Is health equity considered in systematic reviews of the Cochrane Musculoskeletal Group? Tackling the wider social determinants of health and health inequalities: evidence from systematic reviews. Developing methods for systematic reviewing in health services delivery and organization: an example from a review of access to health care for people with learning disabilities. Part 1. Identifying the literature. Appraising the evidence: applying sex- and gender-based analysis (SGBA) to Cochrane systematic reviews on cardiovascular diseases. Improving services for disadvantaged childbearing women. The effects of an 'explicit' values clarification exercise in a woman's decision aid regarding postmenopausal hormone therapy. Examination of the analytic quality of behavioral health randomized clinical trials. Evaluation of an intervention for hospitalized African American smokers. Reducing social inequalities in smoking: can evidence inform policy? A pilot study. Supporting the delivery of cost-effective interventions in primary health-care systems in low-income and middle-income countries: an overview of systematic reviews. Strategies for improving the quality of health care in maternal and child health in low- and middle-income countries: an overview of systematic reviews. Cross validation of some psychometric properties of the CSQ and its differential return rate as a function of token financial incentive. Systematic reviews of health effects of social interventions: 1. Finding the evidence: how far should you go? The impact of evidence-based guideline dissemination for the assessment and treatment of major depression in a managed behavioral health care organization. A study of client-focused case management and consumer advocacy: the Community and Consumer Service Project. Impact of patient care appraisal on physician behaviour in the office setting. Early experience with pay-for-performance: from concept to practice. Effectiveness and efficiency of a literature search strategy to answer questions on the etiology of occupational diseases: a controlled trial. Measuring the saving attributable to an antibiotic prescribing policy. Effectiveness of report cards based on chart audits of residents' adherence to practice guidelines on practice performance: a randomized controlled trial. Evaluation of general practice computer templates. Lessons from a pilot randomised controlled trial. Effective/efficient mental health programs for school-age children: a synthesis of reviews. Systematic reviews reveal unrepresentative evidence for the development of drug formularies for poor and nonwhite populations. Tailoring systematic reviews to meet critical priorities in maternal health in the intrapartum period. Use of an 'evidence-based implementation' strategy to implement evidence-based care of asthma into rural district hospital emergency departments. Fees-for-services, cost recovery, and equity in a district of Burkina Faso operating the Bamako Initiative.
To determine whether Cochrane Musculoskeletal Group (CMSG) systematic reviews and corresponding primary studies of rheumatoid arthritis interventions report and analyze the data needed to assess the effectiveness of interventions in reducing socioeconomic differences in health and/or improving the health of the poor.
                We selected all CMSG reviews on rheumatoid arthritis published since issue 1, 2003. Fourteen reviews were identified; 147 of the 156 primary studies included in these reviews were obtained and assessed. We extracted data on whether the dimensions place of residence, race/ethnicity/culture, occupation, gender, religion, education, socioeconomic status, and social capital and networks (PROGRESS) were reported or analyzed, and whether any interventions were aimed at disadvantaged or low- and middle-income country populations.
                Among the dimensions of PROGRESS reported at baseline in 147 primary studies, gender (89%) was the most commonly reported, followed by education (25%) and race/ethnicity (18%). Less than 50% of the systematic reviews reported dimensions of PROGRESS even when they had been reported in the primary study. Of 147 primary studies, 6 (5%) were aimed specifically at disadvantaged populations; another 6 reported on effectiveness by at least 1 dimension of PROGRESS.
                Primary studies of interventions for rheumatoid arthritis generally reported few variables necessary to answer questions about health inequalities. Most CMSG systematic reviews failed to assess those variables even when described in the primary studies. The Cochrane Health Equity Field welcomes the opportunity to provide guidance to systematic review authors on incorporating equity considerations into their reviews. There is increasing pressure to tackle the wider social determinants of health through the implementation of appropriate interventions. However, turning these demands for better evidence about interventions around the social determinants of health into action requires identifying what we already know and highlighting areas for further development.
                Systematic review methodology was used to identify systematic reviews (from 2000 to 2007, developed countries only) that described the health effects of any intervention based on the wider social determinants of health: water and sanitation, agriculture and food, access to health and social care services, unemployment and welfare, working conditions, housing and living environment, education, and transport.
                Thirty systematic reviews were identified. Generally, the effects of interventions on health inequalities were unclear. However, there is suggestive systematic review evidence that certain categories of intervention may impact positively on inequalities or on the health of specific disadvantaged groups, particularly interventions in the fields of housing and the work environment.
                Intervention studies that address inequalities in health are a priority area for future public health research. Our objectives were to identify literature on: (i) theory, evidence and gaps in knowledge relating to the help-seeking behaviour of people with learning disabilities and their carers; (ii) barriers experienced by people with learning disabilities in securing access to the full range of health services; (iii) interventions which improve access to health services by people with learning disabilities.
                twenty-eight bibliographic databases, research registers, organizational websites or library catalogues; reference lists from identified studies; contact with experts; current awareness and contents alerting services in the area of learning disabilities.
                Inclusion criteria were English language literature from 1980 onwards, relating to people with learning disabilities of any age and all study designs. The main criteria for assessment was relevance to the Guilliford et al. model of access to health care (Gulliford et al. Access to health care. Report of a Scoping Exercise for the National Co-ordinating Centre for NHS Service Delivery and Organisation R & D (NCCSDO). London: NCCSDO, 2001), which was modified to the special needs of people with learning disabilities. Inclusion criteria focused on relevance to the model with initial criteria revised in light of literature identified and comments from a consultation exercise with people with learning disabilities, family and paid carers and experts in the field. Data abstraction was completed independently and selected studies were evaluated for scientific rigour and the results synthesized.
                In total, 2221 items were identified as potentially relevant and 82 studies fully evaluated.
                The process of identifying relevant literature was characterized by a process of clarifying the concept under investigation and sensitive search techniques which led to an initial over-identification of non-relevant records from database searches. Thesaurus terms were of limited value, forcing a reliance on using free-text terms and alternative methods of identifying literature to supplement and improve the recall of the database searches. A key enabler in identifying relevant literature was the depth and breadth of knowledge built up by the reviewers whilst engaged in this process. To examine the use of sex- and gender-based analysis (SGBA) in systematic reviews of cardiovascular health in order to strengthen the evidence base for clinical practice and policy.
                To determine the current status of SGBA in systematic reviews, an appraisal tool was developed by the research team and applied by an independent reviewer to a random sample of 38 Cochrane systematic reviews. The sample was drawn from reviews addressing interventions for cardiovascular diseases (CVD). A random sample of Cochrane reviews in cardiovascular health was selected from the Cochrane Library, Issue 3, 2001, to Issue 3, 2007. The main outcome measure was the number of reviews that included analysis of sex or gender or both.
                Our findings showed that SGBA was generally absent in the sampled reviews. Data were rarely disaggregated by sex; only 2 of 38 reviews reported any sex or gender research gaps. Only one quarter of the reviews included a rationale as to why any subgroup analyses by sex were or were not completed. None of the 38 reviews met all of the appraisal tool criteria. As well, we found that where sex or gender was mentioned, the terms were used interchangeably.
                Despite increasing evidence over the past decade documenting that sex and gender frequently matter in CVD, this study demonstrated that SGBA was rarely considered in systematic reviews. We suggest this omission has important implications for assuring the quality of research and of evidence-based policy and practice and for achieving equitable health outcomes for women and men. To build a robust evidence base for future work in cardiovascular health, we propose that the methodologies of systematic reviews and of SGBA be refined and synchronized to enhance the collection, synthesis, and analysis of evidence for decision making. Tackling health inequalities is high on the political agenda of the Labour government. The government wants to reduce inequalities through policies based on evidence, the health of childbearing women and their babies being priority areas for action. National Service Frameworks (NSFs) are being set up to ensure high quality services for all groups. The External Working Group looking into maternity services for the Children's NSF seeks evidence upon which to plan strategies for all women, while focusing attention on the most disadvantaged. Wide differentials are noted between high- and low-income groups in the outcomes of pregnancy and the health of babies. The worst outcomes appear to be concentrated in small subgroups of disadvantaged women.
                To report on a review of studies of interventions improving perinatal outcomes for disadvantaged women, to inform policy and practice around the organization and delivery of statutory services in the UK.
                We searched six relevant databases for reviews, intervention studies, audits and descriptions of services reporting outcomes for disadvantaged groups of women, published between 1990 and 2003. Synthesis was performed around what works and what does not work. Gaps in the evidence base were identified.
                We found limited evidence of effective and promising interventions for childbearing women from minority ethnic groups, women experiencing domestic violence, women with mental health illness and HIV infected women. Few studies were well-designed or powered to detect effectiveness. There were no studies of interventions for women prisoners, homeless women and travellers.
                Searching for intervention studies primarily by participant subgroup has brought in evidence from few well-designed studies on which to plan policy. Combining this approach with searching for intervention studies addressing behaviour like smoking, and needs like social support, may provide further evidence to tackle inequalities in the perinatal period. OBJECTIVE: To evaluate the incremental effect of a graphic weigh-scale values clarification exercise to explicitly consider the personal importance of the benefits versus the risks in a woman's decision aid regarding postmenopausal hormone therapy. DESIGN: Randomized controlled trial. Intervention Decision aid including information on options, benefits and risks, and their probabilities either followed by: (1) a graphic weigh-scale values clarification exercise to explicitly consider the personal importance of each benefit and risk; or (2) a summary of the main benefits and risks to implicitly consider benefits versus the risks. SAMPLE: Two-hundred and one women aged 50-69 years from Ottawa, Canada, who had never used hormone therapy. OUTCOME: Perceived clarity of values, a sub-scale of the decisional conflict scale; congruence between personal values of benefits and risks (measured on 0-10 importance rating scale) and choices (accept, decline, unsure regarding preventive hormone therapy [HRT]) using discriminant function analysis. RESULTS: There were no statistically significant differences between interventions in perceived clarity of values and overall congruence between values and choices. Amongst those choosing HRT, there was a trend in those exposed to the graphic weigh-scale exercise to have better congruence between values and choices compared to implicit values clarification (P = 0.06). CONCLUSION: The use of the graphic weigh-scale exercise in a decision aid conveys no overall short-term benefit. Further study is needed to specifically determine effects in those changing the status quo and on the quality of patient-practitioner communication and persistence with decisions. Adoption of evidence-based practice (EBP) policy has implications for clinicians and researchers alike. In fields that have already adopted EBP, evidence-based practice guidelines derive from systematic reviews of research evidence. Ultimately, such guidelines serve as tools used by practitioners. Systematic reviews of treatment efficacy and effectiveness reserve their strongest endorsements for treatments that are supported by high-quality randomized clinical trials (RCTs). It is unknown how well RCTs reported in behavioral science journals fare compared to quality standards set forth in fields that pioneered the evidence-based movement. We compared analytic quality features of all behavioral health RCTs (n = 73) published in three leading behavioral journals and two leading medical journals between January 2000 and July 2003. A behavioral health trial was operationalized as one employing a behavioral treatment modality to prevent or treat an acute or chronic physical disease or condition. Findings revealed areas of weakness in analytic aspects of the behavioral health RCTs reported in both sets of journals. Weaknesses were more pronounced in behavioral journals. The authors offer recommendations for improving the analytic quality of behavioral health RCTs to ensure that evidence about behavioral treatments is highly weighted in systematic reviews.
                (c) 2006 Wiley Periodicals, Inc. To evaluate the effectiveness of a smoking cessation intervention based on the transtheoretical model of change with a sample of low-income African American smokers admitted to an indigent-care hospital.
                The intervention incorporated components shown to be effective in increasing cessation in other populations, tailored to a bedside counseling format with follow-up contact postdischarge.
                Intervention patients were significantly more likely to advance in stage than were control patients.
                A hospital-offered bedside intervention offers promise in reaching underserved smokers with effective, though limited, cessation assistance. To assess the potential contribution of evidence from existing systematic reviews of effectiveness to answering the question: what works in reducing social inequalities in smoking?
                The Cochrane Library (2002/4).
                Systematic reviews of the effectiveness of community based tobacco control interventions, and all the primary studies included in one of these reviews.
                Reviews and primary studies were assessed for intent to assess the social distribution of intervention effects, information about the social inclusiveness or targeting of interventions, baseline sociodemographic data collected on participants, and estimates of effect size stratified by sociodemographic variables.
                Only one review aimed to examine outcomes stratified by sex, age or socioeconomic status, and these aims were only achieved with respect to sex. Sociodemographic data about participants were frequently collected in primary studies, but not used to compare intervention effects between social groups.
                There may be scope for using existing research more effectively to contribute to evidence based policy to reduce social inequalities in smoking-by explicitly seeking stratified outcome data in new systematic reviews, by re-analysing original datasets, and/or by meta-analysis of individual participant data. Strengthening health systems is a key challenge to improving the delivery of cost-effective interventions in primary health care and achieving the vision of the Alma-Ata Declaration. Effective governance, financial and delivery arrangements within health systems, and effective implementation strategies are needed urgently in low-income and middle-income countries. This overview summarises the evidence from systematic reviews of health systems arrangements and implementation strategies, with a particular focus on evidence relevant to primary health care in such settings. Although evidence is sparse, there are several promising health systems arrangements and implementation strategies for strengthening primary health care. However, their introduction must be accompanied by rigorous evaluations. The evidence base needs urgently to be strengthened, synthesised, and taken into account in policy and practice, particularly for the benefit of those who have been excluded from the health care advances of recent decades. There are many systematic reviews of continuing education programmes and educational strategies for quality improvement in health care. Most of the reviewed studies are one-off evaluations rather than impact evaluations with long-term follow-up. There are few systematic reviews of organisational, financial and regulatory interventions, and few high-quality studies. These interventions are probably as or more important than educational strategies, although they are less well evaluated. Few studies have been undertaken in low- and middle-income countries (LMIC) or that address maternal and child health (MCH). Thus, the results of the available studies and reviews need to be interpreted cautiously when applied to LMIC. Interactive workshops, reminders and multifaceted interventions can improve professional practice, and they generally have moderate effects. Educational outreach visits consistently improve prescribing but have variable effects on other behaviours. Audit and feedback interventions have variable effects on professional practice, but most often these are small to moderate effects. Mass-media and patient-mediated interventions may change professional practice. Multifaceted interventions that combine several quality-improvement strategies are also effective but may not be more so than single interventions. While all of these strategies are applicable to MCH in LMIC, the applicability of the results to rural settings, in particular, may be limited. Use of these strategies could exacerbate inequalities, and this should be taken into consideration when planning implementation. Scaling up and sustainability may be difficult to achieve in LMIC contexts and need careful consideration. The use of financial interventions has not been well studied; financial incentives and disincentives may be difficult to use effectively and efficiently, although their impact on practice needs to be considered. Organisational interventions are likely to be important, given that there are often underlying organisational or system problems. Regulatory interventions have not been well evaluated, but may sometimes be both inexpensive and effective. There are no 'magic bullets' or simple solutions for ensuring the quality of health care services. Interventions should be selected or tailored to address the underlying reasons for a failure to deliver effective services. Decision-makers should select the most appropriate interventions for specific problems. This requires a governance structure that clearly assigns responsibility for quality-improvement activities, priority setting, selection and design of interventions, and evaluation. The Consumer Satisfaction Questionnaire (CSQ) was developed by Larsen, Atkisson, Hargreaves, and Nguyen (1979) and has been mentioned as a possible "standard scale" for the evaluation of consumer satisfaction with mental health treatment because of its unidimensionality, reliability, validity and ease of use. A mail survey of ex-clients who had terminated treatment during the preceding year from one of six offices of a regional mental health center in the Rocky Mountain area strongly cross-validated these characteristics as well as other results from the consumer satisfaction literature. In addition, based upon evidence from marketing research, a randomly selected half of the ex-clients surveyed was offered a token inducement of two cents for returning the questionnaire while the other half was not. A significantly greater proportion of ex-clients who received the token inducement returned their questionnaires than did those who had not. This approach appears to be promising and further research with it is indicated. There is little guidance on how to identify useful evidence about the health effects of social interventions. The aim of this study was to assess the value of different ways of finding this type of information.
                Retrospective analysis of the sources of studies for one systematic review.
                Case study of a systematic review of the effectiveness of interventions in promoting a population shift from using cars towards walking and cycling.
                Only four of the 69 relevant studies were found in a "first-line" health database such as Medline. About half of all relevant studies were found through the specialist Transport database. Nine relevant studies were found through purposive internet searches and seven relevant studies were found by chance. The unique contribution of experts was not to identify additional studies, but to provide more information about those already found in the literature.
                Most of the evidence needed for this review was not found in studies indexed in familiar literature databases. Applying a sensitive search strategy across multiple databases and interfaces is very labour intensive. Retrospective analysis suggests that a more efficient method might have been to search a few key resources, then to ask authors and experts directly for the most robust reports of studies identified. However, internet publications and serendipitous discoveries did make a significant contribution to the total set of relevant evidence. Undertaking a comprehensive search may provide unique evidence and insights that would not be obtained using a more focused search. This study tests whether a managed behavioral health care organization can influence adherence to practice guidelines for the treatment of major depression in a randomized trial of guideline dissemination. Guidelines were disseminated to mental health clinicians (N = 443) under one of three conditions: (1) a general mailing of guidelines to clinicians, (2) a mailing in which guidelines were targeted to a patient starting treatment with the clinician, and (3) no mailing of guidelines. The results showed no effects of guideline dissemination as measured by self-report of patients and clinicians and through episode characteristics derived from claims data, despite sentinel effects. Results also showed high rates of clinician-reported guideline adherence that were not detected in the claims data, indicating significant undertreatment of depression. Results suggest that mental health systems must look to other dissemination strategies to improve adherence to standards of care and raise the performance of independent practicing clinicians. The study investigated the provision of client-focused services to community-based clients with schizophrenia and bipolar disorder. It hypothesised that the delivery of more client-focused services would improve client outcome in terms of functioning, disability and satisfaction with services. Client-focused services were developed using an empowerment model of case management and by the addition of consumer advocates.
                Clients referred for case management were randomly allocated to one of three groups: standard case management (n = 35), client-focused case management (n = 39), or client-focused case management plus consumer advocacy (n = 45). Measures of functioning, disability, quality of life, burden of care and service satisfaction were measured at baseline and 12 months. Outcome data were collected concerning number and duration of hospital readmission, crisis intervention and compliance with treatment and services.
                While there were no differences between the groups on quantitative measures of functioning, disability, quality of life, service satisfaction and burden of care, there were significant between-group differences on qualitative measures of satisfaction with services.
                Several methodological difficulties hampered interpretation of the findings. Although clients did not differ on outcome measures of functioning and disability, the group receiving client-focused case management reported greater satisfaction with service delivery. The effect of patient care appraisal on physicians' management of patients' problems was assessed. Sixteen family physicians were involved. The eight in the experimental group helped in the selection of two of the five disease conditions to be audited and in the generation of optimal criteria of care for two of the conditions. Participation in the generation of optimal criteria was followed by a significant improvement in the physicians' behaviour, but involvement in the selection of the conditions to be audited caused no change. The patient care appraisal did not lead to significant improvement of physicians' management of the conditions. In a second analysis, in which only essential criteria of care were considered, the physicians who participated in the patient care appraisal significantly improved their management of patients' problems. However, participation in the selection of the conditions and in the generation of the criteria of care had no effect on their performance. Patient care appraisal is an effective tool in continuing medical education and leads to improvement in the quality of care, provided the process focuses on essential criteria of care. The adoption of pay-for-performance mechanisms for quality improvement is growing rapidly. Although there is intense interest in and optimism about pay-for-performance programs, there is little published research on pay-for-performance in health care.
                To evaluate the impact of a prototypical physician pay-for-performance program on quality of care.
                We evaluated a natural experiment with pay-for-performance using administrative reports of physician group quality from a large health plan for an intervention group (California physician groups) and a contemporaneous comparison group (Pacific Northwest physician groups). Quality improvement reports were included from October 2001 through April 2004 issued to approximately 300 large physician organizations.
                Three process measures of clinical quality: cervical cancer screening, mammography, and hemoglobin A1c testing.
                Improvements in clinical quality scores were as follows: for cervical cancer screening, 5.3% for California vs 1.7% for Pacific Northwest; for mammography, 1.9% vs 0.2%; and for hemoglobin A1c, 2.1% vs 2.1%. Compared with physician groups in the Pacific Northwest, the California network demonstrated greater quality improvement after the pay-for-performance intervention only in cervical cancer screening (a 3.6% difference in improvement [P = .02]). In total, the plan awarded 3.4 million dollars (27% of the amount set aside) in bonus payments between July 2003 and April 2004, the first year of the program. For all 3 measures, physician groups with baseline performance at or above the performance threshold for receipt of a bonus improved the least but garnered the largest share of the bonus payments.
                Paying clinicians to reach a common, fixed performance target may produce little gain in quality for the money spent and will largely reward those with higher performance at baseline. To evaluate the effectiveness and efficiency of a search strategy to find evidence-based answers to questions related to the possible occupational etiology of diseases.
                A controlled trial of 70 occupational health physicians and 55 insurance physicians who were asked to answer one out of four 'occupational disease case-vignettes' following the steps of evidence-based medicine (EBM). The intervention group were given the search strategy as a tool.
                The intervention group scored significantly better than the control group in answering the main question of the case-vignette correctly (57% versus 37%) using more adequate search terms. The intervention group scored significantly better regarding satisfaction with the applied search strategy (28% very satisfied versus 8%). We found no differences in time spent in solving the case or in the intention of future practice of EBM.
                The introduction and application of specific search strategies can have a positive effect on the effectiveness of searching literature. Future initiatives for developing and testing specific search strategies in the field of occupational health should be encouraged. An analytical framework is suggested for the economic evaluation of policies to improve the management of hospital infection. Consideration of the costs and benefits to be expected from improved policies implies the existence of an optimal infection rate which is higher than the minimum attainable. It follows that hospitals can and probably do spend too much on infection control in, at least, some areas. This optimal approach is not operational at present but its data requirements might be thought of as an agenda for future research. In the meantime, progress in infection control economics depends on a piecemeal approach. An example is given in the estimation of the cost savings attributable to an improved antibiotic prescribing policy at the Royal Liverpool Hospital. Medical record audits have been used to provide physicians with feedback about their compliance with preventive health and disease management recommendations.
                To determine if report cards summarizing medicine residents' preventive health and disease management practices can be used as a feedback tool to improve practice performance.
                Randomized, blinded, controlled study of 44 internal medicine residents using an individualized 78-item report card based on outpatient record audits.
                Four hundred ninety-seven charts were retrospectively audited at baseline and 284 charts in follow-up. There were no significant differences in baseline performance between the residents in the intervention and control group. There were no differences in performance scores between residents receiving report cards and those who had not in immunizations, counseling, total preventive health, diabetes, hypertension, and total disease management.
                Intensive data-based feedback using report cards may not be a successful way to improve ambulatory performance of medical house officers. We conducted a pilot randomised trial of computerised templates for the management of asthma and diabetes in general practice in six general practices in North London. Uptake of the guidelines by general practitioners and practice nurses was assessed using qualitative (semi-structured interviews designed to assess the users' views) and quantitative (change in use of the template during the study period) outcome measures. The practice nurses used the templates frequently but general practitioners rarely used them. Several reasons were offered for non-use of the templates, such as the length of the template and non-involvement in the care of asthma or diabetes. Despite this, however, health professionals were favourably disposed to the use of templates for general clinical care. Pilot investigations of computerised templates are best achieved by observational or quasi-experimental methods rather than a randomised controlled trial. The use of both qualitative and quantitative methods in this study allowed exploration of the barriers to use of computers. The prevalence of mental health problems, some of which seem to be occurring among younger cohorts, leads researchers and policy-makers to search for practical solutions to reduce the burden of suffering on children and their families, and the costs to society both immediate and long term. Numerous programs are in place to reduce or alleviate problem behaviour or disorders and/or assist positive youth development. Evaluated results are dispersed throughout the literature. To assess findings and determine common elements of effective children's services, a literature search was undertaken for evidence-based evaluations of non-clinical programs for school-age children. Prescriptive comments aim to inform service-providers, policy-makers and families about best practices for effective services such as: early, long-term intervention including reinforcement, follow-up and an ecological focus with family and community sector involvement; consistent adult staffing; and interactive, non-didactic programming adapted to gender, age and cultural needs. Gaps are identified in our understanding of efficiencies that result from effective programs. Policy implications include the need to develop strategies for intersectoral interventions, including: new financing arrangements to encourage (not penalize) interagency cooperation and, to ensure services reach appropriate segments of the population; replication of best practices; and publicizing information about benefits and cost savings. In many jurisdictions legislative changes could create incentives for services to collaborate on service delivery. Joint decision-making would require intersectoral governance, pooling of some funding, and policy changes to retain savings at the local level. Savings could finance expansion of services for additional youth. To explore implications of using systematic drug class reviews to develop U.S. Medicaid drug formularies. We assess racial/ethnic, gender, and socioeconomic status (SES) concordance between Medicaid populations and studies synthesized in Drug Effectiveness Review Project (DERP) systematic reviews.
                Review of 32 DERP systematic reviews for subpopulation reporting/analysis and concordance with Medicaid populations.
                Among Medicaid recipients in DERP member states and nationally, minorities are overrepresented (21% to 57%) compared with their presence in the population (10% to 30%). Fifty-nine percent of DERP reviews reported insufficient evidence to evaluate drug effects by race/ethnicity or gender. Three percent of reviews found evidence of differential effects by race and 13% by gender. Twenty-four percent found evidence of no difference by race and 9% found no difference by gender. Most of this evidence was described as weak, limited, or of poor quality. Eighty percent of Medicaid recipients are poor or near-poor. DERP does not report on SES.
                DERP reviews reveal deficiencies of the evidence when applied to Medicaid populations. To increase health equity and provide evidence for policies that serve socially disadvantaged populations, drug trials, and other studies should include more members of these populations. Systematic reviews should include low-SES as a prespecified subgroup. Health care practitioners and researchers commonly call for greater reliance on evidence as a means to achieve improvement in quality of care. Systematic reviews provide a means to accelerate the use of evidence-based clinical interventions and public health practices. The extent to which these time- and resource-intensive systematic reviews currently address critical maternal health priorities in the intrapartum period is unclear. This analysis summarises key maternal health and research priorities, maps these priorities to existing reviews, identifies gaps in the literature that can be addressed with systematic reviews, and highlights key methodological concerns in conducting systematic reviews. The analysis draws on published data on maternal morbidities and an overview of 108 systematic reviews in Medline in the past 5 years using the MeSH terms 'Delivery, Obstetric,' to draw the links between health priorities, research priorities, existing evidence and missing evidence. Key causes of morbidity during labour and delivery in the United States include haemorrhage, pre-eclampsia and eclampsia, obstetric trauma and infection. Analyses of maternal morbidity and mortality suggest that key concerns include racial and ethnic disparities in health outcomes and the prevention of adverse events. Systematic reviews, however, generally tend to focus on the reduction of harms associated with interventions, are frequently limited to randomised designs, and do not address issues of health disparities. The results suggest that advances in evidence-based care in maternal health require that systematic reviews address issues of prevention of adverse events, include a larger variety of study designs when necessary and pay closer attention to health disparities. To determine if an evidence-based implementation (EBI) could lead to the successful implementation of evidence based care for adult asthma in small rural district hospitals.
                A controlled trial involving eight small rural hospitals (four each in the study and control groups) was conducted. Retrospective pre-intervention audits were conducted at all eight hospitals for 7 months (1 January 2004 to 31 July 2004) and evidence-practice gaps identified. An EBI was then used to implement established guidelines for the management of asthma in the study hospitals. Post-intervention audits were then performed over a period of 7 months (1 October 2004 to 31 April 2005).
                There were 52 presentations of asthma in the study hospitals in the pre-implementation phase and 47 post-implementation. The corresponding numbers for the control hospitals were 46 and 42 respectively. There were no statistically significant differences in the severity between the groups. Following the EBI there were significant improvements at the study hospitals for the documentation of severity (8% to 62%, p <0.001), use of spirometry (12% to 62%, p <0.001) and the use of written short-term asthma plans (9% to 26%, p = 0.05). There was a decrease in use of ipratropium in mild asthma (44% to 30%, p = 0.228), an increase in the use of systemic steroids (61% to 72%, p = 0.255) and no change in prescribing antibiotics for afebrile patients with asthma (21% to 21% p = 0.956). There was no significant change in practice at the control hospitals except for a decrease in the use of systemic steroids (48% to 21%, p = 0.011). For the six clinical indicators aggregate there was a significant increase in compliance with guidelines at the study hospitals (36% to 62%, p < 0.001) but no change at the control hospitals (31% to 31%, p = 0.970).
                The pre-intervention audits demonstrated low levels of compliance with asthma guidelines across six clinical indicators. An EBI significantly improved compliance across these six indicators, and no improvement was noted in the control hospitals. This study demonstrates that an EBI can alter clinical practice in small rural district hospitals. To gauge the effects of operating the Bamako Initiative in Kongoussi district, Burkina Faso.
                Qualitative and quasi-experimental quantitative methodologies were used.
                Following the introduction of fees-for-services in July 1997, the number of consultations for curative care fell over a period of three years by an average of 15.4% at "case" health centres but increased by 30.5% at "control" health centres. Moreover, although the operational results for essential drugs depots were not known, expenditure increased on average 2.7 times more than income and did not keep pace with the decline in the utilization of services. Persons in charge of the management committees had difficulties in releasing funds to ensure access to care for the poor.
                The introduction of fees-for-services had an adverse effect on service utilization. The study district is in a position to bear the financial cost of taking care of the poor and the community is able to identify such people. Incentives must be introduced by the state and be swiftly applied so that the communities agree to a more equitable system and thereby allow access to care for those excluded from services because they are unable to pay.
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 assess and report effects on health equity in systematic reviews.