76 Professional Case Management March/April 2009

Professional Case ManagementVol. 14, No. 2, 76–81Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

Evidenced-Based Case ManagementPractice, Part 1The Systematic Review

Terry Throckmorton, PhD, RN, and Pamela E. Windle, MS, RN, NE-BC, CPAN, CAPA

A B S T R A C TObjectives: This article aims to (1) describe the steps in the development of a systematic review, (2) discuss theuse of systematic reviews in developing an evidence base for case management practice, and (3) present listingsof agencies that provide systematic reviews on clinical topics and resources to evaluate systematic reviews forapplication to practice. Primary Practice Settings: Evidence-based practice is mandated for all healthcare professionals regardless ofsetting. For nonacademic settings, a lack of library resources may make this mandate difficult to accomplish.Systematic reviews are available through agency Web sites and, therefore, are accessible to anyone with Internetaccess. Findings/Conclusions: Evidence-based practice supports professionalism, patient safety, and quality care.However, most case managers, have heavy workloads and limited time to complete literature reviews adequateto provide a basis for clinical decision making. For that reason, systematic reviews are developed and publishedby a variety of professional groups, including clinicians, academics, researchers, and library systems. This articlefocuses on the systematic review and includes definitions, a comparison of types of reviews, the process forcompleting systematic reviews, sources of systematic reviews, and tools used to critique them. Implications for Case Management Practice: Systematic reviews can be helpful tools to allow busy casemanagers to provide the safest and most effective care to their patients. They can support the development ofguidelines specific to case management such as transitioning care to other institutions or to the patient’s home,management of the patient in the community, and prevention of recidivism or unplanned return to an acute caresetting.

Key Words: case management, critical appraisal, evidence-based practice, research, sources of evidence, systematic review

The authors have no conflict of interest.

Address correspondence to Terry Throckmorton, PhD,RN, The Methodist Hospital, 6565 Fannin, MGJH11.018, Houston, TX 77030 (TAThrockmorton@tmhs.org).

This article is Part 1 of a two-part series designedto provide information on sources of evidencefor incorporation into practice. Part 1 describes

the systematic review, how it is conducted, tools tocritique reviews, and how they can be used to supportpractice. Part 2 will address meta-analysis, how theprocess differs from systematic review, how toevaluate a meta-analysis, and how to use theevidence in practice.

Evidence-based practice (EBP) has been with usin various forms and degrees throughout the historyof our profession. Over the last 10–20 years, a veryrefined comprehensive approach to establishing anevidence base for clinical practice has evolved.Healthcare, and certainly case management, hasmoved from the original few reference citations sup-porting practices to the more formal research utiliza-tion process, and then to the current comprehensive

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evidence-based approach to supporting practice de-cisions. As the process has developed, the requiredskills and the volume of work have also escalated.Each of us as practicing clinicians, case managers,educators, practitioners, and managers should beknowledgeable of the process involved in EBP andthe skills required. This article addresses the system-atic review, one aspect of EBP that, when availablefor a specific topic, can save case managers andother healthcare professionals a significant amountof time and work.

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provide evidence around a specific variable for a re-search study or as a basis for designing a process im-provement or similar project. Narrative reviews mayor may not be biased toward the proposed interven-tion the investigator planned to study. There is oftena critique of the study designs and an effort to definewhat has not been covered in previous research.Unlike systematic reviews, standard literature reviewsdo not usually have stringent criteria for (1) whattypes of studies are included and (2) rigorous evalua-tion of the validity and reliability of the measurementand outcomes. There may or may not be bias in thepresentation of the studies. There is usually not a sig-nificant effort to determine what unpublished evi-dence is available and what those studies indicate.Occasionally, studies presented at professional meet-ings are included in the review. See Table 1 for defini-tions of terms used in this article.

Systematic reviews can be classified as investiga-tions in themselves, with a stated methodology andcollection of data for analysis. They involve an ex-haustive review of the literature for specific types ofstudies outlined in explicit selection criteria. Each ar-ticle is critiqued using standard critique guidelines,and conclusions are drawn about the validity of thedata and the applicability of the findings to practice.Systematic reviews are divided into two types: quali-tative and quantitative or meta-analysis (Cook et al.,1997; Duke University Medical Library, 2004).Qualitative systematic reviews are summaries of allthe studies found on a well-defined topic along withan evaluation of the scientific merit of the studies.Quantitative reviews or meta-analyses are systematicreviews in which the results of multiple studies are

EVIDENCE-BASED PRACTICE

“Evidence-based practice is the conscientious, delib-erate, and judicious use of the best available evi-dence” (Sackett, Rosenberg, Gray, Haynes, &Richardson, 1996) in conjunction with clinical expe-rience and patient preference to make decisionsabout patient care (American PsychologicalAssociation, 2006; Gambrill, 2003; Gilgun, 2006;Ingersoll, 2000). As the definition implies, best evi-dence means that the clinician actually knows whatevidence exists and what portion of the evidence rep-resents the best available evidence. Obviously,reviewing the literature for all available studies andcritiquing them to determine the best current ap-proach requires a time commitment that most casemanagers do not have. This process also often requireslevels of expertise in research and statistical analysisthat clinicians may not have acquired. In its best form,the process also includes analysis of any availableunpublished research. The solution for accomplishingEBP for most areas of practice, including case manage-ment, is to utilize systematic reviews of research.

TYPES OF REVIEWS

A systematic review is the use of scientific methods toassemble, critically appraise, and synthesize pertinentstudies that address a specific clinical question (Pai et al., 2004; Sweet & Moynihan, 2007). Systematicreviews, one of the higher levels of evidence, are verydifferent from the standard literature reviews thathave served us in the past. Literature reviews, some-times called narrative reviews, are often developed to

TABLE 1Definitions

Terms Definitions

Evidence-based practice “Evidence-based practice is the conscientious, deliberate, and judicious use of the best available evidence” (Sackett et al., 1996) in conjunction with clinical experienceand patient preference to make decisions about patient care (American PsychologicalAssociation, 2006; Gambrill, 2003; Gilgun, 2006; Ingersoll, 2000).

Narrative or descriptive review Narrative reviews are literature summaries related to a specific topic that are most frequently completed to support a research study or project. There may or may not be acritique of the included articles, and there is often no description of the search strategy.

Systematic or qualitative review A systematic review is the use of scientific methods to assemble, critically appraise, and synthesize pertinent studies that address a specific clinical question (Pai et al.,2004; Sweet & Moynihan, 2007). Systematic reviews may also be called qualitative re-views (Cook, Mulrow, & Haynes, 1997).

Meta-analysis or Quantitative reviews or meta-analyses are systematic reviews in which the results quantitative review of multiple studies are pooled and analyzed as though they were one study (Cook

et al., 1997; Sackett et al., 1996).

Critical appraisal Critical appraisal is the systematic review of a research study using standard criteria to determine its scientific merit.

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pooled and analyzed as though they were one study.These three types of reviews—narrative, qualitativesystematic, and quantitative systematic—may also becalled reviews, overviews, and meta-analysis by someexperts (Centre for Evidence-Based Dentistry, 2008;Sackett et al., 1996). Case managers can use the sys-tematic reviews to provide a broader base of evidenceon which to base practice and make decisions. Forexample, The Cochrane Library of SystematicReviews includes a review on transitioning patients toa nurse-led step-down unit before transitioning homeand another manuscript on day centers for patientswith mental illness. The available reviews may sup-port a specific process for transitioning care but moreoften will support nursing interventions that improvethe quality of care for patients transitioned to differ-ent levels inside and outside of the care system.

HOW IS A SYSTEMATIC REVIEW CONDUCTED?Step 1: Determining Whether the Review Is Necessary and Feasible

Researchers who decide to undertake a systematic re-view begin by sharing their idea with the subject andmethodology experts. Experts in this area can provideadvice about the worth and feasibility of the topic.Surveying the systematic review sources is also impor-tant to ensure that the proposed work has not alreadybeen done. A general survey of the available literaturewill allow the investigator to estimate need and feasi-bility. If there is no research available, then the sys-tematic review is not feasible. Before progressing anyfurther, the investigator may want to consider wherethe review will be published. Each organization thatmaintains a library of systematic reviews has require-ments for how the review is to be conducted and theformat for how the report is to be written. TheCochrane Library (Oxman, 1995) is probably the bestknown and has published its manual on its Web site.

Step 2: Formulating the Research Question

The criteria for the question are similar to those forany evidence-based literature search: population or

“Evidence-based practice is the consci-entious, deliberate, and judicious useof the best available evidence” in con-junction with clinical experience andpatient preference to make decisionsabout patient care.

medical problem, specific intervention of interest,comparison group, outcome of interest, and specificstudy design. Each criterion should be clearly de-fined. An example would be as follows:

• Population: Patients being transferred from hos-pital to nursing home Intervention: Use of a stan-dard format for handoff from nursing home toEmergency Medical Transport to hospital

• Comparison Group: Standard reporting process• Outcome: Reduction in errors related to incom-

plete reporting Study Design—randomized con-trolled trials

Step 3: Selecting a Study Protocol

There are multiple approaches to designing the pro-tocol for the systematic review, most of which aredefined by the organization for which the review willbe done. Investigators who are not working with aspecific systematic review collective can still adoptthe format of one of the groups such as the CochraneCollaboration (http://www.cochrane.org/). The in-vestigator should be aware of the time commitmentand the cost of conducting a systematic review.Most reviews commonly last from 6 to 18 months.Costs include the investigator’s time, photocopying,interlibrary loans, and possibly long-distance phonecalls to speak with the authors of unpublished stud-ies. In this technological age of e-mail and theInternet, photocopying and phone expenses may bediminished, but some costs should be expected.

Step 4: Determining a Search Strategy and the Extent of the Search

Initially, the investigator should determine what disci-plines are likely to have published literature related tothe topic and whether there are any previously com-pleted reviews. Then the related search drives are iden-tified. The criteria for the question are expanded todetermine inclusion and exclusion criteria. In otherwords, how terms must be defined, what is acceptableas a treatment, and how the outcomes should be mea-sured. In addition to standard search drives, citationindexes can be used to identify the authors who are re-peatedly cited by other researchers. These studies areusually the baseline or landmark studies related toyour topic. Other approaches that may be used aremanual searches of journal index pages and searchesof the reference lists in articles already selected for thereview. Finally, unpublished studies can be obtainedfrom the abstracts presented at conferences. The ab-stracts of many professional associations are publishedon their Web sites or in their journals. The authorscan be contacted for the details of the studies.

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review for their purposes. See Table 2 for sources ofappraisal instruments.

Uses and Availability

Obviously, systematic reviews constitute a signifi-cant investment in terms of time, expense, andexpertise. For the busy case manager with largecaseloads for follow-up who has very little time tocomplete the well-designed and executed literaturesearches, current systematic reviews are great finds.Systematic reviews may provide an overview of re-search related to community care of patients withchronic disease or of independent nursing functionsthat may enhance the patient’s transition from hos-pital or interim care to home. For example, the

Step 5: Matching References With theCriteria for Inclusion

This process eliminates those that do not measureup, analyzing the validity of the results and rankingthe articles according to value. It facilitates theinvestigator’s effort to provide the best availableevidence on a specific, precisely defined topic.

Step 6: Organizing and Writing the Review

Readers who hope to use the systematic review willexpect that the final document includes a descriptionof each step and the process used to accomplish it.The readers can then estimate the rigor of the reviewand better assess the validity of the completed

TABLE 2Samples

Critical Appraisal Skills Program http://www.phru.nhs.uk/Pages/PHD/resources.htm

Centre for Evidence Based Medicine http://www.cebm.net/?o�1016

AHRQ Systems to Rate the Strength http://www.ahrq.gov/clinic/epcsums/strengthsum.htmof Scientific Evidence Summary

Systematic Review Critical Appraisal Worksheet http://www.uphs.upenn.edu/medicine/education/residents/curriculum/journalclub/PDF’s/Systematic_Review.pdf; http://pennhealth.com/search/search.aspx?uphs_st=Health&col=inter&q=Systematic+Review+Critical+Appraisal+Worksheet

Pediatric Critical Care Web site http://pedsccm.org/EBJournal_Resources.php

University of Glasgow http://www.gla.ac.uk/departments/generalpracticeprimarycare/ evidencebasedpractice/checklists/#d.en.19536

Evaluation of systematic reviews of http://ebn.bmj.com/cgi/reprint/4/4/100.pdftreatment or prevention interventions

Netting the Evidence http://www.shef.ac.uk/scharr/ir/netting/appraising.htm

Duke University Medical Library http://www.mclibrary.duke.edu/training/pdaformat/overviewpda.html

TABLE 3Systematic Review Sources

The Cochrane Collaboration http://www.cochrane.org/

BMJ Systematic Reviews in Health Care www.bmj.com

National Guidelines Clearinghouse http://www.guideline.gov/

Agency for Healthcare Research and Quality http://www.ahrq.gov/clinic/epcix.htm

PubMed Clinical Queries http://www.ncbi.nlm.nih.gov/entrez/query/static/clinical.shtml

Joanna Briggs Institute http://www.joannabriggs.edu.au/pubs/systematic_reviews.php

Health Information Research Unit http://hiru.mcmaster.ca/epc/projects.asp

Task Force on Community Preventive Services http://www.thecommunityguide.org/

Centre for Evidence Based Medicine http://www.cebm.net/?o�1016

Clinical Evidence http://www.library.ualberta.ca/databases/databaseinfo/index.cfm?ID�3119

Health Links, University of Washington http://healthlinks.washington.edu/ebp

MD Consult http://www.library.ualberta.ca/databases/databaseinfo/index.cfm?ID�101

Nursing Best Practice Guidelines http://www.rnao.org/Page.asp?PageID�861&SiteNodeID�

133&BL_ExpandID�&AA_Shell�

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Cochrane Database of Systematic Reviews includesa systematic review on telephone follow-up of pa-tients discharged home and one on home-basedversus center-based physical activity programs inolder adults.

Currently, the majority of the systematic reviewsare disease management focused with a much smallernumber related to healthcare process. However,many of the clinical systematic reviews can be usedby case managers to determine the optimum routefor patients to take through the system and into thecommunity on the basis of the current best evidencefor disease management and rehabilitation.

Issues related to transition of care from home,through the varied outpatient and inpatient points,and back to home have long been recognized bynurses, but have only recently received generalrecognition as a necessary focus for caregivers. Asthe research in this area begins to accumulate, re-searchers may decide that a systematic review is nec-essary. In the interim, case managers are in an excel-lent position to collaborate with nurse investigatorsto design and conduct the research needed to sup-port practice and safeguard the patient.

SOURCES OF SYSTEMATIC REVIEWS

Sources of systematic reviews have incrementallyincreased as the demand for EBP has grown. Someof these sources are listed in Table 3. Each of theseWeb sites was accessed on December 10, 2008.Most of the sources are Web based and easily ac-cessible to case managers in any setting with com-puter access. Commercial search drives, such asNursing Reference Center, Dynamed, ClinicalEvidence, Up to Date, and MD Consult are avail-able by subscription.

Just as sources of systematic reviews have in-creased, so have Web sites with criteria for the eval-uation of systematic reviews. Because there aremany individuals and organizations conducting sys-tematic reviews with varying degrees of rigor, evalu-ation of the validity of the review is an importantstep before applying the results to changes in prac-

tice. A sampling of these Web sites is listed in Table 2. All Web sites were accessed on December10, 2008.

SUMMARY

Systematic reviews, clearly, can be helpful for busycase managers in their attempt to plan the most cur-rent and safest care for their patients. However, aswith any other tool, there is an inherent responsibil-ity in case management to evaluate the validity of theresulting recommendations. In addition, case man-agers will want to compare the populations includedin the research for similarity with the ones withwhich they are working. Finally, as with any new ap-proach, patient preferences must be considered. Thebest case management process can be very ineffectiveor inefficient if the process does not work well withyour population or institution or is not accepted bymanagement. Patients make decisions about theirhealthcare on the basis of circumstances or prefer-ences that may not have been considered in the re-search for the systematic review. Case managers andclinical nurses are in the best position to understandthe bases for patients’ decisions and to adjust bestpractices to meet the needs of patients. A systematicreview identifying best processes in discharging pa-tients to the next continuum of care or transferringto the next level of care, when available, might revealsome differences in the processes and provide helpfulsuggestions that may result in improved options forthe case manager and interdisciplinary team in mak-ing the transition. Systematic reviews about the effi-cacy of specific types of community resources mayassist the case manager in determining referrals, theneed for follow-up evaluation of the program, andthe criteria to use in evaluating it.

REFERENCES

American Psychological Association. (2006). APA presi-dential task force on evidence based practice.Washington, DC: Author.

Centre for Evidence-Based Dentistry. (2008). Systematicreviews. Retrieved December 10, 2008, from http://www.cebd.org/ index.aspx?o�1059

Cochrane Database of Systematic Reviews. (2008, 4thQuarter). Retrieved December 10, 2008, fromhttp://www.cochrane.org/

Cook, D. J., Mulrow, C. D., & Haynes, R. B. (1997).Systematic reviews: Synthesis of best evidence forclinical decisions. Academia and Clinic, 126(5),376–380.

Duke University Medical Library. (2004). Evaluating a sys-tematic review article. Retrieved December 10, 2008,from http://www.mclibrary.duke.edu/training/pdaformat/overviewpda.html

(As) with any new approach, patientpreferences must be considered. Thebest case management process can bevery ineffective or inefficient if theprocess does not work well with yourpopulation or institution or is not ac-cepted by management.

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based medicine: What it is and what it isn’t. BritishMedical Journal, 312, 71–72. Retrieved from http://bmj.bmjjournals.com/cgi/content/full/312/7023/71

Sweet, M., & Moynihan, R. (2007). Improving popula-tion health: The uses of systematic reviews. RetrievedFebruary 12, 2009, from http://www.milbank.org/reports

Terry Throckmorton, PhD, RN, is an experienced researcher and has servedon several institutional review boards and scientific review committees. She hasserved for two terms as institutional review board vice chair for a large oncologycenter. She is a nurse scientist for a large medical center hospital system and hastaught research and statistics at Texas Woman’s University.

Pamela E. Windle, MS, RN, NE-BC, CPAN, CAPA, is an experienced peri-anesthesia nurse manager, has conducted several research studies in her de-partment, is very active with nursing professional organizations, and is anASPAN past president. She has been the JoPAN research columnist and is cur-rently the coeditor for the second edition of Nursing PeriAnesthesia CoreCurriculum book.

Gambrill, E. (2003). Evidence-based practice: Implicationsfor knowledge development and use in social work. InA. Rosen & E. Proctor (Eds.), Developing practiceguidelines for social work intervention (pp. 37–58).New York: Columbia University Press.

Gilgun, J. (2006). The four cornerstones of qualitative re-search. Qualitative Health Research, 16(3), 436–443.

Ingersoll, G. L. (2000). Evidence-based nursing: What it isand what it isn’t. Nursing Outlook, 48(4), 151–152.

Oxman, A. (Ed). (1995). Preparing and maintaining sys-tematic reviews. In Cochrane Collaboration handbook,section VI. Oxford, UK: Cochrane Collaboration.

Pai, M., McCulloch, M., Gorman, J., Pai, N., Enanoria,W., Kennedy, G., et al. (2004). Systematic reviewsand meta-analyses: An illustrated step-by-step guide.The National Medical Journal of India, 17(2),86–95.

Sackett, D. L., Rosenberg, W. M. C., Gray, J. A. M.,Haynes, R. B., & Richardson, W. S. (1996). Evidence

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