Journal of Midwifery & Women’s Health
www.jmwh.org
Evidence-Based Practice
Current Resources for Evidence-Based Practice, September/October 2014 Nicole S. Carlson, CNM, MS
THE EVIDENCE ON EVIDENCE-BASED PRACTICE
The phrase evidence-based practice (EBP) is used so frequently in health care that the words have lost their meaning for many clinicians. Often used as a synonym for good, EBP is too frequently used to promote health care that may not include practices based on current evidence. However, as an approach that has been linked in numerous studies to better outcomes of care, EBP is a subject worthy of true understanding. So what is evidence-based practice? Evidence-based practice is defined as the use of “the best evidence to provide the care most appropriate to each patient.”3 The Institute of Medicine (IOM) has set a goal that by the year 2020, 90% of all clinical decisions will be supported by the best available evidence.3 In a traditional model of clinical practice, providers were trained in a standard way to understand and handle clinical situations; then, they spent their careers using these methodologies to care for their many patients. With time and practice, clinicians could look forward to achieving expertise in their speciality areas. With such expertise, they would know how to handle nearly every clinical situation and no longer experience the stress of having to learn new skills or new information. In the age of EBP, health care providers are still trained in the basics of clinical practice, but they are now expected to constantly change their practices and understanding of clinical phenomena in keeping with the newest evidence. Change can be stressful, even when it is understood as necessary for improvement. Some clinicians who embrace changes in EBP experience additional stress when they work within organizations that are resistant to the constant adaptations necessary in an EBP model. Studies point to several key factors necessary for EBP adoption: the strong belief that EBP improves patient outcomes and care, a solid understanding of EBP knowledge and skills, professional involvement with an EBP mentor, and working within an organizational culture that promotes EBP.5,7 Not every health care provider has these key factors in place personally or culturally. This variation in the ability to implement EBP is visible in the vast differences that currently exist in the United States, from community to community and hospital to hospital, related to common outcomes reflecting successful EBP implementation. For example, key perinatal quality indicators highlighted recently by the Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN), such as skin-to-skin contact following birth Published simultaneously in the Journal of Obstetric, Gynecologic, & Neonatal Nursing. 2014.43(5).
1526-9523/09/$36.00 doi:10.1111/jmwh.12239
and breastfeeding support, vary widely in hospitals across the United States.2 In various health care settings, studies found that clinicians are less likely to use EBP when they are more stressed,1 do not feel confident using tools to physically access new evidence,8 or work with other clinicians or administrators who resist EBP changes.6 Many of these barriers to EBP were first identified more than 2 decades ago but to date have not been the focus of widespread efforts to increase the use of EBP. Currently, individuals, organizations, and health care communities must adopt EBP or face increasingly harsh consequences. As quality in perinatal health care becomes more linked to reimbursement via the Affordable Care Act (ACA) and the recommendations of The Joint Commission, EBP is no longer optional. Starting January 1, 2014, The Joint Commission began requiring hospitals with 1,100 births or more per year to use new perinatal quality measures.4 These new perinatal quality measures are linked to outcomes that have been shown to be sensitive to the level of evidence-based care present in an institution, including rates of cesareans and elective births. Section 2701 of the ACA now mandates the use of health care quality measurement for adult beneficiaries of Medicaid.9 Although health care quality measurement for Medicare patients has been enforced by The Joint Commission for many years, efforts to measure the quality of perinatal care were hampered by the state-by-state differences in the administration of Medicaid, the public insurance that is most often used by childbearing women. These changes from the ACA and The Joint Commission will bring the care of women and infants in the United States under the lens of quality measurement at an unprecedented level. Wide variations in the use of EBP in perinatal care will now be revealed for consumers and health care reimbursement entities alike. With the idea that change must start at home, the Journal of Midwifery & Women’s Health and the Journal of Obstetric, Gynecologic, & Neonatal Nursing will continue to offer this column highlighting current resources for evidencebased practice as a joint publication. In the coming year, the column will focus on common barriers to EBP change as identified in the literature, provide guidance for clinicians on accessing the evidence, discuss ways to balance the results of large systematic reviews with the needs of individual women and infants, and offer tips for interpreting the conclusions of scientific studies. In addition, the column will continue to provide lists of current evidence, including featured reviews of studies with particular importance for perinatal and women’s health clinicians.
c 2014 by the American College of Nurse-Midwives
533
1.Aarons GA, Glisson C, Green PD, et al. The organizational social context of mental health services and clinician attitudes toward evidencebased practice: a United States national study. Implement Sci 2012; 7:56. 2.Association of Women’s Health, Obstetric and Neonatal Nurses. Women’s health and perinatal nursing care quality draft measures specifications. AWHONN; Published 2013. Retrieved from https://www.awhonn.org/awhonn/content.do?name=02 PracticeResources/02 perinatalqualitymeasures.htm. Accessed July 1, 2014. 3.Olsen M, Goolsby WA, McGinnis JM. Leadership Committments to Improve Value in Healthcare: Finding Common Ground Workshop Summary. Washington, DC: National Academies Press; 2009. 4.The Joint Commission. Improving performance on perinatal care measures. The Source 2013;11(7):16–19. Retrieved from http://www.jointcommission.org/assets/1/6/S7 TS V11 N7.pdf. Accessed July 1, 2014. 5.Melnyk BM. Building cultures and environments that facilitate clinician behavior change to evidence-based practice: what works? Worldviews Evid Based Nurs. 2014;11(2):79–80. 6.Melnyk BM, Fineout-Overholt E, Gallagher-Ford L, Kaplan L. The state of evidence-based practice in US nurses: critical implications for nurse leaders and educators. J Nurs Adm. 2012;42(9):410–417. 7.Melnyk BM, Fineout-Overholt E, Giggleman M, Cruz R. Correlates among cognitive beliefs, EBP implementation, organizational culture, cohesion and job satisfaction in evidence-based practice mentors from a community hospital system. Nurs Outlook. 2010;58(6):301–308. 8.Pravikoff DS, Tanner AB, Pierce ST. Readiness of U.S. nurses for evidence-based practice. Am J Nurs. 2005;105(9):40–51; quiz 2. 9.Sakala C. U.S. health care reform legislation offers major new gains to childbearing women and newborns. Birth. 2010;37(4):337–340.
New Systematic Reviews in CDSR: Neonatal
r r r r r r
Updated Systematic Reviews in CDSR: Women’s Health
r r
r r
r r r r r r r
Laparoscopic surgery for endometriosis Adjuvant chemotherapy for advanced endometrial cancer Non-steroidal anti-inflammatory agents to induce regression and prevent the progression of cervical intraepithelial neoplasia Effectiveness of different treatment modalities for the management of adult-onset granulosa cell tumours of the ovary (primary and recurrent) Hormonal contraception for women exposed to HIV infection Steroidal contraceptives: effect on carbohydrate metabolism in women without diabetes mellitus Surgical treatment of stage IA2 cervical cancer
r r r r r
Indwelling bladder catheterization as part of intraoperative and postoperative care for cesarean section Planned home versus hospital care for preterm prelabour rupture of membranes (PPROM) prior to 37 weeks’ gestation Prostaglandins for management of retained placenta Magnesium supplementation in pregnancy Techniques of monitoring blood glucose during pregnancy for women with pre-existing diabetes
534
Customized versus population-based growth charts as a screening tool for detecting small for gestational age infants in low-risk pregnancy women Nitric oxide donors for treating preterm labour
Updated Systematic Reviews in CDSR: Neonatal
r r r
Late erythropoietin for preventing red blood cell transfusion in preterm and/or low birth weight infants Early (⬍8 days) postnatal corticosteroids for preventing chronic lung disease in preterm infants Late (⬎7 days) postnatal corticosteroids for chronic lung disease in preterm infants
FROM THE DATABASE OF ABSTRACTS AND REVIEWS OF EFFECTS (DARE) Recent Abstract Entries Assessing Quality of Systematic Reviews: Pregnancy and Birth
r r
New Systematic Reviews in CDSR: Pregnancy and Birth
Laparoscopy for the management of acute lower abdominal pain in women of childbearing age Pelvic floor muscle training versus no treatment, or inactive control treatments, for urinary incontinence in women
Updated Systematic Reviews in CDSR: Pregnancy and Birth
FROM COCHRANE DATABASE OF SYSTEMATIC REVIEWS (CDSR) ISSUES 4 AND 5, 2014 New Systematic Reviews in CDSR: Women’s Health
Oral contraceptives for functional ovarian cysts Probiotics for prevention of necrotizing enterocolitis in preterm infants Kangaroo mother care to reduce morbidity and mortality in low birthweight infants Higher versus lower protein intake in formula-fed low birth weight infants Formula versus donor breast milk for feeding preterm or low birth weight infants Physical activity programs for promoting bone mineralization and growth in preterm infants
r
Effects of exercise on diastasis of the rectus abdominis muscle in the antenatal and postnatal periods: a systematic review Low-dose aspirin for prevention of morbidity and mortality from pre-eclampsia: a systematic evidence review for the U.S Preventive Services Task Force Omission of the bladder flap at caesarean section reduces delivery time without increased morbidity: a meta-analysis of randomised controlled trials
Recent Abstract Entries Assessing Quality of Systematic Reviews: Neonatal
r
Interventions designed to promote exclusive breastfeeding in high-income countries: a systematic review Volume 59, No. 5, September/October 2014
Recent Abstract Entries Assessing Quality of Systematic Reviews: Women’s Health
r
Effect of radiotherapy after mastectomy and axillary surgery on 10-year recurrence and 20-year breast cancer mortality: meta-analysis of individual patient data for 8135 women in 22 randomised trials
Featured Review: Henderson JT, Whitlock EP, O’Connor E, et al. Low-dose aspirin for prevention of morbidity and mortality from pre-eclampsia: A systematic evidence review for the U.S. Preventative Services Task Force. Ann Intern Med. 2014;160:695–703. This systematic review and meta-analysis of the literature was funded by the Agency for Healthcare Research and Quality to update the U.S. Preventative Services Task Force recommendations on the use of low-dose aspirin for the prevention of preeclampsia among women with heightened risk. Predictors of women at high risk for preeclampsia vary from study to study, but the most common predictors include a history of preeclampsia in previous pregnancy, renal disease, autoimmune disease, diabetes, chronic hypertension, antiphospholipid syndrome, and multifetal pregnancy. In addition, women with several moderate risk predictors for preeclampsia might also be designated as high risk. These moderate risk predictors include nulliparity, advanced maternal age (ࣙ40 years), interpregnancy interval greater than 10 years, high body mass index (ࣙ35 kg/m2 ), and family history (mother or sister) of preeclampsia. Several other systematic reviews have found aspirin to be beneficial for the reduction of preeclampsia among women identified as high risk. However, this review also evaluated the use of aspirin for the prevention of other poor perinatal health outcomes and for harms to the woman or neonate following use in pregnancy. Following a broad search of the literature published from 2006 to 2013, authors of this review independently selected studies to be included and evaluated the quality of all included studies. All studies chosen for this review were scored as fair or good quality. In the primary analysis of this review, benefits of low-dose aspirin use during pregnancy among women at high risk for preeclampsia was evaluated from 2 large randomized controlled trials (RCTs) and 13 smaller RCTs. In the secondary analysis, 6 RCTs and 2 large cohort studies were chosen to estimate harms to women at any risk level who took aspirin during pregnancy. Daily use of aspirin starting after the first trimester at doses ranging between 60 and 100 mg was associated with a risk reduction of 14% for preterm birth before 37 weeks’ gestation (relative risk [RR], 0.86; 95% confidence interval [CI], 0.76–0.98) for 11,779 women at high risk of preeclampsia in 10 trials included in the primary meta-analysis of this study. Meta-analysis of 13 trials (N = 12,504 women) revealed a 20% reduction in intrauterine growth restriction (IUGR) (RR, 0.80; 95% CI, 0.65–0.99) with aspirin use during pregnancy by women at high risk for preeclampsia. This meta-analysis also showed a 24% reduction in preeclampsia with aspirin treatment (RR, 0.76; 95% CI, 0.62–0.95). Although aspirin dosages greater than 75 mg per day were associated with greater risk reduction compared to aspirin dosages less than 75 mg per day, authors of this review were unable to make conclusions about dosage effects because there were not adequate sample Journal of Midwifery & Women’s Health r www.jmwh.org
sizes of women taking higher dosages of aspirin among the included studies. The authors found no evidence of perinatal harm from low-dose aspirin use during pregnancy by women at high or average risk for preeclampsia. Perinatal harms assessed included placental abruption, postpartum hemorrhage, and intracranial hemorrhage in neonates. They also noted that in the one trial of longer-term developmental outcomes of infants born to women receiving aspirin during pregnancy, no treatment differences were observed. Comment: This meta-analysis and systematic review has findings consistent with results from a recent Cochrane review and the Perinatal Antiplatelet Review of International Trials (PARIS) Collaboration individual participant data meta-analysis. In all of these studies, prophylactic, lowdose aspirin use during the final 2 trimesters of pregnancy was found to be associated with a reduced risk for preeclampsia, IUGR, preterm birth, and perinatal mortality among women at high risk for preeclampsia. Although this meta-analysis reflects only modest effect sizes, the perinatal outcomes reduced with low-dose aspirin use are associated with multiple downstream harms to both mothers and infants. The authors also found no evidence of perinatal harm from low-dose aspirin use in pregnancy, although even the large numbers of women included in this study are too small to reliably evaluate the risk of rare maternal mortality and morbidity outcomes with aspirin use during pregnancy. Although African American women in the United States are most likely to experience preeclampsia, they are not well represented in this or other systematic reviews on preeclampsia. Therefore, future research including this important subpopulation is needed. Featured Review: Grimes DA, Jones LB, Lopez LM, Schulz KF. Oral contraceptives for functional ovarian cysts. Cochrane Database of Systematic Reviews. 2014;(4)CD006134. Functional ovarian cysts occur commonly in many women of reproductive age, and more than 250,000 US women per year are hospitalized as a result of functional ovarian cysts, including follicular and corpus luteum cysts. Although functional ovarian cysts will often resolve spontaneously, they can cause severe discomfort. Treatment for functional ovarian cysts commonly includes surgical intervention and/or combined oral contraceptives (COCs). COCs were first used to treat follicular ovarian cysts in the 1970s based on the results of an uncontrolled case series report of 286 women with adnexal masses, in which the authors concluded that COCs resulted in a more rapid shrinkage of functional ovarian cysts. COCs are known to have a strong protectant effect against the formation of functional ovarian cysts. However, the use of COCs to treat pre-existing functional ovarian cysts was the basis of this updated Cochrane review. This systematic review and meta-analysis included 8 RCTs with a total of 686 women. Included studies were evaluated for methodological quality and chosen based on a search performed in March 2014 of all trials that focused on COCs as treatment for ovarian cysts. Data from included RCTs were abstracted and used to calculate odds ratios or mean 535
differences with 95% CIs. Studies included in this metaanalysis were assessed to have some quality limitations involving nonrandom methods of sequence allocation, inadequate allocation concealment, and small sample sizes. Only studies in which the authors used the same COCs (exposure) and outcomes were aggregated for this meta-analysis. Use of COCs was evaluated as treatment for ovarian cysts arising spontaneously and arising following the use of fertility drugs during ovulation induction. Overall, COC use was not found to hasten the resolution of functional ovarian cysts. Early studies leading to the clinical impression that COC could be used to treat functional ovarian cysts were flawed by lack of contemporaneous control groups. This meta-analysis revealed no difference in control versus COC treatment groups for the resolution of functional ovarian cysts. Most of these cysts resolved spontaneously. Those cysts that did not resolve within several months were unlikely to be functional cysts and therefore required surgical evaluation. Comment: The authors of this meta-analysis found that COCs are not effective in the treatment of functional ovarian cysts. Although COCs might be used to suppress the formation of functional ovarian cysts in women with this history, they should not be used to shrink existing cysts. Adnexal masses thought to be functional ovarian cysts might be followed with watchful waiting for 2 to 3 menstrual cycles. If ovarian cysts persist beyond this time period or are large or painful, surgical management is recommended. EVIDENCE-BASED REVIEWS FROM OTHER SOURCES
r
r r r
r
r
r
r r
Recent Evidence-Based Reviews: Women’s Health
r r
r r r
r r r
Albuquerque RC, Baltar VT, Marchioni DM. Breast cancer and dietary patterns: A systematic review. Nutr Rev. 2014;72(1):1–17. Anthoulakis C, Nikoloudis N. Pelvic MRI as the “gold standard” in the subsequent evaluation of ultrasoundindeterminate adnexal lesions: a systematic review. Gynecol Oncol. 2014;132(3):661–8. Brandao T, Schulz MS, Matos PM. Psychological intervention with couples coping with breast cancer: a systematic review. Psychol Health. 2014;29(5):491–516. Harris HR, Orsini N, Wolk A. Vitamin C and survival among women with breast cancer: a meta-analysis. Eur J Cancer. 2014;50(7):1223–31. Kleppe M, Amkreutz LC, Van Gorp T, et al. Lymph-node metastasis in stage I and II sex cord stromal and malignant germ cell tumours of the ovary: a systematic review. Gynecol Oncol. 2014;133(1):124–7. Li S, Xu H, Li SC, Qi XQ, Sun WJ. Vitamin D receptor rs2228570 polymorphism and susceptibly to ovarian cancer: A meta-analysis. Tumour Biol. 2014;35(2):1319–22. Mei J, Duan HX, Wang LL, et al. XRCC1 polymorphisms and cervical cancer risk: An updated meta-analysis. Tumour Biol. 2014;35(2):1221–31. Mohr SB, Gorham ED, Kim J, Hofflich H, Garland CF. Meta-analysis of vitamin D sufficiency for improving survival of patients with breast cancer. Anticancer Res. 2014;34(3):1163–6.
536
r
Nagata C, Mizoue T, Tanaka K, et al. Soy intake and breast cancer risk: an evaluation based on a systematic review of epidemiologic evidence among the Japanese population. Jpn J Clin Oncol. 2014;44(3):282–95. Pace LE, Keating NL. A systematic assessment of benefits and risks to guide breast cancer screening decisions. JAMA. 2014;311(13):1327–35. Reidy M, Denieffe S. Breast cancer in younger women from diverse cultural backgrounds. Br J Nurs. 2014;23(4):S19– 22. Robbins CL, Hutchings Y, Dietz PM, Kuklina EV, Callaghan WM. History of preterm birth and subsequent cardiovascular disease: A systematic review. Am J Obstet Gynecol. 2014;210(4):285–97. Rositch AF, Soeters HM, Offutt-Powell TN, et al. The incidence of human papillomavirus infection following treatment for cervical neoplasia: a systematic review. Gynecol Oncol. 2014;132(3):767–79. Tiernan JP, Verghese ET, Nair A, et al. Systematic review and meta-analysis of cytokeratin 19-based one-step nucleic acid amplification versus histopathology for sentinel lymph node assessment in breast cancer. Br J Surg. 2014;101(4):298–306. van der Ploeg JM, van der Steen A, Oude Rengerink K, van der Vaart CH, Roovers JP. Prolapse surgery with or without stress incontinence surgery for pelvic organ prolapse: a systematic review and meta-analysis of randomised trials. BJOG. 2014;121(5):537–47. Xu HB, Yang H, Liu T, Chen H. Association of CTLA4 gene polymorphism (rs5742909) with cervical cancer: a metaanalysis. Tumour Biol. 2014;35(2):1605–8. Yoo GJ, Levine EG, Pasick R. Breast cancer and coping among women of color: a systematic review of the literature. Support Care Cancer. 2014;22(3):811–24. Zakher B, Blazina I, Chou R. Association between knowledge of HIV-positive status or use of antiretroviral therapy and high-risk transmission behaviors: Systematic review. AIDS Care. 2014;26(4):514–21.
Recent Evidence-Based Reviews: Pregnancy & Birth
r r
r
r
r
Laopaiboon M, Lumbiganon P, Intarut N, et al. Advanced maternal age and pregnancy outcomes: a multicountry assessment. BJOG. 2014;121(Suppl 1):49–56. Leventakou V, Roumeliotaki T, Martinez D, et al. Fish intake during pregnancy, fetal growth, and gestational length in 19 European birth cohort studies. Am J Clin Nutr. 2014;99(3):506–16. Morisaki N, Togoobaatar G, Vogel JP, et al. Risk factors for spontaneous and provider-initiated preterm delivery in high and low Human Development Index countries: a secondary analysis of the World Health Organization Multicountry Survey on Maternal and Newborn Health. BJOG. 2014;121(Suppl 1):101–9. Pineles BL, Park E, Samet JM. Systematic review and meta-analysis of miscarriage and maternal exposure to tobacco smoke during pregnancy. Am J Epidemiol. 2014;179(7):807–23. Rodger MA, Carrier M, Le Gal G, et al. Meta-analysis of low-molecular-weight heparin to prevent recurrent Volume 59, No. 5, September/October 2014
r
r
r
placenta-mediated pregnancy complications. Blood. 2014;123(6):822–8. Sheldon WR, Blum J, Vogel JP, et al. Postpartum haemorrhage management, risks, and maternal outcomes: findings from the World Health Organization Multicountry Survey on Maternal and Newborn Health. BJOG. 2014;121(Suppl 1):5–13. Tolcher MC, Johnson RL, El-Nashar SA, West CP. Decision-to-incision time and neonatal outcomes: a systematic review and meta-analysis. Obstet Gynecol. 2014;123(3):536–48. Vogel JP, Souza JP, Mori R, et al. Maternal complications and perinatal mortality: findings of the World Health Organization Multicountry Survey on Maternal and Newborn Health. BJOG. 2014;121(Suppl 1):76–88.
Recent Evidence-Based Reviews: Neonatal
r r
r
Been JV, Nurmatov UB, Cox B, et al. Effect of smoke-free legislation on perinatal and child health: A systematic review and meta-analysis. Lancet. 2014;383(9928):1549–60. Giaccone A, Jensen E, Davis P, Schmidt B. Definitions of extubation success in very premature infants: A systematic review. Archives of Disease in Childhood Fetal & Neonatal Edition. 2014;99(2):F124–7. Gruzieva O, Gehring U, Aalberse R, et al. Meta-analysis of air pollution exposure association with allergic sensitization in European birth cohorts. J Allergy Clin Immunol. 2014;133(3):767–76.e7.
Journal of Midwifery & Women’s Health r www.jmwh.org
r
r r
r
r r
Malin GL, Morris RK, Riley R, Teune MJ, Khan KS. When is birthweight at term abnormally low? A systematic review and meta-analysis of the association and predictive ability of current birthweight standards for neonatal outcomes. BJOG. 2014;121(5):515–26. Parker RI. Transfusion in critically ill children: indications, risks, and challenges. Crit Care Med. 2014;42(3):675–90. Peng W, Zhu H, Shi H, Liu E. Volume-targeted ventilation is more suitable than pressure-limited ventilation for preterm infants: A systematic review and meta-analysis. Archives of Disease in Childhood Fetal & Neonatal Edition. 2014;99(2):F158–65. Steiner MB, Tang X, Gossett JM, Malik S, Prodhan P. Timing of complete repair of non-ductal-dependent tetralogy of Fallot and short-term postoperative outcomes, a multicenter analysis. J Thorac Cardiovasc Surg. 2014;147(4):1299–305. Tinnion R, Gillone J, Cheetham T, Embleton N. Preterm birth and subsequent insulin sensitivity: a systematic review. Arch Dis Child. 2014;99(4):362–8. Xu H, Zeng T, Liu JY, et al. Measures to reduce mother-tochild transmission of Hepatitis B virus in China: a metaanalysis. Dig Dis Sci. 2014;59(2):242–58.
AUTHOR
Nicole S. Carlson, CNM, MS, is a doctoral student in the University of Colorado Denver’s College of Nursing and is President of the Georgia Affiliate of ACNM.
537
www.jmwh.org
Evidence-Based Practice
Current Resources for Evidence-Based Practice, September/October 2014 Nicole S. Carlson, CNM, MS
THE EVIDENCE ON EVIDENCE-BASED PRACTICE
The phrase evidence-based practice (EBP) is used so frequently in health care that the words have lost their meaning for many clinicians. Often used as a synonym for good, EBP is too frequently used to promote health care that may not include practices based on current evidence. However, as an approach that has been linked in numerous studies to better outcomes of care, EBP is a subject worthy of true understanding. So what is evidence-based practice? Evidence-based practice is defined as the use of “the best evidence to provide the care most appropriate to each patient.”3 The Institute of Medicine (IOM) has set a goal that by the year 2020, 90% of all clinical decisions will be supported by the best available evidence.3 In a traditional model of clinical practice, providers were trained in a standard way to understand and handle clinical situations; then, they spent their careers using these methodologies to care for their many patients. With time and practice, clinicians could look forward to achieving expertise in their speciality areas. With such expertise, they would know how to handle nearly every clinical situation and no longer experience the stress of having to learn new skills or new information. In the age of EBP, health care providers are still trained in the basics of clinical practice, but they are now expected to constantly change their practices and understanding of clinical phenomena in keeping with the newest evidence. Change can be stressful, even when it is understood as necessary for improvement. Some clinicians who embrace changes in EBP experience additional stress when they work within organizations that are resistant to the constant adaptations necessary in an EBP model. Studies point to several key factors necessary for EBP adoption: the strong belief that EBP improves patient outcomes and care, a solid understanding of EBP knowledge and skills, professional involvement with an EBP mentor, and working within an organizational culture that promotes EBP.5,7 Not every health care provider has these key factors in place personally or culturally. This variation in the ability to implement EBP is visible in the vast differences that currently exist in the United States, from community to community and hospital to hospital, related to common outcomes reflecting successful EBP implementation. For example, key perinatal quality indicators highlighted recently by the Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN), such as skin-to-skin contact following birth Published simultaneously in the Journal of Obstetric, Gynecologic, & Neonatal Nursing. 2014.43(5).
1526-9523/09/$36.00 doi:10.1111/jmwh.12239
and breastfeeding support, vary widely in hospitals across the United States.2 In various health care settings, studies found that clinicians are less likely to use EBP when they are more stressed,1 do not feel confident using tools to physically access new evidence,8 or work with other clinicians or administrators who resist EBP changes.6 Many of these barriers to EBP were first identified more than 2 decades ago but to date have not been the focus of widespread efforts to increase the use of EBP. Currently, individuals, organizations, and health care communities must adopt EBP or face increasingly harsh consequences. As quality in perinatal health care becomes more linked to reimbursement via the Affordable Care Act (ACA) and the recommendations of The Joint Commission, EBP is no longer optional. Starting January 1, 2014, The Joint Commission began requiring hospitals with 1,100 births or more per year to use new perinatal quality measures.4 These new perinatal quality measures are linked to outcomes that have been shown to be sensitive to the level of evidence-based care present in an institution, including rates of cesareans and elective births. Section 2701 of the ACA now mandates the use of health care quality measurement for adult beneficiaries of Medicaid.9 Although health care quality measurement for Medicare patients has been enforced by The Joint Commission for many years, efforts to measure the quality of perinatal care were hampered by the state-by-state differences in the administration of Medicaid, the public insurance that is most often used by childbearing women. These changes from the ACA and The Joint Commission will bring the care of women and infants in the United States under the lens of quality measurement at an unprecedented level. Wide variations in the use of EBP in perinatal care will now be revealed for consumers and health care reimbursement entities alike. With the idea that change must start at home, the Journal of Midwifery & Women’s Health and the Journal of Obstetric, Gynecologic, & Neonatal Nursing will continue to offer this column highlighting current resources for evidencebased practice as a joint publication. In the coming year, the column will focus on common barriers to EBP change as identified in the literature, provide guidance for clinicians on accessing the evidence, discuss ways to balance the results of large systematic reviews with the needs of individual women and infants, and offer tips for interpreting the conclusions of scientific studies. In addition, the column will continue to provide lists of current evidence, including featured reviews of studies with particular importance for perinatal and women’s health clinicians.
c 2014 by the American College of Nurse-Midwives
533
1.Aarons GA, Glisson C, Green PD, et al. The organizational social context of mental health services and clinician attitudes toward evidencebased practice: a United States national study. Implement Sci 2012; 7:56. 2.Association of Women’s Health, Obstetric and Neonatal Nurses. Women’s health and perinatal nursing care quality draft measures specifications. AWHONN; Published 2013. Retrieved from https://www.awhonn.org/awhonn/content.do?name=02 PracticeResources/02 perinatalqualitymeasures.htm. Accessed July 1, 2014. 3.Olsen M, Goolsby WA, McGinnis JM. Leadership Committments to Improve Value in Healthcare: Finding Common Ground Workshop Summary. Washington, DC: National Academies Press; 2009. 4.The Joint Commission. Improving performance on perinatal care measures. The Source 2013;11(7):16–19. Retrieved from http://www.jointcommission.org/assets/1/6/S7 TS V11 N7.pdf. Accessed July 1, 2014. 5.Melnyk BM. Building cultures and environments that facilitate clinician behavior change to evidence-based practice: what works? Worldviews Evid Based Nurs. 2014;11(2):79–80. 6.Melnyk BM, Fineout-Overholt E, Gallagher-Ford L, Kaplan L. The state of evidence-based practice in US nurses: critical implications for nurse leaders and educators. J Nurs Adm. 2012;42(9):410–417. 7.Melnyk BM, Fineout-Overholt E, Giggleman M, Cruz R. Correlates among cognitive beliefs, EBP implementation, organizational culture, cohesion and job satisfaction in evidence-based practice mentors from a community hospital system. Nurs Outlook. 2010;58(6):301–308. 8.Pravikoff DS, Tanner AB, Pierce ST. Readiness of U.S. nurses for evidence-based practice. Am J Nurs. 2005;105(9):40–51; quiz 2. 9.Sakala C. U.S. health care reform legislation offers major new gains to childbearing women and newborns. Birth. 2010;37(4):337–340.
New Systematic Reviews in CDSR: Neonatal
r r r r r r
Updated Systematic Reviews in CDSR: Women’s Health
r r
r r
r r r r r r r
Laparoscopic surgery for endometriosis Adjuvant chemotherapy for advanced endometrial cancer Non-steroidal anti-inflammatory agents to induce regression and prevent the progression of cervical intraepithelial neoplasia Effectiveness of different treatment modalities for the management of adult-onset granulosa cell tumours of the ovary (primary and recurrent) Hormonal contraception for women exposed to HIV infection Steroidal contraceptives: effect on carbohydrate metabolism in women without diabetes mellitus Surgical treatment of stage IA2 cervical cancer
r r r r r
Indwelling bladder catheterization as part of intraoperative and postoperative care for cesarean section Planned home versus hospital care for preterm prelabour rupture of membranes (PPROM) prior to 37 weeks’ gestation Prostaglandins for management of retained placenta Magnesium supplementation in pregnancy Techniques of monitoring blood glucose during pregnancy for women with pre-existing diabetes
534
Customized versus population-based growth charts as a screening tool for detecting small for gestational age infants in low-risk pregnancy women Nitric oxide donors for treating preterm labour
Updated Systematic Reviews in CDSR: Neonatal
r r r
Late erythropoietin for preventing red blood cell transfusion in preterm and/or low birth weight infants Early (⬍8 days) postnatal corticosteroids for preventing chronic lung disease in preterm infants Late (⬎7 days) postnatal corticosteroids for chronic lung disease in preterm infants
FROM THE DATABASE OF ABSTRACTS AND REVIEWS OF EFFECTS (DARE) Recent Abstract Entries Assessing Quality of Systematic Reviews: Pregnancy and Birth
r r
New Systematic Reviews in CDSR: Pregnancy and Birth
Laparoscopy for the management of acute lower abdominal pain in women of childbearing age Pelvic floor muscle training versus no treatment, or inactive control treatments, for urinary incontinence in women
Updated Systematic Reviews in CDSR: Pregnancy and Birth
FROM COCHRANE DATABASE OF SYSTEMATIC REVIEWS (CDSR) ISSUES 4 AND 5, 2014 New Systematic Reviews in CDSR: Women’s Health
Oral contraceptives for functional ovarian cysts Probiotics for prevention of necrotizing enterocolitis in preterm infants Kangaroo mother care to reduce morbidity and mortality in low birthweight infants Higher versus lower protein intake in formula-fed low birth weight infants Formula versus donor breast milk for feeding preterm or low birth weight infants Physical activity programs for promoting bone mineralization and growth in preterm infants
r
Effects of exercise on diastasis of the rectus abdominis muscle in the antenatal and postnatal periods: a systematic review Low-dose aspirin for prevention of morbidity and mortality from pre-eclampsia: a systematic evidence review for the U.S Preventive Services Task Force Omission of the bladder flap at caesarean section reduces delivery time without increased morbidity: a meta-analysis of randomised controlled trials
Recent Abstract Entries Assessing Quality of Systematic Reviews: Neonatal
r
Interventions designed to promote exclusive breastfeeding in high-income countries: a systematic review Volume 59, No. 5, September/October 2014
Recent Abstract Entries Assessing Quality of Systematic Reviews: Women’s Health
r
Effect of radiotherapy after mastectomy and axillary surgery on 10-year recurrence and 20-year breast cancer mortality: meta-analysis of individual patient data for 8135 women in 22 randomised trials
Featured Review: Henderson JT, Whitlock EP, O’Connor E, et al. Low-dose aspirin for prevention of morbidity and mortality from pre-eclampsia: A systematic evidence review for the U.S. Preventative Services Task Force. Ann Intern Med. 2014;160:695–703. This systematic review and meta-analysis of the literature was funded by the Agency for Healthcare Research and Quality to update the U.S. Preventative Services Task Force recommendations on the use of low-dose aspirin for the prevention of preeclampsia among women with heightened risk. Predictors of women at high risk for preeclampsia vary from study to study, but the most common predictors include a history of preeclampsia in previous pregnancy, renal disease, autoimmune disease, diabetes, chronic hypertension, antiphospholipid syndrome, and multifetal pregnancy. In addition, women with several moderate risk predictors for preeclampsia might also be designated as high risk. These moderate risk predictors include nulliparity, advanced maternal age (ࣙ40 years), interpregnancy interval greater than 10 years, high body mass index (ࣙ35 kg/m2 ), and family history (mother or sister) of preeclampsia. Several other systematic reviews have found aspirin to be beneficial for the reduction of preeclampsia among women identified as high risk. However, this review also evaluated the use of aspirin for the prevention of other poor perinatal health outcomes and for harms to the woman or neonate following use in pregnancy. Following a broad search of the literature published from 2006 to 2013, authors of this review independently selected studies to be included and evaluated the quality of all included studies. All studies chosen for this review were scored as fair or good quality. In the primary analysis of this review, benefits of low-dose aspirin use during pregnancy among women at high risk for preeclampsia was evaluated from 2 large randomized controlled trials (RCTs) and 13 smaller RCTs. In the secondary analysis, 6 RCTs and 2 large cohort studies were chosen to estimate harms to women at any risk level who took aspirin during pregnancy. Daily use of aspirin starting after the first trimester at doses ranging between 60 and 100 mg was associated with a risk reduction of 14% for preterm birth before 37 weeks’ gestation (relative risk [RR], 0.86; 95% confidence interval [CI], 0.76–0.98) for 11,779 women at high risk of preeclampsia in 10 trials included in the primary meta-analysis of this study. Meta-analysis of 13 trials (N = 12,504 women) revealed a 20% reduction in intrauterine growth restriction (IUGR) (RR, 0.80; 95% CI, 0.65–0.99) with aspirin use during pregnancy by women at high risk for preeclampsia. This meta-analysis also showed a 24% reduction in preeclampsia with aspirin treatment (RR, 0.76; 95% CI, 0.62–0.95). Although aspirin dosages greater than 75 mg per day were associated with greater risk reduction compared to aspirin dosages less than 75 mg per day, authors of this review were unable to make conclusions about dosage effects because there were not adequate sample Journal of Midwifery & Women’s Health r www.jmwh.org
sizes of women taking higher dosages of aspirin among the included studies. The authors found no evidence of perinatal harm from low-dose aspirin use during pregnancy by women at high or average risk for preeclampsia. Perinatal harms assessed included placental abruption, postpartum hemorrhage, and intracranial hemorrhage in neonates. They also noted that in the one trial of longer-term developmental outcomes of infants born to women receiving aspirin during pregnancy, no treatment differences were observed. Comment: This meta-analysis and systematic review has findings consistent with results from a recent Cochrane review and the Perinatal Antiplatelet Review of International Trials (PARIS) Collaboration individual participant data meta-analysis. In all of these studies, prophylactic, lowdose aspirin use during the final 2 trimesters of pregnancy was found to be associated with a reduced risk for preeclampsia, IUGR, preterm birth, and perinatal mortality among women at high risk for preeclampsia. Although this meta-analysis reflects only modest effect sizes, the perinatal outcomes reduced with low-dose aspirin use are associated with multiple downstream harms to both mothers and infants. The authors also found no evidence of perinatal harm from low-dose aspirin use in pregnancy, although even the large numbers of women included in this study are too small to reliably evaluate the risk of rare maternal mortality and morbidity outcomes with aspirin use during pregnancy. Although African American women in the United States are most likely to experience preeclampsia, they are not well represented in this or other systematic reviews on preeclampsia. Therefore, future research including this important subpopulation is needed. Featured Review: Grimes DA, Jones LB, Lopez LM, Schulz KF. Oral contraceptives for functional ovarian cysts. Cochrane Database of Systematic Reviews. 2014;(4)CD006134. Functional ovarian cysts occur commonly in many women of reproductive age, and more than 250,000 US women per year are hospitalized as a result of functional ovarian cysts, including follicular and corpus luteum cysts. Although functional ovarian cysts will often resolve spontaneously, they can cause severe discomfort. Treatment for functional ovarian cysts commonly includes surgical intervention and/or combined oral contraceptives (COCs). COCs were first used to treat follicular ovarian cysts in the 1970s based on the results of an uncontrolled case series report of 286 women with adnexal masses, in which the authors concluded that COCs resulted in a more rapid shrinkage of functional ovarian cysts. COCs are known to have a strong protectant effect against the formation of functional ovarian cysts. However, the use of COCs to treat pre-existing functional ovarian cysts was the basis of this updated Cochrane review. This systematic review and meta-analysis included 8 RCTs with a total of 686 women. Included studies were evaluated for methodological quality and chosen based on a search performed in March 2014 of all trials that focused on COCs as treatment for ovarian cysts. Data from included RCTs were abstracted and used to calculate odds ratios or mean 535
differences with 95% CIs. Studies included in this metaanalysis were assessed to have some quality limitations involving nonrandom methods of sequence allocation, inadequate allocation concealment, and small sample sizes. Only studies in which the authors used the same COCs (exposure) and outcomes were aggregated for this meta-analysis. Use of COCs was evaluated as treatment for ovarian cysts arising spontaneously and arising following the use of fertility drugs during ovulation induction. Overall, COC use was not found to hasten the resolution of functional ovarian cysts. Early studies leading to the clinical impression that COC could be used to treat functional ovarian cysts were flawed by lack of contemporaneous control groups. This meta-analysis revealed no difference in control versus COC treatment groups for the resolution of functional ovarian cysts. Most of these cysts resolved spontaneously. Those cysts that did not resolve within several months were unlikely to be functional cysts and therefore required surgical evaluation. Comment: The authors of this meta-analysis found that COCs are not effective in the treatment of functional ovarian cysts. Although COCs might be used to suppress the formation of functional ovarian cysts in women with this history, they should not be used to shrink existing cysts. Adnexal masses thought to be functional ovarian cysts might be followed with watchful waiting for 2 to 3 menstrual cycles. If ovarian cysts persist beyond this time period or are large or painful, surgical management is recommended. EVIDENCE-BASED REVIEWS FROM OTHER SOURCES
r
r r r
r
r
r
r r
Recent Evidence-Based Reviews: Women’s Health
r r
r r r
r r r
Albuquerque RC, Baltar VT, Marchioni DM. Breast cancer and dietary patterns: A systematic review. Nutr Rev. 2014;72(1):1–17. Anthoulakis C, Nikoloudis N. Pelvic MRI as the “gold standard” in the subsequent evaluation of ultrasoundindeterminate adnexal lesions: a systematic review. Gynecol Oncol. 2014;132(3):661–8. Brandao T, Schulz MS, Matos PM. Psychological intervention with couples coping with breast cancer: a systematic review. Psychol Health. 2014;29(5):491–516. Harris HR, Orsini N, Wolk A. Vitamin C and survival among women with breast cancer: a meta-analysis. Eur J Cancer. 2014;50(7):1223–31. Kleppe M, Amkreutz LC, Van Gorp T, et al. Lymph-node metastasis in stage I and II sex cord stromal and malignant germ cell tumours of the ovary: a systematic review. Gynecol Oncol. 2014;133(1):124–7. Li S, Xu H, Li SC, Qi XQ, Sun WJ. Vitamin D receptor rs2228570 polymorphism and susceptibly to ovarian cancer: A meta-analysis. Tumour Biol. 2014;35(2):1319–22. Mei J, Duan HX, Wang LL, et al. XRCC1 polymorphisms and cervical cancer risk: An updated meta-analysis. Tumour Biol. 2014;35(2):1221–31. Mohr SB, Gorham ED, Kim J, Hofflich H, Garland CF. Meta-analysis of vitamin D sufficiency for improving survival of patients with breast cancer. Anticancer Res. 2014;34(3):1163–6.
536
r
Nagata C, Mizoue T, Tanaka K, et al. Soy intake and breast cancer risk: an evaluation based on a systematic review of epidemiologic evidence among the Japanese population. Jpn J Clin Oncol. 2014;44(3):282–95. Pace LE, Keating NL. A systematic assessment of benefits and risks to guide breast cancer screening decisions. JAMA. 2014;311(13):1327–35. Reidy M, Denieffe S. Breast cancer in younger women from diverse cultural backgrounds. Br J Nurs. 2014;23(4):S19– 22. Robbins CL, Hutchings Y, Dietz PM, Kuklina EV, Callaghan WM. History of preterm birth and subsequent cardiovascular disease: A systematic review. Am J Obstet Gynecol. 2014;210(4):285–97. Rositch AF, Soeters HM, Offutt-Powell TN, et al. The incidence of human papillomavirus infection following treatment for cervical neoplasia: a systematic review. Gynecol Oncol. 2014;132(3):767–79. Tiernan JP, Verghese ET, Nair A, et al. Systematic review and meta-analysis of cytokeratin 19-based one-step nucleic acid amplification versus histopathology for sentinel lymph node assessment in breast cancer. Br J Surg. 2014;101(4):298–306. van der Ploeg JM, van der Steen A, Oude Rengerink K, van der Vaart CH, Roovers JP. Prolapse surgery with or without stress incontinence surgery for pelvic organ prolapse: a systematic review and meta-analysis of randomised trials. BJOG. 2014;121(5):537–47. Xu HB, Yang H, Liu T, Chen H. Association of CTLA4 gene polymorphism (rs5742909) with cervical cancer: a metaanalysis. Tumour Biol. 2014;35(2):1605–8. Yoo GJ, Levine EG, Pasick R. Breast cancer and coping among women of color: a systematic review of the literature. Support Care Cancer. 2014;22(3):811–24. Zakher B, Blazina I, Chou R. Association between knowledge of HIV-positive status or use of antiretroviral therapy and high-risk transmission behaviors: Systematic review. AIDS Care. 2014;26(4):514–21.
Recent Evidence-Based Reviews: Pregnancy & Birth
r r
r
r
r
Laopaiboon M, Lumbiganon P, Intarut N, et al. Advanced maternal age and pregnancy outcomes: a multicountry assessment. BJOG. 2014;121(Suppl 1):49–56. Leventakou V, Roumeliotaki T, Martinez D, et al. Fish intake during pregnancy, fetal growth, and gestational length in 19 European birth cohort studies. Am J Clin Nutr. 2014;99(3):506–16. Morisaki N, Togoobaatar G, Vogel JP, et al. Risk factors for spontaneous and provider-initiated preterm delivery in high and low Human Development Index countries: a secondary analysis of the World Health Organization Multicountry Survey on Maternal and Newborn Health. BJOG. 2014;121(Suppl 1):101–9. Pineles BL, Park E, Samet JM. Systematic review and meta-analysis of miscarriage and maternal exposure to tobacco smoke during pregnancy. Am J Epidemiol. 2014;179(7):807–23. Rodger MA, Carrier M, Le Gal G, et al. Meta-analysis of low-molecular-weight heparin to prevent recurrent Volume 59, No. 5, September/October 2014
r
r
r
placenta-mediated pregnancy complications. Blood. 2014;123(6):822–8. Sheldon WR, Blum J, Vogel JP, et al. Postpartum haemorrhage management, risks, and maternal outcomes: findings from the World Health Organization Multicountry Survey on Maternal and Newborn Health. BJOG. 2014;121(Suppl 1):5–13. Tolcher MC, Johnson RL, El-Nashar SA, West CP. Decision-to-incision time and neonatal outcomes: a systematic review and meta-analysis. Obstet Gynecol. 2014;123(3):536–48. Vogel JP, Souza JP, Mori R, et al. Maternal complications and perinatal mortality: findings of the World Health Organization Multicountry Survey on Maternal and Newborn Health. BJOG. 2014;121(Suppl 1):76–88.
Recent Evidence-Based Reviews: Neonatal
r r
r
Been JV, Nurmatov UB, Cox B, et al. Effect of smoke-free legislation on perinatal and child health: A systematic review and meta-analysis. Lancet. 2014;383(9928):1549–60. Giaccone A, Jensen E, Davis P, Schmidt B. Definitions of extubation success in very premature infants: A systematic review. Archives of Disease in Childhood Fetal & Neonatal Edition. 2014;99(2):F124–7. Gruzieva O, Gehring U, Aalberse R, et al. Meta-analysis of air pollution exposure association with allergic sensitization in European birth cohorts. J Allergy Clin Immunol. 2014;133(3):767–76.e7.
Journal of Midwifery & Women’s Health r www.jmwh.org
r
r r
r
r r
Malin GL, Morris RK, Riley R, Teune MJ, Khan KS. When is birthweight at term abnormally low? A systematic review and meta-analysis of the association and predictive ability of current birthweight standards for neonatal outcomes. BJOG. 2014;121(5):515–26. Parker RI. Transfusion in critically ill children: indications, risks, and challenges. Crit Care Med. 2014;42(3):675–90. Peng W, Zhu H, Shi H, Liu E. Volume-targeted ventilation is more suitable than pressure-limited ventilation for preterm infants: A systematic review and meta-analysis. Archives of Disease in Childhood Fetal & Neonatal Edition. 2014;99(2):F158–65. Steiner MB, Tang X, Gossett JM, Malik S, Prodhan P. Timing of complete repair of non-ductal-dependent tetralogy of Fallot and short-term postoperative outcomes, a multicenter analysis. J Thorac Cardiovasc Surg. 2014;147(4):1299–305. Tinnion R, Gillone J, Cheetham T, Embleton N. Preterm birth and subsequent insulin sensitivity: a systematic review. Arch Dis Child. 2014;99(4):362–8. Xu H, Zeng T, Liu JY, et al. Measures to reduce mother-tochild transmission of Hepatitis B virus in China: a metaanalysis. Dig Dis Sci. 2014;59(2):242–58.
AUTHOR
Nicole S. Carlson, CNM, MS, is a doctoral student in the University of Colorado Denver’s College of Nursing and is President of the Georgia Affiliate of ACNM.
537
