Knowledge Synthesis: An Overview

• Knowledge synthesis summarizes findings from multiple studies, offering a comprehensive understanding of a research question
• Knowledge synthesis is used in evidence-based practice (EBP) to develop clinical guidelines, policy recommendations, and research priorities.

Types of Questions Answered by Knowledge Synthesis:

• Effectiveness Questions (Intervention-Based):
  • Example: "What is the effect of early mobilization on ICU patient recovery?"
  • Answered by systematic reviews and meta-analyses comparing intervention vs. control.
  • Key source is the Cochrane Collaboration.
• Diagnosis Questions:
  • Example: "What is the accuracy of MRI compared to X-ray for detecting bone fractures?"
  • Answered by systematic reviews evaluating diagnostic test performance.
  • Key measures include sensitivity, specificity, and likelihood ratios.
• Prognosis Questions:
  • Example: "What are the long-term survival rates for patients with heart failure?"
  • Answered by systematic reviews of longitudinal cohort studies.
• Etiology or Risk Factor Questions:
  • Example: "Is smoking a risk factor for Alzheimer's disease?"
  • Answered by systematic reviews of observational studies (cohort, case-control studies).
• Experiential Questions (Qualitative Evidence):
  • Example: "What are the lived experiences of patients undergoing chemotherapy?"
  • Answered by meta-syntheses of qualitative research.
• Cost-Effectiveness Questions:
  • Example: "Is robotic-assisted surgery more cost-effective than traditional surgery?"
  • Answered by economic evaluations included in systematic reviews.

Application in Nursing:

• Guides clinical decision-making by integrating the best available evidence.
• Supports the development of practice guidelines for patient care.

Role of Systematic Reviews and Practice Guidelines in Clinical Decision-Making:

• Systematic reviews are structured, comprehensive syntheses of existing research on a specific topic, using rigorous methods to locate, evaluate, and summarize research findings.
• Clinical Practice Guidelines (CPGs) are evidence-based recommendations developed from systematic reviews, guiding clinical decisions, reducing variability in practice, and improving patient outcomes.

Role of Systematic Reviews in Clinical Decision-Making:

• Provides the Best Available Evidence:
  • Identifies high-quality research for a specific question.
  • Reduces bias by critically appraising included studies.
• Supports Evidence-Based Practice (EBP):
  • Helps clinicians integrate research findings into practice.
  • Cochrane reviews provide best practices for wound-care management.
• Resolves Conflicting Evidence:
  • Aggregates findings from multiple studies to determine the true effect of an intervention.
• Improves Policy and Protocol Development:
  • Used to develop clinical guidelines and inform healthcare policies.

Role of Practice Guidelines in Clinical Decision-Making:

• Standardizes Patient Care:
  • Ensures consistency and high-quality care across healthcare settings.
  • Example: American Heart Association guidelines for CPR.
• Reduces Uncertainty in Treatment Choices:
  • Offers clear, evidence-based recommendations for clinicians.
• Improves Patient Outcomes:
  • Guidelines for sepsis management can improve survival rates.
• Supports Shared Decision-Making:
  • Helps clinicians discuss risks and benefits of treatment options with patients.

Sources for Systematic Reviews and Guidelines:

• Cochrane Collaboration focuses on systematic reviews of healthcare interventions.
• Joanna Briggs Institute focuses on evidence-based nursing practices.
• National Guideline Clearinghouse is a U.S.-based repository of clinical guidelines.
• World Health Organization (WHO) provides global health practice recommendations.

Example in Nursing Practice:

• Systematic Review identifies the best wound dressing for diabetic ulcers.
• Practice Guideline provides a step-by-step protocol for wound management in diabetic patients.

Evaluating Systematic Reviews:

• Use the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) Checklist to determine the quality and applicability of a systematic review.

Key Criteria for Evaluating a Systematic Review:

• Relevance of Research Question:
  • Does it clearly state the clinical question using PICO(S) format?
  • Is the question important for clinical practice?
• Comprehensiveness of the Literature Search:
  • Does it search multiple databases (e.g., PubMed, Cochrane, CINAHL)?
  • Does it include grey literature (unpublished studies) to reduce publication bias?
• Clear Inclusion and Exclusion Criteria:
  • Are the eligibility criteria for selecting studies well-defined?
  • Does it specify study types, populations, and interventions?
• Risk of Bias Assessment:
  • Does it evaluate study quality using tools like the Cochrane Risk of Bias tool?
  • Are there efforts to minimize bias (randomization, blinding, allocation concealment)?
• Consistency of Results:
  • Do most studies show similar effect sizes and directions?
  • Is there a heterogeneity analysis (I² statistic)?
• Use of Meta-Analysis:
  • If included, is the meta-analysis appropriately conducted?
  • Are forest plots, funnel plots, and confidence intervals presented?
• Transparency and Replicability
  • Follows PRISMA guidelines for reporting.
  • The data sources and methodologies are clearly described.

Evaluating Clinical Practice Guidelines (CPGs):

• Use the AGREE II (Appraisal of Guidelines for Research & Evaluation) tool to assess guideline quality.

Key Criteria for Evaluating Clinical Guidelines:

• Scope and Purpose:
  • Does it address a specific clinical condition?
  • Are objectives and target populations clearly defined?
• Stakeholder Involvement:
  • Were clinicians, researchers, and patients involved in development?
  • Example: WHO guidelines involve multidisciplinary experts.
• Rigor of Development:
  • Were guidelines developed using systematic reviews?
  • Is the evidence graded based on strength and quality?
• Clarity of Recommendations:
  • Are recommendations specific and actionable?
  • Are treatment options clearly outlined?
• Applicability in Clinical Practice:
  • Are barriers to implementation addressed?
  • Is there supporting education or training for clinicians?
• Editorial Independence:
  • Are conflicts of interest disclosed?
  • Were guidelines externally reviewed before publication?

Evaluating a Systematic Review and Practice Guideline:

• Relevance:
  • Systematic Review: Does it address a clinical question?
  • Clinical Practice Guideline: Is the condition/population clearly defined?
• Search Strategy:
  • Systematic Review: Uses multiple databases?
  • Clinical Practice Guideline: Based on systematic reviews?
• Risk of Bias:
  • Systematic Review: Were studies appraised for bias?
  • Clinical Practice Guideline: Were conflicts of interest disclosed?
• Consistency:
  • Systematic Review: Are results consistent across studies?
  • Clinical Practice Guideline: Are recommendations clear and applicable?
• Transparency:
  • Systematic Review: Follows PRISMA?
  • Clinical Practice Guideline: Developed using AGREE II framework?

Key Takeaways:

• Types of Questions Answered:
  • Systematic reviews address effectiveness, diagnosis, prognosis, risk factors, qualitative experiences, and cost-effectiveness.
• Role of Systematic Reviews & Guidelines:
  • Provides high-quality evidence for clinical decision-making and standardizes care.
• Evaluating Systematic Reviews & Guidelines:
  • Use PRISMA for systematic reviews and AGREE II for practice guidelines to assess quality.