NC receives funding from the NIHR to run Cochrane Wounds, she is the coordinating editor and JD is the Joint Co-ordinating editor. NC, JD, TG and JC have authored Cochrane reviews. This does not alter our adherence to PLOS ONE policies on sharing data and materials.
‡ These authors also contributed equally to this work.
Complex wounds such as leg and foot ulcers are common, resource intensive and have negative impacts on patients’ wellbeing. Evidence-based decision-making, substantiated by high quality evidence such as from systematic reviews, is widely advocated for improving patient care and healthcare efficiency. Consequently, we set out to classify and map the extent to which up-to-date systematic reviews containing robust evidence exist for wound care uncertainties prioritised by community-based healthcare professionals.
We asked healthcare professionals to prioritise uncertainties based on complex wound care decisions, and then classified 28 uncertainties according to the type and level of decision. For each uncertainty, we searched for relevant systematic reviews. Two independent reviewers screened abstracts and full texts of reviews against the following criteria: meeting an a priori definition of a systematic review, sufficiently addressing the uncertainty, published during or after 2012, and identifying high quality research evidence.
The most common uncertainty type was ‘interventions’ 24/28 (85%); the majority concerned wound level decisions 15/28 (53%) however, service delivery level decisions (10/28) were given highest priority. Overall, we found 162 potentially relevant reviews of which 57 (35%) were not systematic reviews. Of 106 systematic reviews, only 28 were relevant to an uncertainty and 18 of these were published within the preceding five years; none identified high quality research evidence.
Despite the growing volume of published primary research, healthcare professionals delivering wound care have important clinical uncertainties which are not addressed by up-to-date systematic reviews containing high certainty evidence. These are high priority topics requiring new research and systematic reviews which are regularly updated. To reduce clinical and research waste, we recommend systematic reviewers and researchers make greater efforts to ensure that research addresses important clinical uncertainties and is of sufficient rigour to inform practice.
The commonest types of complex wounds are venous leg ulcers, complex surgical wounds, pressure ulcers and foot ulcers (due to diabetes and other causes) [
The quality of evidence derived from wound care trials tends to limited due to drawing on: underpowered studies that have small numbers of participants and/or few event numbers, short-term follow-up and sub-optimal use of research methods and outcomes [
It has been estimated that about 80% of biomedical research is wasted [
Uncertainty identification and priority setting has been undertaken for pressure ulcers, general wound or burns care [
After harvesting decision uncertainties it is also necessary to establish whether elicited uncertainties are ‘genuine’ uncertainties (i.e., not already answered by research) or areas where relevant research findings exist but are not known. This paper describes the process by which we mapped existing evidence to the 28 wound care uncertainties gathered from healthcare professionals. We followed a pragmatic and generic evidence-based practice approach [
We mapped the nature of existing systematic review evidence for the 28 highest priority wound care uncertainties expressed by community-based healthcare professionals in the UK. We conducted this in two stages; firstly, we broadly classified our priorities into types and the level of clinical decision. We then systematically searched the literature for reviews using pre-specified criteria to identify up-to-date systematic reviews containing high quality evidence addressing any of the 28 uncertainties.
We classified the wound care uncertainties using an adaptation of the decision typology of McCaughan et al [
Category | Definition |
---|---|
Assessment | Deciding how to determine if signs and/or symptoms are present; deciding which signs and/or symptoms to search for |
Diagnosis | Deciding what diagnostic label is indicated by presenting signs and symptoms |
Intervention | Deciding what intervention to offer/use, and/or when |
Communication | Deciding how to give or gain information |
Referral | Deciding who to refer to and/or when |
Information-seeking | Deciding if pursuing/not pursuing further information before making a decision |
Wound | Making decisions about wound care |
Patient | Making decisions about patient care |
Service | Making decisions about service organisation, delivery and management |
For each of the 28 uncertainties we systematically searched for reviews and assessed them against four criteria in sequence, namely: whether they were clearly defined systematic reviews according to pre-specified conditions; and when so, if they were sufficiently relevant to the uncertainty; then whether they were sufficiently up-to-date (published or updated in the last 5 years) and if the systematic review identified high quality research evidence using a clear and appropriate criteria or framework (for example GRADE [
We present the total number of review records screened, the four criteria used for screening abstracts/full papers, and the number of reviews meeting/not meeting each criterion. a,NHS centre for reviews and dissemination (2002) The Database of abstracts of reviews of effects (DARE). Effectiveness Matters: 6:1–4. b,Hemingway P, Brereton N (2009) What is a systematic review?. What is? series: Hayward Medical Communcations. c,Moher D, Liberati A, Tetzlaff J, Altman DG, The PG (2009) Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement. PLoS Med 6: e1000097. d,Shea BJ, Grimshaw JM, Wells GA, Boers M, Andersson N, Hamel C, et al. (2007) Development of AMSTAR: a measurement tool to assess the methodological quality of systematic reviews. BMC Med Res Methodol 7: 10.
We did not place language or year of publication limitations on our searches (as we wanted to determine if wound care systematic reviews that met our uncertainties existed but had not been updated). Overviews of systematic reviews were not eligible; instead we searched the reference lists of overviews for relevant systematic reviews that may not have been identified in our searches. We also noted any systematic review protocols returned in our searches.
We searched the Cochrane Database of Systematic Reviews (CDSR) up to 8th August 2016 and the Database of Abstracts of Reviews of Effects (DARE) to 31st March 2015 via the Cochrane Library; and PubMed using the ‘systematic[sb]’ search filter until 8th August 2016. We developed 26 bespoke searches for each of the 28 uncertainties (
One reviewer ran the searches and then screened the results by title to remove any obviously irrelevant hits. The abstracts of potentially relevant reviews were screened by two people independently. Those reviews thought to be relevant based on title and abstract were obtained as full-text and a final decision on inclusion was based on this. Any disagreement regarding eligibility was resolved by reference to a third reviewer. We recorded search results, screening and evaluation processes in an Excel (Microsoft Office 2010) spread sheet.
The 28 uncertainties, classified by type and level of decision, are listed in order of highest ranking with their priority ranking score given by the healthcare professionals (see
Number | Uncertainty | Ranking | Type of decision | Level of decision |
---|---|---|---|---|
Does patient involvement in their dressing changes improve outcomes or increase negative outcomes? | 1 | Intervention | Patient | |
What is the most reliable and valid method of grading pressure ulcers? | 1 | Assessment | Wound | |
Would standardising wound assessments and tools across NHS settings improve staff productivity and patient outcomes? | 3 | Assessment | Service | |
How does nursing and/or professional skill mix influence wound outcomes in community settings? | 3 | Intervention | Service | |
What training is required to best manage patients with complex wounds? | Intervention | Service | ||
Do integrated team-based interventions aimed at better communication and collaborative working, improve patient outcomes? | 3 | Intervention | Service | |
Does continuing professional development in wound care improve the quality of care and patient outcomes compared with no annual update? | 3 | Intervention | Service | |
What effects do electronic patient records have on patient and service outcomes across a wound care service compared to paper records? | 3 | Intervention | Wound | |
Which treatments are most effective for over granulation? |
3 | Intervention | Service | |
What is the most clinical and cost-effective criteria for referring to specialist services (e.g. tissue viability/podiatry) to ensure appropriate use of resources and referral time? | 3 | Intervention | Service | |
How do we differentiate between diabetic foot wounds and pressure ulcers? | 3 | Diagnosis | Wound | |
Does this influence management and outcomes? | Intervention | Wound | ||
Do patients with venous leg ulceration heal quicker when treated in a dedicated leg ulcer clinic compared with general community clinics? | 3 | Intervention | Service | |
What are the effects of different cleansing agents on infection and healing of wounds in community settings? | 12 | Intervention | Wound | |
What are the clinical and cost effective methods for managing an excess of wound exudate? | 12 | Intervention | Wound | |
Does sharp debridement speed up wound healing in chronic wounds compared with dressings (HCL, hydrogels etc)? | 12 | Intervention | Wound | |
How should we identify where biofilm is impeding wound healing? | 12 |
Diagnosis |
Wound | |
What is the best way to manage a biofilm? | Intervention | Wound | ||
How do we promote adherence to interventions and health behaviours in people at high risk of foot problems? | 12 | Intervention | Patient | |
Do anti-microbial containing wound dressings heal infected wounds more quickly than oral antimicrobials? | 12 | Intervention | Wound | |
Does a prescribed two week treatment plan, using the same type of dressing, affect healing outcomes versus ad-hoc dressing selection? | 12 | Intervention | Wound | |
What is the best way of cleaning venous leg ulcers in terms of promoting healing and preventing infection? | 12 | Intervention | Wound | |
Do psychological interventions (i.e., aimed at changing health beliefs and behaviours) improve the healing/reduce the incidence of ulcers on the feet of people with diabetes? | 20 | Intervention | Patient | |
How can accurate detection of clinical infection be facilitated across different skill mixes? | 20 | Intervention | Service | |
What should be used for infected wounds when the bacteria are resistant to antibiotics? | 20 | Intervention | Wound | |
Does off-loading for people with foot wounds Improve wound healing compared with usual (or increased) activity? | 23 | Intervention | Wound | |
What impact do walk in centres have on patients outcomes versus treatment room clinics? | 23 | Intervention | Service | |
Does stopping packing a sinus wound when it has healed to 1cm depth and then treating with medical honey speed wound healing compared with usual care? | 23 | Intervention | Wound |
Uncertainty questions with identification number are presented with priority ranking given by healthcare professionals; they are also classified by type and level of decision. Uncertainties 4, 10 and 15 consisted of two questions which are considered separately in this paper; i.e. a total of 28 uncertainties are presented.
We screened 20,457 record titles from 26 searches for the 28 uncertainties (
Uncertainty | Total number of records screened | Records removed following title screen, de-duplication and removal of protocols/ overviews | Reviews screened by abstract and full text |
---|---|---|---|
1 | 22 | 22 | 0 |
2 | 183 | 178 | 5 |
3 | 1430 | 1418 | 12 |
4a | 398 | 395 | 3 |
4b | 1684 | 1684 | 0 |
5 | 3353 | 3336 | 17 |
6 | 532 | 528 | 3 |
7 | 2563 | 2546 | 17 |
8 | 129 | 129 | 0 |
9 | 174 | 169 | 5 |
10a | 70 | 65 | 2 |
10b | 3 | ||
11 | 47 | 43 | 4 |
12 | 248 | 239 | 9 |
13 | 63 | 61 | 2 |
14 | 696 | 683 | 13 |
15a | 42 | 37 | 3 |
15b | 3 | ||
16 | 306 | 295 | 11 |
17 | 770 | 760 | 10 |
18 | 3633 | 3629 | 4 |
19 | 16 | 14 | 2 |
20 | 130 | 128 | 2 |
21 | 3161 | 3152 | 9 |
22 | 178 | 175 | 3 |
23 | 331 | 321 | 10 |
24 | 137 | 132 | 5 |
25 | 162 | 157 | 5 |
Number of review records identified through the Cochrane Library and PubMed per uncertainty, records removed following title screen and screened by abstract and full text.
We identified a total of 162 potential systematic reviews for full text screening regarding 28 healthcare professionals’ uncertainties (see
Uncertainty | Decision type | Decision level | Reviews |
1.Systematic review | 2.Addresses uncertainty | 3.Published in last 5 years | 4.Identifies robust evidence |
---|---|---|---|---|---|---|---|
1 | Intervention | Patient | 0 | 0 | 0 | 0 | 0 |
2 | Assessment | Wound | 5 | 2 | 1 | 1 | 0 |
3 | Assessment | Service | 12 | 10 | 0 | 0 | 0 |
4a | Intervention | Service | 3 | 3 | 0 | 0 | 0 |
4b | Intervention | Service | 0 | 0 | 0 | 0 | 0 |
5 | Intervention | Service | 17 | 11 | 4 | 2 | 0 |
6 | Intervention | Service | 3 | 2 | 0 | 0 | 0 |
7 | Intervention | Service | 17 | 6 | 1 | 0 | 0 |
8 | Intervention | Wound | 0 | 0 | 0 | 0 | 0 |
9 | Intervention | Service | 5 | 4 | 0 | 0 | 0 |
10a | Diagnosis | Wound | 2 | 0 | 0 | 0 | 0 |
10b | Intervention | Wound | 3 | 1 | 0 | 0 | 0 |
11 | Intervention | Service | 4 | 4 | 0 | 0 | 0 |
12 | Intervention | Wound | 9 | 4 | 4 | 2 | 0 |
13 | Intervention | Wound | 2 | 2 | 0 | 0 | 0 |
14 | Intervention | Wound | 13 | 11 | 1 | 1 | 0 |
15a | Diagnosis | Wound | 3 | 0 | 0 | 0 | 0 |
15b | Intervention | Wound | 3 | 0 | 0 | 0 | 0 |
16 | Intervention | Patient | 11 | 11 | 7 | 4 | 0 |
17 | Intervention | Wound | 10 | 7 | 1 | 0 | 0 |
18 | Intervention | Wound | 4 | 4 | 0 | 0 | 0 |
19 | Intervention | Wound | 2 | 2 | 2 | 2 | 0 |
20 | Intervention | Patient | 2 | 1 | 0 | 0 | 0 |
21 | Intervention | Service | 9 | 6 | 0 | 0 | 0 |
22 | Intervention | Wound | 3 | 3 | 1 | 1 | 0 |
23 | Intervention | Wound | 10 | 8 | 5 | 4 | 0 |
24 | Intervention | Service | 5 | 3 | 0 | 0 | 0 |
25 | Intervention | Wound | 5 | 1 | 1 | 1 | 0 |
Total | 162 | 106 | 28 | 18 | 0 |
We have mapped the availability of relevant, up-to-date systematic reviews against 28 wound care decision uncertainties identified and prioritised by community-based healthcare professionals (nurses, podiatrists and managers). In the final stage of our mapping process we assessed the quality of primary research evidence identified in each systematic review and judged the extent to which it closed the expressed uncertainty (i.e. “answered the question”). A previous initiative, the Global Evidence Mapping (GEM) Initiative, considered evidence for Traumatic Brain and Spinal Cord Injuries [
After extensive searching we found that none of the 28 wound care uncertainties are resolved by good quality primary research evidence found within up-to-date systematic reviews. Following thorough scrutiny we found there were 19 important uncertainties with no relevant, up to date systematic reviews. While we identified 18 up-to-date, systematic reviews relevant to 9/28 uncertainties, none of these reviews identified high quality research evidence that answered the question. We did not, therefore, find that healthcare professionals were unaware of good wound care evidence (i.e. we did not identify wound care research knowledge transfer or implementation gaps). Instead, we identified a lack of systematic reviews and high quality primary research evidence; while not explicitly linked with evidence to meet clinical uncertainties, a lack of good quality wound care research has been previously reported [
Our search and screening originally identified 162 review articles of which 57 were rejected as not meeting our pre-determined definition of a ‘systematic review’. Most commonly these rejected reviews either did not have an explicit, comprehensive search strategy with evidence of systematic data extraction or evidence of critical appraisal of included studies. Some of these ineligible reviews were entitled ‘systematic reviews,’ highlighting that readers should be aware of misleading labelling of wound care publications and need to be able to distinguish systematic from other forms of review. It should also be noted that both “unsystematic” and out of date systematic reviews have the potential for producing misleading information for busy practitioners who do not have the resources to undertake full critical appraisals of the information they need to inform decision-making. The issue of review mislabelling also has significance for journal editors who should ensure that reviews they accept for publication and label as ‘systematic reviews’ adhere to PRISMA reporting guidelines [
We were unable to find any systematic review for six uncertainties (
Once a review has been undertaken, it needs to be updated as new research becomes available (such an approach is advocated by Cochrane [
We classified the 28 complex wound care uncertainties identified by healthcare professionals in accordance with the type and level of decision. Through this process we found that most uncertainties concerned decisions about interventions (24 of 28); this concurs with previous evidence gathered from nurses in hospital and community settings which concluded that most of their clinical judgements concerned selection of interventions [
We already know that there are deficiencies in the randomised controlled trials conducted about wound treatments [
We also uniquely identified that while most uncertainties concerned wound level decisions, service level decisions tended to have the highest priority: the reasons for this are likely to be multi-factorial. One partial explanation may be the importance of service delivery and management decisions in wound care [
While we identified 75 reviews for ten service level uncertainties, only five were relevant and systematic. Cochrane Effective Practice and Organisation of Care [
Nearly 73% (77/106) of the systematic reviews we found did not sufficiently match the key elements of the healthcare professionals’ uncertainties and this raises essential questions about the nature of research evidence and who is involved in producing it, as ensuring the relevance and applicability for clinical practice of research is essential in order to maximise its value and avoid research waste [
Indeed it has been suggested that the very process of identifying and prioritising researchable questions is part of the researchers’ tacit knowledge [
When considering and prioritising clinical uncertainties it is important to consider that some staff may feel relatively ‘certain’ about some clinical decisions where research evidence is uncertain. This, in turn, might impact on how uncertainties are prioritised. For example, treatment clinical decisions might be informed by local policies and tradition rather than research knowledge [
We acknowledge some limitations regarding this paper. The clinical wound care uncertainties were generated by healthcare managers and practitioners in one locality of the UK and did not include the voices of patients and service planners. Nonetheless, given that we were unable to identify robust, research-based information on the priority areas in the international literature; and given their nature, we think it is likely these questions have relevance nationally and probably internationally (although the prioritisation may vary). The uncertainties of service planners and patients are also important and investigation of these stakeholders’ uncertainties needs further investigation. We propose that our mapping method, as presented in this paper, is an applicable adjuvant to such work.
Our mapping used simple search strategies which may have missed some evidence accessible through other unsearched databases; however, we searched databases through which we were most likely to identify international and quality healthcare systematic reviews. In determining if something addressed the uncertainty question directly or indirectly a measure of judgement required in deciding how much of the uncertainty was answered; however, we increased the reliability of our judgements by a consensus approach and dialogue with fellow investigators.
We acknowledge that we have only included systematic reviews and that some clinical guidelines are based on systematic review evidence undertaken during the guideline development process. We attempted to review systematic reviews that were part of guidelines and identified 44,000 guidelines relevant to the 28 uncertainties and then drew a purposeful sample of the first three, highest prioritised uncertainties (1 wound level intervention, 1 patient level assessment and 1 service level assessment). We found that none of the 100 guidelines we evaluated from 13000 search results for these 3 uncertainties had identified relevant, contemporary, high quality systematic review evidence; therefore, we conclude our findings are robust.
Our uncertainties were only collected from one locality within the UK; however, we contend that the uncertainties identified can apply to other complex wound care settings and are not addressed by internationally accessible systematic reviews. Nonetheless, the ranking of wound care uncertainties may vary between localities and should be verified in other settings. Finally we note that some uncertainties may have been addressed by primary research which are yet to be included in an up-to-date systematic review.
The currently available systematic reviews do not address community healthcare professionals’ wound care uncertainties. Whilst good quality systematic reviews have been conducted, many uncertainties remain and further rigorous reviews are required to meet demand. This is the first study that mapped and evaluated complex wound care uncertainties identified by healthcare professionals; and the first to compare healthcare professionals’ prioritised wound care uncertainties against existing systematic review evidence, through development of a decision-making typology and evidence mapping. This paper generates insight for researchers and commissioners of wound care research to inform the development and commissioning of meaningful research that avoids research waste. The methods presented here can also be used to assess other types of the research evidence or evidence about uncertainties generated in other healthcare fields. Our evidence mapping also generates useful knowledge for educators and healthcare managers about the types of wound care decisions that currently do not have a strong, synthesised and appraised research-base; where healthcare professionals and patients may need guidance until a better wound care evidence-base is established.
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The authors are grateful to Katy Rothwell, Programme Manager, NIHR CLAHRC Greater Manchester and many colleagues within the CLAHRC Wound Care Programme, who have assisted with and supported this work. We also thank the four community NHS Trusts in Greater Manchester for their backing and Reetu Child, Academic Engagement Librarian at the University of Manchester, who helped us to define wound care terms and refine our initial search strategies.