506968 research-article2013

WJNXXX10.1177/0193945913506968Western Journal of Nursing ResearchEditorial

Editorial

WJNR Welcomes Umbrella Reviews

Western Journal of Nursing Research 2014, Vol 36(2) 147­–151 © The Author(s) 2013 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0193945913506968 wjn.sagepub.com

The sizable number of published review articles in the literature that integrate related research questions has justified the need for the development and publication of umbrella reviews that synthesize findings across multiple reviews. Also referred to in the literature as overviews of reviews, reviews of reviews, and systematic reviews of systematic reviews, umbrella reviews have the primary objective of addressing specific research questions by examination of the findings of previous reviews (Becker & Oxman, 2008). By synthesizing across previous reviews, patterns in findings can be identified that permit conclusions to be drawn about the state of research in an area, that help resolve discrepancies in conclusions drawn by different reviews, and can identify the direction future research should take (Becker & Oxman, 2008; Cooper & Koenka, 2012). The Western Journal of Nursing Research (WJNR) publishes a wide variety of review articles of a quantitative and qualitative nature, including narrative, systematic, and integrated reviews, meta-analyses, and meta-syntheses. For research questions in which the primary research is extensive and there is a burgeoning number of published reviews of that research, umbrella reviews are the logical next step in advancing knowledge to improve health outcomes. Therefore, WJNR also welcomes submissions of high-quality umbrella reviews that are rigorous and transparent in their approach. Here we provide some information that may assist authors who may be contemplating preparation of an umbrella review. The methods used in conducting searches and collecting data for umbrella reviews are similar to those used to prepare reviews of primary studies, however, because the unit of analysis in an umbrella review is the review rather than the primary study, the search strategies used and types of data collected will be different (Becker & Oxman, 2008; Smith, Devane, Begley, & Clarke, 2011). Umbrella reviews require explicit purpose statements and delineation of the questions or issues that will be addressed. The research questions being addressed by the umbrella review will determine the inclusion criteria for reviews as well as inform the search strategy to be used to locate potentially eligible reviews. In locating reviews, sufficiently broad search strategies should be used to compensate for the limitations inherent to computerized

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databases, which may only provide information for a certain range of years or a particular set of journals (Cooper & Koenka, 2012; Smith et al., 2011). One search of a single database such as MEDLINE is rarely adequate; online searches should include multiple different databases. Searching should also extend to other methods as necessary. Manual searches of key journals and of reference lists of located reviews are recommended to obtain reviews that are difficult to find or access through online searching (Smith et al., 2011). Once reviews are located, they must be closely assessed for eligibility for inclusion in the analysis sample. Inclusion criteria often will specify the purpose of the review, the review method employed (e.g., integrated review, meta-synthesis), and features of primary studies such as sample characteristics, study design (e.g., measurement of concepts and variables), and intervention characteristics (Foster & Hammersley, 1998; Smith et al., 2011). Any conceptual and operational definitions applied to inclusion criteria should be articulated in the umbrella review. For example, it may be necessary to precisely define what is meant by the term intervention in a particular area of investigation. Consistent application of inclusion criteria will yield an unbiased set of reviews for analysis (Smith et al., 2011). Umbrella review articles often include a flowchart of the inclusion of reviews and reasons why some reviews may have been excluded (Cooper & Koenka, 2012). In analyzing eligible reviews, umbrella reviews move past serial presentation of the content of each review to provide new knowledge through the identification of consistencies and inconsistencies across reviews. Identification of the patterns across reviews requires some means to extract data from the articles (Cislak, Safron, Pratt, Gaspar, & Luszczynska, 2012; Ernst & Lee, 2010; Hagen et al., 2012; Lee, Choi, Posadzki, & Ernst, 2012; Mahtani et al., 2013; Momsen, Rasmussen, Nielsen, Iversen, & Lund, 2012; Safron, Cislak, Gaspar, & Luszczynska, 2011; Smith et al., 2011; Wilson et al., 2012). Data collection from review articles is somewhat akin to coding information from primary study articles for purposes of meta-analysis. In fact, development of a coding frame may be the most useful means to ensure consistent and complete data collection across all included review articles. Useful information to extract from reviews includes the focus or purpose of the review, primary study inclusion criteria, the total number of primary studies included, and the total number of individual subjects across all studies examined in the review. When reporting reviewers’ conclusions about primary studies, it is important to transcribe the data on which those conclusions were based, be they meta-analysis effect sizes, narrative review vote counts, or meta-synthesis themes. Depending on the purpose of the umbrella review, additional information may also need to be collected from reviews such as assessments of intervention characteristics, intervention moderators, or

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whether interventions were theory-guided. Other informative data to collect from review articles are evaluations of the methodological strengths and limitations of included primary studies as well as reviewers’ suggestions for future research. Construction of multiple tables is often necessary to clearly present all the data collected from reviews (Cooper & Koenka, 2012; Smith et al., 2011). Well-constructed tables will facilitate analysis because they make patterns in the data easier to detect. When all reviews agree on a particular point, umbrella review conclusions are straightforward. However, apparent inconsistencies across review articles addressing the same topic will require a detailed, critical examination of the data to identify potential reasons for the discrepancies. For example, two reviews may have reached different conclusions about the efficacy of a particular intervention because of significant variations in the characteristics of research participants in the studies included for analysis in the review—participants may have been significantly older in one set of studies or of a different racial composition. The validity and strength of conclusions drawn by any review article are dependent on the methodological quality of the review (Cooper & Koenka, 2012; Smith et al., 2011). Umbrella reviews should therefore always include a quality assessment of all included reviews. Common review article quality criteria include adequacy of searching, specificity and appropriateness of inclusion criteria, data extraction validity, assessment of potential bias in primary studies, quality of data reported about individual studies, and procedures to summarize or synthesize across primary studies. Several tools are available that can be used to assess review quality, such as the Assessment of Multiple Systematic Reviews (AMSTAR; Shea et al., 2007) and Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA; Moher, Liberati, Tetzlaff, Altman, & The PRISMA Group, 2009). Overall conclusions drawn in the umbrella review must always be interpreted in the context of the quality of included reviews. In addition to drawing conclusions about the current state of research in an area of investigation based on findings of included reviews, umbrella reviews should also make very specific suggestions regarding future research. These suggestions most often arise from an examination of reviewers’ assessments of the methodological strengths and limitations of the primary studies in their analysis sample. This information can also be placed in tables and grouped by sampling, measurement, design, and the like to once again look for patterns in the data. Examination of these tables can reveal gaps or problems in the research or conversely can identify areas in which no further primary research is needed. Umbrella reviews may be useful to inform theory development as well. For example, evidence from multiple review articles about predicted

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relationships among key constructs may provide evidence for theoretical propositions. Conclusions from umbrella reviews, especially when the umbrella review resolves perceived discrepancies among previous reviews, can be very useful for policy development. As with all forms of inquiry, umbrella reviews have their limitations. They are constrained by the scope and rigor of the reviews included in the analysis sample. Narrative reviews are of particularly limited value for umbrella reviews because they typically provide summaries of individual studies rather than conducting synthesis across studies. Another problem is that interpretation of review findings may be limited by the extent to which previous reviews address nearly identical samples of primary studies (Smith et al., 2011). Some or all of the same primary studies may be included in two or more reviews. The extent of sample overlap can be precisely assessed in umbrella reviews by generating a grid of primary studies reported in review articles (Cooper & Koenka, 2012). Despite these limitations, carefully prepared umbrella reviews can provide scientists, clinicians, and policy makers with a broader view of a research area than any single review can. Not surprisingly, a growing number of articles have been published to assist investigators in conducting and writing high-quality umbrella reviews (e.g., Becker & Oxman, 2008; Cooper & Koenka, 2012; Smith et al., 2011). Even so, early career nurse researchers contemplating preparation of an umbrella review should consider working collaboratively with a more senior investigator because an extensive knowledge of conceptual and methodological issues is essential to creating an outstanding review. Vicki S. Conn, PhD, RN, FAAN (Editor) and Tamara G. Coon Sells, PhD University of Missouri, Columbia, USA References Becker, L. A., & Oxman, A. D. (2008). Overviews of reviews. In J. P. T. Higgins & S. Green (Eds.), Cochrane handbook for systematic reviews of interventions (pp. 607-631). Hoboken, NJ: John Wiley & Sons. Cislak, A., Safron, M., Pratt, M., Gaspar, T., & Luszczynska, A. (2012). Familyrelated predictors of body weight and weight-related behaviours among children and adolescents: A systematic umbrella review. Child: Care, Health, and Development, 38, 321-331. doi:10.1111/j.1365-2214.2011.01285.x Cooper, H., & Koenka, A. C. (2012). The overview of reviews: Unique challenges and opportunities when research syntheses are the principal elements of new integrative scholarship. American Psychologist, 67, 446-462. doi:10.1037/ a00271192012-04006-001 [pii]

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Ernst, E., & Lee, M. S. (2010). Acupuncture for rheumatic conditions: An overview of systematic reviews. Rheumatology, 49, 1957-1961. doi:0.1093/rheumatology/ keq180keq180 [pii] Foster, P., & Hammersley, M. (1998). A review of reviews: Structure and function in reviews of educational research. British Educational Research Journal, 24, 609-628. Hagen, K. B., Dagfinrud, H., Moe, R. H., Osteras, N., Kjeken, I., Grotle, M., & Smedslund, G. (2012). Exercise therapy for bone and muscle health: An overview of systematic reviews. BMC Medicine, 10(1), Article 167. doi:1741-701510-167 [pii]10.1186/1741-7015-10-167 Lee, M. S., Choi, J., Posadzki, P., & Ernst, E. (2012). Aromatherapy for health care: An overview of systematic reviews. Maturitas, 71, 257-260. doi:10.1016/j. maturitas.2011.12.018S0378-5122(12)00006-0 [pii] Mahtani, K. R., Protheroe, J., Slight, S. P., Demarzo, M. M. P., Blakeman, T., Barton, C. A., Brijnath, B., & Roberts, N. (2013). Can the London 2012 Olympics “inspire a generation” to do more physical or sporting activities? An overview of systematic reviews. BMJ Open, 3(1), e002058. doi:10.1136/bmjopen2012-002058e002058 [pii] Moher, D., Liberati, A., Tetzlaff, J., Altman, D. G., & The PRISMA Group. (2009). Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement. PLoS Med, 6(6), e1000097. doi:10.1371/journal.pmed 1000097 Momsen, A. M., Rasmussen, J. O., Nielsen, C. V., Iversen, M. D., & Lund, H. (2012). Multidisciplinary team care in rehabilitation: An overview of reviews. Journal of Rehabilitation Medicine, 44, 901-912. doi:10.2340/16501977-1040 Safron, M., Cislak, A., Gaspar, T., & Luszczynska, A. (2011). Effects of school-based interventions targeting obesity-related behaviors and body weight change: A systematic umbrella review. Behavioral Medicine, 37, 15-25. doi:10.1080/08964289. 2010.543194933884266 [pii] Shea, B. J., Grimshaw, J. M., Wells, G. A., Boers, M., Andersson, N., Hamel, C., . . .Bouter, L. M. (2007). Development of AMSTAR: A measurement tool to assess the methodological quality of systematic reviews. BMC Medical Research Methodology, 7, Article 10. doi:10.1186/1471-2288-7-10 Smith, V., Devane, D., Begley, C. M., & Clarke, M. (2011). Methodology in conducting a systematic review of systematic reviews of healthcare interventions. BMC Medical Research Methodology, 11(1), Article 15. doi:10.1186/1471-2288-11151471-2288-11-15 [pii] Wilson, M. G., Husbands, W., Makoroka, L., Rueda, S., Greenspan, N. R., Eady, A., . . .Rourke, S. (2012). Counselling, case management and health promotion for people living with HIV/AIDS: An overview of systematic reviews. AIDS and Behavior, 17, 1612-1625. doi:10.1007/s10461-012-0283-1

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WJNR welcomes umbrella reviews.

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