Rapid review question
What interventions are effective in increasing uptake and completion of treatment for DR and /or DMO among people with diabetes in LMICs?
Protocol and registration
We used the STARR Decision Tool and the WHO practical guide to carefully consider the methods most appropriate for this rapid review and the possible limitations introduced by those methods.25, 26
Additional file 1 provides the adapted preferred reporting items for systematic reviews and meta-analysis protocols (PRISMA-P) which is used to report this protocol.
The protocol was registered on the Open Science Framework (OSF): osf.io/h5wgr, more details are provided in Additional file 2. Any protocol amendments will be documented in the registration site.27
Eligibility Criteria
Table 1: Eligibility Criteria
Population
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Adults (aged ≥18 years) with Type 1 or Type 2 diabetes in LMICs who have been identified as needing treatment for DR and/or DMO
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Intervention
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Any intervention that seeks to increase uptake and/or completion of treatment for DR and/or DMO amongst adults with diabetes
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Comparator
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Usual care or another intervention
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Outcomes
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1.Proportion of patients initiating treatment for DR and/or DMO among those to whom it is recommended
2.Proportion of patients completing treatment for DR and/or DMO among those to whom it is recommended
3.Proportion of patients completing treatment for DR and/or DMO among those initiating treatment
4.Number and proportion of DR and/or DMO rounds from the recommended treatment protocol completed per patient
5.Cost-effectiveness of intervention to increase DR/DMO treatment uptake or completion
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Study design
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Any interventional or observational comparative study.
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We will limit the search to peer-reviewed publications of studies conducted in LMICs in any setting in the last 20 years, (i.e. community or facility-based), that examine the uptake and/or completion of treatment prescribed for DR or DMO. Studies will only be included if they report at least one of the first four outcomes. We will restrict to publications in the English language. We will only include studies where a full-text report is available.
Information Sources
We will search MEDLINE, Embase, Global Health and the Cochrane Register of Studies. The search strategies will be developed by a Cochrane Eyes and Vision Information Specialist (IG). Grey literature will not be considered.
Search strategy (included in Additional file 3)
Data management and selection process
Screening will be done using online review management software (Covidence, Veritas Health Innovation, Melbourne, Australia. Available at www.covidence.org). Each title and abstract will be screened independently by two reviewers. Disagreements will be resolved by discussion. Full text articles describing potentially relevant studies will be screened by two reviewers independently against the inclusion and exclusion criteria and any differences resolved by consensus. A PRISMA flow diagram will be completed to summarise the study selection process.
Risk of bias assessment
Risk of bias will be assessed by a single reviewer using SIGN critical appraisal checklists for this purpose, available at https://www.sign.ac.uk. The overall risk of bias for included studies will be reported in narrative form and used to interpret the findings of the review.
Data extraction
A custom designed Excel data extraction form will be piloted by two reviewers on 3 papers and adapted accordingly. Data will be extracted by one reviewer, and the accuracy of data extraction will be checked by a second reviewer for 10% of studies. If there are significant data extraction errors (for example important errors in more than 1% of records) then a further set of records will be checked. The following data items will be collected for each identified intervention.
Table 2. Data items
Data categories
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Example data outcomes
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Publication characteristics
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Authors, title, publication date, journal citation
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Study characteristics
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Design
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Dates of data collection
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Population characteristics
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Country
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Population demographics (age, gender)
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Sample size
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Intervention characteristics
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Setting (rural/urban, community/hospital)
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Intervention target: patients, providers, policy makers
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Treatment indication: pan retinal laser photocoagulation (PRP) for PDR, focal laser, intravitreal AntiVEGF or steroids for DMO
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Treatment completion guideline: e.g.: number of laser sessions, number of burns, number of injections.
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Type of intervention: e.g.: guidelines, treatment regime, educational programmes, financial subsidies, follow up prompts and reminders, ongoing quality assurance and improvement processes, electronic patient management
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Factors associated with uptake/completion of treatment: provider and patient
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Outcomes
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Proportion of patients initiating treatment for DR and/or DMO among those to whom it is recommended
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Proportion of patients completing treatment for DR and/or DMO among those to whom it is recommended
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Proportion of patients completing treatment for DR and/or DMO among those initiating treatment
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Number and proportion of DR and/or DMO rounds from the recommended treatment protocol completed per patient
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Cost-effectiveness of intervention to increase DR/DMO treatment uptake or completion
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Data synthesis
We anticipate that there will be clinical and methodological diversity in the studies that we find, so we plan to summarize the data narratively, following SWiM reporting guidance: Synthesis Without Meta-analysis.28
We will report outcomes in terms of proportions in intervention and comparator groups and will calculate the risk ratio with 95% confidence intervals as the main measure of effect, but this will be dependent on how the data are reported by the included studies. In observational studies, for example, adjusted odds ratios may be the most appropriate measure of effect. We will present key characteristics such as study design, sample size and risk of bias in tables and use visual displays for effect estimates when possible. We will consider heterogeneity by examining study design, geographical location, demographic characteristics such as age and sex as well as the nature of the interventions and the settings in which they have been applied. We will use the GRADE approach, as applied to narrative syntheses, to assess the certainty of the synthesis findings.29
Depending on the findings, we will group studies by setting, intervention target (patients, health providers, health system), type of intervention, study design and outcomes. For each comparison and outcome, we will provide a description of the findings alongside the certainty of the evidence, ensuring consistency with the review question and providing a judgement as to the extent to which the studies contribute to the synthesis.