Controlled Before-after Studies Research Articles

The effect of minimum volume standards in hospitals (MIVOS) — protocol of a systematic review

BackgroundThe volume-outcome relationship, i.e., higher hospital volume results in better health outcomes, has been established for different surgical procedures as well as for certain nonsurgical medical interventions. Accordingly, many countries such as Germany, the USA, Canada, the UK, and Switzerland have established minimum volume standards. To date, there is a lack of systematically summarized evidence regarding the effects of such regulations.MethodsTo be included in the review, studies must measure any effects connected to minimum volume standards. Outcomes of interest include the following: (1) patient-related outcomes, (2) process-related outcomes, and (3) health system-related outcomes. We will include (cluster) randomized controlled trials ([C]RCTs), non-randomized controlled trials (nRCTs), controlled before-after studies (CBAs), and interrupted time-series studies (ITSs). We will apply no restrictions regarding language, publication date, and publication status. We will search MEDLINE (via PubMed), Embase (via Embase), CENTRAL (via Cochrane Library), CINHAL (via EBSCO), EconLit (via EBSCO), PDQ evidence for informed health policymaking, health systems evidence, OpenGrey, and also trial registries for relevant studies. We will further search manually for additional studies by cross-checking the reference lists of all included primary studies as well as cross-checking the reference lists of relevant systematic reviews.To evaluate the risk of bias, we will use the ROBINS-I and RoB 2 risk-of-bias tools for the corresponding study designs. For data synthesis and statistical analyses, we will follow the guidance published by the EPOC Cochrane group (Cochrane Effective Practice and Organisation of Care (EPOC), EPOC Resources for review authors, 2019).DiscussionThis systematic review focuses on minimum volume standards and the outcomes used to measure their effects. It is designed to provide thorough and encompassing evidence-based information on this topic. Thus, it will inform decision-makers and policymakers with respect to the effects of minimum volume standards and inform further studies in regard to research gaps.Systematic review registrationPROSPERO CRD42022318883

Effectiveness of a provider and patient-focused intervention to improve hypertension management and control in the primary health care setting in Cuba: a controlled before-after study

BackgroundImplementation research to improve hypertension control is scarce in Latin America. We assessed the effectiveness of an intervention aimed at primary care practitioners and hypertensive patients in a setting that provides integrated care through an accessible network of family practices.MethodsWe conducted in Cardenas and Santiago, Cuba, a controlled before-after study in 122 family practices, which are staffed with a doctor and a nurse. The intervention comprised a control arm (usual care), an arm with a component targeting providers (hypertension management workshops), and an arm with, on top of the latter, a component targeting patients (hypertension schools). To evaluate the effect, we undertook a baseline survey before the intervention and an endline survey sixteen months after its start. In each survey, we randomly included 1400 hypertensive patients. Controlled hypertension, defined as a mean systolic and diastolic blood pressure below 140 and 90 mmHg, respectively, was the primary endpoint assessed. We performed linear and logistic regression with a Generalized Estimating Equations approach to determine if the proportion of patients with controlled hypertension changed following the intervention.ResultsSeventy-three doctors, including substitutes, and 54 nurses from the 61 intervention family practices attended the provider workshops, and 3308 patients −51.6% of the eligible ones- participated in the hypertension schools. Adherence to anti-hypertensive medication improved from 42% at baseline to 63% at the endline in the intervention arms. Under the provider intervention, the proportion of patients with controlled hypertension increased by 18.9%, from 48.7% at baseline to 67.6% at endline. However, adding the component that targeted hypertensive patients did not augment the effect. Compared to patients in the control arm, the adjusted OR of having controlled hypertension was 2.36 (95% CI, 1.73–3.22) in the provider and 2.00 (95% CI, 1.68–2.37) in the provider plus patient intervention arm.ConclusionsThe intervention’s patient component remains to be fine-tuned. Still, we demonstrate that it is feasible to substantially improve hypertension outcomes by intervention at the primary care level, despite an already relatively high control rate.

Effectiveness of ultraviolet-C disinfection systems for reduction of multi-drug resistant organism infections in healthcare settings: A systematic review and meta-analysis.

This study aimed to summarise the findings of the studies assessing the effectiveness of ultraviolet C (UV-C) room disinfection in reducing the incidence rate of healthcare-associated multi-drug-resistant organism (MDRO) infections. A systematic screening was conducted using PubMed, EMBASE, and Scopus for randomised controlled trials (RCTs), quasi-experimental studies, and before-after studies, which assessed the efficacy of the UV-C disinfectant system in reducing the incidence of MDRO infections. A random-effects model was used for the analysis. Effect sizes were described as incidence rate ratio (IRR) with 95% confidence intervals (CI). Nine studies were included, all of which were conducted in the USA. No statistically significant reduction in Clostridioides difficile (CD) (IRR: 0.90, 95% CI; 0.62-1.32) and vancomycin-resistant enterococcal (VRE) infection rates (IRR 0.72, 95% CI; 0.38-1.37) was observed with the use of UV-C, but the risk of Gram-negative rod infection was reduced (IRR 0.82, 95% CI; 0.68-0.99).

Family-centred interventions for Indigenous early childhood well-being by primary healthcare services.

Family-centred interventions for Indigenous early childhood well-being by primary healthcare services.

A Systematic Review of Antimicrobial Stewardship Interventions to Improve Management of Bacteriuria in Hospitalized Adults.

To determine whether implementation of antimicrobial stewardship (AMS) interventions improve management of bacteriuria in hospitalized adults. EMBASE, MEDLINE, CINAHL, and Clinical Trials Registries via Cochrane CENTRAL were searched from inception through May 2021. Reference lists of included studies were searched, and Scopus was used to retrieve articles that cited included references. Randomized and nonrandomized trials, controlled before-after studies, interrupted time-series studies, and repeated measures studies evaluating AMS interventions for hospitalized adult inpatients with bacteriuria were included. Risk of bias was assessed independently by 3 team members and compared. Results were summarized descriptively. The search yielded 5509 articles, of which 13 met inclusion criteria. Most common interventions included education (N = 8) and audit and feedback (N = 5) alone or in combination with other interventions. Where assessed, resource and antimicrobial use primarily decreased and appropriateness of antimicrobial use improved; however, impact on guideline adherence was variable. All studies were rated as having unclear or serious risk of bias. This review summarizes and assesses the quality of evidence for AMS interventions to improve the management of bacteriuria. Results provide guidance to both AMS teams and researchers aiming to develop and/or evaluate AMS interventions for management of bacteriuria. This review demonstrated benefit of AMS interventions on management of bacteriuria. However, most studies had some risk of bias, and an overall effect across studies is unclear due to heterogeneity in outcome measures.

Impact of conditional cash transfer programmes on antenatal care service uptake in low and middle-income countries: a systematic review

ObjectiveAntenatal care (ANC) is crucial to protecting the health of pregnant women and their unborn children; however, the uptake of ANC among pregnant women in low and middle-income countries (LMICs)...

Effect of COVID-19 vaccines for the treatment of people with post-COVID-19 condition: a rapid review

Background: Vaccination for coronavirus disease 2019 (COVID-19) has demonstrated reduced risk of hospitalisation and death against more recent variants of COVID-19. Some studies suggested improvements in patients with post-COVID-19 condition (PCC) following vaccination. We systematically explored available evidence on the effect of COVID-19 vaccines for the treatment of people with PCC. Methods: We conducted a rapid review of the literature following systematic approaches. We searched Medline (OVID), EMBASE (Elsevier), ClinicalTrials.gov, and the International Clinical Trials Registry Platform (ICTRP) for randomised trials, non-randomised trials, controlled before-after studies, and interrupted time-series studies of the effect of COVID-19 vaccines for treating people with PCC. Two independent review authors screened citations. Two review authors extracted data independently. We had planned to assess the risk of bias and use the GRADE approach (Grading of Recommendations, Assessment, Development, and Evaluation) to assess the certainty of evidence if there were completed studies. Results: We identified two ongoing randomised controlled trials. Both trials examine the effectiveness of therapeutic vaccines on PCC. The anticipated completion date of the CIMAvax-EGFA trial is January 2023, and the completion date of the COVID-19 mRNA vaccine trial is not stated. Conclusions: There is currently an absence of high‐quality evidence evaluating the effectiveness of COVID-19 vaccines for treating people with post-COVID-19 condition. The absence of published studies and only two ongoing trials highlight the need for additional studies on the effectiveness of vaccines for PCC. We recommend that researchers consider PCC as per the definition provided by the World Health Organization and use the available core outcome set for PCC in deciding which outcomes to measure and report in the trials. PROPSERO registration: CRD42022330821 (20/06/2022)

The health system and health impacts of primary healthcare reform in China: A systematic review

Abstract Background China has undergone a comprehensive primary healthcare(PHC) reform since 2009 aiming to deliver accessible, higher-quality, and equitable healthcare. However, there is limited understanding of the effectiveness of this reform. This systematic review synthesizes evidence on health system and health impacts of this reform. Methods We searched 13 international databases and three Chinese databases for quantitative studies assessing the impacts of this reform published between January 2009 and March 2020. We searched for studies in English or Mandarin. Eligible study designs were RCTs, quasi-experimental studies and controlled before-after studies. We included studies that: assessed PHC policies since 2009; had geographical, temporal or population comparators; and assessed any outcome measures of health expenditures, health service utilisation, quality of care or health outcomes. Study quality was assessed using ROBINS-I, and results synthesized narratively. PROSPERO: CRD42021239991. Results Of 35,480 titles, 37 studies were included (27 in English and ten in Mandarin). Eight were considered at low risk of bias. The 37 studies covered all major PHC policies since 2009, but mostly focused on the essential medicine (N = 15) and financing (N = 10). The quantity and quality of studies on service delivery policies(e.g., family physician and essential health services), were low(N = 3,with moderate or serious risk of bias). 17 studies found that the PHC reforms promoted primary care utilisation. Its impacts on quality and health improvement appear limited to people with chronic diseases(N = 11). Evidence on primary care costs and OOPs were not clear. Some evidence showed that the reforms were pro-equity with benefits accrued in disadvantaged regions and groups. Conclusions Comprehensive PHC reforms can deliver some benefits related to utilisation and health for high-risk and vulnerable populations. Policymakers should continue to prioritize PHC to achieve Universal Health Coverage. Key messages • The finding suggests that large-scale and comprehensive primary healthcare reforms can deliver benefits related to utilisation and health for high-risk and vulnerable populations. • Future research should include more robust study designs and seek to better understand the impact of major PHC reforms on quality of care, health outcomes and equity.

Effects of Online Mental Health Classes on Mental Health and Stigma: a Controlled Before-After Study with 1-Month Follow-Up

Though the importance of mental health education has been emphasised, how learning about mental health helps the learners’ mental health remains to be evaluated. Accordingly, this study aimed to appraise the mental health effects of online mental health classes in a controlled before-after study with a 1-month follow-up. The Depression, Anxiety and Stress Scale-21 and Depression Stigma Scale were completed by 16 students in a mental health class and 12 in a non-mental health class. While there was no significant difference in depression, anxiety and stress, between groups (type of class) and within groups (assessment points), the levels of stigma were significantly lower in mental health students than non-mental health students at post-semester (p = .004). Findings illustrate temporal effectiveness of mental health classes on stigma; however, continuous education is needed to maintain the effects. Educators in mental health are recommended to design a long-term plan to support learners’ mental health.

Validation of the Italian version of the Tool to Measure Parenting Self-Efficacy questionnaire using data from an intervention study.

Parent self-efficacy (PSE), parents' confidence in their ability to successfully raise their children, has proved to be a powerful direct predictor of specific positive parenting practices. The aim of this study was to validate the Italian version of the Tool to Measure Parenting Self-Efficacy (TOPSE) using data from the questionnaires previously completed in a controlled before-after study conducted in 2015 to evaluate a newsletter programme to help improve parenting. Mothers and fathers of newborns were asked to complete the TOPSE at the child's birth (t0), at 6 months (t1) and at 12 months (t2): 265 TOPSE questionnaires were collected at t0 (43%), 158 at t1 (26%) and 188 at t2 (31%). We measured internal reliability using Cronbach's alpha for each of the eight domains of the TOPSE. The intracluster correlation coefficient (ICC) was used to evaluate the external reliability only for parents with more than one child. Responsiveness was measured by testing the ability of the questionnaire to detect differences between groups and times that we expected to be measurable, based on consolidated findings in the literature. Mean scores of PSE improved from t0 to t2 (Hypothesis 1), PSE was lower at baseline for first-time parents than for those with multiple children (Hypothesis 2) and the improvement from t0 to t2 was stronger for first-time parents than for parents with multiple children (Hypothesis 3). Based on our sample of questionnaires, the Italian version of the TOPSE was reliable for almost all of the domains except for Emotion, Self-acceptance and Learning, which could be refined by re-framing or dropping one item. External reliability was moderate, bearing in mind that the questionnaire was repeated at different times over 12 months, during which parents normally change. Responsiveness was good, especially for the Emotion and Empathy domains.

Perioperative care bundles for the prevention of surgical-site infections: meta-analysis.

Care bundles are used widely to prevent surgical-site infections (SSIs). Recent systematic reviews suggested larger effects from bundles with more interventions. These reviews were largely based on uncontrolled before-after studies and did not consider their biases. The aim of this meta-analysis was to determine the effectiveness of care bundles to prevent SSIs and explore characteristics of effective care bundles. A systematic review, reanalysis, and meta-analysis of available evidence were undertaken. RCTs, controlled before-after studies, and uncontrolled before-after studies with sufficient data for reanalysis as interrupted time series studies (ITS) were eligible. Studies investigating the use of a care bundle, with at least one intraoperative intervention, compared with standard care were included. Four RCTs, 1 controlled before-after study, and 13 ITS were included. Pooled data from RCTs were heterogeneous. Meta-analysis of ITS resulted in a level change of -1.16 (95 per cent c.i.-1.78 to -0.53), indicating a reduction in SSI. The effect was larger when the care bundle comprised a higher proportion of evidence-based interventions. Meta-regression analyses did not show statistically significant associations between effect estimates and number of interventions, number of evidence-based interventions, or proportion of evidence-based interventions. Meta-analysis of ITS indicated that perioperative care bundles prevent SSI. This effect is inconsistent across RCTs. Larger bundles were not associated with a larger effect, but the effect may be larger if the care bundle contains a high proportion of evidence-based interventions. No strong evidence for characteristics of effective care bundles was identified.

Early spontaneous breathing for acute respiratory distress syndrome in individuals with COVID-19.

Acute respiratory distress syndrome (ARDS) represents the most severe course of COVID-19 (caused by the SARS-CoV-2 virus), usually resulting in a prolonged stay in an intensive care unit (ICU) and high mortality rates. Despite the fact that most affected individuals need invasive mechanical ventilation (IMV), evidence on specific ventilation strategies for ARDS caused by COVID-19 is scarce. Spontaneous breathing during IMV is part of a therapeutic concept comprising light levels of sedation and the avoidance of neuromuscular blocking agents (NMBA). This approach is potentially associated with both advantages (e.g. a preserved diaphragmatic motility and an optimised ventilation-perfusion ratio of the ventilated lung), as well as risks (e.g. a higher rate of ventilator-induced lung injury or a worsening of pulmonary oedema due to increases in transpulmonary pressure). As a consequence, spontaneous breathing in people with COVID-19-ARDS who are receiving IMV is subject to an ongoing debate amongst intensivists. To assess the benefits and harms of early spontaneous breathing activity in invasively ventilated people with COVID-19 with ARDS compared to ventilation strategies that avoid spontaneous breathing. We searched the Cochrane COVID-19 Study Register (which includes CENTRAL, PubMed, Embase, Clinical Trials.gov WHO ICTRP, and medRxiv) and the WHO COVID-19 Global literature on coronavirus disease to identify completed and ongoing studies from their inception to 2 March 2022. Eligible study designs comprised randomised controlled trials (RCTs) that evaluated spontaneous breathing in participants with COVID-19-related ARDS compared to ventilation strategies that avoided spontaneous breathing (e.g. using NMBA or deep sedation levels). Additionally, we considered controlled before-after studies, interrupted time series with comparison group, prospective cohort studies and retrospective cohort studies. For these non-RCT studies, we considered a minimum total number of 50 participants to be compared as necessary for inclusion. Prioritised outcomes were all-cause mortality, clinical improvement or worsening, quality of life, rate of (serious) adverse events and rate of pneumothorax. Additional outcomes were need for tracheostomy, duration of ICU length of stay and duration of hospitalisation. We followed the methods outlined in the Cochrane Handbook for Systematic Reviews of Interventions. Two review authors independently screened all studies at the title/abstract and full-text screening stage. We also planned to conduct data extraction and risk of bias assessment in duplicate. We planned to conduct meta-analysis for each prioritised outcome, as well as subgroup analyses of mortality regarding severity of oxygenation impairment and duration of ARDS. In addition, we planned to perform sensitivity analyses for studies at high risk of bias, studies using NMBA in addition to deep sedation level to avoid spontaneous breathing and a comparison of preprints versus peer-reviewed articles. We planned to assess the certainty of evidence using the GRADE approach. We identified no eligible studies for this review. We found no direct evidence on whether early spontaneous breathing in SARS-CoV-2-induced ARDS is beneficial or detrimental to this particular group of patients. RCTs comparing early spontaneous breathing with ventilatory strategies not allowing for spontaneous breathing in SARS-CoV-2-induced ARDS are necessary to determine its value within the treatment of severely ill people with COVID-19. Additionally, studies should aim to clarify whether treatment effects differ between people with SARS-CoV-2-induced ARDS and people with non-SARS-CoV-2-induced ARDS.

Pharmaceutical policies: effects of regulating drug insurance schemes.

Drug insurance schemes are systems that provide access to medicines on a prepaid basis and could potentially improve access to essential medicines and reduce out-of-pocket payments for vulnerable populations. To assess the effects on drug use, drug expenditure, healthcare utilisation and healthcare outcomes of alternative policies for regulating drug insurance schemes. We searched CENTRAL, MEDLINE, Embase, nine other databases, and two trials registers between November 2014 and September 2020, including a citation search for included studies on 15 September 2021 using Web of Science. We screened reference lists of all the relevant reports that we retrieved and reports from the Background section. Authors of relevant papers, relevant organisations, and discussion lists were contacted to identify additional studies, including unpublished and ongoing studies. We planned to include randomised trials, non-randomised trials, interrupted time-series studies (including controlled ITS [CITS] and repeated measures [RM] studies), and controlled before-after (CBA) studies. Two review authors independently assessed the search results and reference lists of relevant reports, retrieved the full text of potentially relevant references and independently applied the inclusion criteria to those studies. We resolved disagreements by discussion, and when necessary by including a third review author. We excluded studies of the following pharmaceutical policies covered in other Cochrane Reviews: those that determined how decisions were made about which conditions or drugs were covered; those that placed restrictions on reimbursement for drugs that were covered; and those that regulated out-of-pocket payments for drugs. Two review authors independently extracted data from the included studies and assessed risk of bias for each study, with disagreements being resolved by consensus. We used the criteria suggested by Cochrane Effective Practice and Organisation of Care (EPOC) to assess the risk of bias of included studies. For randomised trials, non-randomised trials and controlled before-after studies, we planned to report relative effects. For dichotomous outcomes, we reported the risk ratio (RR) when possible and adjusted for baseline differences in the outcome measures. For interrupted time series and controlled interrupted time-series studies, we computed changes along two dimensions: change in level; and change in slope. We undertook a structured synthesis following the EPOC guidance on this topic, describing the range of effects found in the studies for each category of outcomes. We identified 58 studies that met the inclusion criteria (25 interrupted time-series studies and 33 controlled before-after studies). Most of the studies (54) assessed a single policy implemented in the United States (US) healthcare system: Medicare Part D. The other four assessed other drug insurance schemes from Canada and the US, but only one of them provided analysable data for inclusion in the quantitative synthesis. The introduction of drug insurance schemes may increase prescription drug use (low-certainty evidence). On the other hand, Medicare Part D may decrease drug expenditure measured as both out-of-pocket spending and total drug spending (low-certainty evidence). Regarding healthcare utilisation, drug insurance policies (such as Medicare Part D) may lead to a small increase in visits to the emergency department. However, it is uncertain whether this type of policy increases or decreases hospital admissions or outpatient visits by beneficiaries of the scheme because the certainty of the evidence was very low. Likewise, it is uncertain if the policy increases or reduces health outcomes such as mortality because the certainty of the evidence was very low. The introduction of drug insurance schemes such as Medicare Part D in the US health system may increase prescription drug use and may decrease out-of-pocket payments by the beneficiaries of the scheme and total drug expenditures. It may also lead to a small increase in visits to the emergency department by the beneficiaries of the policy. Its effects on other healthcare utilisation outcomes and on health outcomes are uncertain because of the very low certainty of the evidence. The applicability of this evidence to settings outside US healthcare islimited.

Flooding and emergency department visits: Effect modification by the CDC/ATSDR Social Vulnerability Index

The Centers for Disease Control and Prevention (CDC)/Agency for Toxic Substances and Disease Registry (ATSDR) Social Vulnerability Index (SVI) is a census-based metric that includes 15 socioeconomic and demographic factors split into four themes relevant to disaster planning, response, and recovery. Using CDC/ATSDR SVI, health outcomes, and remote sensing data, we sought to understand the differences in the occurrence of overall and cause-specific emergency department (ED) visits before and after a 2017 flood event in Texas following Hurricane Harvey, modified by different levels of social vulnerability. We used a controlled before-after study design to estimate the association between flooding and overall and cause-specific ED visits after adjusting for the baseline period, seasonal trends, and individual-level characteristics. We estimated rate ratios stratified by CDC/ATSDR SVI quartiles (overall and 4 themes separately) and tested for the presence of effect modification. Positive effect modification was found such that total ED visits from flooded census tracts with moderate, high, and very high levels of social vulnerability were less reduced compared to tracts with the least vulnerability during flooding and the month following the flood event. The CDC/ATSDR SVI socioeconomic status theme, household composition and disability theme, and housing and transportation type theme explained this result. We found predominantly negative effect modification with higher ED visits among tracts with the least vulnerability for ED visits related to insect bites, dehydration, and intestinal infectious diseases.

Fortification of salt with iron and iodine versus fortification of salt with iodine alone for improving iron and iodine status.

Fortification of salt with iron and iodine versus fortification of salt with iodine alone for improving iron and iodine status.

The Impact of School Meal Programs on Educational Outcomes in African Schoolchildren: A Systematic Review.

Malnutrition and hunger can lower a child’s ability to learn effectively. Many countries in Africa experience high rates of childhood undernutrition, and school feeding programs are a common tool used to address this challenge. A systematic review was conducted to evaluate the effect of school-provided meals on educational outcomes in preschool and primary school children. Specific outcomes of interest in this review included test scores, attendance, and enrollment rates. PubMed and Scopus were used for an electronic search of relevant studies. Studies included in this review were randomized and non-randomized controlled trials, prospective cohort studies, controlled before-after studies, and pre/post-test design studies published in the past 10 years in English in sub-Sahara Africa. Findings from the nine studies included in this review suggest a positive correlation between school feeding programs and educational outcomes. Although mealtime may reduce classroom time, the benefits of providing a meal outweigh the potential loss of learning time because hungry children may not learn as effectively. In conclusion, it is recommended that school meal programs be implemented and expanded. To improve general wellbeing and learning capabilities of children, school meals should be employed starting at a young age. More research on school feeding programs is needed concerning the preschool age group (2–5 years), as there is a limited amount of information in this area.

Do recommended interventions widen or narrow inequalities in musculoskeletal health? An equity-focussed systematic review of differential effectiveness.

BackgroundIt is unclear whether seven interventions recommended by Public Health England for preventing and managing common musculoskeletal conditions reduce or widen health inequalities in adults with musculoskeletal conditions.MethodsWe used citation searches of Web of Science (date of ‘parent publication’ for each intervention to April 2021) to identify original research articles reporting subgroup or moderator analyses of intervention effects by social stratifiers defined using the PROGRESS-Plus frameworks. Randomized controlled trials, controlled before-after studies, interrupted time series, systematic reviews presenting subgroup/stratified analyses or meta-regressions, individual participant data meta-analyses and modelling studies were eligible. Two reviewers independently assessed the credibility of effect moderation claims using Instrument to assess the Credibility of Effect Moderation Analyses. A narrative approach to synthesis was used (PROSPERO registration number: CRD42019140018).ResultsOf 1480 potentially relevant studies, seven eligible analyses of single trials and five meta-analyses were included. Among these, we found eight claims of potential differential effectiveness according to social characteristics, but none that were judged to have high credibility.ConclusionsIn the absence of highly credible evidence of differential effectiveness in different social groups, and given ongoing national implementation, equity concerns may be best served by investing in monitoring and action aimed at ensuring fair access to these interventions.

Interventions to reduce pedestrian road traffic injuries: A systematic review of randomized controlled trials, cluster randomized controlled trials, interrupted time-series, and controlled before-after studies.

BackgroundRoad traffic injuries are among the top ten causes of death globally, with the highest burden in low and middle-income countries, where over a third of deaths occur among pedestrians and cyclists. Several interventions to mitigate the burden among pedestrians have been widely implemented, however, the effectiveness has not been systematically examined.ObjectivesTo assess the effectiveness of interventions to reduce road traffic crashes, injuries, hospitalizations and deaths among pedestrians.MethodsWe considered studies that evaluated interventions to reduce road traffic crashes, injuries, hospitalizations and/or deaths among pedestrians. We considered randomized controlled trials, interrupted time-series studies, and controlled before-after studies. We searched MEDLINE, EMBASE, Web of Science, WHO Global Health Index, Health Evidence, Transport Research International Documentation and ClinicalTrials.gov through 31 August 2020, and the reference lists of all included studies. Two reviewers independently screened titles and abstracts and full texts, extracted data and assessed the risk of bias. We summarized findings narratively with text and tables.ResultsA total of 69123 unique records were identified through the searches, with 26 of these meeting our eligibility criteria. All except two of these were conducted in high-income countries and most were from urban settings. The majority of studies observed either a clear effect favoring the intervention or an unclear effect potentially favoring the intervention and these included: changes to the road environment (19/27); changes to legislation and enforcement (12/12); and road user behavior/education combined with either changes to the road environment (3/3) or with legislation and enforcement (1/1). A small number of studies observed either a null effect or an effect favoring the control.ConclusionsAlthough the highest burden of road traffic injuries exists in LMICs, very few studies have examined the effectiveness of available interventions in these settings. Studies indicate that road environment, legislation and enforcement interventions alone produce positive effects on pedestrian safety. In combination with or with road user behavior/education interventions they are particularly effective in improving pedestrian safety.

Can SBAR be implemented with high fidelity and does it improve communication between healthcare workers? A systematic review

ObjectiveTo characterise the extent to which health professionals perform SBAR (situation, background, assessment, recommendation) as intended (ie, with high fidelity) and the extent to which its use improves communication clarity...

Early warning systems and rapid response systems for the prevention of patient deterioration on acute adult hospital wards.

Early warning systems and rapid response systems for the prevention of patient deterioration on acute adult hospital wards.