Systematische Reviews zur Wirksamkeit der multidisziplinären Rehabilitation

Die systematische Auswertung („Review“) und Metaanalyse der Ergebnisse kontrollierter klinischer Studien gilt als „Goldstandard“ der evidenzbasierten Medizin und kann dennoch zu unterschiedlichen und sogar vermeintlich widersprüchlichen Ergebnissen führen. Die folgenden Ausführungen sollen helfen, systematische Reviews zur multidisziplinären Rehabilitation korrekt zu interpretieren, um kritische Schlussfolgerungen für die klinische Praxis zu ermöglichen.

Abstract

Systematic reviews and meta-analyses of clinical trials are considered to represent the highest level of scientific evidence in clinical medicine provided internationally accepted guidelines and checklists are followed.

In systematic reviews and meta-analyses all clinical studies focussing a specific predefined clinical question are collected and evaluated. The results of systematic reviews strongly depend on the study protocol, including the exact definition of the population of interest, the therapeutic intervention under consideration and, last not least, the time period of observation. Moreover, evaluating multidisciplinary rehabilitation, its specifications with regard to therapeutic content, intensity and duration, supervision and general framework must be considered for correctly estimating determinants that control therapeutic success or failure.

The range of potential risks of bias arising during planning, realization and publication of clinical studies is considerable and needs to be carefully estimated with regard to each single study included in meta-analysis.

Taking together, the incremental scientific value of systematic reviews and meta-analyses cannot be taken for granted, but strongly depends on the methodological quality of the clinical studies being included as well as on the systematic process of the meta-analysis and the critical interpretation of the results.

Schlüsselwörter

systematische Übersichtsarbeiten - systematische Reviews - Metaanalyse - multidisziplinäre Rehabilitation - klinische Wirksamkeit - wissenschaftliche Evidenz

Keywords

systematic review - meta-analyses - multidisciplinary rehabilitation - clinical effectiveness - scientific evidence

Publication History

Article published online:
07 June 2024

• Literatur

• 1 Anderson L, Oldridge N, Thompson DR. et al. Exercise-Based Cardiac Rehabilitation for Coronary Heart Disease: Cochrane Systematic Review and Meta-Analysis. J Am Coll Cardiol 2016; 67: 1-12
• 2 van Halewijn G, Deckers J, Tay HY. et al. Lessons from contemporary trials of cardiovascular prevention and rehabilitation: A systematic review and meta-analysis. Int J Cardiol 2017; 232: 294-303
• 3 Salzwedel A, Jensen K, Rauch B. et al. Effectiveness of comprehensive cardiac rehabilitation in coronary artery disease patients treated according to contemporary evidence based medicine: Update of the Cardiac Rehabilitation Outcome Study (CROS-II. Eur J Prev Cardiolog 2020; 27: 1756-1774
• 4 Oxford Centre for Evidence-Based Medicine: Levels of Evidence (March 2009) – Centre for Evidence-Based Medicine (CEBM), University of Oxford (22.09.2022). Im Internet: https://www.cebm.ox.ac.uk/resources/levels-of-evidence/oxford-centre-for-evidence-based-medicine-levels-of-evidence-march-2009; Stand: 16.01.2023
• 5 Deutsches Institut für Medizinische Dokumentation und Information. ICF: Internationale Klassifikation der Funktionsfähigkeit, Behinderung und Gesundheit. DIMDI-Klassifikationen. Neu-Isenburg: MMI, Med. Medien-Informations-GmbH; 2005
• 6 Boutron I, Altman DG, Moher D. et al. CONSORT Statement for Randomized Trials of Nonpharmacologic Treatments: A 2017 Update and a CONSORT Extension for Nonpharmacologic Trial Abstracts. Ann Intern Med 2017; 167: 40-47
• 7 Page MJ, McKenzie J, Bossuyt P. et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. Rev Esp Cardiol (Engl Ed) 2021; 74: 790-799
• 8 Moher D, Liberati A, Tetzlaff J. et al. Bevorzugte Report Items für systematische Übersichten und Meta-Analysen: Das PRISMA-Statement. Dtsch Med Wochenschr 2011; 136: e25-e25
• 9 Brooke BS, Schwartz TA, Pawlik TM.. MOOSE Reporting Guidelines for Meta-analyses of Observational Studies. JAMA Surg 2021; 156: 787-788
• 10 Critical Appraisal Skills Programme. CASP Systematic Review Checklist. Im Internet: https://casp-uk.net/images/checklist/documents/CASP-Systematic-Review-Checklist/CASP-Systematic-Review-Checklist-2018_fillable-form.pdf; Stand: 16.02.2023
• 11 Booth A, Clarke M, Dooley G. et al. The nuts and bolts of PROSPERO: an international prospective register of systematic reviews. Syst Rev 2012; 1: 2
• 12 Rauch B, Salzwedel A, Bjarnason-Wehrens B. et al. Cardiac Rehabilitation in German Speaking Countries of Europe-Evidence-Based Guidelines from Germany, Austria and Switzerland LLKardReha-DACH-Part 1. J Clin Med 2021; 10: 2192
• 13 Rauch G, Rauch B, Schüler S. et al. Opportunities and challenges of clinical trials in cardiology using composite primary endpoints. World J Cardiol 2015; 7: 1-5
• 14 Higgins JPT, Thompson SG.. Quantifying heterogeneity in a meta-analysis. Stat Med 2002; 21: 1539-1558
• 15 Rücker G, Schwarzer G, Carpenter JR. et al. Undue reliance on I(2) in assessing heterogeneity may mislead. BMC Med Res Methodol 2008; 8: 79
• 16 Lundh A, Gøtzsche PC.. Recommendations by Cochrane Review Groups for assessment of the risk of bias in studies. BMC Med Res Methodol 2008; 8: 22
• 17 Wells GA, Shea B, OʼConnell D. et al. The Newcastle-Ottawa Scale (NOS) for assessing the quality of nonrandomised studies in meta-analyses. Im Internet: http://www.ohri.ca/programs/clinical_epidemiology/oxford.asp; Stand: 16.01.2023
• 18 Wells GA, Shea B, Higgins JPT. et al. Checklists of methodological issues for review authors to consider when including non-randomized studies in systematic reviews. Res Synth Methods 2013; 4: 63-77
• 19 Sterne JA, Hernán MA, Reeves BC. et al. ROBINS-I: a tool for assessing risk of bias in non-randomised studies of interventions. BMJ 2016; 355: i4919
• 20 Nussbaumer-Streit B, Grillich L, Glechner A. et al. GRADE: Von der Evidenz zur Empfehlung oder Entscheidung – ein systematischer und transparenter Ansatz, um gut informierte Entscheidungen im Gesundheitswesen zu treffen. 1: Einleitung. Z Evid Fortbild Qual Gesundhwes 2018; 134: 57-66
• 21 Fisher LD, Dixon DO, Herson J. et al. Intention to Treat in Clinical Trials. In: Peace K, ed. Statistical Issues in Drug Research and Development. Boca Raton, FL: CRC Press; 2017: 331-350
• 22 Egger M, Davey Smith G, Schneider M. et al. Bias in meta-analysis detected by a simple, graphical test. BMJ 1997; 315: 629-634