About EffectiveOlderPeopleCare.org
What is EffectiveOlderPeopleCare.org?
EffectiveOlderPeopleCare.org is a fully indexed, searchable, web-enabled database of evidence for the management of older people's care and rehabilitation.
What will I find in EffectiveOlderPeopleCare.org?
EffectiveOlderPeopleCare.org provides you with a systematic, accessible and transparent database of the evidence of effectiveness of interventions in the care of older people.
Topic – question - intervention
- Evidence about aspects of older people's care management is presented in TOPICS.
- A TOPIC reflects a problem that an older patient may have (e.g. poor balance), or a problem relating to the management of an older patient (e.g. where should the patient be cared for?).
- For each topic, one or more relevant QUESTIONs have been asked; these questions ask about the effectiveness of an intervention.
- For each question, one or more INTERVENTIONs have been identified.
- You can browse the TOPICs – QUESTIONs – INTERVENTIONs as a ‘tree-view’ or flow diagram, or you can use the search facility to go straight to the question and intervention of interest to you.
Evidence statement, critical appraisals and guidelines
- The Cochrane database for systematic reviews has been searched to find the relevant high quality evidence relating to the QUESTION and INTERVENTION. This produces references systematic reviews. [Read about searching for the evidence]
- For each intervention, an EVIDENCE STATEMENT is presented, based on the evidence found in the literature search. The evidence statement uses a systematic method to categorise the level of effectiveness of the intervention, and to provide a clear statement of the benefits and harms of the intervention. [Read about the method of summarising the evidence into an evidence statement]
- The evidence statement is based on CRITICAL APPRAISALS of the relevant Cochrane systematic reviews [Read about appraising the evidence]
- The evidence statement also provides direct links to national GUIDELINES related to the intervention and question. (http://www.sign.ac.uk/ and http://www.nice.org.uk/page.aspx?o=guidelines.completed) [Read about how national guidelines are linked to questions and interventions]
- If you click on a QUESTION you will see a list of interventions, each with an evidence ‘category’ (Beneficial, Likely to be beneficial, Trade-off between benefits and harms, Unknown effectiveness, Unlikely to be beneficial, Likely to be ineffective or harmful.) and a clear statement of the evidence found. (Find out more about the evidence categories: http://www.clinicalevidence.com/ceweb/about/guide.jsp" target="_self">www.clinicalevidence.com/ceweb/about/guide.jsp )
- If you click on an INTERVENTION you will see the same evidence category and statement of evidence for that one intervention. In addition you will also see a statement of the benefits and/or harms of the interventions; key comments regarding the available evidence and it’s appraisal; and direct links to the critical appraisals of the individual systematic reviews or randomised controlled trials, and to any relevant guidelines.
How has EffectiveOlderPeopleCare.org compiled this evidence?
Evidence-based practice is reliant on the availability and accessibility of robust research evidence. For this research to make an impact it has to be relevant. Rigorous steps have therefore been taken to identify relevant topics in older people's care. Following consultation with professionals working in the field the selection of topics was refined to themes covering common health issues (i.e.continence, falls etc) and different models of service organisation (i.e. acute care, long term care etc)
2. Development of a framework for classifying and organising information
It was important to develop an accessible framework that would allow users to easily locate a topic of interest to them. The list of topics was systematically examined, and common themes were identified and grouped. Each major topic or theme branches into subsections that finish with the summary evidence for a particular intervention.
3. Defining questions
The first stage in the database development process was to convert the information needs of the health professionals into clinical questions that can potentially be answered by reference to the research literature.
4. Types of evidence used to answer the questions
EffectiveOlderPeopleCare.org is primarily interested in providing answers to questions about interventions in the management of frail older patients and their carers and about the best organisation of services for older people. The most appropriate study designs to answer these questions are randomised controlled trials and systematic reviews of RCTs. The types of evidence used by EffectiveOlderPeopleCare.org has been limited to Cochrane Systematic Reviews (CSR).
EffectiveOlderPeopleCare.org does not address other types of clinical questions that may arise including prognosis, diagnosis or aetiology.
EffectiveOlderPeopleCare.org hand searched the Cochrane Database of Systematic Reviews (CDSR) evidence relating to each question defined. CDSR is a database found on the Cochrane Library.
What is the Cochrane Database of Systematic Reviews (CDSR)?
The Cochrane Database of Systematic Reviews is a database of high quality systematic reviews of evidence, usually from randomised controlled trials which is updated on a quarterly basis. Advantages of Cochrane Reviews, as compared to other reviews of effectiveness, include:
Having searched for and found the evidence in the form of systematic reviews , the next stage is to critically appraise this evidence. Critical appraisal is a process to determine whether evidence is valid (close to the truth, believable, free from bias) and important (and therefore useful to you as a health care professional). EffectiveOlderPeopleCare.org uses an explicit, systematic process to critically appraise the evidence.
Appraising a systematic review
Systematic reviews are scientific investigations. They give an overview of all of the primary research studies which address the same or similar research questions. Primary research study designs are critically appraised, data are synthesised and results interpreted.
Systematic reviews use strategies to limit bias and random error. Strategies used include:
- the use of pre-planned methods
- the development of a clearly formulated question
- a comprehensive search of all potentially relevant articles
- the use of explicit, reproducible criteria in the selection of primary research studies for review.
However, reviews can still have methodological problems. These can include:
- failure to present a clearly formulated review question
- failure to identify a primary outcome of interest
- failure to adequately report criteria for selecting studies to be included in the review
- failure to avoid bias in the selection of studies
- failure to adequately report criteria used to assess validity
- failure to apply criteria to assess the validity of selected studies
Methodological problems in systematic reviews can lead to distorted results and false conclusions. It is therefore important that the methodology of a systematic review is critically appraised before any conclusions are drawn from the presented results.
EffectiveOlderPeopleCare.org critically appraises each systematic review using a standard and explicit process. This process involves asking seven simple questions about the methodology of the systematic review:
- Is the review question clearly formulated? (Condition of interest; participants; interventions; outcomes; comparisons; types of study)
- Is there a primary outcome of interest?
- Have the authors conducted a thorough search for all relevant studies (bibliographic databases; reference lists; personal contact, hand search etc)
- Did the reviewers assess for (and document): method of allocation concealment in the included trials?
- Did the reviewers assess for (and document): blindness of those receiving care? blindness of those providing care?
- Did the reviewers assess for (and document): completeness of follow-up? intention to treat analysis?
- Did the reviewers assess for (and document): blinding of outcome assessor(s)? identification of specification of pre-defined primary outcomes in trials.
Having critically appraised systematic reviews related to a topic, question or intervention, EffectiveOlderPeopleCare.org summarises the evidence producing an Evidence Statement. The evidence statement includes:
Summary statement
A summary statement provides the results of the evidence-based practice investigation into the effectiveness of the intervention under examination for the problem/patient population of interest and includes a brief statement on the type of research evidence that this information is based on.
Benefits and harms
More detailed information is presented in terms of ‘benefits’ and potential ‘harms’ of the intervention to patients. This information is accompanied by comments on the volume of evidence and the external validity or generalisability/ applicability of results.
Categorisation of evidence
The level of evidence available to determine the effectiveness of each intervention addressing a particular problem is summarised and categorised using the following system which has been derived (with permission) from "Clinical Evidence" "Clinical Evidence", BMJ Publishing Group, is a compendium of evidence on what works in healthcare.
Beneficial
| Interventions whose effectiveness has been demonstrated by clear evidence from randomised controlled trial(s) with an expectation of harms that is small compared with the benefits. |
Likely to be beneficial
| Interventions for which effectiveness is less well established than those listed under ‘beneficial’. |
Trade-off between benefits and harms
| Interventions for which clinicians and patients should weigh up the beneficial and harmful effects according to individual circumstances and priorities. |
Unknown effectiveness
| Interventions where there are currently insufficient data or data of inadequate quality. |
Unlikely to be beneficial
| Interventions for which lack of effectiveness is less well established than those listed under ‘likely to be ineffective or harmful’. |
Likely to be ineffective or harmful
| Interventions whose lack of effectiveness or harmfulness has been demonstrated by clear evidence. |
The method of summarising and categorising the evidence used has been derived (with permission) from Clinical Evidence
http://www.clinicalevidence.com/ceweb/index.jspUnknown effectiveness
Many of the interventions used to treat specific problems have been graded as ‘unknown effectiveness’. If you see this in relation to an intervention that you are currently providing or would like to provide, it’s worth remembering that lack of evidence of effectiveness is not evidence of lack of effect…we just do not have enough evidence from the right type of Cochrane systematic review at this moment in time to support or refute the use of that particular intervention for that specific problem.
EffectiveOlderPeopleCare.org has handsearched high-quality National Guidelines including those from the Scottish Intercollegiate Guidelines Network (SIGN) http://www.sign.ac.uk/, the National Institute of Clinical Excellence (NICE) http://www.nice.org.uk/page.aspx?o=guidelines.completed from England and Wales, and has identified those that relate to specific questions and interventions relevant for care of older people. Hyperlinks to take you directly to the relevant guideline are available within the standard evidence statement.
Why EffectiveOlderPeopleCare.org is not a guideline:
EffectiveOlderPeopleCare.org contains standard statements, based on our assessment of the best available evidence, about whether a particular intervention is likely to beneficial or not. The clinician still needs to apply this information to the context of their particular patient and healthcare system.
Limitations of EffectiveOlderPeopleCare.org
TOPICS – QUESTIONS – INTERVENTIONS
The topics, questions and interventions have been developed and structured by the research team using a variety of different strategies. Whilst every effort has been made to make the structure of this evidence simple, logical and comprehensive, there can at times be ambiguity in the language used. It is therefore possible that users may experience difficulties finding the topic/question of interest to them, or that an intervention of interest has not been covered. Please contact the secretary of the Geriatric Academic Department, Glasgow Royal Infirmary, email: cf37r@clinmed.gla.ac.uk or hjm2n@clinmend.gla.ac.uk if you experience any such difficulties.
EVIDENCE STATEMENTS – CRITICAL APPRAISALS
Critically appraised topics (CATs) are each produced by one person who is trained and experienced in critical appraisal. Whilst every effort has been made to ensure that each CAT follows a very structured and systematic process, and that all stages of this process are explicit, the introduction of bias and error through personal interpretation of evidence is impossible to avoid entirely. The advisory team does view and comment on the CATs; this should reduce, but not entirely avoid, bias and error within CATs.
A more acceptable and robust method to avoid the introduction of bias and error would be to use two independent reviewers for each CAT. Unfortunately limited time and resources have, to date, prevented this.
Quality of evidence
The highest quality of evidence regarding the effectiveness of an intervention should come from a Cochrane Systematic Review. The methods of a Cochrane Systematic Review involve the use of two or more independent reviewers and a panel of experts to provide comments on the methodology and content. Read more about the methods of Cochrane Systematic Reviews.
What if there’s no evidence?
Within EffectiveOlderPeopleCare.org you will find several evidence statements which state that “we found no Cochrane systematic reviews addressing this intervention”.
Knowledge of where there is and where there is not high quality evidence is an advantage. We believe that the clear identification of topics and interventions that have not been adequately researched is a strength of EffectiveOlderPeopleCare.org and not a limitation.
Knowledge of the gaps in clinical trial evidence provides two clear advantages:
- It shows researchers where further evidence is required and can be used to set the research agenda.
- It empowers clinicians to justify their choice of treatments using less robust evidence – for example randomised controlled trials, single case studies, expert opinion and personal experience.
An absence, or lack, of evidence is not evidence of no effect. An intervention may be effective, despite the lack of high quality evidence.