.76), zoledronic acid (RR: 0.72; 95%CI: 0.61-0.84) and pamidronate (RR: 0.76; 95%CI: 0.67-0.85) to be significantly superior to placebo. Due to insufficient or heterogeneous data, overall survival, quality of life, pain response and adverse events were not able to be analyzed within the network. Although data were sparse on adverse events, the risk of significant adverse events appeared low. The results of this review can therefore be used to formulate clinical studies more precisely in order to standardise and focus on patient-relevant outcomes.

[The curriculum for rotation physicians within the CHIR-Net]

INTRODUCTION

CHIR-Net is a German national surgical network for clinical trials. It is supported by the Federal Ministry for Education and Research (BMBF 01GH0605) to establish infrastructure and expertise in the conduct of clinical trials within the surgical disciplines. An important aspect of this network is a qualified advanced training for physicians deployed at the CHIR-Net as part of a job rotation.

METHODS

A catalog of activities for the time of rotation within the network has been developed in cooperation with the CHIR-Net, the deployed physicians and cooperating regional clinical trials centers (ZKS/KKS).

RESULT

The focal points of the physicians' rotation in the CHIR-Net are outlined in a curriculum that has been established and evaluated in the network since January 2008.

CONCLUSION

After the rotation time at the CHIR-Net the skilled physicians act as multipliers of specialized knowledge on clinical research. In this way the acquired expertise will be transferred into clinical practice and treatment of patients within research projects will benefit directly.

Chemotherapy plus Rituximab versus chemotherapy alone for B-cell non-Hodgkin's lymphoma

BACKGROUND

Rituximab has been shown to improve response rates and progression free survival when added to chemotherapy in patients with indolent and mantle cell lymphoma. However, the impact of R on overall survival (OS) when given in combination with chemotherapy (R-chemo) has remained unclear so far.

OBJECTIVES

We thus performed a comprehensive systematic review in this group of patients to compare R-chemo with chemotherapy alone with respect to OS. Other endpoints were overall response rate (ORR), toxicity and disease control as assessed by measures such as time to treatment failure (TTF), event free-survival (EFS), progression free-survival (PFS) and time to progression (TTP).

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library), MEDLINE, EMBASE and conference proceeding from 1990 to 2005.

SELECTION CRITERIA

Only randomised controlled trials (RCT) comparing R-chemo with chemotherapy alone in patients with newly diagnosed or relapsed indolent lymphoma and mantle cell lymphoma (MCL) were included.

DATA COLLECTION AND ANALYSIS

Two review authors extracted data and assessed the study quality. Number needed to treat (NNT) were calculated to facilitate interpretation.

MAIN RESULTS

Seven randomised controlled trials involving 1943 patients with follicular lymphoma, mantle cell lymphoma, or other indolent lymphomas were included in the meta-analysis. Five studies were published as full-text articles, and two were in abstract form. Patients treated with R-chemo had better overall survival (hazard ratio [HR] for mortality 0.65; 95% confidence interval (CI) 0.54 to 0.78), overall response (relative risk of tumour response 1.21; 95% CI 1.16 to 1.27), and disease control (HR of disease event 0.62; 95% CI 0.55 to 0.71) than patients treated with chemotherapy alone. R-chemo improved overall survival in patients with follicular lymphoma (HR for mortality 0.63; 95% CI 0.51 to 0.79) and in patients with mantle cell lymphoma (HR for mortality 0.60; 95% CI 0.37 to 0.98). However, in the latter case, there was heterogeneity among the trials (P 0.07), making the survival benefit less reliable.

AUTHORS' CONCLUSIONS

The systematic review demonstrated improved OS for patients with indolent lymphoma, particularly in the subgroups of follicular and in mantle cell lymphoma when treated with R-chemo compared to chemotherapy alone.