Background: We explored the performance of three machine learning tools designed to facilitate title and abstract screening in systematic reviews (SRs) when used to (a) eliminate irrelevant records (automated simulation) and (b) complement the work of a single reviewer (semi-automated simulation). We evaluated user experiences for each tool.Methods: We subjected three SRs to two retrospective screening simulations. In each tool (Abstrackr, DistillerSR, RobotAnalyst), we screened a 200-record training set and downloaded the predicted relevance of the remaining records. We calculated the proportion missed and workload and time savings compared to dual independent screening. To test user experiences, eight research staff tried each tool and completed a survey.Results: Using Abstrackr, DistillerSR, and RobotAnalyst, respectively, the median (range) proportion missed was 5 (0 to 28) percent, 97 (96 to 100) percent, and 70 (23 to 100) percent for the automated simulation and 1 (0 to 2) percent, 2 (0 to 7) percent, and 2 (0 to 4) percent for the semi-automated simulation. The median (range) workload savings was 90 (82 to 93) percent, 99 (98 to 99) percent, and 85 (85 to 88) percent for the automated simulation and 40 (32 to 43) percent, 49 (48 to 49) percent, and 35 (34 to 38) percent for the semi-automated simulation. The median (range) time savings was 154 (91 to 183), 185 (95 to 201), and 157 (86 to 172) hours for the automated simulation and 61 (42 to 82), 92 (46 to 100), and 64 (37 to 71) hours for the semi-automated simulation. Abstrackr identified 33–90% of records missed by a single reviewer. RobotAnalyst performed less well and DistillerSR provided no relative advantage. User experiences depended on user friendliness, qualities of the user interface, features and functions, trustworthiness, ease and speed of obtaining predictions, and practicality of the export file(s).Conclusions: The workload savings afforded in the automated simulation came with increased risk of missing relevant records. Supplementing a single reviewer’s decisions with relevance predictions (semi-automated simulation) sometimes reduced the proportion missed, but performance varied by tool and SR. Designing tools based on reviewers’ self-identified preferences may improve their compatibility with present workflows.Systematic review registration: Not applicable.

Overviews of reviews of healthcare interventions (overviews) integrate information from multiple systematic reviews (SRs) to provide a single synthesis of relevant evidence for decision-making. Overviews may identify multiple SRs that examine the same intervention for the same condition and include some, but not all, of the same primary studies. Different researchers use different approaches to manage these “overlapping SRs,” but each approach has advantages and disadvantages. This study aimed to develop an evidence-based decision tool to help researchers make informed inclusion decisions when conducting overviews of healthcare interventions. We used a two-stage process to develop the decision tool. First, we conducted a multiple case study to obtain empirical evidence upon which the tool is based. We systematically conducted seven overviews five times each, making five different decisions about which SRs to include in the overviews, for a total of 35 overviews; we then examined the impact of the five inclusion decisions on the overviews’ comprehensiveness and challenges, within and across the seven overview cases. Second, we used a structured, iterative process to transform the evidence obtained from the multiple case study into an empirically based decision tool with accompanying descriptive text. The resulting decision tool contains four questions: (1) Do Cochrane SRs likely examine all relevant intervention comparisons and available data? (2) Do the Cochrane SRs overlap? (3) Do the non-Cochrane SRs overlap? (4) Are researchers prepared and able to avoid double-counting outcome data from overlapping SRs, by ensuring that each primary study’s outcome data are extracted from overlapping SRs only once? Guidance is provided to help researchers answer each question, and empirical evidence is provided regarding the advantages, disadvantages, and potential trade-offs of the different inclusion decisions. This evidence-based decision tool is designed to provide researchers with the knowledge and means to make informed inclusion decisions in overviews. The tool can provide practical guidance and support for overview authors by helping them consider questions that could affect the comprehensiveness and complexity of their overviews. We hope this tool will be a useful resource for researchers conducting overviews, and we welcome discussion, testing, and refinement of the proposed tool.

The use of technology such as computers, tablets, and smartphones to improve access to and the delivery of mental health care (eMental Health care) is growing worldwide. However, despite the rapidly expanding evidence base demonstrating the efficacy of eMental Health care, its implementation in clinical practice and health care systems remains fragmented. To date, no peer-reviewed, key-informant studies have reported on the perspectives of decision-makers concerned with whether and how to implement eMental Health care. From September to November 2015, we conducted 31 interviews with key informants responsible for leadership, policy, research, and/ or information technology in organizations influential in the adoption of technology for eMental Health care. Deductive and inductive thematic analyses of transcripts were conducted using the Behavior Change Wheel as an organizing framework. Frequency and intensity effect sizes were calculated for emerging themes to further explore patterns within the data. Key informant responses (n = 31) representing 6 developed countries and multiple organizations showed consensus on common factors impacting implementation: individual and organizational capacities (e.g., computer literacy skills [patients and providers], knowledge gaps about cyber security, limited knowledge of available services); motivational drivers of technology-based care (e.g., extending care, data analytics); and opportunities for health systems to advance eMental Health care implementation (e.g., intersectoral research, rapid testing cycles, sustainable funding). Frequency effect sizes showed strong associations between implementation and credibility, knowledge, workflow, patient empowerment, electronic medical record (EMR) integration, sustained funding and intersectoral networks. Intensity effect sizes showed the highest concentration of statements (>10% of all comments) related to funding, credibility, knowledge gaps, and patient empowerment. This study provides previously unavailable information about key informant perspectives on eMental Health care implementation. The themes that emerged, namely the need to intensify intersectoral research, measure/monitor readiness to implement, define cost-utility benchmarks, raise awareness about available technologies, and test assumptions that ‘proven’ technologies will be easily integrated can inform the design and evaluation of eMental Health care implementation models.

Background: The clinical pathway is a tool that operationalizes best evidence recommendations and clinical practice guidelines in an accessible format for ‘point of care’ management by multidisciplinary health teams in hospital settings. While high-quality, expert-developed clinical pathways have many potential benefits, their impact has been limited by variable implementation strategies and suboptimal research designs. Best strategies for implementing pathways into hospital settings remain unknown. This study will seek to develop and comprehensively evaluate best strategies for effective local implementation of externally developed expert clinical pathways. Design/methods: We will develop a theory-based and knowledge user-informed intervention strategy to implement two pediatric clinical pathways: asthma and gastroenteritis. Using a balanced incomplete block design, we will randomize 16 community emergency departments to receive the intervention for one clinical pathway and serve as control for the alternate clinical pathway, thus conducting two cluster randomized controlled trials to evaluate this implementation intervention. A minimization procedure will be used to randomize sites. Intervention sites will receive a tailored strategy to support full clinical pathway implementation. We will evaluate implementation strategy effectiveness through measurement of relevant process and clinical outcomes. The primary process outcome will be the presence of an appropriately completed clinical pathway on the chart for relevant patients. Primary clinical outcomes for each clinical pathway include the following: Asthma—the proportion of asthmatic patients treated appropriately with corticosteroids in the emergency department and at discharge; and Gastroenteritis—the proportion of relevant patients appropriately treated with oral rehydration therapy. Data sources include chart audits, administrative databases, environmental scans, and qualitative interviews. We will also conduct an overall process evaluation to assess the implementation strategy and an economic analysis to evaluate implementation costs and benefits. Discussion: This study will contribute to the body of evidence supporting effective strategies for clinical pathway implementation, and ultimately reducing the research to practice gaps by operationalizing best evidence care recommendations through effective use of clinical pathways. Trial registration: ClinicalTrials.gov:NCT01815710

Overviews of reviews (overviews) compile information from multiple systematic reviews (SRs) to provide a single synthesis of relevant evidence for decision-making. Overviews may identify multiple SRs that examine the same intervention for the same condition and include some, but not all, of the same primary studies. There is currently limited guidance on whether and how to include these overlapping SRs in overviews. Our objectives were to assess how different inclusion decisions in overviews of healthcare interventions affect their comprehensiveness and results, and document challenges encountered when making different inclusion decisions in overviews. We used five inclusion decisions to conduct overviews across seven topic areas, resulting in 35 overviews. The inclusion decisions were (1) include all Cochrane and non-Cochrane SRs, (2) include only Cochrane SRs, or consider all Cochrane and non-Cochrane SRs but include only non-overlapping SRs, and in the case of overlapping SRs, select (3) the Cochrane SR, (4) the most recent SR (by publication or search date), or (5) the highest quality SR (assessed using AMSTAR). For each topic area and inclusion scenario, we documented the amount of outcome data lost and changed and the challenges involved. When conducting overviews, including only Cochrane SRs, instead of all SRs, often led to loss/change of outcome data (median 31% of outcomes lost/changed; range 0–100%). Considering all Cochrane and non-Cochrane SRs but including only non-overlapping SRs and selecting the Cochrane SR for groups of overlapping SRs (instead of the most recent or highest quality SRs) allowed the most outcome data to be recaptured (median 42% of lost/changed outcome recaptured; range 28–86%). Across all inclusion scenarios, challenges were encountered when extracting data from overlapping SRs. Overlapping SRs present a methodological challenge for overview authors. This study demonstrates that different inclusion decisions affect the comprehensiveness and results of overviews in different ways, depending in part on whether Cochrane SRs examine all intervention comparisons relevant to the overview. Study results were used to develop an evidence-based decision tool that provides practical guidance for overview authors.

Use of the Internet to deliver cognitive behavioural therapy, a frontline treatment for anxiety disorders, is emerging as an option to increase access to treatment among adolescents with anxiety disorders. This study examined the usability of the Internet-based component of Breathe, a CBT program designed for adolescents with mild to moderate anxiety and impairments. A mixed-method usability testing design with semi-structured interviews, task completion, and survey by trained usability moderators was undertaken with two interactive cycles to determine the usability (ease of use, efficiency, errors, and user satisfaction) of the user interface and content areas of the program. Purposeful sampling was used to recruit mental health clinicians with expertise in treating adolescent anxiety disorders and young people aged 15 to 24 years involved. Testing involved using Web-conferencing software that allowed remote participation through personal computers. Two testing cycles involved participants completing structured ‘think aloud’ and ‘cognitive walkthrough’ tasks within the program. At the end of each cycle participants completed a 15-item global usability evaluation survey and were asked a series of open-ended questions. Descriptive and simple content analyses were used to identify and score usability issues for frequency and severity. Five clinicians and four young people (all < 20 years of age) participated. Most participants described their computer skills as ‘good’ (60 % clinicians, 50 % young people), and attitudes toward Internet-based health care ranged from negative (75 % young people) to positive (60 % clinicians, 25 % young people). Scores from the global usability evaluation after both testing cycles ranged from 3.5 to 5 out of 5 in strong agreement/support of the program in terms of user performance indicators (i.e., learnability, efficiency and number of errors) and user satisfaction. Participants were able to complete all critical tasks with minimal errors. Errors and issues identified during testing were predominantly around enhancements to the visual design and navigational support. Opinions across usability elements did not differ between young people and clinician participants. A multi-method remote usability approach provided the opportunity to improve the technical interface, therapeutic messaging and user experience of an Internet-based treatment program for adolescent anxiety disorders.