How effects on health equity are assessed in systematic reviews of interventions.

BACKGROUND: Enhancing health equity is endorsed in the Sustainable Development Goals. The failure of systematic reviews to consider potential differences in effects across equity factors is cited by decision-makers as a limitation to their ability to inform policy and program decisions.  OBJECTIVES: To explore what methods systematic reviewers use to consider health equity in systematic reviews of effectiveness. SEARCH METHODS: We searched the following databases up to 26 February 2021: MEDLINE, PsycINFO, the Cochrane Methodology Register, CINAHL, Education Resources Information Center, Education Abstracts, Criminal Justice Abstracts, Hein Index to Foreign Legal Periodicals, PAIS International, Social Services Abstracts, Sociological Abstracts, Digital Dissertations and the Health Technology Assessment Database. We searched SCOPUS to identify articles that cited any of the included studies on 10 June 10 2021. We contacted authors and searched the reference lists of included studies to identify additional potentially relevant studies. SELECTION CRITERIA: We included empirical studies of cohorts of systematic reviews that assessed methods for measuring effects on health inequalities. We define health inequalities as unfair and avoidable differences across socially stratifying factors that limit opportunities for health. We operationalised this by assessing studies which evaluated differences in health across any component of the PROGRESS-Plus acronym, which stands for Place of residence, Race/ethnicity/culture/language, Occupation, Gender or sex, Religion, Education, Socioeconomic status, Social capital. "Plus" stands for other factors associated with discrimination, exclusion, marginalisation or vulnerability such as personal characteristics (e.g. age, disability), relationships that limit opportunities for health (e.g. children in a household with parents who smoke) or environmental situations which provide limited control of opportunities for health (e.g. school food environment). DATA COLLECTION AND ANALYSIS: Two review authors independently extracted data using a pre-tested form. Risk of bias was appraised for included studies according to the potential for bias in selection and detection of systematic reviews.  MAIN RESULTS: In total, 48,814 studies were identified and the titles and abstracts were screened in duplicate. In this updated review, we identified an additional 124 methodological studies published in the 10 years since the first version of this review, which included 34 studies. Thus, 158 methodological studies met our criteria for inclusion. The methods used by these studies focused on evidence relevant to populations experiencing health inequity (108 out of 158 studies), assess subgroup analysis across PROGRESS-Plus (26 out of 158 studies), assess analysis of a gradient in effect across PROGRESS-Plus (2 out of 158 studies) or use a combination of subgroup analysis and focused approaches (20 out of 158 studies). The most common PROGRESS-Plus factors assessed were age (43 studies), socioeconomic status in 35 studies, low- and middle-income countries in 24 studies, gender or sex in 22 studies, race or ethnicity in 17 studies, and four studies assessed multiple factors across which health inequity may exist. Only 16 studies provided a definition of health inequity. Five methodological approaches to consider health equity in systematic reviews of effectiveness were identified: 1) descriptive assessment of reporting and analysis in systematic reviews (140 of 158 studies used a type of descriptive method); 2) descriptive assessment of reporting and analysis in original trials (50 studies); 3) analytic approaches which assessed differential effects across one or more PROGRESS-Plus factors (16 studies); 4) applicability assessment (25 studies) and 5) stakeholder engagement (28 studies), which is a new finding in this update and examines the appraisal of whether relevant stakeholders with lived experience of health inequity were included in the design of systematic reviews or design and delivery of interventions. Reporting for both approaches (analytic and applicability) lacked transparency and was insufficiently detailed to enable the assessment of credibility. AUTHORS' CONCLUSIONS: There is a need for improvement in conceptual clarity about the definition of health equity, describing sufficient detail about analytic approaches (including subgroup analyses) and transparent reporting of judgments required for applicability assessments in order to consider health equity in systematic reviews of effectiveness.

Solución tamponada frente a solución salina al 0.9% en adultos y niños gravemente enfermos / Buffered solutions versus 0.9% saline for resuscitation in critically ill adults and children

FUNDAMENTO: La terapia de fluidos intravenosos sirve como piedra angular del tratamiento de un amplio espectro de enfermedades graves. Conocer su impacto en términos de resultados clínicos es una cuestión importante. Existen algunas dudas sobre si el uso de una solución salina al 0,9%puede causar mayor mortalidad entre pacientes hospitalizados o un empeoramiento relevante de su función renal. El objetivo de esta revisión Cochrane fue averiguar si la fluidoterapia con soluciones tamponadas (solución salina a base de agua con un búfer para mantener un pH constante) daba como resultado menos muertes en el hospital y menos daño en los riñones de adultos y niños gravemente enfermos, en comparación con la solución salina al 0,9%. CARACTERÍSTICAS DE LOS ESTUDIOS: Se encontraron 21 estudios realizados tanto en niños como en adultos, con un total de 20.213 participantes. Estos estudios compararon las soluciones tamponadas con las soluciones salinas al 0,9% para adultos y niños gravemente enfermos (incluidos aquellos con sepsis, traumatismos, quemaduras o conmoción) a quienes no se les había realizado una cirugía planificada. Se excluyeron los ensayos en los que los participantes recibieron una cirugía planificada (electiva). Estos estudios se realizaron en 13 países. FUENTES DE FINANCIACIÓN: Doce de los estudios incluidos fueron financiados por gobiernos u organizaciones sin ánimo de lucro, 2 recibieron financiación mixta, uno fue financiado por una empresa cuyo papel en el estudio no se aclaró, y 6 no proporcionaron detalles. Resultados principales. Las soluciones tamponadas no parecen reducir las muertes hospitalarias o el empeoramiento de la función renal (del riñón) en adultos y niños gravemente enfermos, en comparación con la solución salina al 0,9%. La revisión muestra que, en comparación con los pacientes que recibieron soluciones salinas al 0,9%: 1) las soluciones tamponadas tuvieron poca o ninguna repercusión en la mortalidad general (19.664 participantes; 14 estudios; evidencia de calidad alta); 2) las soluciones tamponadas probablemente pueden tener poco o ningún efecto en la reducción del número de pacientes con empeoramiento de la función renal (18.701participantes; 9 estudios; evidencia de calidad baja); y 3) no hay certeza de que las soluciones tamponadas reduzcan el deterioro funcional de otros órganos (por ejemplo, pulmonar, hepática o cerebral), las alteraciones electrolíticas (aumento o disminución del cloruro o el sodio u otras sales)y la necesidad de recibir transfusiones de sangre, porque la calidad de la evidencia es muy baja. Ninguno de los estudios examinó la pérdida de sangre, los trastornos de la coagulación (en relación con el riesgo de hemorragias o coágulos) y la calidad de vida. Los resultados variaron en cuanto a los puntos temporales en los que se informaron, la unidad de medida utilizada y las medidas informadas. No se registró la cantidad total de líquido administrado durante la terapia de fluidos. Solo 4 estudios incluyeron niños. Estos niños estaban menos enfermos que los participantes incluidos en los ensayos con adultos, y no se informó sobre el daño renal. Los 3 estudios en curso, una vez publicados y evaluados, pueden alterar las conclusiones de esta revisión. ¿Cómo de actual es esta revisión? Se buscaron los estudios publicados hasta julio de 2018

No disponible

Buffered solutions versus 0.9% saline for resuscitation in critically ill adults and children.

BACKGROUND: Fluid therapy is one of the main interventions provided for critically ill patients, although there is no general consensus regarding the type of solution. Among crystalloid solutions, 0.9% saline is the most commonly administered. Buffered solutions may offer some theoretical advantages (less metabolic acidosis, less electrolyte disturbance), but the clinical relevance of these remains unknown. OBJECTIVES: To assess the effects of buffered solutions versus 0.9% saline for resuscitation in critically ill adults and children. SEARCH METHODS: We searched the following databases to July 2018: CENTRAL, MEDLINE, Embase, CINAHL, and four trials registers. We checked references, conducted backward and forward citation searching of relevant articles, and contacted study authors to identify additional studies. We imposed no language restrictions. SELECTION CRITERIA: We included randomized controlled trials (RCTs) with parallel or cross-over design examining buffered solutions versus intravenous 0.9% saline in a critical care setting (resuscitation or maintenance). We included studies on participants with critical illness (including trauma and burns) or undergoing emergency surgery during critical illness who required intravenous fluid therapy. We included studies of adults and children. We included studies with more than two arms if they fulfilled all of our inclusion criteria. We excluded studies performed in persons undergoing elective surgery and studies with multiple interventions in the same arm. DATA COLLECTION AND ANALYSIS: We used Cochrane's standard methodological procedures. We assessed our intervention effects using random-effects models, but when one or two trials contributed to 75% of randomized participants, we used fixed-effect models. We reported outcomes with 95% confidence intervals (CIs). MAIN RESULTS: We included 21 RCTs (20,213 participants) and identified three ongoing studies. Three RCTs contributed 19,054 participants (94.2%). Four RCTs (402 participants) were conducted among children with severe dehydration and dengue shock syndrome. Fourteen trials reported results on mortality, and nine reported on acute renal injury. Sixteen included trials were conducted in adults, four in the paediatric population, and one trial limited neither minimum or maximum age as an inclusion criterion. Eight studies involving 19,218 participants were rated as high methodological quality (trials with overall low risk of bias according to the domains: allocation concealment, blinding of participants/assessors, incomplete outcome data, and selective reporting), and in the remaining trials, some form of bias was introduced or could not be ruled out.We found no evidence of an effect of buffered solutions on in-hospital mortality (odds ratio (OR) 0.91, 95% CI 0.83 to 1.01; 19,664 participants; 14 studies; high-certainty evidence). Based on a mortality rate of 119 per 1000, buffered solutions could reduce mortality by 21 per 1000 or could increase mortality by 1 per 1000. Similarly, we found no evidence of an effect of buffered solutions on acute renal injury (OR 0.92, 95% CI 0.84 to 1.00; 18,701 participants; 9 studies; low-certainty evidence). Based on a rate of 121 per 1000, buffered solutions could reduce the rate of acute renal injury by 19 per 1000, or result in no difference in the rate of acute renal injury. Buffered solutions did not show an effect on organ system dysfunction (OR 0.80, 95% CI 0.40 to 1.61; 266 participants; 5 studies; very low-certainty evidence). Evidence on the effects of buffered solutions on electrolyte disturbances varied: potassium (mean difference (MD) 0.09, 95% CI -0.10 to 0.27; 158 participants; 4 studies; very low-certainty evidence); chloride (MD -3.02, 95% CI -5.24 to -0.80; 351 participants; 7 studies; very low-certainty evidence); pH (MD 0.04, 95% CI 0.02 to 0.06; 200 participants; 3 studies; very low-certainty evidence); and bicarbonate (MD 2.26, 95% CI 1.25 to 3.27; 344 participants; 6 studies; very low-certainty evidence). AUTHORS' CONCLUSIONS: We found no effect of buffered solutions on preventing in-hospital mortality compared to 0.9% saline solutions in critically ill patients. The certainty of evidence for this finding was high, indicating that further research would detect little or no difference in mortality. The effects of buffered solutions and 0.9% saline solutions on preventing acute kidney injury were similar in this setting. The certainty of evidence for this finding was low, and further research could change this conclusion. Patients treated with buffered solutions showed lower chloride levels, higher levels of bicarbonate, and higher pH. The certainty of evidence for these findings was very low. Future research should further examine patient-centred outcomes such as quality of life. The three ongoing studies once published and assessed may alter the conclusions of the review.