Effectiveness of interventions to reduce adverse outcomes among older adults following emergency department discharge: Protocol for an overview of systematic reviews

Mairéad Conneely; Katie Robinson; Siobhán Leahy; Dominic Trépel; Fionnuala Jordan; Rose Galvin

doi:10.12688/hrbopenres.13027.2

Home Browse Effectiveness of interventions to reduce adverse outcomes among older...

ALL Metrics

Views

Downloads

Get PDF

Get XML

Export

▬

✚

Study Protocol

Revised

Effectiveness of interventions to reduce adverse outcomes among older adults following emergency department discharge: Protocol for an overview of systematic reviews

[version 2; peer review: 2 approved]

Mairéad Conneely ¹, Katie Robinson¹, Siobhán Leahy¹, Dominic Trépel², Fionnuala Jordan³, Rose Galvin¹

Mairéad Conneely ¹, Katie Robinson¹, [...] Siobhán Leahy¹, Dominic Trépel², Fionnuala Jordan³, Rose Galvin¹

PUBLISHED 06 Apr 2021

Author details Author details

¹ School of Allied Health, Faculty of Education and Health Sciences, Ageing Research Centre, Health Research Institute, University of Limerick, Limerick, Ireland, V94 TPPX, Ireland
² Trinity Institute of Neurosciences, School of Medicine, Trinity College Dublin, Dublin, Ireland, DO2 PN40, Ireland
³ School of Nursing and Midwifery, National University of Ireland Galway, Galway, Ireland, H91 TK33, Ireland

Mairéad Conneely
Roles: Conceptualization, Methodology, Project Administration, Writing – Original Draft Preparation, Writing – Review & Editing

Katie Robinson
Roles: Supervision, Writing – Review & Editing

Siobhán Leahy
Roles: Supervision, Writing – Review & Editing

Dominic Trépel
Roles: Supervision, Writing – Review & Editing

Fionnuala Jordan
Roles: Methodology, Supervision, Writing – Review & Editing

Rose Galvin
Roles: Conceptualization, Funding Acquisition, Methodology, Project Administration, Supervision, Writing – Review & Editing

OPEN PEER REVIEW

REVIEWER STATUS

Abstract

Background: Older adults are frequent users of Emergency departments (ED) and this trend will continue due to population ageing and the associated increase in healthcare needs. Older adults are vulnerable to adverse outcomes following ED discharge. A number of heterogeneous interventions have been developed and implemented to improve clinical outcomes among this cohort. A growing number of systematic reviews have synthesised evidence regarding ED interventions using varying methodologies. This overview aims to synthesise the totality of evidence in order to evaluate the effectiveness of interventions to reduce adverse outcomes in older adults discharged from the ED.
Methods: To identify relevant reviews, the following databases will be searched: Cochrane Database of Systematic reviews, Joanna Briggs Institute Database of Systematic Reviews and Implementation Reports, Databases of Abstracts of Reviews of Effects, PubMed, MEDLINE, Epistemonikos, Ageline, Embase, PEDro, Scopus, CINAHL and the PROSPERO register. The search for grey literature will include Open Grey and Grey Literature Reports. Systematic reviews of randomised controlled trials will be analysed to assess the effect of ED interventions on clinical and process outcomes in older adults. Methodological quality of the reviews will be assessed using the Assessment of Multiple Systematic Reviews 2 tool. The review will be reported in accordance to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Summary of findings will include a hierarchical rank of interventions based on estimates of effects and the quality of evidence.
Discussion: This overview is required given the number of systematic reviews published regarding the effectiveness of various ED interventions for older adults at risk of adverse outcomes following discharge from the ED. There is a need to examine the totality of evidence using rigorous analytic techniques to inform best care and potentially develop a hierarchy of treatment options.
PROSPERO registration: CRD42020145315 (28/04/2020)

Keywords

Older adults, aged, Emergency department, adverse outcomes, interventions, systematic reviews, evidence synthesis, overviews

Corresponding author: Mairéad Conneely

Competing interests: No competing interests were disclosed.

Grant information: Health Research Board Ireland [CDA-2018-005]
The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Copyright: © 2021 Conneely M et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

How to cite: Conneely M, Robinson K, Leahy S et al. Effectiveness of interventions to reduce adverse outcomes among older adults following emergency department discharge: Protocol for an overview of systematic reviews [version 2; peer review: 2 approved]. HRB Open Res 2021, 3:27 (https://doi.org/10.12688/hrbopenres.13027.2) First published: 22 May 2020, 3:27 (https://doi.org/10.12688/hrbopenres.13027.1) Latest published: 06 Apr 2021, 3:27 (https://doi.org/10.12688/hrbopenres.13027.2)

Revised Amendments from Version 1

Many thanks to the reviewers for their useful feedback and suggestions. We have reflected on the feedback received and have revised the manuscript in line with this. Specifically, this updated version provides more detail on the algorithm to GRADE and the unit of analysis in an overview being a systematic review.

See the authors' detailed response to the review by Ruth McCullagh
See the authors' detailed response to the review by Michelle Gates

Introduction

Population ageing is increasing in most countries worldwide¹. Across Organisation for Economic Co-operation and Development (OECD) countries, the proportion of the population aged over 65 years has increased from less than 9% in 1960 to 17% in 2015 and is expected to rise to 28% in 2050^2,3. This change in demographics presents both opportunities and challenges⁴ Longer life is a valuable resource and presents many opportunities to older adults to have productive and healthy years⁵. Although increased life expectancy is assumed to be accompanied by an increase in healthy life years, there is little evidence that older adults living today are living with an enhanced health status than their parents did at the equivalent age¹. Older adults (aged ≥65 years of age) are the main users of health care services⁶ and account for a substantial amount of health care costs^7,8.

Multimorbidity (the co-existence of ≥2 chronic conditions) is common in older adults^1,9 and affects more than half of those aged 60 and over^10,11, with increasing prevalence in those aged over 80 years^1,4. Multimorbidity is also correlated with increased health care utilisation and subsequent health care costs¹⁰ as multimorbidity can cause problematic clustering of certain morbidities¹², and affect treatment of one morbidity and management of another¹. The combination of population ageing, multimorbidity and physiological changes in older age¹³ mean that older adults account for some of the highest percentage of acute care services use¹⁴ and have been described as “frequent users” of emergency departments (ED)^15,16, accounting for 12–24% of all Emergency department (ED) attendees^17,18. The reasons why more older adults are seeking ED services are numerous including shortage of aged-care facilities, barriers to accessing primary care services and changes in family demographics¹⁹.

Older adults experience longer lengths of stay while in the ED^18,20 and the visits require a high level of urgency and require more resources^18,21,22. In terms of community support services, international estimates demonstrate that between 45% to 60% of older adults presenting to the ED will be discharged directly home to the community²³. A growing body of evidence demonstrates high rates of adverse outcomes post discharge from the ED^13,24 as older adults encounter a period of increased vulnerability following presentation to, and subsequent discharge from, the ED¹⁵. A systematic review of 32 prospective and retrospective cohort studies concluded that approximately 20% of older people discharged from the ED return within 30 days, while 17% experience functional decline²⁵. Older adults, who return to the ED early following initial presentation, or index visit, are reported to return for the same complaint again¹⁸ indicating concerns that a lack of continuation of appropriate care may contribute to this form of health care utilisation²⁴. There is a high rate of nursing home admission following ED discharge and older adults have a higher rate of mortality than younger age groups following ED discharge^18,26.

The number of adverse outcomes reported following an index visit has led to the development of a number of interventions described in the literature to improve the health status of older adults^22,27. These interventions include single strategies such as ED staffing, modifications strategies to improve ED care delivery such as risk profiling, nurse led interventions, comprehensive geriatric assessments, case management within the ED and post-discharge and discharge planning^14,22,28,29. A systematic review of nine studies focusing solely on ED-based interventions reported that interventions that extended beyond referral and those with an integrated model of care (multifaceted interventions) may lead to improved outcomes including nursing home admission, ED revisits, hospitalisation and death²⁹. The authors also reported that the use of a clinical risk screening tool in the ED could potentially allow for identification of older adults most likely to benefit from interventions, but this was not consistent for all outcomes. On the contrary, a systematic review of nine studies by Lowthian et al.²² in 2015, reviewed the effectiveness of ED -community transitional strategies such as geriatric assessment, community-based referral, and GP liaison on post-discharge outcomes. This review reported no evidence of the effectiveness of the ED transitional strategy intervention for unplanned revisits, hospitalisation 30 days post discharge or mortality 18 months follow up. A systematic review by Hughes et al. (2019) evaluated the effectiveness of ED interventions aimed at improving clinical, patient experience and health care utilisation included 15 studies (9 randomised controlled trials)²⁷. This review explored the impact of interventions that were delivered during the ED visit, following discharge and across the ED-primary care interface using a variety of strategies (case management, discharge planning, and management/medication safety). The authors reported that interventions were heterogeneous with a mixed pattern of effects on clinical and process outcomes.

Given the diverse findings across these systematic reviews, there is a need to conduct an overview of systematic reviews to synthesise the evidence relating to the impact of ED interventions on a number of outcomes for older adults. An overview can highlight gaps in the literature^30,31 and this method of evidence synthesis³² is timely to evaluate the effectiveness of ED interventions on reducing adverse outcomes for older adults following ED discharge. The objectives of this overview are:

1. To identify, appraise and synthesise all relevant systematic reviews of ED based interventions, transitional interventions from the ED to the community and ED initiated interventions to reduce adverse outcomes (clinical outcomes, healthcare utilisation, and patient care experience) in older adults following ED discharge.

2. To identify commonalities and differences between these ED interventions with attention focusing on the characteristics of interventions, the quality of the evidence, the absolute risk difference and other pertinent factors such as heterogeneity (clinical and methodological) within and across reviews.

Methods

Protocol

An overview of systematic reviews will be conducted to identify systematic reviews (with/without meta-analysis) investigating the effectiveness of interventions to reduce adverse outcomes in older adults following index visit to the ED. In line with recommendations to improve transparency and reduce potential bias, the authors developed this protocol to outline the key objectives of this overview and what methodology will be employed³³. There is an absence of specific reporting guidelines for overviews of reviews of healthcare interventions with the Preferred Reporting Items for Overviews of Reviews (PRIOR) guidelines currently under development³⁴. This protocol was designed in accordance with the methodological framework provided by the Joanna Briggs Institute (JBI) Reviewer’s Manual³⁵, and using the guidance of the relevant items of the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) standardised reporting guidelines³⁶.

This protocol has been prepared with guidance from the PRISMA-Protocols (PRISMA-P) statement³⁷. The PRISMA-P checklist was developed to standardise the conduct and reporting of protocols of systematic reviews that synthesise accumulated data from primary studies, in particular studies that evaluate the effects of interventions and thus not all PRISMA-P items will be applicable for this overview. The relevant sections of the checklist will be used for this protocol in the absence of specific guidelines for the conduction and reporting of overviews of reviews. This methodology has been recommended in the absence of specific guidelines for reporting overviews³². The protocol was registered with PROSPERO on 28th April 2020 (CRD42020145315).

Search strategy

The authors developed a comprehensive search strategy which has been peer reviewed by a dedicated Education and Health Sciences academic information specialist librarian using the Peer Review of Electronic Searches Model³⁸. The aim of the search strategy is to locate all pertinent research, both published and unpublished systematic reviews, in accordance with best practice for conducting a search strategy for an overview³⁵. A three-step search strategy will be utilised in this overview to ensure a comprehensive search of the literature³⁵. The authors conducted an initial search limited to EMBASE and PubMed databases to identify systematic reviews relevant to the overview research question. Following this, key words within the titles and abstract were identified and analysed and finally index terms for the systematic reviews were analysed in line with the recommendations for conducting a search strategy for an overview³⁵. These steps guided the development of a search strategy including the identified keywords and index terms which will be adapted for each database for the second step of the search strategy³⁵. To illustrate, the full electronic database search strategy for the Embase database is detailed in Table 1.

Table 1. Search strategy for Embase Database.

NUMBER	QUERY	RESULTS
1	'aged'/exp OR 'aged	4,503,863
2	'older adults':ti,ab OR 'older adult':ti,ab OR 'older people':ti,ab OR 'older patient':ab,ti OR 'older patients':ab,ti OR 'very elderly' OR senior:ti,ab OR seniors:ab,ti OR 'aged':ti,ab OR 'geriatric patient':ab,ti OR 'geriatric care'/exp OR 'geriatric care' OR 'geriatrics'/exp OR 'geriatrics' OR geriatric:ti,ab OR 'geriatric assessment'/exp OR 'geriatric assessment' OR 'elderly care':de OR 'gerontology':ab,ti	1,276,936
3	'very elderly'/exp OR 'very elderly'	191,476
4	'emergency health service'/exp OR 'emergency health service'	100,904
5	'emergency department':ab,ti OR 'emergency departments':ab,ti OR 'emergency ward':ab,ti OR'emergency treatment':ab,ti OR 'emergency health service' OR 'emergency room':ab,ti OR 'hospital':ab,ti OR 'emergency unit':ab,ti OR 'trauma unit':ab,ti OR 'emergency nursing':ab,ti OR'emergency care':ti,ab OR 'acute medical unit':ab,ti OR 'emergency medicine':ab,ti	1,695,708
6	'systematic review':ab,ti	184,484
7	#1 OR #2 OR #3	4,676,994
8	#4 OR #5	1,696,511
9	#7 AND #8	497,954
10	#6 AND #9	355

The third step will involve a manual search for systematic reviews via a search of the reference lists of all included systematic reviews selected for critical appraisal³⁵.

To identify relevant systematic reviews, the following electronic databases will be searched following recommendations from the JBI Reviewers Manual³⁵: the Cochrane Database of Systematic Reviews, Joanna Briggs Institute Database of Systematic Reviews and Implementation Reports, Databases of Abstracts of Reviews of Effects, PubMed, 1966 to date; OVID Medline, 1996 to date; Embase, 1974 to date; Cumulative Index to Nursing and Allied Health Literature (CINAHL) (EBSCO Host), 1981 to date; Epistemonikos; AGELINE, 1978 to date; PEDro, 1999 to date; Scopus and the PROSPERO register³⁹. A comprehensive search will encompass a search of the grey literature, reports from governments and non-government organisations as per best practice in conducting an overview^35,39.

Study selection

Screening. A two-stage process will be utilised to examine the results of the search strategies of all databases. Citations from each database will be exported by MC to a master reference management library, EndnoteX8 (Clarivate Analytics, PA, USA) and duplicates will be removed by MC. Stage 1 will involve screening of titles and abstracts in this master database by two independent reviewers (MC and RG) against the inclusion criteria for the overview as per best practice³⁵. In Stage 2, full text articles will be retrieved for all systematic reviews that meet the inclusion criteria for the overview identified in the initial screening (Stage 1) and also for studies where there is a query on based on the Stage 1 screening of title and abstract.

A comparison of these systematic reviews will be conducted by the same two independent reviewers (MC and RG) and discrepancies will be resolved by consensus or by a third reviewer (SL). The process of the entire search and selection processes will be presented in a PRISMA flow diagram.

Inclusion and exclusion criteria

Types of studies. The unit for analysis will be quantitative systematic reviews with or without meta-analysis, and research synthesis that investigates the effectiveness of ED interventions delivered to older adults following discharge from the ED. Eligible systematic reviews will be appraised by two independent reviewers (MC and RG) for methodological quality prior to inclusion in the overview, using a standardised critical appraisal tool, JBI Critical Appraisal Checklist for Systematic Reviews and Research Synthesis³⁵. Any disagreements that arise between the two reviewers will be resolved through consensus or discussion or guidance from a third reviewer (SL) will be employed³⁵. A narrative summary of the results of the critical appraisal of systematic reviews will be presented supported by relevant supporting tables and/or figures³⁵. Following discussion between authors, the quality of each systematic review will be based on the predetermined criteria^35,40,41.

A score of 0–3 representing very low-quality score; a score of 4–6 representing a low quality score; a score of 7–9 representing a moderate-quality score; and a score of 10–11 will be considered a high-quality score. A score of 0-3 indicates a very low-quality systematic review, and thus a systematic review will be excluded if it does not meet >3 of the 11 criteria³⁵.

This overview of systematic reviews will include systematic reviews published in any language. If a systematic review is an update of a previous systematic review, the most recent and highest quality systematic review will be considered and the lower quality systematic review will be excluded from the overview³⁹.

Eligibility criteria using PICOT framework

Population. This overview will consider existing systematic reviews that include older adults (65 years and over) following an index visit to the ED or Acute Medical Unit (AMU) discharged within 72 hours of index visit.

Interventions. Systematic reviews that analyse the effect of ED based interventions, transitional interventions and ED initiated interventions on outcomes for older adults who present to the ED with an index complaint.

Comparator:

All comparators will be considered.

Outcomes:

Primary clinical outcome. Functional status/decline

Systematic reviews reporting overall functional status including measures of functional ability assessed using a validated tool such as:

A measure of functional decline or ability (Activities of Daily Living):

Barthel’s ADL Index (BI),

Functional Independence Measure (FIM),

Physical functioning aspect of the Health Related Quality of Life Short Form 36

Secondary outcomes

Secondary Clinical outcomes

Health related Quality of life (EuroQol, EQ-5D)
Mortality

Secondary outcomes

Healthcare Utilisation: ED readmission, hospital admission rates (following ED discharge)
Patient experience or satisfaction: studies reporting any validated measure of patient experience and satisfaction
ED Length of stay (LOS)

Table 2 summarises the population, intervention, comparator, outcome and study design (PICOS) statement.

Table 2. PICOTS Statement.

STUDY CHARACTERISTIC	INCLUSION CRITERIA
Population	Systematic reviews including older adults aged 65 years and over who present to an ED for acute, urgent or emergency care.
Interventions	Any intervention strategy including: Comprehensive geriatric assessment within the ED Geriatric nursing assessment within the ED Interventions initiated in the ED used to guide appropriate follow-up and referral Discharge Planning Case Management Medication safety Strategies guided by 2014 Geriatric Emergency Department guidelines
Comparator	Systematic reviews that include studies that compare interventions to usual or enhanced care (e.g. information or educational control)
Outcomes	• Primary outcomes: Functional decline Overall functional status (or sub domains of physical or mental functioning), • Secondary outcomes : health related quality of life; mortality; Patient satisfaction/experience (any validated measure of patient satisfaction/experience); Healthcare utilisation: ED readmission; unplanned hospital admission (following ED discharge)
Setting	Emergency departments
Study design	Quantitative systematic reviews of randomised controlled trials with or without meta-analysis
Timing	Time points that are logically affected by the intervention and are clinically relevant, including short (e.g. 30 days) and longer (e.g. 90 days) time points

Public and patient involvement

Members of the public and patients will not be involved in this overview of systematic reviews. The authors anticipate that the findings of this review (which represents Phase 1 of the Medical Research Council framework for developing and evaluating complex interventions⁴²) will represent the first stage in the design of a pilot intervention to address the risk of adverse outcomes in older adults following discharge from the ED. The subsequent phases will have a strong public and patient involvement.

Data collection and extraction. Two independent reviewers (MC and RG) will extract data from the selected systematic reviews using the standardised data extraction tool in JBI SUMARI³⁹. This will be piloted to ensure that the content and mechanism of data recording is accurate. The following information will be extracted from each systematic review as recommended by the JBI Manual for the conduct of overviews³⁵:

1. Citation details (authors and year of publication)
2. Objectives of the included systematic review
3. Type of review
4. Study population
5. Setting and context
6. Number of databases searched
7. Date range of database searching
8. Publication date range of studies included in the review that inform each outcome of interest
9. Number of randomised controlled trials (RCTs) included and the country of origin of the RCT
10. Tool used to critically appraise the primary studies and their quality rating
11. Outcomes reported that are relevant to the overview research question with effect estimates, SE and CI as available.
12. Methods of analysis employed to synthesis the evidence
13. Comments of overview authors regarding any included study, including potential confounding variables

Should any disagreements arise between the two reviewers, these will be resolved through discussion or with guidance from a third reviewer (SL)³⁵. Should a systematic review present unclear, missing or incompletely reported data, we will endeavour to contact the authors of the systematic review to obtain the data and document same.

Methodological quality of included reviews

The methodological quality of the included systematic reviews will be assessed by two independent reviewers (MC and RG) using the Assessment of Multiple Systematic Reviews 2 (an update of AMSTAR) tool⁴³. The AMSTAR 2 is a 16-item checklist utilised to assess the quality of systematic reviews that include randomised or non-randomised studies of healthcare interventions⁴³. The AMSTAR-2 includes 10 items from the original AMSTAR tool⁴⁴. Reviewers score each domain with ‘yes’ or ‘no’, or in some domains there is a third option of ‘partial yes’. The quality of each systematic review will be rated as high, moderate, low and critically low. Any disagreements that may arise will be resolved through discussion or will be addressed by a third reviewer (SL).

Assessing the quality of evidence

An algorithm that assigns the Grading of Recommendations, Assessment, Development and Evaluation (GRADE)^30,45,46 framework level of evidence will be used to grade the certainty of evidence. This algorithm is a new methodological approach to assessing the quality and certainty of evidence in overviews⁴⁶ and has been used in recent overviews^47,48. This approach will assess the quality of the evidence relating to the primary and secondary outcomes included in RCTs in systematic reviews as detailed above. Two independent reviewers (MC and RG) will assess the quality of evidence for each outcome in each systematic review independently. Any disagreements that may arise will be resolved through discussion or will be addressed by a third reviewer (SL). In this algorithm, each systematic review starts with a ranking of high certainty (no downgrade) and is downgraded one level per serious methodological concerns as outlined in Box 1 below.

Box 1. Algorithm for applying GRADE level of evidence in systematic reviews48

A systematic review is downgraded 1 Level as per the following methodological concerns:

1. Number of participants within pooled analyses (100–199 participants)

2. Risk of bias in randomisation and blinding for <75% included studies

3: Heterogeneity as measured by a recognised measure of statistical heterogeneity, I² > than 75%;

4: ‘No’ to one of the AMSTAR 2 questions 2, 4, 5 and 6 (corresponding to a priori research design, search characteristics, independence of study design and data extraction).

A systematic review is downgraded two levels per very serious methodological concerns:

1: Number of participants within pooled analyses (1–99 participants)

2: ‘No’ to two or more of the AMSTAR 2 questions 2, 4, 5 and 6 (corresponding to a priori research design, search characteristics, independence of study design and data extraction).

Dealing with overlap. The issue of overlapping reviews (studies appearing in more than one review) is a challenge to authors of overviews. A matrix of evidence table will be collated and examined by two independent reviewers (MC and RG) to assess the amount of overlap between systematic reviews. Should multiple systematic reviews exist investigating the population for the same outcome, the following will be applied:

1. If the primary studies are completely overlapping, the most recent, highest quality (based on the AMSTAR 2), most relevant, and most comprehensive systematic review will be selected.
2. If the primary studies partially overlap, both reviews will be retained if the lower quality review consists of more than one-third new studies.

Data synthesis and analysis

The results extracted from each systematic reviews will be presented both quantitatively and qualitatively to answer the objectives of this overview³⁵. The authors will present key quantitative results in tables accompanied by narrative interpretation as per best practice in presenting a summary of evidence in an overview³⁹. The results of the various sections of the overview will be presented in a Summary of Evidence table that will name the ED intervention (s), identify the systematic review(s) and provide a clear indication of the results³⁹. Given the anticipated heterogeneity, the findings will be summarised using a narrative synthesis approach.

The data contained within each systematic review (including effect estimates and 95% confidence intervals) will be reported in a narrative summary. Interventions will be ranked according to estimates of the absolute risk difference and the results of the methodological quality of the evidence³⁵. A summary of ED interventions will be developed with consideration of the certainty of the evidence and AMSTAR-2.

Discussion

This overview will employ robust methodology to present a synthesis of evidence from systematic reviews regarding the effectiveness of ED interventions and strategies on reducing adverse outcomes in older adults following index visit to the ED. Given the breadth of interventions and the diversity of the findings reported in systematic reviews, there is a need to conduct an overview to provide a broader and high-quality evidence synthesis. This overview will identify systematic reviews, and compare and contrast the results of several systematic reviews, as well as explore the reasons for the findings. As overviews are a new form of research synthesis, a number of challenges regarding the methodological conduct of an overview are described in the literature^33,49,50. These issues will be discussed when presenting the findings of the overview. To the best of our knowledge this is the first overview of systematic reviews published exploring this research question.

Dissemination of findings

The findings of this umbrella review will be disseminated through the publication of peer-reviewed manuscripts. Additionally, findings will be presented at both national and international conferences and via a Public and Patient Involvement group of older adults.

Study status

Searching and screening have been completed.

Data availability

Underlying data

No data are associated with this article.

Reporting guidelines

Figshare: PRISMA-P checklist for ‘Effectiveness of interventions to reduce adverse outcomes among older adults following emergency department discharge: Protocol for an overview of systematic reviews’ https://doi.org/10.6084/m9.figshare.12179022.v1⁵¹

Data are available under the terms of the Creative Commons Attribution 4.0 International license (CC-BY 4.0).

Faculty Opinions recommended

References

1. Beard JR, Officer A, de Carvalho IA, et al.: The World report on ageing and health: a policy framework for healthy ageing. Lancet. 2016; 387(10033): 2145–54. PubMed Abstract | Publisher Full Text | Free Full Text
2. Economic Policy Committee: The 2009 Ageing Report: economic and budgetary projections for the EU-27 Member States (2008-2060). European Economy. 2009. Reference Source
3. European Commission Directorate-General for Economic and Financial Affairs: The 2018 Ageing Report Economic and Budgetary Projections for the EU Member States (2016-2070). Luxembourg. 2018. Reference Source
4. Beard JR, Bloom DE: Towards a comprehensive public health response to population ageing. Lancet. 2015; 385(9968): 658–61. PubMed Abstract | Publisher Full Text | Free Full Text
5. Chatterji S, Byles J, Cutler D, et al.: Health, functioning, and disability in older adults--present status and future implications. Lancet. 2015; 385(9967): 563–75. PubMed Abstract | Publisher Full Text | Free Full Text
6. Dufour I, Chouinard MC, Dubuc N, et al.: Factors associated with frequent use of emergency-department services in a geriatric population: a systematic review. BMC Geriatr. 2019; 19(1): 185. PubMed Abstract | Publisher Full Text | Free Full Text
7. Marengoni A, Angleman S, Meinow B, et al.: Coexisting chronic conditions in the older population: Variation by health indicators. Eur J Intern Med. 2016; 31: 29–34. PubMed Abstract | Publisher Full Text
8. Poupard N, Tang CY, Shields N: Community-based case management does not reduce hospital admissions for older people: a systematic review and meta-analysis. Aust Health Rev. 2020; 44(1): 83–92. PubMed Abstract | Publisher Full Text
9. Preston L, Chambers D, Campbell F, et al.: What evidence is there for the identification and management of frail older people in the emergency department? A systematic mapping review. Health Services and Delivery Research. 2018; 6(16). PubMed Abstract | Publisher Full Text
10. Marengoni A, Angleman S, Melis R, et al.: Aging with multimorbidity: a systematic review of the literature. Ageing Res Rev. 2011; 10(4): 430–39. PubMed Abstract | Publisher Full Text
11. Arokiasamy P, Uttamacharya U, Jain K, et al.: The impact of multimorbidity on adult physical and mental health in low- and middle-income countries: what does the study on global ageing and adult health (SAGE) reveal? BMC Med. 2015; 13(1): 178. PubMed Abstract | Publisher Full Text | Free Full Text
12. The Lancet: Making more of multimorbidity: an emerging priority. Lancet. 2018; 391(10131): 1637. PubMed Abstract | Publisher Full Text
13. Ellis G, Marshall T, Ritchie C: Comprehensive geriatric assessment in the emergency department. Clin Interv Aging. 2014; 9: 2033–43. PubMed Abstract | Publisher Full Text | Free Full Text
14. Conroy SP, Stevens T, Parker SG, et al.: A systematic review of comprehensive geriatric assessment to improve outcomes for frail older people being rapidly discharged from acute hospital: 'interface geriatrics'. Age Ageing. 2011; 40(4): 436–43. PubMed Abstract | Publisher Full Text
15. Gruneir A, Silver MJ, Rochon PA: Emergency department use by older adults: a literature review on trends, appropriateness, and consequences of unmet health care needs. Med Care Res Rev. 2011; 68(2): 131–55. PubMed Abstract | Publisher Full Text
16. Soril L, Leggett L, Lorenzetti D, et al.: Characteristics of frequent users of the emergency department in the general adult population: A systematic review of international healthcare systems. Health Policy. 2016; 120(5): 452–61. PubMed Abstract | Publisher Full Text
17. Samaras N, Chevalley T, Samaras D, et al.: Older patients in the emergency department: a review. Ann Emerg Med. 2010; 56(3): 261–9. PubMed Abstract | Publisher Full Text
18. Aminzadeh F, Dalziel WB: Older adults in the emergency department: a systematic review of patterns of use, adverse outcomes, and effectiveness of interventions. Ann Emerg Med. 2002; 39(3): 238–47. PubMed Abstract | Publisher Full Text
19. Ryvicker M, Gallo WT, Fahs MC: Environmental factors associated with primary care access among urban older adults. Soc Sci Med. 2012; 75(5): 914–21. PubMed Abstract | Publisher Full Text | Free Full Text
20. Roberts DC, McKay MP, Shaffer A: Increasing rates of emergency department visits for elderly patients in the United States, 1993 to 2003. Ann Emerg Med. 2008; 51(6): 769–74. PubMed Abstract | Publisher Full Text
21. McCusker J, Karp I, Cardin S, et al.: Determinants of emergency department visits by older adults: a systematic review. Acad Emerg Med. 2003; 10(12): 1362–70. PubMed Abstract | Publisher Full Text
22. Lowthian JA, McGinnes RA, Brand CA, et al.: Discharging older patients from the emergency department effectively: a systematic review and meta-analysis. Age Ageing. 2015; 44(5): 761–70. PubMed Abstract | Publisher Full Text
23. Naughton C, Drennan J, Treacy P, et al.: The role of health and non-health-related factors in repeat emergency department visits in an elderly urban population. Emerg Med J. 2010; 27(9): 683–7. PubMed Abstract | Publisher Full Text
24. Hastings SN, Heflin MT: A systematic review of interventions to improve outcomes for elders discharged from the emergency department. Acad Emerg Med. 2005; 12(10): 978–86. PubMed Abstract | Publisher Full Text
25. Galvin R, Gilleit Y, Wallace E, et al.: Adverse outcomes in older adults attending emergency departments: a systematic review and meta-analysis of the Identification of Seniors At Risk (ISAR) screening tool. Age Ageing. 2017; 46(2): 179–86. PubMed Abstract | Publisher Full Text
26. Arendts G, Fitzhardinge S, Pronk K, et al.: Outcomes in older patients requiring comprehensive allied health care prior to discharge from the emergency department. Emerg Med Australas. 2013; 25(2): 127–31. PubMed Abstract | Publisher Full Text
27. Hughes JM, Freiermuth CE, Shepherd-Banigan M, et al.: Emergency Department Interventions for Older Adults: A Systematic Review. J Am Geriatr Soc. 2019; 67(7): 1516–25. PubMed Abstract | Publisher Full Text | Free Full Text
28. Fealy G, McCarron M, O’Neill D, et al.: Effectiveness of gerontologically informed nursing assessment and referral interventions for older persons attending the emergency department: systematic review. J Adv Nurs. 2009; 65(5): 934–45. PubMed Abstract | Publisher Full Text
29. Karam G, Radden Z, Berall LE, et al.: Efficacy of emergency department-based interventions designed to reduce repeat visits and other adverse outcomes for older patients after discharge: A systematic review. Geriatr Gerontol Int. 2015; 15(9): 1107–17. PubMed Abstract | Publisher Full Text | Free Full Text
30. Lunny C, Brennan SE, McDonald S, et al.: Toward a comprehensive evidence map of overview of systematic review methods: paper 2-risk of bias assessment; synthesis, presentation and summary of the findings; and assessment of the certainty of the evidence. Syst Rev. 2018; 7(1): 159. PubMed Abstract | Publisher Full Text | Free Full Text
31. Pollock A, Campbell P, Brunton G, et al.: Selecting and implementing overview methods: implications from five exemplar overviews. Syst Rev. 2017; 6(1): 145. PubMed Abstract | Publisher Full Text | Free Full Text
32. Lunny C, Brennan SE, McDonald S, et al.: Evidence map of studies evaluating methods for conducting, interpreting and reporting overviews of systematic reviews of interventions: rationale and design. Syst Rev. 2016; 5: 4. PubMed Abstract | Publisher Full Text | Free Full Text
33. Hunt H, Pollock A, Campbell P, et al.: An introduction to overviews of reviews: planning a relevant research question and objective for an overview. Syst Rev. 2018; 7(1): 39. Publisher Full Text
34. Pollock M, Fernandes RM, Pieper D, et al.: Preferred Reporting Items for Overviews of Reviews (PRIOR): a protocol for development of a reporting guideline for overviews of reviews of healthcare interventions. Syst Rev. 2019; 8(1): 335. PubMed Abstract | Publisher Full Text | Free Full Text
35. Aromataris E, Fernandez R, Godfrey C, et al.: Chapter 10: Umbrella Reviews. In: Aromataris E, Munn Z, eds. Joanna Briggs Institute Reviewer's Manual. The Joanna Briggs Institute, 2017: The Joanna Briggs Institute, 2017. Reference Source
36. Moher D, Liberati A, Tetzlaff J, et al.: Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. Ann Intern Med. 2009; 151(4): 264–9. PubMed Abstract | Publisher Full Text
37. Shamseer L, Moher D, Clarke M, et al.: Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015: elaboration and explanation. BMJ. 2015; 350: g7647. PubMed Abstract | Publisher Full Text
38. McGowan J, Sampson M, Lefebvre C: An Evidence Based Checklist for the Peer Review of Electronic Search Strategies (PRESS EBC). Evid Based Libr Inf Pract. 2010; 5(1): 149–54. Publisher Full Text
39. Aromataris E, Fernandez R, Godfrey CM, et al.: Summarizing systematic reviews: methodological development, conduct and reporting of an umbrella review approach. Int J Evid Based Healthc. 2015; 13(3): 132–40. PubMed Abstract | Publisher Full Text
40. Santos E, Duarte C, Marques A, et al.: Effectiveness of non-pharmacological and non-surgical interventions on the impact of rheumatoid arthritis: an umbrella review protocol. JBI Database System Rev Implement Rep. 2019; 17(1): 22–27. PubMed Abstract | Publisher Full Text
41. McNeil J, Denis AM, Michel U, et al.: Effectiveness of non-pharmacological strategies for managing delirium in hospitalized postoperative adults: an umbrella review protocol. JBI Database System Rev Implement Rep. 2018; 16(3): 594–602. PubMed Abstract | Publisher Full Text
42. Craig P, Dieppe P, Macintyre S, et al.: Developing and evaluating complex interventions: the new Medical Research Council guidance. Int J Nurs Stud. 2013; 50(5): 587–92. PubMed Abstract | Publisher Full Text
43. Shea BJ, Reeves BC, Wells G, et al.: AMSTAR 2: a critical appraisal tool for systematic reviews that include randomised or non-randomised studies of healthcare interventions, or both. BMJ. 2017; 358: j4008. PubMed Abstract | Publisher Full Text | Free Full Text
44. Shea BJ, Grimshaw JM, Wells GA, et al.: Development of AMSTAR: a measurement tool to assess the methodological quality of systematic reviews. BMC Med Res Methodol. 2007; 7: 10. PubMed Abstract | Publisher Full Text | Free Full Text
45. Guyatt GH, Oxman AD, Vist GE, et al.: GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. BMJ. 2008; 336(7650): 924-6. PubMed Abstract | Publisher Full Text | Free Full Text
46. Pollock A, Farmer SE, Brady MC, et al.: An algorithm was developed to assign GRADE levels of evidence to comparisons within systematic reviews. J Clin Epidemiol. 2016; 70: 106–110. PubMed Abstract | Publisher Full Text | Free Full Text
47. Pollock A, Farmer SE, Brady MC, et al.: Interventions for improving upper limb function after stroke. Cochrane Database Syst Rev. 2014; (11): CD010820. PubMed Abstract | Publisher Full Text | Free Full Text
48. Rios P, Cardoso R, Morra D, et al.: Comparative effectiveness and safety of pharmacological and non-pharmacological interventions for insomnia: an overview of reviews. Syst Rev. 2019; 8(1): 281. PubMed Abstract | Publisher Full Text | Free Full Text
49. Pieper D, Buechter R, Jerinic P, et al.: Overviews of reviews often have limited rigor: a systematic review. J Clin Epidemiol. 2012; 65(12): 1267–73. PubMed Abstract | Publisher Full Text
50. Lewis R, Hendry M, Din N, et al.: Pragmatic methods for reviewing exceptionally large bodies of evidence: systematic mapping review and overview of systematic reviews using lung cancer survival as an exemplar. Syst Rev. 2019; 8(1): 171. PubMed Abstract | Publisher Full Text | Free Full Text
51. Conneely M, Robinson K, Trépel D, et al.: Effectiveness of interventions to reduce adverse outcomes among older adults following Emergency Department discharge: Protocol for an Overview of Systematic Reviews PRISMA-P Checklist MC.docx.pdf. figshare. Journal contribution. 2020. https://www.doi.org/10.6084/m9.figshare.12179022.v1

Comments on this article Comments (0)

Version 2

VERSION 2 PUBLISHED 22 May 2020

Author details Author details

Mairéad Conneely
Roles: Conceptualization, Methodology, Project Administration, Writing – Original Draft Preparation, Writing – Review & Editing

Katie Robinson
Roles: Supervision, Writing – Review & Editing

Siobhán Leahy
Roles: Supervision, Writing – Review & Editing

Dominic Trépel
Roles: Supervision, Writing – Review & Editing

Fionnuala Jordan
Roles: Methodology, Supervision, Writing – Review & Editing

Rose Galvin
Roles: Conceptualization, Funding Acquisition, Methodology, Project Administration, Supervision, Writing – Review & Editing

Competing interests

No competing interests were disclosed.

Grant information

Health Research Board Ireland [CDA-2018-005]
The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Article Versions (2)

version 2

Revised

Published: 06 Apr 2021, 3:27

https://doi.org/10.12688/hrbopenres.13027.2

version 1

Published: 22 May 2020, 3:27

https://doi.org/10.12688/hrbopenres.13027.1

© 2021 Conneely M et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Download

Export To

metrics

VIEWS

691

downloads

Citations

SEE MORE DETAILS

CITE

how to cite this article

Conneely M, Robinson K, Leahy S et al. Effectiveness of interventions to reduce adverse outcomes among older adults following emergency department discharge: Protocol for an overview of systematic reviews [version 2; peer review: 2 approved]. HRB Open Res 2021, 3:27 (https://doi.org/10.12688/hrbopenres.13027.2)

NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article.

track

receive updates on this article

Track an article to receive email alerts on any updates to this article.

Open Peer Review

Version 2

VERSION 2

PUBLISHED 06 Apr 2021

Revised

Views

Reviewer Report 24 May 2021

Ruth McCullagh, Discipline of Physiotherapy, School of Clinical Therapies, University College Cork, Cork, Ireland

Approved

https://doi.org/10.21956/hrbopenres.14436.r29251

Thank you very much for the opportunity to review your protocol. I have no ... Continue reading

CITE

Report a concern

Respond or Comment

Views

Reviewer Report 26 Apr 2021

Michelle Gates, Alberta Research Centre for Health Evidence, Department of Pediatrics, University of Alberta, Edmonton, AB, Canada

Approved

https://doi.org/10.21956/hrbopenres.14436.r29252

Thank you for considering my earlier suggestions.

Abstract:

Good overall. I would still strongly recommend not hierarchically ranking the interventions (other than potentially by strength of evidence). I think you have removed this

Thank you for considering my earlier suggestions.

Abstract:

Good overall. I would still strongly recommend not hierarchically ranking the interventions (other than potentially by strength of evidence). I think you have removed this from the text, so it would be good to remove here as well.

Methods:

Please note that PRISMA is a reporting guideline, not a methodological standard. Therefore, it would be preferable to say that you will report the review according to PRISMA. I would say the same for PRISMA-P, it should not guide conduct, but reporting only. For conduct you may e.g., follow the Cochrane Handbook or other methodological guidance.
I would say that GRADE is not a new approach, but indeed it has not yet been adapted for use in overviews. It therefore is useful that you have provided an algorithm.
For GRADE, often 300 events is considered adequate for precision. For risk of bias, you may want to check how this impacts the results. Heterogeneity may also encompass the direction of effects that you see (and not just the I2).
Note that a poor quality systematic review may still report data from good studies. This might be something to think about when applying GRADE based on AMSTAR score.

Competing Interests: No competing interests were disclosed.

Reviewer Expertise: Evidence synthesis

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.

CITE

Report a concern

Respond or Comment

Version 1

VERSION 1

PUBLISHED 22 May 2020

Views

Reviewer Report 15 Mar 2021

Michelle Gates, Alberta Research Centre for Health Evidence, Department of Pediatrics, University of Alberta, Edmonton, AB, Canada

Approved with Reservations

https://doi.org/10.21956/hrbopenres.14122.r28503

Thank you for the opportunity to review this protocol for an overview of reviews of interventions in the emergency department to reduce adverse outcomes among older adults following discharge (e.g., return to ED, among others). It seems generally well planned. ... Continue reading

Before 'longer life is a valuable' it looks like a new sentence should start.
Could be more specific in the objective statement about which PICOTs are of interest (e.g., which interventions, in specific population, and specific outcomes).
Can likely remove the paragraph describing overviews of reviews. Would then replace the earlier objective statement with one or all of the 3 specific objectives.
I think that identification of the evidence is part of the overview process but should not be a specific objective.
It would be good for the objectives to be in PICOT format.

Methods:

Please note that the PRISMA and PRISMA-P are reporting guidelines, they are not meant to guide design.
For the search I think it might be useful to include terms other than 'systematic review' as these are often named differently (e.g., review, meta-analysis, among others).
It is not fully clear from the description how full text screening will happen. Please clarify.
Why will pooled analyses (I am assuming this is from non-systematic reviews) be included?
Are only high quality systematic reviews going to be included? It is not clear. If not, I am not sure why critical appraisal is happening at the selection stage.
In the eligibility criteria, please indicate comparators of interest in the text.
Are you including only reviews of RCTs? It seems like this from the data extraction section but I do not see this within the eligibility criteria.
It is not clear why the quality of the systematic reviews is being assessed twice - first the JBI criteria are listed at the selection stage, then later AMSTAR-2.
Dealing with overlap - if both reviews are kept, what will you do about the overlap? What will you do if the reviews appraised their primary studies differently?
What will you do if reviews do not report an appraisal of the quality of their included studies? Will you appraise these yourself, or report them as missing?
What will you do if all the information needed for GRADE is not available within the systematic reviews? For e.g. if quality appraisal is missing as above?
Would it make sense (if not conducting new syntheses) to extract GRADE assessments directly from the systematic reviews?
It looks like the evidence will be presented qualitatively only. Will there be meta-analysis? If not, I would not say there will be a quantitative synthesis.
I would caution strongly against a hierarchical summary of results, as it is important to not make informal indirect comparisons across the findings of different systematic reviews. Please see Cochrane handbook Ch 5 for more information on this. It is difficult to assess the transitivity assumption in overviews of reviews.

Is the rationale for, and objectives of, the study clearly described?

Partly
Is the study design appropriate for the research question?

Yes
Are sufficient details of the methods provided to allow replication by others?

Partly
Are the datasets clearly presented in a useable and accessible format?

Not applicable

Competing Interests: No competing interests were disclosed.

Reviewer Expertise: Evidence synthesis

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.

CITE

Report a concern

Author Response 06 Apr 2021

Mairead Conneely, School of Allied Health, Faculty of Education and Health Sciences, Ageing Research Centre, Health Research Institute, University of Limerick, Limerick, V94 TPPX, Ireland

06 Apr 2021

Author Response

Many thanks for your time spent reviewing this protocol and for your constructive and insightful feedback and comments. We have reflected upon your feedback and made revisions to our manuscript ... Continue reading Many thanks for your time spent reviewing this protocol and for your constructive and insightful feedback and comments. We have reflected upon your feedback and made revisions to our manuscript in line with it. Please see below a detailed point by point response to all comments (reviewer's comments in bold and authors’ responses in black).

SECTION: INTRODUCTION

Comment 1: Before 'longer life is a valuable' it looks like a new sentence should start.
Response: Many thanks for this comment. This error has been amended

Comment 2: Could be more specific in the objective statement about which PICOTs are of interest (e.g., which interventions, in specific population, and specific outcomes).
Response: Many thanks for this comment. The objectives have been edited for more explicit statement aligned to PICOT framework.

Comment 3: Can likely remove the paragraph describing overviews of reviews. Would then replace the earlier objective statement with one or all of the 3 specific objectives
Response:  Many thanks for this comment. This section has been condensed to one sentence to link the previous paragraph to the objectives of the Overview.

Comment 4: I think that identification of the evidence is part of the overview process but should not be a specific objective.
Response: Many thanks for this comment. We have merged objectives one and 3 in the revised manuscript.

Comment 5: It would be good for the objectives to be in PICOT format
Response: Many thanks for this comment. The objectives have been edited to specify the PICOT statement.

SECTION: METHODS

Comment 1:Please note that the PRISMA and PRISMA-P are reporting guidelines, they are not meant to guide design.
Response: Many thanks for this comment. The wording has been edited for clarity.

Comment 2: For the search I think it might be useful to include terms other than 'systematic review' as these are often named differently (e.g., review, meta-analysis, among others).
Response:  Many thanks for this comment. The JBI Manual of Evidence Synthesis Chapter 10 recommends the use of the term “systematic review” to broaden the search as far as possible and recommend not using terms such as meta-analysis as the return may be limited to meta-analysis and risk losing out of potentially relevant systematic reviews. We sought clarification on this also from the information specialist and she concurred with the process outlined by JBI.

Comment 3: It is not fully clear from the description how full text screening will happen. Please clarify.
Response: Many thanks for this comment. Further details have been added to this section for an explicit description of the screening process.

Comment 4: Why will pooled analyses (I am assuming this is from non-systematic reviews) be included
Response: Many thanks for this comment. The JBI Manual recommends including pooled analyses due to different terms used. For comprehensiveness, if there was a systematic review that did pooled analysis, that met our PICOT, it would be pertinent to include. However, we understand the confusion with different terminology and have deleted.

Comment 5:  Are only high quality systematic reviews going to be included? It is not clear. If not, I am not sure why critical appraisal is happening at the selection stage
Response: Many thanks for this comment. We have amended the updated manuscript to address this query. All relevant systematic reviews will be screened for inclusion using the JBI Critical Appraisal Checklist for Systematic Reviews and Research Synthesis. A score of 0-3 indicates a very low-quality score and such studies will be excluded. This initial screening of quality using the JBI Checklist has been conducted in other overviews also and we have referenced same in the manuscript.

Comment 6: In the eligibility criteria, please indicate comparators of interest in the text.
Response: Many thanks for this comment. Comparators have been added to the text as part of the PICOT.

Comment 7: are you including only reviews of RCTs? It seems like this from the data extraction section but I do not see this within the eligibility criteria.
Response: Many thanks for this comment. This is already outlined in the PICOT statement in Table 2.

Comment 8: It is not clear why the quality of the systematic reviews is being assessed twice - first the JBI criteria are listed at the selection stage, then later AMSTAR-2.
Response: Many thanks for this comment.  The sentence on the scoring of the JBI Critical Appraisal has been edited to make explicit the exclusion of a systematic review based on >3 of the 11 criteria as suggested in the JBI Manual for the conduct of systematic reviews. Thus only Systematic reviews that score higher than 3/11 will be included in this overview. Thus the JBI Critical appraisal tool will be used as a screening tool for a minimal acceptable standard for a systematic review. The methodological quality of the included systematic reviews will be assessed using the AMSTAR 2 tool. The use of the AMSTAR 2 tool always informs the algorithm to GRADE for evaluation of the quality of evidence.

Comment 9: Dealing with overlap - if both reviews are kept, what will you do about the overlap? What will you do if the reviews appraised their primary studies differently?
Response: Many thanks for this comment. In the presence of complete overlap between reviews, the highest quality review, as determined by the AMSTAR 2, will be included in data synthesis and analysis. In cases, where there is complete overlap and the reviews receive the same rating using the AMSTAR 2, then the most recently published review will be included. However, for this umbrella review our unit of analysis is the systematic review and consequently, we will not be performing a quality rating of the primary studies. This is described in Methods section, subsection "Dealing with Overlap" of the manuscript.

Comment 10: What will you do if reviews do not report an appraisal of the quality of their included studies? Will you appraise these yourself, or report them as missing?
Response: Many thanks for this comment. We agree that the use of a predetermined tool to assess the quality rating of primary studies in included systematic reviews can strengthen the review. However, for this overview review our unit of analysis is the systematic review and consequently, we will not be performing a quality rating of the primary studies. As part of the JBI Critical Appraisal Checklist for Systematic Reviews and Research Syntheses, we will record and present whether systematic reviews completed critical appraisal by two or more reviewers independently. Additionally, as part of the AMSTAR 2 we will be recording if the authors of the systematic reviews used a satisfactory tool to assess for risk of bias.

Comment 11: What will you do if all the information needed for GRADE is not available within the systematic reviews? For e.g. if quality appraisal is missing as above
Response: Many thanks for this comment. As per the recommendations outlined by Pollock et al 2017, which we have referenced, “If ROB for individual trials was not reported within the review, we
were conservative and assumed that less than 75% of participants had low ROB”. We have added a box detailing the algorithm to GRADE for further details on the algorithm.

Comment 12: Would it make sense (if not conducting new syntheses) to extract GRADE assessments directly from the systematic reviews?
Response: Many thanks for this comment. Cochrane systematic reviews will have this Grade Assessment detail. However, non-Cochrane reviews will may not present an assessment of the quality of the evidence or may present many methods. For consistency, we will apply the GRADE algorithm to all systematic reviews as opposed to extracting the regular GRADE which would be a different tool.
The unit of analysis is a systematic review and the algorithm to GRADE is applied at the level of the systematic review.

Comment 13: It looks like the evidence will be presented qualitatively only. Will there be meta-analysis? If not, I would not say there will be a quantitative synthesis.
Response: Many thanks for this comment. The wording has been edited to highlight qualitative only.

Comment 14:  I would caution strongly against a hierarchical summary of results, as it is important to not make informal indirect comparisons across the findings of different systematic reviews. Please see Cochrane handbook Ch 5 for more information on this. It is difficult to assess the transitivity assumption in overviews of reviews.
Response: Many thanks for this comment. The JBI Manual recommends the use of a hierarchical summary of results. However, we understand the reservation with the use of the term and have edited this section accordingly.
Many thanks for your time spent reviewing this protocol and for your constructive and insightful feedback and comments. We have reflected upon your feedback and made revisions to our manuscript in line with it. Please see below a detailed point by point response to all comments (reviewer's comments in bold and authors’ responses in black).

SECTION: INTRODUCTION

Comment 1: Before 'longer life is a valuable' it looks like a new sentence should start.
Response: Many thanks for this comment. This error has been amended

Comment 2: Could be more specific in the objective statement about which PICOTs are of interest (e.g., which interventions, in specific population, and specific outcomes).
Response: Many thanks for this comment. The objectives have been edited for more explicit statement aligned to PICOT framework.

Comment 3: Can likely remove the paragraph describing overviews of reviews. Would then replace the earlier objective statement with one or all of the 3 specific objectives
Response:  Many thanks for this comment. This section has been condensed to one sentence to link the previous paragraph to the objectives of the Overview.

Comment 4: I think that identification of the evidence is part of the overview process but should not be a specific objective.
Response: Many thanks for this comment. We have merged objectives one and 3 in the revised manuscript.

Comment 5: It would be good for the objectives to be in PICOT format
Response: Many thanks for this comment. The objectives have been edited to specify the PICOT statement.

SECTION: METHODS

Comment 1:Please note that the PRISMA and PRISMA-P are reporting guidelines, they are not meant to guide design.
Response: Many thanks for this comment. The wording has been edited for clarity.

Comment 2: For the search I think it might be useful to include terms other than 'systematic review' as these are often named differently (e.g., review, meta-analysis, among others).
Response:  Many thanks for this comment. The JBI Manual of Evidence Synthesis Chapter 10 recommends the use of the term “systematic review” to broaden the search as far as possible and recommend not using terms such as meta-analysis as the return may be limited to meta-analysis and risk losing out of potentially relevant systematic reviews. We sought clarification on this also from the information specialist and she concurred with the process outlined by JBI.

Comment 3: It is not fully clear from the description how full text screening will happen. Please clarify.
Response: Many thanks for this comment. Further details have been added to this section for an explicit description of the screening process.

Comment 4: Why will pooled analyses (I am assuming this is from non-systematic reviews) be included
Response: Many thanks for this comment. The JBI Manual recommends including pooled analyses due to different terms used. For comprehensiveness, if there was a systematic review that did pooled analysis, that met our PICOT, it would be pertinent to include. However, we understand the confusion with different terminology and have deleted.

Comment 5:  Are only high quality systematic reviews going to be included? It is not clear. If not, I am not sure why critical appraisal is happening at the selection stage
Response: Many thanks for this comment. We have amended the updated manuscript to address this query. All relevant systematic reviews will be screened for inclusion using the JBI Critical Appraisal Checklist for Systematic Reviews and Research Synthesis. A score of 0-3 indicates a very low-quality score and such studies will be excluded. This initial screening of quality using the JBI Checklist has been conducted in other overviews also and we have referenced same in the manuscript.

Comment 6: In the eligibility criteria, please indicate comparators of interest in the text.
Response: Many thanks for this comment. Comparators have been added to the text as part of the PICOT.

Comment 7: are you including only reviews of RCTs? It seems like this from the data extraction section but I do not see this within the eligibility criteria.
Response: Many thanks for this comment. This is already outlined in the PICOT statement in Table 2.

Comment 8: It is not clear why the quality of the systematic reviews is being assessed twice - first the JBI criteria are listed at the selection stage, then later AMSTAR-2.
Response: Many thanks for this comment.  The sentence on the scoring of the JBI Critical Appraisal has been edited to make explicit the exclusion of a systematic review based on >3 of the 11 criteria as suggested in the JBI Manual for the conduct of systematic reviews. Thus only Systematic reviews that score higher than 3/11 will be included in this overview. Thus the JBI Critical appraisal tool will be used as a screening tool for a minimal acceptable standard for a systematic review. The methodological quality of the included systematic reviews will be assessed using the AMSTAR 2 tool. The use of the AMSTAR 2 tool always informs the algorithm to GRADE for evaluation of the quality of evidence.

Comment 9: Dealing with overlap - if both reviews are kept, what will you do about the overlap? What will you do if the reviews appraised their primary studies differently?
Response: Many thanks for this comment. In the presence of complete overlap between reviews, the highest quality review, as determined by the AMSTAR 2, will be included in data synthesis and analysis. In cases, where there is complete overlap and the reviews receive the same rating using the AMSTAR 2, then the most recently published review will be included. However, for this umbrella review our unit of analysis is the systematic review and consequently, we will not be performing a quality rating of the primary studies. This is described in Methods section, subsection "Dealing with Overlap" of the manuscript.

Comment 10: What will you do if reviews do not report an appraisal of the quality of their included studies? Will you appraise these yourself, or report them as missing?
Response: Many thanks for this comment. We agree that the use of a predetermined tool to assess the quality rating of primary studies in included systematic reviews can strengthen the review. However, for this overview review our unit of analysis is the systematic review and consequently, we will not be performing a quality rating of the primary studies. As part of the JBI Critical Appraisal Checklist for Systematic Reviews and Research Syntheses, we will record and present whether systematic reviews completed critical appraisal by two or more reviewers independently. Additionally, as part of the AMSTAR 2 we will be recording if the authors of the systematic reviews used a satisfactory tool to assess for risk of bias.

Comment 11: What will you do if all the information needed for GRADE is not available within the systematic reviews? For e.g. if quality appraisal is missing as above
Response: Many thanks for this comment. As per the recommendations outlined by Pollock et al 2017, which we have referenced, “If ROB for individual trials was not reported within the review, we
were conservative and assumed that less than 75% of participants had low ROB”. We have added a box detailing the algorithm to GRADE for further details on the algorithm.

Comment 12: Would it make sense (if not conducting new syntheses) to extract GRADE assessments directly from the systematic reviews?
Response: Many thanks for this comment. Cochrane systematic reviews will have this Grade Assessment detail. However, non-Cochrane reviews will may not present an assessment of the quality of the evidence or may present many methods. For consistency, we will apply the GRADE algorithm to all systematic reviews as opposed to extracting the regular GRADE which would be a different tool.
The unit of analysis is a systematic review and the algorithm to GRADE is applied at the level of the systematic review.

Comment 13: It looks like the evidence will be presented qualitatively only. Will there be meta-analysis? If not, I would not say there will be a quantitative synthesis.
Response: Many thanks for this comment. The wording has been edited to highlight qualitative only.

Comment 14:  I would caution strongly against a hierarchical summary of results, as it is important to not make informal indirect comparisons across the findings of different systematic reviews. Please see Cochrane handbook Ch 5 for more information on this. It is difficult to assess the transitivity assumption in overviews of reviews.
Response: Many thanks for this comment. The JBI Manual recommends the use of a hierarchical summary of results. However, we understand the reservation with the use of the term and have edited this section accordingly.
Competing Interests: No competing interests were disclosed. Close
Report a concern
Respond or Comment

COMMENTS ON THIS REPORT

Author Response 06 Apr 2021

Mairead Conneely, School of Allied Health, Faculty of Education and Health Sciences, Ageing Research Centre, Health Research Institute, University of Limerick, Limerick, V94 TPPX, Ireland

06 Apr 2021

Author Response

Many thanks for your time spent reviewing this protocol and for your constructive and insightful feedback and comments. We have reflected upon your feedback and made revisions to our manuscript ... Continue reading Many thanks for your time spent reviewing this protocol and for your constructive and insightful feedback and comments. We have reflected upon your feedback and made revisions to our manuscript in line with it. Please see below a detailed point by point response to all comments (reviewer's comments in bold and authors’ responses in black).

SECTION: INTRODUCTION

Comment 1: Before 'longer life is a valuable' it looks like a new sentence should start.
Response: Many thanks for this comment. This error has been amended

Comment 2: Could be more specific in the objective statement about which PICOTs are of interest (e.g., which interventions, in specific population, and specific outcomes).
Response: Many thanks for this comment. The objectives have been edited for more explicit statement aligned to PICOT framework.

Comment 3: Can likely remove the paragraph describing overviews of reviews. Would then replace the earlier objective statement with one or all of the 3 specific objectives
Response:  Many thanks for this comment. This section has been condensed to one sentence to link the previous paragraph to the objectives of the Overview.

Comment 4: I think that identification of the evidence is part of the overview process but should not be a specific objective.
Response: Many thanks for this comment. We have merged objectives one and 3 in the revised manuscript.

Comment 5: It would be good for the objectives to be in PICOT format
Response: Many thanks for this comment. The objectives have been edited to specify the PICOT statement.

SECTION: METHODS

Comment 1:Please note that the PRISMA and PRISMA-P are reporting guidelines, they are not meant to guide design.
Response: Many thanks for this comment. The wording has been edited for clarity.

Comment 2: For the search I think it might be useful to include terms other than 'systematic review' as these are often named differently (e.g., review, meta-analysis, among others).
Response:  Many thanks for this comment. The JBI Manual of Evidence Synthesis Chapter 10 recommends the use of the term “systematic review” to broaden the search as far as possible and recommend not using terms such as meta-analysis as the return may be limited to meta-analysis and risk losing out of potentially relevant systematic reviews. We sought clarification on this also from the information specialist and she concurred with the process outlined by JBI.

Comment 3: It is not fully clear from the description how full text screening will happen. Please clarify.
Response: Many thanks for this comment. Further details have been added to this section for an explicit description of the screening process.

Comment 4: Why will pooled analyses (I am assuming this is from non-systematic reviews) be included
Response: Many thanks for this comment. The JBI Manual recommends including pooled analyses due to different terms used. For comprehensiveness, if there was a systematic review that did pooled analysis, that met our PICOT, it would be pertinent to include. However, we understand the confusion with different terminology and have deleted.

Comment 5:  Are only high quality systematic reviews going to be included? It is not clear. If not, I am not sure why critical appraisal is happening at the selection stage
Response: Many thanks for this comment. We have amended the updated manuscript to address this query. All relevant systematic reviews will be screened for inclusion using the JBI Critical Appraisal Checklist for Systematic Reviews and Research Synthesis. A score of 0-3 indicates a very low-quality score and such studies will be excluded. This initial screening of quality using the JBI Checklist has been conducted in other overviews also and we have referenced same in the manuscript.

Comment 6: In the eligibility criteria, please indicate comparators of interest in the text.
Response: Many thanks for this comment. Comparators have been added to the text as part of the PICOT.

Comment 7: are you including only reviews of RCTs? It seems like this from the data extraction section but I do not see this within the eligibility criteria.
Response: Many thanks for this comment. This is already outlined in the PICOT statement in Table 2.

Comment 8: It is not clear why the quality of the systematic reviews is being assessed twice - first the JBI criteria are listed at the selection stage, then later AMSTAR-2.
Response: Many thanks for this comment.  The sentence on the scoring of the JBI Critical Appraisal has been edited to make explicit the exclusion of a systematic review based on >3 of the 11 criteria as suggested in the JBI Manual for the conduct of systematic reviews. Thus only Systematic reviews that score higher than 3/11 will be included in this overview. Thus the JBI Critical appraisal tool will be used as a screening tool for a minimal acceptable standard for a systematic review. The methodological quality of the included systematic reviews will be assessed using the AMSTAR 2 tool. The use of the AMSTAR 2 tool always informs the algorithm to GRADE for evaluation of the quality of evidence.

Comment 9: Dealing with overlap - if both reviews are kept, what will you do about the overlap? What will you do if the reviews appraised their primary studies differently?
Response: Many thanks for this comment. In the presence of complete overlap between reviews, the highest quality review, as determined by the AMSTAR 2, will be included in data synthesis and analysis. In cases, where there is complete overlap and the reviews receive the same rating using the AMSTAR 2, then the most recently published review will be included. However, for this umbrella review our unit of analysis is the systematic review and consequently, we will not be performing a quality rating of the primary studies. This is described in Methods section, subsection "Dealing with Overlap" of the manuscript.

Comment 10: What will you do if reviews do not report an appraisal of the quality of their included studies? Will you appraise these yourself, or report them as missing?
Response: Many thanks for this comment. We agree that the use of a predetermined tool to assess the quality rating of primary studies in included systematic reviews can strengthen the review. However, for this overview review our unit of analysis is the systematic review and consequently, we will not be performing a quality rating of the primary studies. As part of the JBI Critical Appraisal Checklist for Systematic Reviews and Research Syntheses, we will record and present whether systematic reviews completed critical appraisal by two or more reviewers independently. Additionally, as part of the AMSTAR 2 we will be recording if the authors of the systematic reviews used a satisfactory tool to assess for risk of bias.

Comment 11: What will you do if all the information needed for GRADE is not available within the systematic reviews? For e.g. if quality appraisal is missing as above
Response: Many thanks for this comment. As per the recommendations outlined by Pollock et al 2017, which we have referenced, “If ROB for individual trials was not reported within the review, we
were conservative and assumed that less than 75% of participants had low ROB”. We have added a box detailing the algorithm to GRADE for further details on the algorithm.

Comment 12: Would it make sense (if not conducting new syntheses) to extract GRADE assessments directly from the systematic reviews?
Response: Many thanks for this comment. Cochrane systematic reviews will have this Grade Assessment detail. However, non-Cochrane reviews will may not present an assessment of the quality of the evidence or may present many methods. For consistency, we will apply the GRADE algorithm to all systematic reviews as opposed to extracting the regular GRADE which would be a different tool.
The unit of analysis is a systematic review and the algorithm to GRADE is applied at the level of the systematic review.

Comment 13: It looks like the evidence will be presented qualitatively only. Will there be meta-analysis? If not, I would not say there will be a quantitative synthesis.
Response: Many thanks for this comment. The wording has been edited to highlight qualitative only.

Comment 14:  I would caution strongly against a hierarchical summary of results, as it is important to not make informal indirect comparisons across the findings of different systematic reviews. Please see Cochrane handbook Ch 5 for more information on this. It is difficult to assess the transitivity assumption in overviews of reviews.
Response: Many thanks for this comment. The JBI Manual recommends the use of a hierarchical summary of results. However, we understand the reservation with the use of the term and have edited this section accordingly.
Many thanks for your time spent reviewing this protocol and for your constructive and insightful feedback and comments. We have reflected upon your feedback and made revisions to our manuscript in line with it. Please see below a detailed point by point response to all comments (reviewer's comments in bold and authors’ responses in black).

SECTION: INTRODUCTION

Comment 1: Before 'longer life is a valuable' it looks like a new sentence should start.
Response: Many thanks for this comment. This error has been amended

Comment 2: Could be more specific in the objective statement about which PICOTs are of interest (e.g., which interventions, in specific population, and specific outcomes).
Response: Many thanks for this comment. The objectives have been edited for more explicit statement aligned to PICOT framework.

Comment 3: Can likely remove the paragraph describing overviews of reviews. Would then replace the earlier objective statement with one or all of the 3 specific objectives
Response:  Many thanks for this comment. This section has been condensed to one sentence to link the previous paragraph to the objectives of the Overview.

Comment 4: I think that identification of the evidence is part of the overview process but should not be a specific objective.
Response: Many thanks for this comment. We have merged objectives one and 3 in the revised manuscript.

Comment 5: It would be good for the objectives to be in PICOT format
Response: Many thanks for this comment. The objectives have been edited to specify the PICOT statement.

SECTION: METHODS

Comment 1:Please note that the PRISMA and PRISMA-P are reporting guidelines, they are not meant to guide design.
Response: Many thanks for this comment. The wording has been edited for clarity.

Comment 2: For the search I think it might be useful to include terms other than 'systematic review' as these are often named differently (e.g., review, meta-analysis, among others).
Response:  Many thanks for this comment. The JBI Manual of Evidence Synthesis Chapter 10 recommends the use of the term “systematic review” to broaden the search as far as possible and recommend not using terms such as meta-analysis as the return may be limited to meta-analysis and risk losing out of potentially relevant systematic reviews. We sought clarification on this also from the information specialist and she concurred with the process outlined by JBI.

Comment 3: It is not fully clear from the description how full text screening will happen. Please clarify.
Response: Many thanks for this comment. Further details have been added to this section for an explicit description of the screening process.

Comment 4: Why will pooled analyses (I am assuming this is from non-systematic reviews) be included
Response: Many thanks for this comment. The JBI Manual recommends including pooled analyses due to different terms used. For comprehensiveness, if there was a systematic review that did pooled analysis, that met our PICOT, it would be pertinent to include. However, we understand the confusion with different terminology and have deleted.

Comment 5:  Are only high quality systematic reviews going to be included? It is not clear. If not, I am not sure why critical appraisal is happening at the selection stage
Response: Many thanks for this comment. We have amended the updated manuscript to address this query. All relevant systematic reviews will be screened for inclusion using the JBI Critical Appraisal Checklist for Systematic Reviews and Research Synthesis. A score of 0-3 indicates a very low-quality score and such studies will be excluded. This initial screening of quality using the JBI Checklist has been conducted in other overviews also and we have referenced same in the manuscript.

Comment 6: In the eligibility criteria, please indicate comparators of interest in the text.
Response: Many thanks for this comment. Comparators have been added to the text as part of the PICOT.

Comment 7: are you including only reviews of RCTs? It seems like this from the data extraction section but I do not see this within the eligibility criteria.
Response: Many thanks for this comment. This is already outlined in the PICOT statement in Table 2.

Comment 8: It is not clear why the quality of the systematic reviews is being assessed twice - first the JBI criteria are listed at the selection stage, then later AMSTAR-2.
Response: Many thanks for this comment.  The sentence on the scoring of the JBI Critical Appraisal has been edited to make explicit the exclusion of a systematic review based on >3 of the 11 criteria as suggested in the JBI Manual for the conduct of systematic reviews. Thus only Systematic reviews that score higher than 3/11 will be included in this overview. Thus the JBI Critical appraisal tool will be used as a screening tool for a minimal acceptable standard for a systematic review. The methodological quality of the included systematic reviews will be assessed using the AMSTAR 2 tool. The use of the AMSTAR 2 tool always informs the algorithm to GRADE for evaluation of the quality of evidence.

Comment 9: Dealing with overlap - if both reviews are kept, what will you do about the overlap? What will you do if the reviews appraised their primary studies differently?
Response: Many thanks for this comment. In the presence of complete overlap between reviews, the highest quality review, as determined by the AMSTAR 2, will be included in data synthesis and analysis. In cases, where there is complete overlap and the reviews receive the same rating using the AMSTAR 2, then the most recently published review will be included. However, for this umbrella review our unit of analysis is the systematic review and consequently, we will not be performing a quality rating of the primary studies. This is described in Methods section, subsection "Dealing with Overlap" of the manuscript.

Comment 10: What will you do if reviews do not report an appraisal of the quality of their included studies? Will you appraise these yourself, or report them as missing?
Response: Many thanks for this comment. We agree that the use of a predetermined tool to assess the quality rating of primary studies in included systematic reviews can strengthen the review. However, for this overview review our unit of analysis is the systematic review and consequently, we will not be performing a quality rating of the primary studies. As part of the JBI Critical Appraisal Checklist for Systematic Reviews and Research Syntheses, we will record and present whether systematic reviews completed critical appraisal by two or more reviewers independently. Additionally, as part of the AMSTAR 2 we will be recording if the authors of the systematic reviews used a satisfactory tool to assess for risk of bias.

Comment 11: What will you do if all the information needed for GRADE is not available within the systematic reviews? For e.g. if quality appraisal is missing as above
Response: Many thanks for this comment. As per the recommendations outlined by Pollock et al 2017, which we have referenced, “If ROB for individual trials was not reported within the review, we
were conservative and assumed that less than 75% of participants had low ROB”. We have added a box detailing the algorithm to GRADE for further details on the algorithm.

Comment 12: Would it make sense (if not conducting new syntheses) to extract GRADE assessments directly from the systematic reviews?
Response: Many thanks for this comment. Cochrane systematic reviews will have this Grade Assessment detail. However, non-Cochrane reviews will may not present an assessment of the quality of the evidence or may present many methods. For consistency, we will apply the GRADE algorithm to all systematic reviews as opposed to extracting the regular GRADE which would be a different tool.
The unit of analysis is a systematic review and the algorithm to GRADE is applied at the level of the systematic review.

Comment 13: It looks like the evidence will be presented qualitatively only. Will there be meta-analysis? If not, I would not say there will be a quantitative synthesis.
Response: Many thanks for this comment. The wording has been edited to highlight qualitative only.

Comment 14:  I would caution strongly against a hierarchical summary of results, as it is important to not make informal indirect comparisons across the findings of different systematic reviews. Please see Cochrane handbook Ch 5 for more information on this. It is difficult to assess the transitivity assumption in overviews of reviews.
Response: Many thanks for this comment. The JBI Manual recommends the use of a hierarchical summary of results. However, we understand the reservation with the use of the term and have edited this section accordingly.
Competing Interests: No competing interests were disclosed. Close
Report a concern

Views

Reviewer Report 10 Jul 2020

Ruth McCullagh, Discipline of Physiotherapy, School of Clinical Therapies, University College Cork, Cork, Ireland

Approved

https://doi.org/10.21956/hrbopenres.14122.r27616

Thank you for giving me the opportunity to review your protocol.

The abstract reports need for the study and the planned methods clearly.

The background explains clearly the conflicting outcomes of trials and existing systematic reviews, highlighting the complexity of the problem. An overview of systematic reviews is clearly justified.

The methods described are aligned with the recommended methods and show sound methodology, with a comprehensive search strategy, citeris that match the research question, methods to limit their bias and evaluation of methodological quality of the data.

Wishing you success and I look forward to reading the outcome of the study.

Is the rationale for, and objectives of, the study clearly described?

Yes
Is the study design appropriate for the research question?

Yes
Are sufficient details of the methods provided to allow replication by others?

Yes
Are the datasets clearly presented in a useable and accessible format?

Not applicable

Competing Interests: No competing interests were disclosed.

Reviewer Expertise: Older adult rehabilitation and physiiotherapy

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.

CITE

Report a concern

Author Response 28 Jan 2021

Mairead Conneely, School of Allied Health, Faculty of Education and Health Sciences, Ageing Research Centre, Health Research Institute, University of Limerick, Limerick, V94 TPPX, Ireland

28 Jan 2021

Author Response

Many thanks for reviewing our protocol Dr McCullagh
Mairéad Conneely
Competing Interests: No competing interests were disclosed.
Many thanks for reviewing our protocol Dr McCullagh
Mairéad Conneely
Many thanks for reviewing our protocol Dr McCullagh
Mairéad Conneely
Competing Interests: No competing interests were disclosed. Close
Report a concern
Respond or Comment

COMMENTS ON THIS REPORT

Author Response 28 Jan 2021

Mairead Conneely, School of Allied Health, Faculty of Education and Health Sciences, Ageing Research Centre, Health Research Institute, University of Limerick, Limerick, V94 TPPX, Ireland

28 Jan 2021

Author Response

Many thanks for reviewing our protocol Dr McCullagh
Mairéad Conneely
Competing Interests: No competing interests were disclosed.
Many thanks for reviewing our protocol Dr McCullagh
Mairéad Conneely
Many thanks for reviewing our protocol Dr McCullagh
Mairéad Conneely
Competing Interests: No competing interests were disclosed. Close
Report a concern

Comments on this article Comments (0)

Version 2

VERSION 2 PUBLISHED 22 May 2020

Open Peer Review

Reviewer Status

Reviewer Reports

	Invited Reviewers
	1	2
Version 2 (revision) 06 Apr 21	read	read
Version 1 22 May 20	read	read

Ruth McCullagh, University College Cork, Cork, Ireland
Michelle Gates, University of Alberta, Edmonton, Canada

Comments on this article

All Comments(0)

Add a comment

Back to all reports

Reviewer Report

14 Views

24 May 2021 | for Version 2

Ruth McCullagh, Discipline of Physiotherapy, School of Clinical Therapies, University College Cork, Cork, Ireland

14 Views Cite this report Responses(0)

Approved

Thank you very much for the opportunity to review your protocol. I have no other suggestions to make and wish you the very best of luck with the project.

Competing Interests

No competing interests were disclosed.

Reviewer Expertise

Older adult rehabilitation and physiiotherapy

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.

Respond to this report

Responses (0)

Back to all reports

Reviewer Report

11 Views

26 Apr 2021 | for Version 2

Michelle Gates, Alberta Research Centre for Health Evidence, Department of Pediatrics, University of Alberta, Edmonton, AB, Canada

11 Views Cite this report Responses(0)

Approved

Thank you for considering my earlier suggestions.

Abstract:

Good overall. I would still strongly recommend not hierarchically ranking the interventions (other than potentially by strength of evidence). I think you have removed this from the text, so it would be good to remove here as well.

Methods:

Please note that PRISMA is a reporting guideline, not a methodological standard. Therefore, it would be preferable to say that you will report the review according to PRISMA. I would say the same for PRISMA-P, it should not guide conduct, but reporting only. For conduct you may e.g., follow the Cochrane Handbook or other methodological guidance.
I would say that GRADE is not a new approach, but indeed it has not yet been adapted for use in overviews. It therefore is useful that you have provided an algorithm.
For GRADE, often 300 events is considered adequate for precision. For risk of bias, you may want to check how this impacts the results. Heterogeneity may also encompass the direction of effects that you see (and not just the I2).
Note that a poor quality systematic review may still report data from good studies. This might be something to think about when applying GRADE based on AMSTAR score.

Competing Interests

No competing interests were disclosed.

Reviewer Expertise

Evidence synthesis

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.

Respond to this report

Responses (0)

Back to all reports

Reviewer Report

24 Views

15 Mar 2021 | for Version 1

Michelle Gates, Alberta Research Centre for Health Evidence, Department of Pediatrics, University of Alberta, Edmonton, AB, Canada

24 Views Cite this report Responses(1)

Approved With Reservations

Before 'longer life is a valuable' it looks like a new sentence should start.
Could be more specific in the objective statement about which PICOTs are of interest (e.g., which interventions, in specific population, and specific outcomes).
Can likely remove the paragraph describing overviews of reviews. Would then replace the earlier objective statement with one or all of the 3 specific objectives.
I think that identification of the evidence is part of the overview process but should not be a specific objective.
It would be good for the objectives to be in PICOT format.

Methods:

Please note that the PRISMA and PRISMA-P are reporting guidelines, they are not meant to guide design.
For the search I think it might be useful to include terms other than 'systematic review' as these are often named differently (e.g., review, meta-analysis, among others).
It is not fully clear from the description how full text screening will happen. Please clarify.
Why will pooled analyses (I am assuming this is from non-systematic reviews) be included?
Are only high quality systematic reviews going to be included? It is not clear. If not, I am not sure why critical appraisal is happening at the selection stage.
In the eligibility criteria, please indicate comparators of interest in the text.
Are you including only reviews of RCTs? It seems like this from the data extraction section but I do not see this within the eligibility criteria.
It is not clear why the quality of the systematic reviews is being assessed twice - first the JBI criteria are listed at the selection stage, then later AMSTAR-2.
Dealing with overlap - if both reviews are kept, what will you do about the overlap? What will you do if the reviews appraised their primary studies differently?
What will you do if reviews do not report an appraisal of the quality of their included studies? Will you appraise these yourself, or report them as missing?
What will you do if all the information needed for GRADE is not available within the systematic reviews? For e.g. if quality appraisal is missing as above?
Would it make sense (if not conducting new syntheses) to extract GRADE assessments directly from the systematic reviews?
It looks like the evidence will be presented qualitatively only. Will there be meta-analysis? If not, I would not say there will be a quantitative synthesis.
I would caution strongly against a hierarchical summary of results, as it is important to not make informal indirect comparisons across the findings of different systematic reviews. Please see Cochrane handbook Ch 5 for more information on this. It is difficult to assess the transitivity assumption in overviews of reviews.

Is the rationale for, and objectives of, the study clearly described?

Partly
Is the study design appropriate for the research question?

Yes
Are sufficient details of the methods provided to allow replication by others?

Partly
Are the datasets clearly presented in a useable and accessible format?

Not applicable

Competing Interests

No competing interests were disclosed.

Reviewer Expertise

Evidence synthesis

Respond to this report

Responses (1)

Author Response

06 Apr 2021

Mairead Conneely, School of Allied Health, Faculty of Education and Health Sciences, Ageing Research Centre, Health Research Institute, University of Limerick, Limerick, V94 TPPX, Ireland

Many thanks for your time spent reviewing this protocol and for your constructive and insightful feedback and comments. We have reflected upon your feedback and made revisions to our manuscript in line with it. Please see below a detailed point by point response to all comments (reviewer's comments in bold and authors’ responses in black).

SECTION: INTRODUCTION

Comment 1: Before 'longer life is a valuable' it looks like a new sentence should start.
Response: Many thanks for this comment. This error has been amended

Comment 2: Could be more specific in the objective statement about which PICOTs are of interest (e.g., which interventions, in specific population, and specific outcomes).
Response: Many thanks for this comment. The objectives have been edited for more explicit statement aligned to PICOT framework.

Comment 3: Can likely remove the paragraph describing overviews of reviews. Would then replace the earlier objective statement with one or all of the 3 specific objectives
Response:  Many thanks for this comment. This section has been condensed to one sentence to link the previous paragraph to the objectives of the Overview.

Comment 4: I think that identification of the evidence is part of the overview process but should not be a specific objective.
Response: Many thanks for this comment. We have merged objectives one and 3 in the revised manuscript.

Comment 5: It would be good for the objectives to be in PICOT format
Response: Many thanks for this comment. The objectives have been edited to specify the PICOT statement.

SECTION: METHODS

Comment 1:Please note that the PRISMA and PRISMA-P are reporting guidelines, they are not meant to guide design.
Response: Many thanks for this comment. The wording has been edited for clarity.

Comment 2: For the search I think it might be useful to include terms other than 'systematic review' as these are often named differently (e.g., review, meta-analysis, among others).
Response:  Many thanks for this comment. The JBI Manual of Evidence Synthesis Chapter 10 recommends the use of the term “systematic review” to broaden the search as far as possible and recommend not using terms such as meta-analysis as the return may be limited to meta-analysis and risk losing out of potentially relevant systematic reviews. We sought clarification on this also from the information specialist and she concurred with the process outlined by JBI.

Comment 3: It is not fully clear from the description how full text screening will happen. Please clarify.
Response: Many thanks for this comment. Further details have been added to this section for an explicit description of the screening process.

Comment 4: Why will pooled analyses (I am assuming this is from non-systematic reviews) be included
Response: Many thanks for this comment. The JBI Manual recommends including pooled analyses due to different terms used. For comprehensiveness, if there was a systematic review that did pooled analysis, that met our PICOT, it would be pertinent to include. However, we understand the confusion with different terminology and have deleted.

Comment 5:  Are only high quality systematic reviews going to be included? It is not clear. If not, I am not sure why critical appraisal is happening at the selection stage
Response: Many thanks for this comment. We have amended the updated manuscript to address this query. All relevant systematic reviews will be screened for inclusion using the JBI Critical Appraisal Checklist for Systematic Reviews and Research Synthesis. A score of 0-3 indicates a very low-quality score and such studies will be excluded. This initial screening of quality using the JBI Checklist has been conducted in other overviews also and we have referenced same in the manuscript.

Comment 6: In the eligibility criteria, please indicate comparators of interest in the text.
Response: Many thanks for this comment. Comparators have been added to the text as part of the PICOT.

Comment 7: are you including only reviews of RCTs? It seems like this from the data extraction section but I do not see this within the eligibility criteria.
Response: Many thanks for this comment. This is already outlined in the PICOT statement in Table 2.

Comment 8: It is not clear why the quality of the systematic reviews is being assessed twice - first the JBI criteria are listed at the selection stage, then later AMSTAR-2.
Response: Many thanks for this comment.  The sentence on the scoring of the JBI Critical Appraisal has been edited to make explicit the exclusion of a systematic review based on >3 of the 11 criteria as suggested in the JBI Manual for the conduct of systematic reviews. Thus only Systematic reviews that score higher than 3/11 will be included in this overview. Thus the JBI Critical appraisal tool will be used as a screening tool for a minimal acceptable standard for a systematic review. The methodological quality of the included systematic reviews will be assessed using the AMSTAR 2 tool. The use of the AMSTAR 2 tool always informs the algorithm to GRADE for evaluation of the quality of evidence.

Comment 9: Dealing with overlap - if both reviews are kept, what will you do about the overlap? What will you do if the reviews appraised their primary studies differently?
Response: Many thanks for this comment. In the presence of complete overlap between reviews, the highest quality review, as determined by the AMSTAR 2, will be included in data synthesis and analysis. In cases, where there is complete overlap and the reviews receive the same rating using the AMSTAR 2, then the most recently published review will be included. However, for this umbrella review our unit of analysis is the systematic review and consequently, we will not be performing a quality rating of the primary studies. This is described in Methods section, subsection "Dealing with Overlap" of the manuscript.

Comment 10: What will you do if reviews do not report an appraisal of the quality of their included studies? Will you appraise these yourself, or report them as missing?
Response: Many thanks for this comment. We agree that the use of a predetermined tool to assess the quality rating of primary studies in included systematic reviews can strengthen the review. However, for this overview review our unit of analysis is the systematic review and consequently, we will not be performing a quality rating of the primary studies. As part of the JBI Critical Appraisal Checklist for Systematic Reviews and Research Syntheses, we will record and present whether systematic reviews completed critical appraisal by two or more reviewers independently. Additionally, as part of the AMSTAR 2 we will be recording if the authors of the systematic reviews used a satisfactory tool to assess for risk of bias.

Comment 11: What will you do if all the information needed for GRADE is not available within the systematic reviews? For e.g. if quality appraisal is missing as above
Response: Many thanks for this comment. As per the recommendations outlined by Pollock et al 2017, which we have referenced, “If ROB for individual trials was not reported within the review, we
were conservative and assumed that less than 75% of participants had low ROB”. We have added a box detailing the algorithm to GRADE for further details on the algorithm.

Comment 12: Would it make sense (if not conducting new syntheses) to extract GRADE assessments directly from the systematic reviews?
Response: Many thanks for this comment. Cochrane systematic reviews will have this Grade Assessment detail. However, non-Cochrane reviews will may not present an assessment of the quality of the evidence or may present many methods. For consistency, we will apply the GRADE algorithm to all systematic reviews as opposed to extracting the regular GRADE which would be a different tool.
The unit of analysis is a systematic review and the algorithm to GRADE is applied at the level of the systematic review.

Comment 13: It looks like the evidence will be presented qualitatively only. Will there be meta-analysis? If not, I would not say there will be a quantitative synthesis.
Response: Many thanks for this comment. The wording has been edited to highlight qualitative only.

Comment 14:  I would caution strongly against a hierarchical summary of results, as it is important to not make informal indirect comparisons across the findings of different systematic reviews. Please see Cochrane handbook Ch 5 for more information on this. It is difficult to assess the transitivity assumption in overviews of reviews.
Response: Many thanks for this comment. The JBI Manual recommends the use of a hierarchical summary of results. However, we understand the reservation with the use of the term and have edited this section accordingly.

View more View less

Competing Interests

No competing interests were disclosed.

Back to all reports

Reviewer Report

32 Views

10 Jul 2020 | for Version 1

Ruth McCullagh, Discipline of Physiotherapy, School of Clinical Therapies, University College Cork, Cork, Ireland

32 Views Cite this report Responses(1)

Approved

Is the rationale for, and objectives of, the study clearly described?

Yes
Is the study design appropriate for the research question?

Yes
Are sufficient details of the methods provided to allow replication by others?

Yes
Are the datasets clearly presented in a useable and accessible format?

Not applicable

Competing Interests

No competing interests were disclosed.

Reviewer Expertise

Older adult rehabilitation and physiiotherapy

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.

Respond to this report

Responses (1)

Alongside their report, reviewers assign a status to the article:

Approved - the paper is scientifically sound in its current form and only minor, if any, improvements are suggested

Approved with reservations - A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit.

Not approved - fundamental flaws in the paper seriously undermine the findings and conclusions

[1] 1. Beard JR, Officer A, de Carvalho IA, et al.: The World report on ageing and health: a policy framework for healthy ageing. Lancet. 2016; 387(10033): 2145–54. PubMed Abstract | Publisher Full Text | Free Full Text

[2] 2. Economic Policy Committee: The 2009 Ageing Report: economic and budgetary projections for the EU-27 Member States (2008-2060). European Economy. 2009. Reference Source

[3] 3. European Commission Directorate-General for Economic and Financial Affairs: The 2018 Ageing Report Economic and Budgetary Projections for the EU Member States (2016-2070). Luxembourg. 2018. Reference Source

[4] 4. Beard JR, Bloom DE: Towards a comprehensive public health response to population ageing. Lancet. 2015; 385(9968): 658–61. PubMed Abstract | Publisher Full Text | Free Full Text

[5] 5. Chatterji S, Byles J, Cutler D, et al.: Health, functioning, and disability in older adults--present status and future implications. Lancet. 2015; 385(9967): 563–75. PubMed Abstract | Publisher Full Text | Free Full Text

[6] 6. Dufour I, Chouinard MC, Dubuc N, et al.: Factors associated with frequent use of emergency-department services in a geriatric population: a systematic review. BMC Geriatr. 2019; 19(1): 185. PubMed Abstract | Publisher Full Text | Free Full Text

[7] 7. Marengoni A, Angleman S, Meinow B, et al.: Coexisting chronic conditions in the older population: Variation by health indicators. Eur J Intern Med. 2016; 31: 29–34. PubMed Abstract | Publisher Full Text

[8] 8. Poupard N, Tang CY, Shields N: Community-based case management does not reduce hospital admissions for older people: a systematic review and meta-analysis. Aust Health Rev. 2020; 44(1): 83–92. PubMed Abstract | Publisher Full Text

[9] 9. Preston L, Chambers D, Campbell F, et al.: What evidence is there for the identification and management of frail older people in the emergency department? A systematic mapping review. Health Services and Delivery Research. 2018; 6(16). PubMed Abstract | Publisher Full Text

[10] 10. Marengoni A, Angleman S, Melis R, et al.: Aging with multimorbidity: a systematic review of the literature. Ageing Res Rev. 2011; 10(4): 430–39. PubMed Abstract | Publisher Full Text

[11] 11. Arokiasamy P, Uttamacharya U, Jain K, et al.: The impact of multimorbidity on adult physical and mental health in low- and middle-income countries: what does the study on global ageing and adult health (SAGE) reveal? BMC Med. 2015; 13(1): 178. PubMed Abstract | Publisher Full Text | Free Full Text

[12] 12. The Lancet: Making more of multimorbidity: an emerging priority. Lancet. 2018; 391(10131): 1637. PubMed Abstract | Publisher Full Text

[13] 13. Ellis G, Marshall T, Ritchie C: Comprehensive geriatric assessment in the emergency department. Clin Interv Aging. 2014; 9: 2033–43. PubMed Abstract | Publisher Full Text | Free Full Text

[14] 14. Conroy SP, Stevens T, Parker SG, et al.: A systematic review of comprehensive geriatric assessment to improve outcomes for frail older people being rapidly discharged from acute hospital: 'interface geriatrics'. Age Ageing. 2011; 40(4): 436–43. PubMed Abstract | Publisher Full Text

[15] 15. Gruneir A, Silver MJ, Rochon PA: Emergency department use by older adults: a literature review on trends, appropriateness, and consequences of unmet health care needs. Med Care Res Rev. 2011; 68(2): 131–55. PubMed Abstract | Publisher Full Text

[16] 16. Soril L, Leggett L, Lorenzetti D, et al.: Characteristics of frequent users of the emergency department in the general adult population: A systematic review of international healthcare systems. Health Policy. 2016; 120(5): 452–61. PubMed Abstract | Publisher Full Text

[17] 17. Samaras N, Chevalley T, Samaras D, et al.: Older patients in the emergency department: a review. Ann Emerg Med. 2010; 56(3): 261–9. PubMed Abstract | Publisher Full Text

[18] 18. Aminzadeh F, Dalziel WB: Older adults in the emergency department: a systematic review of patterns of use, adverse outcomes, and effectiveness of interventions. Ann Emerg Med. 2002; 39(3): 238–47. PubMed Abstract | Publisher Full Text

[19] 19. Ryvicker M, Gallo WT, Fahs MC: Environmental factors associated with primary care access among urban older adults. Soc Sci Med. 2012; 75(5): 914–21. PubMed Abstract | Publisher Full Text | Free Full Text

[20] 20. Roberts DC, McKay MP, Shaffer A: Increasing rates of emergency department visits for elderly patients in the United States, 1993 to 2003. Ann Emerg Med. 2008; 51(6): 769–74. PubMed Abstract | Publisher Full Text

[21] 21. McCusker J, Karp I, Cardin S, et al.: Determinants of emergency department visits by older adults: a systematic review. Acad Emerg Med. 2003; 10(12): 1362–70. PubMed Abstract | Publisher Full Text

[22] 22. Lowthian JA, McGinnes RA, Brand CA, et al.: Discharging older patients from the emergency department effectively: a systematic review and meta-analysis. Age Ageing. 2015; 44(5): 761–70. PubMed Abstract | Publisher Full Text

[23] 23. Naughton C, Drennan J, Treacy P, et al.: The role of health and non-health-related factors in repeat emergency department visits in an elderly urban population. Emerg Med J. 2010; 27(9): 683–7. PubMed Abstract | Publisher Full Text

[24] 24. Hastings SN, Heflin MT: A systematic review of interventions to improve outcomes for elders discharged from the emergency department. Acad Emerg Med. 2005; 12(10): 978–86. PubMed Abstract | Publisher Full Text

[25] 25. Galvin R, Gilleit Y, Wallace E, et al.: Adverse outcomes in older adults attending emergency departments: a systematic review and meta-analysis of the Identification of Seniors At Risk (ISAR) screening tool. Age Ageing. 2017; 46(2): 179–86. PubMed Abstract | Publisher Full Text

[26] 26. Arendts G, Fitzhardinge S, Pronk K, et al.: Outcomes in older patients requiring comprehensive allied health care prior to discharge from the emergency department. Emerg Med Australas. 2013; 25(2): 127–31. PubMed Abstract | Publisher Full Text

[27] 27. Hughes JM, Freiermuth CE, Shepherd-Banigan M, et al.: Emergency Department Interventions for Older Adults: A Systematic Review. J Am Geriatr Soc. 2019; 67(7): 1516–25. PubMed Abstract | Publisher Full Text | Free Full Text

[28] 28. Fealy G, McCarron M, O’Neill D, et al.: Effectiveness of gerontologically informed nursing assessment and referral interventions for older persons attending the emergency department: systematic review. J Adv Nurs. 2009; 65(5): 934–45. PubMed Abstract | Publisher Full Text

[29] 29. Karam G, Radden Z, Berall LE, et al.: Efficacy of emergency department-based interventions designed to reduce repeat visits and other adverse outcomes for older patients after discharge: A systematic review. Geriatr Gerontol Int. 2015; 15(9): 1107–17. PubMed Abstract | Publisher Full Text | Free Full Text

[30] 30. Lunny C, Brennan SE, McDonald S, et al.: Toward a comprehensive evidence map of overview of systematic review methods: paper 2-risk of bias assessment; synthesis, presentation and summary of the findings; and assessment of the certainty of the evidence. Syst Rev. 2018; 7(1): 159. PubMed Abstract | Publisher Full Text | Free Full Text

[31] 31. Pollock A, Campbell P, Brunton G, et al.: Selecting and implementing overview methods: implications from five exemplar overviews. Syst Rev. 2017; 6(1): 145. PubMed Abstract | Publisher Full Text | Free Full Text

[32] 32. Lunny C, Brennan SE, McDonald S, et al.: Evidence map of studies evaluating methods for conducting, interpreting and reporting overviews of systematic reviews of interventions: rationale and design. Syst Rev. 2016; 5: 4. PubMed Abstract | Publisher Full Text | Free Full Text

[33] 33. Hunt H, Pollock A, Campbell P, et al.: An introduction to overviews of reviews: planning a relevant research question and objective for an overview. Syst Rev. 2018; 7(1): 39. Publisher Full Text

[34] 34. Pollock M, Fernandes RM, Pieper D, et al.: Preferred Reporting Items for Overviews of Reviews (PRIOR): a protocol for development of a reporting guideline for overviews of reviews of healthcare interventions. Syst Rev. 2019; 8(1): 335. PubMed Abstract | Publisher Full Text | Free Full Text

[35] 35. Aromataris E, Fernandez R, Godfrey C, et al.: Chapter 10: Umbrella Reviews. In: Aromataris E, Munn Z, eds. Joanna Briggs Institute Reviewer's Manual. The Joanna Briggs Institute, 2017: The Joanna Briggs Institute, 2017. Reference Source

[36] 36. Moher D, Liberati A, Tetzlaff J, et al.: Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. Ann Intern Med. 2009; 151(4): 264–9. PubMed Abstract | Publisher Full Text

[37] 37. Shamseer L, Moher D, Clarke M, et al.: Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015: elaboration and explanation. BMJ. 2015; 350: g7647. PubMed Abstract | Publisher Full Text

[38] 38. McGowan J, Sampson M, Lefebvre C: An Evidence Based Checklist for the Peer Review of Electronic Search Strategies (PRESS EBC). Evid Based Libr Inf Pract. 2010; 5(1): 149–54. Publisher Full Text

[39] 39. Aromataris E, Fernandez R, Godfrey CM, et al.: Summarizing systematic reviews: methodological development, conduct and reporting of an umbrella review approach. Int J Evid Based Healthc. 2015; 13(3): 132–40. PubMed Abstract | Publisher Full Text

[40] 40. Santos E, Duarte C, Marques A, et al.: Effectiveness of non-pharmacological and non-surgical interventions on the impact of rheumatoid arthritis: an umbrella review protocol. JBI Database System Rev Implement Rep. 2019; 17(1): 22–27. PubMed Abstract | Publisher Full Text

[41] 41. McNeil J, Denis AM, Michel U, et al.: Effectiveness of non-pharmacological strategies for managing delirium in hospitalized postoperative adults: an umbrella review protocol. JBI Database System Rev Implement Rep. 2018; 16(3): 594–602. PubMed Abstract | Publisher Full Text

[42] 42. Craig P, Dieppe P, Macintyre S, et al.: Developing and evaluating complex interventions: the new Medical Research Council guidance. Int J Nurs Stud. 2013; 50(5): 587–92. PubMed Abstract | Publisher Full Text

[43] 43. Shea BJ, Reeves BC, Wells G, et al.: AMSTAR 2: a critical appraisal tool for systematic reviews that include randomised or non-randomised studies of healthcare interventions, or both. BMJ. 2017; 358: j4008. PubMed Abstract | Publisher Full Text | Free Full Text

[44] 44. Shea BJ, Grimshaw JM, Wells GA, et al.: Development of AMSTAR: a measurement tool to assess the methodological quality of systematic reviews. BMC Med Res Methodol. 2007; 7: 10. PubMed Abstract | Publisher Full Text | Free Full Text

[45] 45. Guyatt GH, Oxman AD, Vist GE, et al.: GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. BMJ. 2008; 336(7650): 924-6. PubMed Abstract | Publisher Full Text | Free Full Text

[46] 46. Pollock A, Farmer SE, Brady MC, et al.: An algorithm was developed to assign GRADE levels of evidence to comparisons within systematic reviews. J Clin Epidemiol. 2016; 70: 106–110. PubMed Abstract | Publisher Full Text | Free Full Text

[47] 47. Pollock A, Farmer SE, Brady MC, et al.: Interventions for improving upper limb function after stroke. Cochrane Database Syst Rev. 2014; (11): CD010820. PubMed Abstract | Publisher Full Text | Free Full Text

[48] 48. Rios P, Cardoso R, Morra D, et al.: Comparative effectiveness and safety of pharmacological and non-pharmacological interventions for insomnia: an overview of reviews. Syst Rev. 2019; 8(1): 281. PubMed Abstract | Publisher Full Text | Free Full Text

[49] 49. Pieper D, Buechter R, Jerinic P, et al.: Overviews of reviews often have limited rigor: a systematic review. J Clin Epidemiol. 2012; 65(12): 1267–73. PubMed Abstract | Publisher Full Text

[50] 50. Lewis R, Hendry M, Din N, et al.: Pragmatic methods for reviewing exceptionally large bodies of evidence: systematic mapping review and overview of systematic reviews using lung cancer survival as an exemplar. Syst Rev. 2019; 8(1): 171. PubMed Abstract | Publisher Full Text | Free Full Text

[51] 51. Conneely M, Robinson K, Trépel D, et al.: Effectiveness of interventions to reduce adverse outcomes among older adults following Emergency Department discharge: Protocol for an Overview of Systematic Reviews PRISMA-P Checklist MC.docx.pdf. figshare. Journal contribution. 2020. https://www.doi.org/10.6084/m9.figshare.12179022.v1

Effectiveness of interventions to reduce adverse outcomes among older adults following emergency department discharge: Protocol for an overview of systematic reviews

Abstract

Keywords

Revised Amendments from Version 1

Introduction

Methods

Protocol

Search strategy

Table 1. Search strategy for Embase Database.

Study selection

Inclusion and exclusion criteria

Eligibility criteria using PICOT framework

Outcomes:

Table 2. PICOTS Statement.

Public and patient involvement

Methodological quality of included reviews

Assessing the quality of evidence

Box 1. Algorithm for applying GRADE level of evidence in systematic reviews48

Data synthesis and analysis

Discussion

Dissemination of findings

Study status

Data availability

Underlying data

Reporting guidelines

References

Comments on this article Comments (0)

Open Peer Review

Comments on this article Comments (0)

Open Peer Review

Reviewer Status

Reviewer Reports

Comments on this article

Are you a HRB-funded researcher?

Thank you!

Effectiveness of interventions to reduce adverse outcomes among older adults following emergency department discharge: Protocol for an overview of systematic reviews

Abstract

Keywords

Revised Amendments from Version 1

Introduction

Methods

Protocol

Search strategy

Table 1. Search strategy for Embase Database.

Study selection

Inclusion and exclusion criteria

Eligibility criteria using PICOT framework

Outcomes:

Table 2. PICOTS Statement.

Public and patient involvement

Methodological quality of included reviews

Assessing the quality of evidence

Box 1. Algorithm for applying GRADE level of evidence in systematic reviews48

Data synthesis and analysis

Discussion

Dissemination of findings

Study status

Data availability

Underlying data

Reporting guidelines

References

Comments on this article Comments (0)

Open Peer Review

Comments on this article Comments (0)

Open Peer Review

Reviewer Status

Reviewer Reports

Comments on this article

Competing Interests Policy

Stay Updated

Are you a HRB-funded researcher?

Thank you!