Effects of task shifting from primary care physicians to nurses: a protocol for an overview of systematic reviews.

INTRODUCTION: Task-shifting from primary care physicians (PCPs) to nurses is one option to better and more efficiently meet the needs of the population in primary care and to overcome PCP shortages. This protocol outlines an overview of systematic reviews to assess the effects of delegation or substitution by nurses of PCPs' activities regarding clinical, patient-relevant, professional and health services-related outcomes. METHODS AND ANALYSIS: We will conduct a systematic literature search for secondary literature in PubMed/MEDLINE, EMBASE, CINAHL and Cochrane databases. Systematic reviews, meta-analyses and Health Technology Assessments in German and English comprising randomised controlled trials and prospective controlled trials will be considered for inclusion. Search terms will include Medical Subject Headings combined with free text words. At least one-third of abstracts and full-text articles are reviewed by two independent reviewers. Methodological quality will be assessed using the Overview Quality Assessment Questionnaire. We will only consider reviews if they include controlled trials, if the profession that substituted or delegated tasks was a nurse, if the profession of the control was a PCP, if the assessed intervention was the same in the intervention and control group and if the Overview Quality Assessment Questionnaire score is ≥5. The corrected covered area will be calculated to describe the degree of overlap of studies in the reviews included in the study. We will report the overview according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. ETHICS AND DISSEMINATION: The overview of secondary literature does not require the approval of an Ethics Committee and will be published in a peer-reviewed journal. PROSPERO REGISTRATION NUMBER: CRD42020183327.

Chronic heart failure patients' experiences of German healthcare services: a protocol for a scoping review.

INTRODUCTION: Chronic heart failure (CHF) is a heterogeneous condition requiring complex treatment from diverse healthcare services. An increasingly holistic understanding of healthcare has resulted in contextual factors such as perceived quality of care, as well as patients' acceptance, preferences and subjective expectations of health services, all gaining in importance. How patients with CHF experience the use of healthcare services has not been studied within the scope of a systematic review in a German healthcare context. The aim of this scoping review is therefore to review systematically the experiences of patients affected by CHF with healthcare services in Germany in the literature and to map the research foci. Further objectives are to identify gaps in evidence, develop further research questions and to inform decision makers concerned with improving healthcare of patients living with CHF. METHODS AND ANALYSIS: This scoping review will be based on a broad search strategy involving systematic and comprehensive electronic database searches in MEDLINE, EMBASE, PsycINFO, PSYNDEX, CINAHL and Cochrane's Database of Systematic Reviews, grey literature searches, as well as hand searches through reference lists and non-indexed key journals. The methodological procedure will be based on an established six-stage framework for conducting scoping reviews that includes two independent reviewers. Data will be systematically extracted, qualitatively and quantitatively analysed and summarised both narratively and visually. To ensure the research questions and extracted information are meaningful, a patient representative will be involved. ETHICS AND DISSEMINATION: Ethical approval will not be required to conduct this review. Results will be disseminated through a clearly illustrated report that will be part of a wider research project. Furthermore, it is intended that the review's findings should be made available to relevant stakeholders through conference presentations and publication in peer-reviewed journals (knowledge transfer). Protocol registration in PROSPERO is not applicable for scoping reviews.

Choosing Wisely: assessment of current US top five list recommendations' trustworthiness using a pragmatic approach.

OBJECTIVES: Identification of sufficiently trustworthy top 5 list recommendations from the US Choosing Wisely campaign. SETTING: Not applicable. PARTICIPANTS: All top 5 list recommendations available from the American Board of Internal Medicine Foundation website. MAIN OUTCOME MEASURES/INTERVENTIONS: Compilation of US top 5 lists and search for current German highly trustworthy (S3) guidelines. Extraction of guideline recommendations, including grade of recommendation (GoR), for suggestions comparable to top 5 list recommendations. For recommendations without guideline equivalents, the methodological quality of the top 5 list development process was assessed using criteria similar to that used to judge guidelines, and relevant meta-literature was identified in cited references. Judgement of sufficient trustworthiness of top 5 list recommendations was based either on an 'A' GoR of guideline equivalents or on high methodological quality and citation of relevant meta-literature. RESULTS: 412 top 5 list recommendations were identified. For 75 (18%), equivalents were found in current German S3 guidelines. 44 of these recommendations were associated with an 'A' GoR, or a strong recommendation based on strong evidence, and 26 had a 'B' or a 'C' GoR. No GoR was provided for 5 recommendations. 337 recommendations had no equivalent in the German S3 guidelines. The methodological quality of the development process was high and relevant meta-literature was cited for 87 top 5 list recommendations. For a further 36, either the methodological quality was high without any meta-literature citations or meta-literature citations existed but the methodological quality was lacking. For the remaining 214 recommendations, either the methodological quality was lacking and no literature was cited or the methodological quality was generally unsatisfactory. CONCLUSIONS: 131 of current US top 5 list recommendations were found to be sufficiently trustworthy. For a substantial number of current US top 5 list recommendations, their trustworthiness remains unclear. Methodological requirements for developing top 5 lists are recommended.

Increasing physical activity for the treatment of hypertension: a systematic review and meta-analysis.

BACKGROUND: Low physical activity has been identified as a major risk factor for cardiovascular disease. Medical societies therefore recommend increased physical activity be part of any antihypertensive therapy. OBJECTIVE: Focusing on patient-relevant outcomes such as mortality and cardiovascular events, this review was conducted to assess the long-term effects of interventions aiming at increasing physical activity in comparison with no such interventions on adult patients with essential hypertension. DATA SOURCES: We searched for high-quality systematic reviews in MEDLINE, EMBASE, Cochrane Database of Systematic Reviews (Cochrane Reviews), Database of Abstracts of Reviews of Effects (Other Reviews) and Health Technology Assessment Database (Technology Assessments) published between 1997 and February 2009 and for randomized controlled trials (RCTs) in MEDLINE, EMBASE and Cochrane Central Register of Controlled Trials (Clinical Trials) published before September 2012. Additional studies were identified by hand searching reference lists of reviews. STUDY SELECTION: RCTs with at least 24 weeks' follow-up that evaluated the effect of increased physical activity on the blood pressure of adults with essential hypertension were included in our review. Primary outcomes were all-cause mortality, cardiovascular morbidity and mortality, end-stage renal disease, quality of life and adverse events. STUDY APPRAISAL AND SYNTHESIS METHODS: When appropriate, we used random effects meta-analyses to determine mean difference with 95 % confidence intervals for each endpoint. All data were analysed using the Review Manager software version 5.0.24 from the Cochrane Collaboration. RESULTS: None of the included nine trials, covering 891 patients with hypertension, provided sufficient data on patient-relevant outcomes such as mortality, cardiovascular events or injuries related to physical activity. Information on changes in systolic and diastolic blood pressure was provided for all included trials. The majority of the included RCTs reported that increased physical activity led to a decrease in systolic and diastolic blood pressure of 5-10 and 1-6 mmHg, respectively, but due to marked heterogeneity in the meta-analyses both for systolic and diastolic blood pressure (I² = 70.0 and 73.0 %), no effect estimates were provided. LIMITATIONS: About 50 % of the included trials were small, evaluating at most 20 participants per study group, and more than twothirds were deemed to have a high risk of bias. CONCLUSIONS: Although a decrease in blood pressure is shown to be a consequence of increased physical activity, RCTs of appropriate study size and quality that examine potential patient-relevant benefits or harms still need to be conducted to evaluate whether physical activity really improves the health of patients with essential hypertension.

Benefit assessment of salt reduction in patients with hypertension: systematic overview.

OBJECTIVE: We assessed the benefits and harm of reduced salt intake in patients with essential hypertension focusing on patient-relevant outcomes and blood pressure. METHODS: A systematic search of five electronic databases was performed to identify high-quality secondary literature based on randomized controlled trials (RCTs). An update primary literature search (RCTs) was performed for the time period up to 2010 that was not covered by secondary literature. Major outcomes were death, cardiovascular morbidity/mortality, hospital stays, terminal renal failure, quality of life, and adverse events. Change in blood pressure was defined as surrogate parameter. RESULTS: Four different systematic reviews and two RCTs met the inclusion criteria. Only one review reported limited data on patient-relevant outcomes. Over an intervention period of up to 12 months, mean SBP was reduced by 3.6-8.0 mmHg in all reviews. For the same intervention period, a statistically significant advantage with regard to mean DBP reduction ranging from 1.9 to 2.8 mmHg was found in three reviews. The fourth publication reported a nonsignificant reduction (DBP reduction of 4.7 mmHg). None of the RCTs identified in the primary literature search update reported data on patient-relevant outcomes. However, both RCTs found blood pressure improvements with salt reduction. CONCLUSION: A benefit from a salt-reduced diet in patients with high blood pressure is not proven with regard to patient-relevant outcomes based on systematic reviews and RCTs published up to 2010. The results indicate a blood pressure-lowering effect through reduced salt intake in hypertensive patients.