The Effectiveness of Exercise Interventions for the Management of Frailty: A Systematic Review Systematic Reviews of Diagnostic Test Accuracy Screening for frailty among older patients with cancer that qualify for abdominal surgery. Protocol for a systematic review of the diagnostic and prognostic utility of tests currently available for the detection of aspirin resistance in patients with established cardiovascular or cerebrovascular disease Effectiveness of exercise interventions on physical function in community-dwelling frail older people: an umbrella review of systematic reviews PROBAST: A Tool to Assess the Risk of Bias and Applicability of Prediction Model Studies PROBAST: A Tool to Assess Risk of Bias and Applicability of Prediction Model Studies: Explanation and Elaboration Interrater reliability in assessing quality of diagnostic accuracy studies using the QUADAS tool. A preliminary assessment. Hysterosalpingosonography for diagnosing tubal occlusion in subfertile women: a systematic review protocol Diagnostic utility of facet (zygapophysial) joint injections in chronic spinal pain: a systematic review of evidence. Rayyan—a web and mobile app for systematic reviews The Development and Validation of a Quality Assessment and Rating of Technique for Injections of the Spine (AQUARIUS) Evaluation of a frailty index based on a comprehensive geriatric assessment in a population based study of elderly Canadians All in the Family: systematic reviews, rapid reviews, scoping reviews, realist reviews, and more Determinants of weight loss maintenance: a systematic review. Comparison of tools for assessing the methodological quality of primary and secondary studies in health technology assessment reports in Germany Home-based health promotion for older people with mild frailty: the HomeHealth intervention development and feasibility RCT. Are interventions effective in improving the ability of older adults to rise from the floor independently? A mixed method systematic review GRADE: assessing the quality of evidence for diagnostic recommendations Evaluation of the Quality of Prognosis Studies in Systematic Reviews Water-loss (intracellular) dehydration assessed using urinary tests: how well do they work? Diagnostic accuracy in older people. Balancing the strengths of systematic and narrative reviews. The effectiveness of interventions to reduce undernutrition and promote eating in older adults with dementia: A systematic review
This systematic review examines the effectiveness of current exercise interventions for the management of frailty . Eight electronic data bases were search ed for r and omized controlled trials that identified their participants as “ frail ” either in the title , abstract , and /or text and included exercise as an independent component of the intervention . Three of the 47 included studies utilized a vali date d definition of frailty to categorize participants . Emerging evidence suggests that exercise  has a positive impact on some physical determinants and on all functional ability outcomes reported in this systematic review . Exercise programs that optimize the health of frail older adults seem to be different from those recommended for healthy older adults . There was a paucity of evidence to characterize the most beneficial exercise program for this population . However , multicomponent training interventions , of long duration ( ≥5 months ) , performed three times per week , for 30–45 minutes per session , generally had superior outcomes than other exercise programs . In conclusion , structured exercise training seems to have a positive impact on frail older adults and may be used for the management of frailty Diagnosis is a critical component of health care , and clinicians , policymakers , and patients routinely face a range of questions regarding diagnostic tests . They want to know whether testing improves outcome ; what test to use , purchase , or recommend in practice guidelines ; and how to interpret test results . Well- design ed  diagnostic test accuracy studies can help in making these decisions , provided that they transparently and fully report their participants , tests , methods , and results as facilitated , for example , by the STARD ( St and ards for Reporting of Diagnostic Accuracy ) statement ( 1 ) . That 25-item checklist was published in many journals and is now adopted by more than 200 scientific journals worldwide . As in other areas of science , systematic review s and meta- analysis of accuracy studies can be used to obtain more precise estimates when small studies addressing the same test and patients in the same setting are available . Review s can also be useful to establish whether and how scientific findings vary by particular subgroups , and may provide summary estimates with a stronger generalizability than estimates from a single study . Systematic review s may help identify the risk for bias that may be present in the original studies and can be used to address questions that were not directly considered in the primary studies , such as comparisons between tests . The Cochrane Collaboration is the largest international organization preparing , maintaining , and promoting systematic review s to help people make well-informed decisions about health care ( 2 ) . The Collaboration decided in 2003 to make preparations for including systematic review s of diagnostic test accuracy in their Cochrane Data base of Systematic Review s. To enable this , a working group ( Appendix ) . was formed to develop methodology , software , and a h and book The first diagnostic test accuracy review was published in the Cochrane Data base in October 2008 . In this paper , we review recent method ological developments concerning problem formulation , location of literature , quality assessment , and meta- analysis of diagnostic accuracy studies by using our experience from the work on the Cochrane H and book . The information presented here is based on the recent literature and up date s previously published guidelines by Irwig and colleagues ( 3 ) . Definition of the Objectives of the Review Diagnostic test accuracy refers to the ability of a test to distinguish between patients with disease ( or more generally , a specified target condition ) and those without . In a study of test accuracy , the results of the test under evaluation , the index test , are compared with those of the reference st and ard determined in the same patients . The reference st and ard is an agreed-on and accurate method for identifying patients who have the target condition . Test results are typically categorized as positive or negative for the target condition . By using such binary test outcomes , the accuracy is most often expressed as the test 's sensitivity ( the proportion of patients with positive results on the reference st and ard that are also positive on the index test ) and specificity ( the proportion of patients with negative results on the reference st and ard that are also negative on the index test ) . Other measures have been proposed and are in use ( 46 ) . It has long been recognized that test accuracy is not a fixed property of a test . It can vary between patient subgroups , with their spectrum of disease , with the clinical setting , or with the test interpreters and may depend on the results of previous testing . For this reason , inclusion of these elements in the study question is essential . In order to make a policy decision to promote use of a new index test , evidence is required that using the new test increases test accuracy over other testing options , including current practice , or that the new test has equivalent accuracy but offers other advantages ( 79 ) . As with the evaluation of interventions , systematic review s need to include comparative analyses between alternative testing strategies and should not focus solely on evaluating the performance of a test in isolation . In relation to the existing situation , 3 possible roles for a new test can be defined : replacement , triage , and add-on ( 7 ) . If a new test is to replace an existing test , then comparing the accuracy of both tests on the same population and with the same reference st and ard provides the most direct evidence . In triage , the new test is used before the existing test or testing pathway , and only patients with a particular result on the triage test continue the testing pathway . When a test is needed to rule out disease in patients who then need no further testing , a test that gives a minimal proportion of falsenegative results and thus a relatively high sensitivity should be used . Triage tests may be less accurate than existing ones , but they have other advantages , such as simplicity or low cost . A third possible role of a new test is add-on . The new test is then positioned after the existing testing pathway to identify false-positive or false-negative results after the existing pathway . The review should provide data to assess the incremental change in accuracy made by adding the new test . An example of a replacement question can be found in a systematic review of the diagnostic accuracy of urinary markers for primary bladder cancer ( 10 ) . Clinicians may use cytology to triage patients before they undergo invasive cystoscopy  , the reference st and ard for bladder cancer . Because cytology combines high specificity with low sensitivity ( 11 ) , the goal of the review was to identify a tumor marker with sufficient accuracy to either replace cytology or be used in addition to cytology . For a marker to replace cytology , it has to achieve equally high specificity with improved sensitivity . New markers that are sensitive but not specific may have roles as adjuncts to conventional testing . The review included studies in which the test under evaluation ( several different tumor markers and cytology ) was evaluated against cystoscopy or histopathology . Included studies compared 1 or more of the markers , cytology only , or a combination of markers and cytology . Although information on accuracy can help clinicians make decisions about tests , good diagnostic accuracy is a desirable but not sufficient condition for the effectiveness of a test ( 8) . To demonstrate that using a new test does more good than harm to patients tested , r and omized trials of test- and -treatment strategies and review s of such trials may be necessary . However , with the possible exception of screening , in most cases , such r and omized trials are not available and systematic review s of test accuracy may provide the most useful evidence available to guide clinical and health policy decision making and use as input for decision and cost-effectiveness analysis ( 12 ) . Identification and Selection of Studies Identifying test accuracy studies is more difficult than search ing for r and omized trials ( 13 ) . There is not a clear , unequivocal keyword or indexing term for an accuracy study in literature data bases comparable with the term r and omized , controlled trial . The Medical Subject Heading sensitivity and specificity may look suitable but is inconsistently applied in most electronic bibliographic data bases . Furthermore , data on diagnostic test accuracy may be hidden in studies that did not have test accuracy estimation as their primary objective . This complicates the efficient identification of diagnostic test accuracy studies in electronic data bases , such as MEDLINE . Until indexing systems properly code studies of test accuracy , search ing for them will remain challenging and may require additional manual search es , such as screening reference lists . In the development of a comprehensive search strategy , review authors can use search strings that refer to the test(s ) under evaluation , the target condition , and the patient description or a subset of these . For tests with a clear name that are used for a single purpose , search ing for publications in which those tests are mentioned may suffice . For other review s , adding the patient description may be necessary , although this is also often poorly indexed . A search strategy in MEDLINE should contain both Medical Subject Headings and free text words . A search strategy for articles about tests for bladder cancer , for example , should include as many synonyms for bladder cancer as possible in the search strategy , including neoplasm , carcinoma , transitional cell , and hematuria . Several method ological electronic search filters for diagnostic test accuracy studies have been developed , each attempting to restrict the search to articles that are most likely to be test accuracy studies ( 1316 ) . These filters rely on indexing terms for research methodology and text words used in reporting results , but they often miss relevant studies and are unlikely to decrease the number of articles one needs to screen . Therefore , they are not recommended for systematic review s ( 17 , 18 ) . The incremental value of search ing in language s other than English and in the gray literature has not yet been fully investigated . In systematic review s of intervention studies , publication bias is an important and well-studied form of bias in which the decision to report and publish studies is linked to their findings . For clinical trials , the magnitude and determinants of publication bias have been identified by tracing the publication history of cohorts of trials review ed by ethics committees and research boards ( 19 ) . A consistent observation has been that studies with significant results are more likely to be published than studies with nonsignificant findings ( 19 ) . Investigating publication bias for diagnostic tests is problematic , because many studies are done without ethical review or study registration ; therefore , identification of cohorts of studies from registration to final publication status OBJECTIVE The Geriatric Assessment ( GA ) is an established method for evaluating and optimizing diagnostic and treatment plans . However , it requires experience and is time-consuming . Therefore , a variety of screening methods have been developed . The aim of this study was to compare their accuracy for predicting frailty among older patients with cancer qualified for abdominal surgery based on comparison to the GA . MATERIAL AND METHODS One hundred and thirty five consecutive patients ≥65years of age were prospect ively enrolled . The diagnostic performance of eight screening tests was evaluated : The Vulnerable Elderly Survey ( VES-13 ) , Triage Risk Screening Tool ( TRST ) , Geriatric 8 ( G8 ) , Groningen Frailty Index ( GFI ) , abbreviated Comprehensive Geriatric Assessment ( aCGA ) , Rockwood , Balducci and Fried score . RESULTS The prevalence of frailty as diagnosed by the GA was 73 % . Screening methods identified frail patients in 40 - 75.5 % of cases . The sensitivity and specificity of these tests in predicting frailty were 52%-97 % ( Fried score-G8 ) and 44 - 100 % ( G8-Rockwood score ) , respectively . The positive and negative predictive values were 82 - 100 % ( Balducci-Rockwood ) and 43 - 84 % ( TRST-G8 ) , respectively . Age significantly influenced the predictive value of the screening tests whereas gender and type of cancer did not . CONCLUSION At present , there is no universal screening test that adequately identifies frailty in at risk older patients . The results of this study showed that the aCGA and G8 were the best screens for older patients with cancer that qualified for elective abdominal surgery ; the G8 had the highest sensitivity and negative predictive value and the aCGA was a good overall assessment tool Background The benefits of aspirin as an anti-platelet agent are well established ; however , there has been much debate about the lack of uniformity in the efficacy of aspirin to inhibit platelet function . In some patients , aspirin fails to inhibit platelets even where compliance has been verified , a phenomenon which has been termed “ aspirin resistance ” . These patients may in turn be at a higher risk of future vascular events . The proportion of “ resistant ” patients identified depends on the type of platelet function test . Therefore , the aim of this systematic review is to determine which , if any , platelet function test has utility in terms of identifying patients with a high risk of vascular events . The review has been registered with PROSPERO ( CRD42012002151 ) . Methods Relevant studies will be sought from bibliographic data bases . Trials registers will be search ed for ongoing studies . Reference lists will be checked and subject experts contacted . There will be no date or language restrictions . St and ard review ing methodology to minimise bias will be employed . Any prospect i ve studies in patients on aspirin therapy and assessing platelet function in relation to relevant clinical outcomes will be included , as will studies reporting prognostic models . Risk of bias assessment will be based on the Quality Assessment of Diagnostic Accuracy Studies guidelines , and suitable criteria for assessing quality of prognostic studies . Data on test accuracy measures , relative risks , odds or hazard ratios will be extracted and meta-analysed , where possible , using a r and om-effects model to account for between- study heterogeneity . Where appropriate , the causes of heterogeneity will be explored through meta-regression and sub-group or sensitivity analyses . If platelet function testing is demonstrated to have diagnostic/predictive utility in a specific population , the potential for a cost-effectiveness analysis will be considered and , if possible , an economic model constructed . This will be supported by a systematic review of existing economic evaluation studies . Discussion The results of the review could indicate if platelet function test(s ) could lead to a reliable prediction of the risk of clinical ly important events in a defined population , and thus support investigations into adjustments to therapy in order to compensate for a predicted poor response to st and ard aspirin Objectives : This umbrella review aim ed to determine the effectiveness of exercise interventions , alone or in combination with other interventions , in improving physical function in community-dwelling older people identified as pre-frail or frail . Introduction : Exercise is said to have a positive impact on muscle mass and strength which improves physical function and hence is beneficial for the treatment of frailty . Several systematic review s discuss the effects of exercise interventions on physical function parameters , such as strength , mobility , gait , balance and physical performance , and indicate that multi-component exercise , including resistance , aerobic , balance and flexibility training , appears to be the best way in which to improve physical function parameters in frail older people . However , there is still uncertainty as to which exercise characteristics ( type , frequency , intensity , duration and combinations ) are the most effective and sustainable over the long-term . Inclusion criteria : Participants were adults , 60 years or over , living in the community and identified as pre-frail or frail . Quantitative systematic review s , with or without meta- analysis that examined the effectiveness of exercise interventions of any form , duration , frequency and intensity , alone or in combination with other interventions design ed to alter physical function parameters in frail older people , were considered . The quantitative outcome measures were physical function , including muscular strength , gait , balance , mobility and physical performance . Methods : An iterative search strategy for ten bibliometric data bases and gray literature was developed . Critical appraisal of seven systematic review s was conducted independently by two review ers using a st and ard Joanna Briggs Institute tool . Data was extracted independently by two review ers using a st and ard Joanna Briggs Institute data extraction tool and summarized using a narrative synthesis approach . Results : Seven systematic review s were included in this umbrella review , with a total of 58 relevant r and omized controlled trials and 6927 participants . Five systematic review s examined the effects of exercise only , while two systematic review s reported on exercise in combination with a nutritional approach , including protein supplementations , as well as fruit and dairy products . The average  exercise frequency was 2–3 times per week ( mean 3.0 ± 1.5 times per week ; range 1–7 weekly ) for 10–90 minutes per session ( mean of 52.0 ± 16.5 mins ) and a total duration of 5–72 weeks with the majority lasting a minimum of 2.5 months ( mean 22.7 ± 17.7 weeks ) . Multi-component exercise interventions can currently be recommended for pre-frail and frail older adults to improve muscular strength , gait speed , balance and physical performance , including resistance , aerobic , balance and flexibility tasks . Resistance training alone also appeared to be beneficial , in particular for improving muscular strength , gait speed and physical performance . Other types of exercise were not sufficiently studied and their effectiveness is yet to be established . Conclusions : Interventions for pre-frail and frail older adults should include multi-component exercises , including in particular resistance training , as well as aerobic , balance and flexibility tasks . Future research should adopt a consistent definition of frailty and investigate the effects of other types of exercise alone or in combination with nutritional interventions so that more specific recommendations can be made Prediction relates to estimating the probability of something currently unknown . In the context of medical research , prediction typically concerns either diagnosis ( probability of a certain condition being present but not yet detected ) or prognosis ( probability of an outcome developing in the future ) ( 13 ) . Prognosis applies not only to sick persons or those with an established diagnosis but also to , for example , pregnant women at risk for diabetes ( 4 ) . Prediction research includes predictor finding studies , prediction model studies ( development , validation , and extending or updating ) , and prediction model impact studies ( 1 ) . Predictor finding studies ( also known as risk factor or prognostic factor studies ) aim to identify which predictors ( such as age , disease stage , or biomarkers ) independently contribute to the prediction of a diagnostic or prognostic outcome ( 1 , 5 ) . Prediction model studies aim to develop , vali date , or up date ( for example , extend ) a multivariable prediction model . A prediction model uses multiple predictors in combination to estimate probabilities to inform and often guide individual care ( 2 , 6 , 7 ) . These models can predict an individual 's probability of either currently having a particular outcome or disease ( diagnostic prediction model ) or having a particular outcome in the future ( prognostic prediction model ) . Both types of model are widely used in various medical domains and setting s ( 810 ) , as evidence d by the large number of models developed in cancer ( 11 , 12 ) , neurology ( 13 , 14 ) , and cardiovascular disease ( 15 ) . Prediction models are sometimes described as  risk prediction models , predictive models , prediction indices or rules , or risk scores ( 2 , 7 ) . An example is QRISK2 for predicting cardiovascular risk ( 16 ) . Prediction model impact studies evaluate the effect of using a model to guide patient care compared with not using such a model . They use a comparative design , such as a r and omized trial , to study the model 's effect on clinical decision making , patient outcomes , or costs of care ( 1 ) . Systematic review s have a key role in evidence -based medicine and the development of clinical guidelines ( 1719 ) . They are considered to provide the most reliable form of evidence for the effects of an intervention or diagnostic test ( 20 , 21 ) . Systematic review s of prediction models are a relatively new and evolving area but are increasingly undertaken to systematic ally identify , appraise , and summarize evidence on the performance of prediction models ( 1 , 6 , 22 ) . Assessing the quality of included studies is a crucial step in any systematic review ( 20 , 21 ) . The QUIPS ( Quality In Prognosis Studies ) tool has been developed to assess risk of bias ( ROB ) in predictor finding ( prognostic factor ) studies ( 23 ) . Research ers can use the revised Cochrane ROB Tool ( ROB 2.0 ) ( 24 ) to investigate the method ological quality of prediction model impact studies that use a r and omized comparative design , or ROBINS-I ( Risk Of Bias In Nonr and omized Studies of Interventions ) for those that use a nonr and omized comparative design ( 25 ) . As more prediction model studies and systematic review s of such studies are used as evidence for clinical guidance , a tool facilitating quality assessment for individual prediction model studies is urgently needed . We present PROBAST ( Prediction model Risk Of Bias ASsessment Tool ) , a tool to assess the ROB and concerns regarding the applicability of diagnostic and prognostic prediction model studies . PROBAST can be used to assess studies of model development and model validation , including those updating a prediction model ( Box 1 [ 26 ] ) . We refer to the accompanying explanation and elaboration document ( 27 ) , for detailed explanations of how to use PROBAST and how to judge ROB and applicability . Box 1 . Types of diagnostic and prognostic modeling studies or reports addressed by PROBAST . Adopted from the TRIPOD ( Transparent Reporting of a multivariable prediction model for Individual Prognosis Or Diagnosis ) and CHARMS ( CHecklist for critical Appraisal and data extraction for systematic Review s of prediction Modelling Studies ) guidance ( 7 , 26 ) . PROBAST = Prediction model Risk Of Bias ASsessment Tool . Methods : Development of PROBAST Development of PROBAST was based on a 4-stage approach for developing health research reporting guidelines : define the scope , review the evidence base , use a Web-based Delphi procedure , and refine the tool through piloting ( 28 ) . Guidelines explicitly aim ed at the development of quality assessment tools were not available at the time ( 29 ) . Development Stage 1 : Scope and Definitions A steering group of 9 experts in prediction model studies and development of quality assessment tools agreed on key features of the desired scope of PROBAST . A panel of 38 experts with different background s further refined the scope during the Web-based Delphi procedure . PROBAST was design ed mainly to assess primary studies included in a systematic review . The group agreed that PROBAST would assess both risk of bias and concerns regarding applicability of a study evaluating a multivariable prediction model to be used for individualized diagnosis or prognosis . A domain-based structure was adopted , similar to that used in other ROB tools , such as ROB 2.0 ( 24 ) , ROBINS-I ( 25 ) , QUADAS-2 ( Quality Assessment of Diagnostic Accuracy Studies 2 ) ( 30 ) , and ROBIS ( 31 ) . We agreed that PROBAST should cover primary studies that develop , vali date , or up date multivariable prediction models aim ing to make individualized predictions of a diagnostic or prognostic outcome ( Box 1 ) . Studies that use multivariable modeling techniques to identify predictors ( such as risk or prognostic factors ) associated with an outcome but do not attempt to develop , vali date , or up date a model for making individualized predictions are not covered by PROBAST ( 5 ) . Therefore , PROBAST is not intended for predictor finding studies or prediction model impact studies . Studies of diagnostic and prognostic models often use different terms for predictors and outcomes ( Box 2 ) . A multivariable prediction model is defined as any combination or equation of 2 or more predictors for estimating probability or risk for an individual ( 6 , 7 , 3234 ) . Box 2 . Differences between diagnostic and prognostic prediction model studies . PROBAST = Prediction model Risk Of Bias ASsessment Tool . Development Stage 2 : Review of Evidence We used the following 3 approaches to build an evidence base to inform the development of PROBAST : identifying relevant method ological review s in the area of prediction model research ( November 2012 to January 2013 ) , asking members of the steering group to identify relevant method ological studies ( January 2013 to March 2013 ) , and using the Delphi procedure to ask members of the wider group to identify additional evidence ( February 2012 to July 2014 ) . Identified literature was used to guide the scope and produce an initial list of signaling questions to consider for inclusion in PROBAST ( 1 , 2 , 57 , 26 , 3340 ) . We grouped signaling questions into common themes to identify possible domains . Additional literature provided as part of the Web-based surveys informed development of the explanation and elaboration document . Development Stage 3 : Web-Based Delphi Procedure We used a modified Delphi process to gain feedback and agreement on the scope , structure , and content of PROBAST . Web-based surveys were developed to gather structured feedback for each round . The 38-member Delphi group comprised method ological experts in prediction model research and development of quality assessment tools , experienced systematic review ers , commissioners , and representatives of reimbursement agencies . We included various stakeholders to ensure that the views of end users , method ological experts , and decision makers were represented . The Delphi process consisted of 7 rounds . Round 1 asked about the scope of the tool , and participants agreed to focus on prediction model studies and follow a domain-based structure . Round 2 aim ed to identify relevant domains and agree on which to include . The signaling questions for domains were refined in rounds 3 to 5 . Respondents used a 1-to-5 Likert scale to rate each proposed signaling question for inclusion . They could also suggest rephrasing , provide supporting evidence ( such as references to relevant studies ) , and suggest missing signaling questions . Round 6 refined the domains and introduced further optional guidance for using PROBAST . In the last round , participants received the agreed draft version of PROBAST and had the opportunity to provide any final feedback . Development Stage 4 : Piloting and Refining the Tool We held 6 workshops on PROBAST at consecutive annual Cochrane Colloquia ( Quebec , Canada , 2013 ; Hyderabad , India , 2014 ; Vienna , Austria , 2015 ; Seoul , South Korea , 2016 ; Cape Town , South Africa , 2017 ; and Edinburgh , United Kingdom , 2018 ) . We also held numerous consecutive workshops with MSc and PhD students ( for example , the master 's program in epidemiology at Utrecht University [ Utrecht , the Netherl and s ] and the Evidence -Based Health Care program at Oxford University [ Oxford , United Kingdom ] ) . In these workshops , we piloted the then-current version of PROBAST to gather feedback on practical issues associated with using the tool so that we could further refine and subsequently vali date it . Finally , more than 50 review groups have already piloted PROBAST versions , including the final version , in their review s. Topics included cancer , cardiology , endocrinology , pulmonology , and orthopedics . All feedback received from these initiatives was used to further inform the content and structure of PROBAST , wording of the signaling questions , and content of the guidance documents ( 27 ) . Results : The PROBAST Tool What Does PROBAST Assess ? PROBAST assesses both risk of bias and concerns regarding applicability of primary studies that developed or vali date d multivariable prediction models for diagnosis or prognosis ( Boxes 1 and 2 ) Prediction models in health care aim to predict for an individual whether a particular outcome , such as disease , is present ( diagnostic models ) or whether it will occur in the future ( prognostic models ) ( 16 ) . Diagnostic models can be used to refer patients for further testing , to initiate treatment , or to inform patients . Prognostic models can be used to aid decisions about preventive lifestyle changes , therapeutic interventions , or monitoring strategies or to stratify risk in r and omized trial design and analysis ( 7 , 8) . Potential users of prediction models include health care professionals , policymakers , guideline developers , patients , and the general public . The medical literature contains thous and s of studies developing and validating prediction models and often has numerous prediction models for the same target population and outcomes . For example , more than 60 models address breast cancer prognosis ( 9 ) , more than 250 exist in obstetrics ( 10 ) , and nearly 800 predict outcomes in patients with cardiovascular disease ( 11 ) . This proliferation of prediction models will increase further with the growth of personalized or precision medicine . Systematic review s are considered the most reliable form of evidence when addressing r and omized therapeutic studies and studies of diagnostic test accuracy ( 12 ) . In the era of personalized and precision medicine , interest in systematic review s of prediction model studies is rapidly growing , as exemplified by the formation of the Cochrane Prognosis Methods Group to support systematic review s of prognosis , including prediction model studies ( 13 , 14 ) . Guidance to facilitate systematic review s of prediction models has been developed ( Table 1 ) , including for search strategies ( 15 , 4143 ) , formulation of the review question ( 16 , 17 ) , data extraction ( 16 ) , and meta- analysis ( 17 , 2225 , 40 , 44 , 45 ) . Table 1 . Guidance on Conducting Systematic Review s of Prediction Model Studies  Assessment of risk of bias ( ROB ) is an essential step in any systematic review . Shortcomings in study design , conduct , and analysis can result in study estimates being at ROBthat is , at risk of results being flawed or distorted . When interpreting results from a systematic review , readers can draw stronger conclusions from a review based on primary studies at low ROB than from one based on studies at high or unclear ROB ( 46 ) . Identifying the studies most relevant to the setting s and population s targeted in the review ( based on the applicability of primary studies to the review question ) is also important . We therefore developed PROBAST ( Prediction model Risk Of Bias ASsessment Tool ) to address the lack of suitable tools design ed specifically to assess ROB and applicability of primary prediction model studies . PROBAST consists of 4 domains containing 20 signaling questions to facilitate ROB assessment ( 39 ) . The structure and rating system are similar to those in tools design ed to assess ROB in r and omized trials ( revised Cochrane ROB Tool [ ROB 2.0 ] ) , diagnostic accuracy studies ( QUADAS-2 [ Quality Assessment of Diagnostic Accuracy Studies 2 ] ) , and systematic review s ( ROBIS ) ( 37 , 47 , 48 ) . Although PROBAST was design ed for use in systematic review s of prediction model studies , it can also be used as a general tool for critical appraisal of ( primary ) prediction model studies . Here , we describe the rationale behind the domains and signaling questions , how to use them , and how to reach domain-level and overall judgments about ROB and applicability of primary studies to a review question . At the Web site ( www.probast.org ) , 5 filled-in examples from across the medical field illustrate these processes . Because this is an area of active research , the tool , examples , and accompanying guidance will be up date d when needed , and the latest version of PROBAST should always be downloaded from the Web site . Focus of PROBAST PROBAST is design ed to assess primary studies that develop , vali date , or up date ( for example , extend ) multivariable prediction models for diagnosis or prognosis ( Boxes 1 and 2 ) . A multivariable prediction model is defined as any combination or equation of 2 or more predictors ( such as age , sex , symptoms , signs , disease stage , or biomarkers ) for estimating for an individual the probability or risk of having ( diagnosis ) or developing ( prognosis ) a particular outcome ( 1 , 4 , 68 , 49 , 50 ) . Other names for prediction model include risk prediction model , predictive model , prediction index or rule , and risk score ( 1 , 38 , 4951 ) . Box 1 . Types of diagnostic and prognostic modeling studies or reports addressed by PROBAST . Adopted from the TRIPOD ( Transparent Reporting of a multivariable prediction model for Individual Prognosis Or Diagnosis ) and CHARMS ( CHecklist for critical Appraisal and data extraction for systematic Review s of prediction Modelling Studies ) guidance ( 8 , 16 ) . Box 2 . Differences between diagnostic and prognostic prediction model studies . PROBAST = Prediction model Risk Of Bias ASsessment Tool . Diagnostic and Prognostic Models Diagnostic prediction models estimate the probability that a certain outcome , the target condition , is currently present . Diagnostic prediction model studies typically include individuals who are suspectedbut not yet knownto have the target condition . Prognostic prediction models estimate the probability that a future outcome or event will occur , such as death , disease recurrence , disease complication , or therapy response . The time period of prediction can vary from hours ( for example , preoperatively predicting postoperative nausea and vomiting ) to years ( for example , predicting lifelong risk for a coronary event ) . Although many prognostic models enroll patients with an established diagnosis , this does not have to be the starting point , as seen in models for predicting development of diabetes in pregnant women ( 52 ) or of osteoporotic fractures in the general population ( 53 ) . Consistent with the TRIPOD ( Transparent Reporting of a multivariable prediction model for Individual Prognosis Or Diagnosis ) statement ( 7 , 8) , PROBAST thus broadly defines prognostic models as those predicting a future outcome in persons at risk for that outcome . Diagnostic and prognostic model studies often use different terms for predictors and outcomes ( Box 2 ) . The cancer literature frequently distinguishes between prognostic and predictive models , such that predictive models identify individuals with differential treatment effects ( 54 ) . These types of ( predictive ) models are outside the scope of this article . Types of Predictors , Outcomes , and Modeling Techniques PROBAST can be used to assess any type of diagnostic or prognostic prediction model aim ed at individualized predictions regardless of the predictors used ; outcomes being predicted ; or methods used to develop , vali date , or up date ( for example , extend ) the model . Predictors range from demographic characteristics , medical history , and physical examination results ; to imaging results , electrophysiology , blood , urine , or tissue measurements , and disease stages or characteristics ; to results from omics and other new biological measurements . Predictors are also called covariates , risk indicators , prognostic factors , determinants , index test results , or independent variables ( 4 , 68 , 49 , 50 , 55 , 56 , 57 ) . PROBAST distinguishes between c and i date predictors and predictors included in the final model ( 57 ) . C and i date predictors are variables considered potentially predictive of the outcome presence ( diagnosis ) or occurrence (prognosis)that is , all those evaluated in the study regardless of whether they are included in the final multivariable model . PROBAST primarily addresses prediction models for binary and time-to-event outcomes because these are the most common in medicine . However , the tool can also be used to assess models predicting nonbinary outcomes , such as continuous scores ( for example , pain scores or cholesterol levels ) or categorical outcomes ( for example , the Glasgow Coma Scale ) . Almost all PROBAST signaling questions apply equally to continuous and categorical outcomes , except questions addressing number of outcome events per predictor and certain measures of model performance ( such as the c-statistic ) , which are not relevant to continuous outcomes . Prediction models usually involve regression modeling techniques , such as logistic regression or survival models . Prediction models may also be developed or vali date d using nonregression techniques , such as neural networks , r and om forests , or support vector machines . As the use of routine care ( and big ) data increases , additional modeling techniques are becoming more common , including machine and artificial learning models . The main differences between studies using regression and other types of prediction modeling include the methods of data analysis ; nonregression development models can often have greater risks of overfitting when data are sparse , and the potential lack of transparency can affect the applicability and usability of the models . In the section on tailoring PROBAST with additional signaling questions , we provide guidance about how PROBAST can be adapted to address other types of outcomes and modeling techniques . Types of Review Questions PROBAST can be used to assess different types of systematic review questions . For some review questions , all prediction model studies are relevant ( including both development and validation ) , but for other questions only validation studies are relevant . Box 3 gives examples of potential review questions for both prognostic and diagnostic prediction models where PROBAST is applicable . CHARMS ( CHecklist for critical Appraisal and data extraction for systematic Review s of prediction Modelling Studies ) and Table 2 provide explicit guidance on how to frame a focused question for review s of prediction model studies ( 16 , 17 ) . Box 3 . Examples of systematic review questions for which PROBAST is suitable . There are various different questions that systematic review s RATIONALE AND OBJECTIVES Quality Assessment of Diagnostic Accuracy Studies ( QUADAS ) is a new tool to measure the method ological quality of diagnostic accuracy studies in systematic review s. We used data from a systematic review of magnetic resonance spectroscopy ( MRS ) in the characterization of suspected brain tumors to provide a preliminary evaluation of the inter-rater reliability of QUADAS . MATERIAL S AND METHODS A structured literature search identified 19 diagnostic accuracy studies . These publications were distributed r and omly to primary and secondary review ers for dual independent assessment . Review ers recorded method ological quality by using QUADAS on a custom- design ed spreadsheet . We calculated correlation , percentage of agreement , and kappa statistic to assess inter-rater reliability . RESULTS Most studies in our review were judged to have used an accurate reference st and ard . Conversely , the MRS literature frequently failed to specify the length of time between index and reference tests or that the clinicians were unaware of the index test findings when reporting the reference st and ard . There was good correlation ( rho = 0.78 ) between review ers in assessment of the overall number of quality criteria met . However , mean agreement for individual QUADAS questions was only fair ( kappa = 0.22 ) and ranged from no agreement beyond chance ( kappa < 0 ) to moderate agreement ( kappa = 0.58 ) . CONCLUSION Inter-rater reliability in our study was relatively low . Nevertheless , we believe that QUADAS potentially is a useful tool for highlighting the strengths and weaknesses of existing diagnostic accuracy studies . Low reliability suggests that different review ers will reach different conclusions if QUADAS is used to exclude " low- quality " articles from meta-analyses . We discuss methods for improving the validity and reliability of QUADAS Background Hysterosalpingosonography has been suggested as a less invasive alternative to hysterosalpingography for detecting tubal occlusion among subfertile women . We aim to determine the diagnostic accuracy of hysterosalpingosonography and to compare it to hysterosalpingography . Methods / design We will conduct a systematic review of diagnostic test accuracy . We will search Medline , Embase , Cochrane Library , Web of Science and Biosis , as well as reference lists of included studies and previous related review articles . Diagnostic studies that compared hysterosalpingosonography ± hysterosalpingography to laparoscopy with chromotubation in women suffering from subfertility will be eligible . Two authors will independently screen for inclusion , data extraction , and quality assessment . Method ological quality will be assessed using the Quality Assessment of Diagnostic Accuracy Study 2 tool ( QUADAS-2 ) . We will use SAS 9.3 ( SAS Institute Inc. , Cary , NC , USA , 2011 ) to program bivariate r and om-effects models , estimate pooled sensitivity and specificity with 95 % confidence intervals and to generate summary receiver operating characteristics curves . We will perform sensitivity analyses to examine the effect of differences in techniques used for hysterosalpingosonography and in method ological quality of studies . Discussion This systematic review will help to determine if hysterosalpingosonography is an adequate alternative screening test for diagnosing tubal occlusion . Accuracy of specific sono-HSG techniques may also be identified . Systematic review registration This review has been registered at PROSPERO . The registration number is BACKGROUND Chronic refractory spinal pain poses a peculiar diagnostic challenge because of multiple putative pain sources , overlapping clinical features , and nonspecific radiologic findings . Diagnostic injection techniques are employed to isolate the source ( s ) of pain . Facet or zygapophysial joint pain is an example of spinal pain diagnosed by local anesthetic injections of the facet joint or its nerve supply . Diagnostic facet joint injections are expected to meet the cardinal features of a diagnostic test ( i.e. , accuracy , safety and reproducibility ) . Accuracy must be compared with a " gold " or criterion st and ard that can confirm presence or absence of a disease . There is , however , no available gold st and ard , such as biopsy , to measure presence or absence of pain . Hence , there is a degree of uncertainty concerning the accuracy of diagnostic facet joint injections . OBJECTIVES To evaluate accuracy , safety and reproducibility of facet or zygapophysial joint injections in diagnosing chronic spinal pain of facet joint origin . STUDY DESIGN A systematic review of the literature for clinical studies on efficacy and utility of facet joint/nerve injections in diagnosing spinal pain from facet joints . METHODS Relevant literature on diagnostic facet injections was identified through data base search es . Excluded were abstract s , review s , book chapters , case reports and studies based on single blocks or blocks without radiologic control . Prospect i ve studies with placebo control , or controlled comparative local anesthetic blocks , were given priority over retrospective studies . Each study was grade d using AHRQ and QUADAS criteria . The level of evidence was classified as conclusive , strong , moderate , limited , or inconclusive . RESULTS Available literature pointed to strong evidence for controlled comparative local anesthetic facet joint medial branch blocks in the diagnosis of neck and low back pain . There was moderate evidence in the diagnosis of pain arising from thoracic facet joints . CONCLUSION The evidence obtained from literature review suggests that controlled comparative local anesthetic blocks of facet joint nerves ( medial branch or dorsal ramus ) are reproducible , reasonably accurate , and safe . The sensitivity , specificity , false-positive rates , and predictive values of these diagnostic tests for neck and low back pain have been vali date d and reproduced in multiple studies Background Synthesis of multiple r and omized controlled trials ( RCTs ) in a systematic review can summarize the effects of individual outcomes and provide numerical answers about the effectiveness of interventions . Filtering of search es is time consuming , and no single method fulfills the principal requirements of speed with accuracy . Automation of systematic review s is driven by a necessity to expedite the availability of current best evidence for policy and clinical decision-making . We developed Rayyan ( http://rayyan.qcri.org ) , a free web and mobile app , that helps expedite the initial screening of abstract s and titles using a process of semi-automation while incorporating a high level of usability . For the beta testing phase , we used two published Cochrane review s in which included studies had been selected manually . Their search es , with 1030 records and 273 records , were uploaded to Rayyan . Different features of Rayyan were tested using these two review s. We also conducted a survey of Rayyan ’s users and collected feedback through a built-in feature . Results Pilot testing of Rayyan focused on usability , accuracy against manual methods , and the added value of the prediction feature . The “ taster ” review ( 273 records ) allowed a quick overview of Rayyan for early comments on usability . The second review ( 1030 records ) required several iterations to identify the previously identified 11 trials . The “ suggestions ” and “ hints , ” based on the “ prediction model , ” appeared as testing progressed beyond five included studies . Post rollout user experiences and a reflexive response by the developers enabled real-time modifications and improvements . The survey respondents reported 40 % average time savings when using Rayyan compared to others tools , with 34 % of the respondents reporting more than 50 % time savings . In addition , around 75 % of the respondents mentioned that screening and labeling studies as well as collaborating on review s to be the two most important features of Rayyan . As of November 2016 , Rayyan users exceed 2000 from over 60 countries conducting hundreds of review s totaling more than 1.6 M citations . Feedback from users , obtained mostly through the app web site and a recent survey , has highlighted the ease in exploration of search es , the time saved , and simplicity in sharing and comparing include-exclude decisions . The strongest features of the app , identified and reported in user feedback , were its ability to help in screening and collaboration as well as the time savings it affords to users . Conclusions Rayyan is responsive and intuitive in use with significant potential to lighten the load of review ers Background and Objectives Systematic review s evaluate the utility of procedural interventions of the spine , including epidural steroid injections ( ESIs ) . However , existing quality assessment tools either fail to account for proper technical quality and patient selection or are not vali date d. We developed and vali date d a simple scale for ESIs to provide a quality assessment and rating of technique for injections of the spine ( AQUARIUS ) . Methods Seven experts generated items iteratively based on prior ESI technique studies and professional judgment . Following testing for face and content validity , a 17-item instrument was used by 8 raters from 2 different background s to assess 12 r and omized controlled trials , selected from 3 different categories . Using frequency of assessment , a 12-item instrument was also generated . Both instruments underwent reliability ( intraclass correlation coefficient ) , validity ( ability to distinguish “ low , ” “ r and om , ” and “ high ” study categories ) , and diagnostic accuracy ( receiver operating characteristics ) testing . Results Both 17- and 12-item instruments were scored consistently by raters regardless of background , with overall intraclass correlation coefficients of 0.72 ( 95 % confidence interval [ CI ] , 0.53–0.89 ) and 0.71 ( 95 % CI , 0.51–0.89 ) , respectively . Both instruments discriminated between clinical trials from all 3 categories . Diagnostic accuracy was similar for the 2 instruments , with areas under receiver operating characteristic curves of 0.89 ( 95 % CI , 0.82–0.96 ) and 0.90 ( 95 % CI , 0.82–0.97 ) , respectively . Conclusions The instrument in both 17- and 12-item formats demonstrates good reliability and diagnostic accuracy in rating ESI studies . As a complement to other tools that assess bias , the instrument may improve the ability to evaluate evidence for systematic review s and improve clinical trial design Background and aims : Objectives were to develop a frailty index ( FI ) based on a st and ard comprehensive geriatric assessment ( CGA ) derived from a clinical examination ; to assess the validity of the FI-CGA and to compare its precision with other frailty measures . Methods : Design : Secondary analysis of a prospect i ve cohort study , with five-year follow-up data . Setting : Second phase of the Canadian Study of Health and Aging ( CSHA-2 ) ; clinical examinations were performed in clinics , nursing homes , and patients ’ homes . Participants : People selected ( as either cognitively impaired cases or unimpaired controls ) to receive the CSHA-2 clinical examination ( n=2305 ; women=1431 ) . Measurements : Clinical and performance-based measures and diagnostic data were extracted to correspond to the 10 impairment domains and the single comorbidity domain of a CGA . The proportion of deficits accumulated in each domain was calculated to yield the FI-CGA . The FI-CGA was vali date d and its predictive ability compared with other frailty measures . Results : Within the seven grade s of fitness/frailty identified , subjects with greater frailty were older , less educated , and more likely to be women . The FI-CGA correlated highly with a previously vali date d , empirically-derived frailty index ( r=0.76 ) . Frailty was associated with higher risk of death ( for each increment in frailty , the hazard ratio , adjusted for age , sex and education , was 1.23 ( 95 % CI 1.18–1.29 ) and institutionalization ( HR 1.20 ; 1.10–1.32 ) . Conclusions : In a population survey , the FI-CGA is a valid means of quantifying frailty from routinely collected data Three years ago , we founded this journal focusing on publishing systematic review s , systematic review protocol s , and associated method ological development papers . Systematic review s , which developed in the social sciences in the 1970s , began to gain rapid momentum during the 1990s in response to concerns by policymakers and clinicians about the scientific validity of the prevailing paradigm of traditional narrative review s written by authoritative experts . What distinguished systematic review s was the use of formal explicit methods , in other words pre-specification , of what exactly was the question to be answered , how evidence was search ed for and assessed , and how it was synthesized in order to reach the conclusion . Importantly , these formal methods were described as part of the review itself in a Methods section . In turn , these methods themselves became the subject of hypothesis-testing studies , as investigators sought how best to search for evidence , assess studies for quality or risk of bias , determine under what conditions meta- analysis was justified , and how to best determine and characterize our confidence in the conclusions . The results of these hypothesis-testing studies led over time to improvements in the methods we use for systematic review s. Thus , systematic review s and this journal are part of an ever-evolving process whose foundations are rooted in the scientific method . Today , new forms of review s are appearing . These have emerged in response to policymakers and other stakeholders ’ needs for information , sometimes emergently or urgently , for which the existing systematic review model does not quite fit . Hence , the rapid review , when time is of the essence ; the scoping review , when what is needed is not detailed answers to specific questions but rather an overview of a broad field ; the evidence map , a cousin of scoping review s that commonly has a specific visual presentation of the evidence across a broad field ; and the realist review , where the question of interest includes how and why complex social interventions work in certain situations , rather than assume they either do or do not work at all . As Editors , we regularly get contacted by prospect i ve authors asking whether realist review s , or scoping review s , etc . , are “ within the scope ” for Systematic Review s , and therefore we judge it an opportune time to state our position on this matter . It is our view that all of these new forms of review s are related to systematic review s , similar to the way that different biological Species within the same Family are related to each other . We consider “ systematic review s ” to be the Family and the different forms of review s to be the different species . Just as in the biological classification , where the related organisms must share certain characteristics , so too must the different types of review s share a common characteristic . In this case , what is shared is their foundation in the scientific method , with their methods articulated in advance in sufficient detail that the review can be reproduced by others . A further defining feature is that there are scholars devoted to improving the methods over time via hypothesis-testing studies . Systematic Review s has responded to these emerging techniques and already publishes papers reporting methods and findings from the systematic review family and has for example published an extremely popular series on rapid review s. We would like to consoli date this position and invite su bmi ssion of these new species of review s , as long as they meet the qualifications just listed . We expect this process of evolution to continue and to refine the methods such that in 10 years ’ time , there will appear new , as yet unimagined species of review s— and perhaps some current species of review will become extinct . Thus , it is with the scientific method , which we believe is the foundation that unites the Family of systematic review BACKGROUND Discerning the determinants of weight loss maintenance is important in the planning of future interventions and policies regarding overweight and obesity . We have therefore systematic ally synthesized recent literature on determinants of weight loss maintenance for individuals with overweight and obesity . METHODS With the use of the Preferred Reporting Items for Systematic Review s and Meta-Analyses statement , prospect i ve studies were identified from search es in PubMed and PsycINFO from 2006 to 2016 . We included articles investigating adults with overweight and obesity undergoing weight loss without surgery or medication .  Included articles were scored on their method ological quality , and a best- evidence synthesis was applied to summarize the results . RESULTS Our search result ed in 8,222 articles of which 67 articles were selected . In total , 124 determinants were identified of which 5 were demographic , 59 were behavioural , 51 were psychological/cognitive and 9 were social and physical environmental determinants . We found consistent evidence that demographic determinants were not predictive of weight loss maintenance . Behavioural and cognitive determinants that promote a reduction in energy intake , an increase in energy expenditure and monitoring of this balance are predictive determinants . CONCLUSION This review identifies key determinants in weight loss maintenance . However , more research regarding cognitive and environmental determinants of weight loss maintenance is needed to advance our knowledge on determinants of weight loss maintenance Health care policy background Findings from scientific studies form the basis for evidence -based health policy decisions . Scientific background Quality assessment s to evaluate the credibility of study results are an essential part of health technology assessment reports and systematic review s. Quality assessment tools ( QAT ) for assessing the study quality examine to what extent study results are systematic ally distorted by confounding or bias ( internal validity ) . The tools can be divided into checklists , scales and component ratings . Research questions What QAT are available to assess the quality of interventional studies or studies in the field of health economics , how do they differ from each other and what conclusions can be drawn from these results for quality assessment s ? Methods A systematic search of relevant data bases from 1988 onwards is done , supplemented by screening of the references , of the HTA reports of the German Agency for Health Technology Assessment ( DAHTA ) and an internet search . The selection of relevant literature , the data extraction and the quality assessment are carried out by two independent review ers . The substantive elements of the QAT are extracted using a modified criteria list consisting of items and domains specific to r and omized trials , observational studies , diagnostic studies , systematic review s and health economic studies . Based on the number of covered items and domains , more and less comprehensive QAT are distinguished . In order to exchange experiences regarding problems in the practical application of tools , a workshop is hosted . Results A total of eight systematic method ological review s is identified as well as 147 QAT : 15 for systematic review s , 80 for r and omized trials , 30 for observational studies , 17 for diagnostic studies and 22 for health economic studies . The tools vary considerably with regard to the content , the performance and quality of operationalisation . Some tools do not only include the items of internal validity but also the items of quality of reporting and external validity . No tool covers all elements or domains . Design -specific generic tools are presented , which cover most of the content criteria . Discussion The evaluation of QAT by using content criteria is difficult , because there is no scientific consensus on the necessary elements of internal validity , and not all of the generally accepted elements are based on empirical evidence . Comparing QAT with regard to contents neglects the operationalisation of the respective parameters , for which the quality and precision are important for transparency , replicability , the correct assessment and interrater reliability . QAT , which mix items on the quality of reporting and internal validity , should be avoided . Conclusions There are different , design -specific tools available which can be preferred for quality assessment , because of its wider coverage of substantive elements of internal validity . To minimise the subjectivity of the assessment , tools with a detailed and precise operationalisation of the individual elements should be applied . For health economic studies , tools should be developed and complemented with instructions , which define the appropriateness of the criteria . Further research is needed to identify study characteristics that influence the internal validity of studies BACKGROUND Mild frailty or pre-frailty is common and yet is potentially reversible . Preventing progression to worsening frailty may benefit individuals and lower health/social care costs . However , we know little about effective approaches to preventing frailty progression . OBJECTIVES ( 1 ) To develop an evidence - and theory-based home-based health promotion intervention for older people with mild frailty . ( 2 ) To assess feasibility , costs and acceptability of ( i ) the intervention and ( ii ) a full-scale clinical effectiveness and cost-effectiveness r and omised controlled trial ( RCT ) . DESIGN Evidence review s , qualitative studies , intervention development and a feasibility RCT with process evaluation . INTERVENTION DEVELOPMENT Two systematic review s ( including systematic search es of 14 data bases and registries , 1990 - 2016 and 1980 - 2014 ) , a state-of-the-art review ( from inception to 2015 ) and policy review identified effective components for our intervention . We collected data on health priorities and potential intervention components from semistructured interviews and focus groups with older people ( aged 65 - 94 years ) ( n = 44 ) , carers ( n = 12 ) and health/social care professionals ( n = 27 ) . These data , and our evidence review s , fed into development of the ' HomeHealth ' intervention in collaboration with older people and multidisciplinary stakeholders . ' HomeHealth ' comprised 3 - 6 sessions with a support worker trained in behaviour change techniques , communication skills , exercise , nutrition and mood . Participants addressed self-directed independence and well-being goals , supported through education , skills training , enabling individuals to overcome barriers , providing feedback , maximising motivation and promoting habit formation . FEASIBILITY RCT Single-blind RCT , individually r and omised to ' HomeHealth ' or treatment as usual ( TAU ) . SETTING Community setting s in London and Hertfordshire , UK . PARTICIPANTS A total of 51 community-dwelling adults aged ≥ 65 years with mild frailty . MAIN OUTCOME MEASURES Feasibility - recruitment , retention , acceptability and intervention costs . Clinical and health economic outcome data at 6 months included functioning , frailty status , well-being , psychological distress , quality of life , capability and NHS and societal service utilisation/costs . RESULTS We successfully recruited to target , with good 6-month retention ( 94 % ) . Trial procedures were acceptable with minimal missing data . Individual r and omisation was feasible . The intervention was acceptable , with good fidelity and modest delivery costs ( £ 307 per patient ) . A total of 96 % of participants identified at least one goal , which were mostly exercise related ( 73 % ) . We found significantly better functioning ( Barthel Index + 1.68 ; p = 0.004 ) , better grip strength ( + 6.48 kg ; p = 0.02 ) , reduced psychological distress ( 12-item General Health Question naire -3.92 ; p = 0.01 ) and increased capability-adjusted life-years [ + 0.017 ; 95 % confidence interval ( CI ) 0.001 to 0.031 ] at 6 months in the intervention arm than the TAU arm , with no differences in other outcomes . NHS and carer support costs were variable but , overall , were lower in the intervention arm than the TAU arm . The main limitation was difficulty maintaining outcome assessor blinding . CONCLUSIONS Evidence is lacking to inform frailty prevention service design , with no large-scale trials of multidomain interventions . From stakeholder/public perspectives , new frailty prevention services should be personalised and encompass multiple domains , particularly socialising and mobility , and can be delivered by trained non-specialists . Our multicomponent health promotion intervention was acceptable and delivered at modest cost . Our small study shows promise for improving clinical outcomes , including functioning and independence . A full-scale individually RCT is feasible . FUTURE WORK A large , definitive RCT of the HomeHealth service is warranted . STUDY REGISTRATION This study is registered as PROSPERO CRD42014010370 and Current Controlled Trials IS RCT N11986672 . FUNDING This project was funded by the National Institute for Health Research ( NIHR ) Health Technology Assessment programme and will be published in full in Health Technology Assessment ; Vol . 21 , No. 73 . See the NIHR Journals Library website for further project information Abstract Purpose : To review available evidence on older people ’s ability to get up off the floor independently and determine the effectiveness of interventions to improve older adults ’ ability to rise from the floor . Material s and methods : Seven data bases were search ed between January 1975 and June 2018 . Eligibility criteria included : people aged ≥60 ; interventions to improve strength/function including ability to get up off the floor  ( for intervention studies ) ; comparison groups ( for r and omized and nonr and omized controlled trials ) ; outcome : quantitative or qualitative evaluation of ability to get up off the floor . Selection of the studies was undertaken in three stages : ( 1 ) titles and abstract s were scanned by one review er , ( 2 ) full abstract screening by one review er , and ( 3 ) articles read in full by two review ers . Results of all articles are summarized and r and omized controlled trials ( RCT ) ( where possible ) were analyzed by meta- analysis to determine intervention effectiveness . Results : Forty-one studies met inclusion criteria . For each of the RCTs that utilized resistance training and /or teaching the skill , a reduction in time to get up off the floor were reported . However , meta-analyses of all RCT interventions indicated no significant change in time for older people to get up off the floor independently with intervention ( MD : –0.43[–1.38 , 0.51 ] ) . Sub-analyses of interventions utilizing resistance training showed an improvement trending towards significance ( MD : –0.81[–1.72 , 0.09 ] ) . Heterogeneity between studies was high , therefore results should be viewed with some caution . Conclusions : Resistance training interventions may improve  older people ’s ability to rise from the floor unassisted . However , knowledge of specific techniques to get up and the effect of simply practicing the task of getting off the floor need to be further explored . Implication for rehabilitation One in three older people living in the community fall each year One aspect of falling that is often overlooked is whether the older person can get themselves up off the floor independently or do they have to wait for assistance . Interventions that include resistance training may help the older person to be able to get up by themselves Making a diagnosis is the bread and butter of clinical practice , but in light of the number of tests now available to clinician , diagnosing illness has become a complicated process . Guidelines for making an evidence -based diagnosis abound , but those making recommendations about diagnostic tests or test strategies must realize that clinicians require support to make diagnostic decisions that they can easily implement in daily practice . The Grading of Recommendations Assessment , Development and Evaluation ( GRADE ) Working Group has developed a rigorous , transparent , and increasingly adopted approach for grading the quality of research evidence and strength of recommendations to guide clinical practice . This editorial summarizes GRADE 's process for developing recommendations for tests ( 1 ) . Clinicians are trained to use tests for screening and diagnosis ; identifying physiologic derangements ; establishing a prognosis ; and monitoring illness and treatment response by assessing signs and symptoms , imaging , biochemistry , pathology , and psychological testing techniques ( 2 ) . Sensitivity , specificity , positive predictive value , likelihood ratios , and diagnostic odds ratios are among the challenging terms that diagnostic studies typically deliver to clinicians , and all have to do with diagnostic accuracy . Not only do clinicians have difficulties remembering the definitions and calculations for these terms , application of the concepts to individual patients is often complicated . Many clinicians order a test despite uncertainty about how to interpret the result , and they also contribute to testing errors by incorrectly ordering tests ( 3 , 4 ) . GRADE 's framework for developing recommendations for diagnostic management studies is based on what is needed for practical clinical applicationthat is , how to weigh the benefits and harms of ordering and using a diagnostic test in caring for patients ( 1 ) . The approach begins with specifying the PICO : the relevant population ( P ) , diagnostic intervention or test ( I ) ( including its purpose , such as triage , replacement , or an add-on test ) , comparison test ( C ) , and patient-important outcomes ( O ) related to the use of a test for a focused clinical question . If a test fails to improve patient-important outcomes , there is no reason to use it , whatever its accuracy . For example , the results of genetic testing for Huntington chorea , an untreatable condition , may provide either welcome reassurance that a patient will not have the condition or the ability to plan for his future knowing that he will sadly fall victim ( 1 ) . Here , the ability to plan is analogous to an effective treatment , and the benefits of planning need to be balanced against the downsides of receiving an early diagnosis ( 5 - 7 ) . The best evidence of test performance comes from large r and omized trials of diagnostic strategies that directly measure patient-important outcomes ( 1 ) . However , these trials are few and far between : An informal review of the Cochrane data base of r and omized trials revealed < 100 such studies . Therefore , most recommendations about diagnostic testing are based on an implicit 2-step process of how the accuracy of a test indirectly changes patient-important outcomes . In the first step , a diagnostic-test accuracy study ( Figure ) , patients may receive both a new test and a reference test ( i.e. , the best available method for detecting the target condition ) . Investigators can then calculate the accuracy of the test compared with the reference test ( first step ) . In the second step , judgments about the patient importance of test accuracy are based on the consequences of being correctly or incorrectly classified as having or not having the disease . These include the benefits and harms of receiving treatment or follow-up tests for those correctly classified as having the disease , reassurance or receipt of other follow-up tests for those correctly classified as not having the disease , receipt of unnecessary treatment or additional tests for those incorrectly classified as having the disease , delayed or no treatment for those incorrectly classified as not having the disease , and any adverse effects of the diagnostic test ( e.g. , from invasive tests ) . Those making recommendations about diagnostic tests must then compare patient-important outcomes ( and costs ) in all patients receiving the new test with all patients receiving the old , or comparator , test . For the first step ( i.e. , assessing test accuracy ) , there are well-described method ological criteria for assessing risk for bias in an estimate of test accuracy , ideally based on a systematic review of relevant studies . For instance , studies of diagnostic test accuracy with a low risk for bias enroll consecutive patients for whom there is legitimate diagnostic uncertaintythat is , the type of patients to whom clinicians would apply the test in the course of regular clinical practice . If studies fail this criterion ( e.g. , only enroll patients with severe disease and healthy controls ) , the apparent accuracy of a test is likely to be misleadingly high ( 8 , 9 ) . The second step shown in the Figure is , in most situations , based on judgments of test accuracy as a surrogate for patient-important outcomes . The key issue about these judgments is that they should be made transparent to those using the recommendations . For example , in the diagnosis of suspected acute urolithiasis , well- design ed studies demonstrate fewer false-negative results with noncontrast helical computed tomography ( CT ) than with intravenous pyelography ( IVP ) ( 10 ) . However , those ureteric stones that CT detects but IVP misses are smaller and therefore are more likely to spontaneously pass . Before r and omized trials evaluating outcomes in patients treated for smaller stones , evidence from observational studies was of lower quality . Thus , it remained uncertain how patients were affected by missed cases and follow-up of incidental findings unrelated to renal calculi with CT .  Recommendations about using one test ( IVP ) over the other ( helical CT ) were based on judgments of how the cases that were detected or missed would fare with or without treatment ( 11 ) . These judgments were likely to be based on indirect evidence and would be less certain than judgments based on direct evidence from a r and omized trial comparing the 2 tests . The GRADE approach requires making these judgments about the relation between accuracy and patient-important outcomes transparent . The example of IVP versus helical CT for patients with suspected acute shows exemplifies how the quality of evidence for an accurate test would be down grade d because of the lack of direct evidence on patient-important outcomes . Uncertainty about patient-important consequences and associated uncertainty about benefits and harms would probably have result ed in weak GRADE recommendations about the use of IVP compared with helical CT . Those making recommendations using the GRADE approach should also explicitly consider judgments and evidence about the values and preferences that patients attach to important consequences , as described more fully elsewhere ( 1 ) . Acknowledgments : This work was partially funded by a The human factor , mobility and Marie Curie Actions Scientist Reintegration European Commission Grant ( IGR 42192 ) GRADE to Dr. Schnemann Prognosis studies are investigations of future events or the evaluation of associations between risk factors and health outcomes in population s of patients ( 1 ) . The results of such studies improve our underst and ing of the clinical course of a disease and assist clinicians in making informed decisions about how best to manage patients . Prognostic research also informs the design of intervention studies by helping define subgroups of patients who may benefit from a new treatment and by providing necessary information about the natural history of a disorder ( 2 ) . There has recently been a rapid increase in the use of systematic review methods to synthesize the evidence on research questions related to prognosis . It is essential that investigators conducting systematic review s thoroughly appraise the method ologic quality of included studies to be confident that a study 's design , conduct , analysis , and interpretation have adequately reduced the opportunity for bias ( 3 , 4 ) . Caution is warranted , however , because inclusion of method ologically weak studies can threaten the internal validity of a systematic review ( 4 ) . This follows abundant empirical evidence that inadequate attention to biases can cause invalid results and inferences ( 5 - 9 ) . However , there is limited consensus on how to appraise the quality of prognosis studies ( 1 ) . A useful framework to assess bias in such studies follows the basic principles of epidemiologic research ( 10 , 11 ) . We focus on 6 areas of potential bias : study participation , study attrition , prognostic factor measurement , confounding measurement and account , outcome measurement , and analysis . The main objectives of our review of review s are to describe methods used to assess the quality of prognosis studies and to describe how well current practice s assess potential biases . Our secondary objective is to develop recommendations to guide future quality appraisal , both within single studies of prognostic factors and within systematic review s of the evidence . We hope this work facilitates future discussion and research on biases in prognosis studies and systematic review s. Methods Literature Search and Study Selection We identified systematic review s of prognosis studies by search ing MEDLINE ( 1966 to October 2005 ) using the search strategy recommended by McKibbon and colleagues ( 12 ) . This strategy combines broad search terms for systematic review s ( systematic review .mp ; meta- analysis .mp ) and a sensitive search strategy for prognosis studies ( cohort , incidence , mortality , follow-up studies , prognos * , predict * , or course ) . We also search ed the reference lists of included review s and method ologic papers to identify other relevant publications . We restricted our search to English- language publications . One review er conducted the search and selected the studies . Systematic review s , defined as review s of published studies with a comprehensive search and systematic selection , were included if they assessed the method ologic quality of the included studies by using 1 or more explicit criteria . We excluded studies if they were meta-analyses of independent patient data only , if their primary goal was to investigate the effectiveness of an intervention or specific diagnostic or screening tests , or if they included studies that were not done on humans . Data Extraction and Synthesis Individual items included in the quality assessment of the systematic review s were recorded as they were reported in the publication ( that is , the information that would be available to readers and future review ers ) . We review ed journal Web sites and contacted the authors of the systematic review s for additional information when authors made such an offer in their original papers . When review s assessed different study design s by using different sets of quality items , we extracted only those items used to assess cohort studies . We constructed a comprehensive list of distinct items that the review s used to assess the quality of their included studies . The full text of each review was screened . All items used by the review authors to assess the quality of studies were extracted into a computerized spreadsheet by 1 review er . Two experienced review ers , a clinical epidemiologist and an epidemiologist , independently synthesized the quality items extracted from the prognosis review s to determine how well the systematic review s assessed potential biases . We did this in 3 steps : 1 ) identified distinct concepts or domains addressed by the quality items ; 2 ) grouped each extracted quality item into the appropriate domain or domains ; and 3 ) identified the domains necessary to assess potential biases in prognosis studies . We then used this information to assess how well the review s ' quality assessment included items from the domains necessary to assess potential biases . After completing each of the first 3 steps , the review ers met to attempt to reach a consensus . The consensus process involved each review er presenting his or her observations and results , followed by discussion and debate . A third review er was available in cases of persistent disagreement or uncertainty . In the first step , all domains addressed by the quality items were identified . The first review er iteratively and progressively defined the domains as items were extracted from the included review s. The second review er defined domains from a r and om list of all extracted quality items . Limited guidance was provided to the review ers so that their assessment s and definitions of domains would be independent . The review ers agreed on a final set of domains that adequately and completely defined all of the extracted items . In the second step , review ers independently grouped each extracted item into the appropriate domains . Review ers considered each extracted item by asking , What is each particular quality item addressing ? or What are the review 's authors getting at with the particular quality assessment item ? . Items were grouped into the domain or domains that best represented the concepts being addressed . For example , the extracted items at least 80 % of the group originally identified was located for follow-up and follow-up was sufficiently complete or does n't jeopardize validity were each independently classified by both review ers as assessing the domain completeness of follow-up adequate , whereas the extracted item quantification and description of all subjects lost to follow-up was classified as assessing the domain completeness of follow-up described . In the third step , we identified the domains necessary to assess potential biases . Each review er considered the ability of the identified domains to adequately address , at least in part , 1 of the following 6 potential biases : 1 ) study participation , 2 ) study attrition , 3 ) prognostic factor measurement , 4 ) confounding measurement and account , 5 ) outcome measurement , and 6 ) analysis . Domains were considered to adequately address part of the framework if information garnered from that domain would inform the assessment of potential bias . For example , both review ers judged that the identified domain study population represents source population or population of interest assessed potential bias in a prognosis study , whereas the domain research question definition did not , although the latter is an important consideration in assessing the inclusion of studies in a systematic review . Finally , on the basis of our previous ratings , we looked at whether each review included items from the domains necessary to assess the 6 potential biases . We calculated the frequency of systematic review s by assessing each potential bias and the number of review s that adequately assessed bias overall . From this systematic synthesis , we developed recommendations for improving quality appraisal in future systematic review s of prognosis studies . We used Microsoft Access and Excel 2002 ( Microsoft Corp. , Redmond , Washington ) for data management and SAS for Windows , version 9.1 ( SAS Institute , Inc. , Cary , North Carolina ) for descriptive statistics . Role of the Funding Sources The funding sources , the Canadian Institutes of Health Research , the Canadian Chiropractic Research Foundation , the Ontario Chiropractic Association , and the Ontario Ministry of Health and Long Term Care , did not have a role in the collection , analysis , or interpretation of the data or in the decision to su bmi t the manuscript for publication . Results We identified 1384 potentially relevant articles . Figure 1 shows a flow chart of studies that were included and excluded . Figure 2 shows the number of review s identified by year of publication . We excluded 131 systematic review s of prognosis studies that did not seem to include any quality assessment of the included studies ; this represented 44 % of prognosis review s. We included 163 review s of prognosis studies in our analysis ( 13 - 175 ) . The most common topics were cancer ( 15 % ) , musculoskeletal disorders and rheumatology ( 13 % ) , cardiovascular ( 10 % ) , neurology ( 10 % ) , and obstetrics ( 10 % ) . Other review s included a wide range of health and health care topics . Sixty-three percent of the review s investigated the association between a specific prognostic factor and a particular outcome ; the remainder investigated multiple prognostic factors or models . The number of primary studies included in each systematic review ranged from 3 to 167 ( median , 18 [ interquartile range , 12 to 31 ] ) . A complete description of the included review s is available from the authors on request . Figure 1 . Flow diagram of inclusion and exclusion criteria of systematic review s. Figure 2 . Number of systematic review s of prognosis studies identified over time . Quality Items One hundred fifty-three review s provided adequate detail to allow extraction of quality items . Eight hundred eighty-two distinct quality items were extracted from the review s. Most review s developed their own set of quality items , with only a few applying criteria from previous review s. Most quality items BACKGROUND Water-loss dehydration ( hypertonic , hyperosmotic , or intracellular dehydration ) is due to insufficient fluid intake and is distinct from hypovolemia due to excess fluid losses . Water-loss dehydration is associated with poor health outcomes such as disability and mortality in older people . Urine specific gravity ( USG ) , urine color , and urine osmolality have been widely advocated for screening for dehydration in older adults . OBJECTIVE We assessed the diagnostic accuracy of urinary measures to screen for water-loss dehydration in older people . DESIGN This was a diagnostic accuracy study of people aged ≥65 y taking part in the DRIE ( Dehydration Recognition In our Elders ; living in long-term care ) or NU-AGE ( Dietary Strategies for Healthy Ageing in Europe ; living in the community ) studies . The reference st and ard was serum osmolality , and index tests included USG , urine color ,  urine osmolality  , urine cloudiness , additional dipstick measures , ability to provide a urine sample , and the volume of a r and om urine sample . Minimum useful diagnostic accuracy was set at sensitivity and specificity ≥70 % or a receiver operating characteristic plot area under the curve ≥0.70 . RESULTS DRIE participants ( women : 67 % ; mean age : 86 y ; n = 162 ) had more limited cognitive and functional abilities than did NU-AGE participants ( women : 64 % ; mean age : 70 y ; n = 151 ) . Nineteen percent of DRIE participants and 22 % of NU-AGE participants were dehydrated ( serum osmolality > 300 mOsm/kg ) . Neither USG nor any other potential urinary tests were usefully diagnostic for water-loss dehydration . CONCLUSIONS Although USG , urine color , and urinary osmolality have been widely advocated for screening for dehydration in older adults , we show , in the largest study to date to our knowledge , that their diagnostic accuracy is too low to be useful , and these measures should not be used to indicate hydration status in older people ( either alone or as part of a wider tranche of tests ) . There is a need to develop simple , inexpensive , and noninvasive tools for the assessment of dehydration in older people . The DRIE study was registered at www . research register.org.uk as 122273 . The NU-AGE trial was registered at clinicialtrials.gov as NCT01754012 The m and ate of Human Reproduction Up date involves several roles : ( i ) to provide a synthesis of evidence that can aid scientists and clinicians in their daily work ; ( ii ) to help reproductive specialists underst and concepts from related disciplines ; and ( iii ) to summarize current knowledge generated by basic science as the foundation of future scientific and clinical advancement . Given that review and synthesis are central to good scientific and clinical practice , and that a grasp of the current state of knowledge is a prerequisite to design ing new studies , it is pertinent to ask which review s are most likely to fulfil the needs of readers . A related question concerns whether systematic review s meet the needs of all review topics and all readers . Summarizing evidence or knowledge is a difficult problem in reproductive medicine , as in other branches of science and medical care ( Eddy et al. , 1992 ) . For each question there may be multiple studies that use different design s and inclusion criteria . For clinical questions , the interventions , outcomes and measures of effect may vary : the effect measures in treatment studies include odds ratios , relative risks and absolute differences . For scientific questions , the experimental species , models and design s may differ . Moreover , it is always uncertain whether all of the relevant evidence has been evaluated . Even when the search has been exhaustive , there are no simple guides on how to interpret conflicting results and whether to accept apparently outlying studies . The choices that the review er makes to address the variable conditions and uncertainties may be conservative , strict and exclusive , or liberal , open and inclusive . The decisions made by the review er may not be consistent throughout and these choices may or may not satisfy the reader who seeks out the review to address a clinical or research question . Faced with uncertainty and doubt , readers nonetheless must form an impression of the evidence and synthesize the state of knowledge in order to address the clinical or research question that stimulated their interest in the review . We argue that the reader is better served when the choices made in the review , regardless of whether they are strict or open , should be explicit , transparent , clearly stated and reproducible by interested readers . This list of objectives for review s is more easily satisfied by systematic review s , which use explicit methods to method ically search , critically appraise and synthesize the available literature on a specific issue . The question or issue need not be clinical : indeed , the concept evolved primarily in psychology studies ( Light and Pillemer , 1984 ) . The systematic review attempts to reduce review er bias through the use of objective , reproducible criteria to select relevant individual publications and assess their validity . A systematic review may include a meta- analysis or statistical summary of the individual study results : the aggregate of effects from several studies yields an average treatment effect that is more precise than the individual study results ( Schlesselman and Collins , 2003 ) . Thus , the systematic review involves explicit , transparent methods which are clearly stated , and reproducible by others . Whether a systematic review of r and omized controlled trials adheres to the guidelines can easily be evaluated by means of a widely used checklist ( the QUORUM statement ) ( Moher et al. , 1999 ) . The strengths of the systematic review include the narrow focus of the question , the comprehensive search for evidence , the criterion-based selection of relevant evidence , the rigorous appraisal of validity , the objective or quantitative summary , and the evidence -based inferences ( Cook et al. , 1997 ) . For some review topics , however , the strengths of the systematic review may turn into weaknesses . The primary problem is that the narrow focus and prescribed methods of the systematic review do not allow for comprehensive coverage . For example , the historical review is an irreplaceable means of tracing the development of a scientific principle or clinical concept , but the narrative thread could be lost in the strict rules of systematic review . As other examples , it would be burdensome to apply systematic methods to a survey on  aneuploidy and fertility in the aging female or to an assessment of mouse knockout models and polycystic ovarian phenotype . Such topics would require the wider scope of a traditional narrative review , in Human Reproduction Up date , Vol.11 , No.2 pp . 103–104 , 2005 doi:10.1093/humupd/dmh058 Advance Access publication December 23 , Executive summary Background Older adults with dementia may have feeding difficulties for several reasons : they may experience deterioration in motor and cognitive skills making eating difficult , they may forget to eat , fail to recognise food or they may suffer from dysphagia . Food intake is often poor and malnutrition is common , leading to adverse health outcomes . This review specifically focussed on how best to promote and achieve ‘ normal ’ eating and feeding in older adults with dementia , in order that undernutrition and its consequences could be avoided . Review Objectives The aim was to identify and assess the effectiveness of interventions that encouraged eating and minimised risk of undernutrition in older adults with dementia . Types of Participants Adults over the age of sixty with dementia in any care setting ( who were not living independently ) . People receiving enteral tube feeding were excluded . Types of Interventions Any intervention that promoted dietary intake e.g. changes in practice of health care workers , family or volunteers , educational interventions , changes in food service . Types of Outcomes The primary outcomes were improvement in dietary intake and /or nutritional status . Measurements included : dietary intake , anthropometry , clinical outcomes , functional indicators . Types of Studies R and omised controlled trials , controlled trials and quasi‐experimental studies with a ‘ before and after ’ design . Search Strategy The search strategy aim ed to find both published and unpublished studies using a three‐step approach . Papers were limited to the English language and a date restriction of 1999 to 2009 was set . Critical appraisal Papers selected for retrieval were assessed by two independent review ers for method ological validity prior to inclusion in the review . Disagreements that arose between the review ers were resolved through discussion . Data Extraction For quantitative studies , data was extracted using a data extraction form developed to include specific details about the interventions , population s , study methods and outcomes of significance to the review question and specific objectives . This was based on the JBI data extraction tool from MAStARI and 2 review ers extracted data independently . Data synthesis Heterogeneity in study design s , interventions and outcomes meant meta‐ analysis was not possible . Findings were discussed in a narrative summary . Results The review included 11 studies . This included one RCT , 1 r and omised crossover study , 3 controlled non‐r and omised trials , 6 quasi‐experimental studies . None of the studies provided robust evidence , however there was moderate evidence ( Level 3 ) to support a Grade B recommendation for improvements in dietary intake and /or nutritional status with the following interventions : education of healthcare staff , simple environmental manipulations such as the use of high contrast tableware or small dining rooms , the introduction of something of interest such as an aquarium or background music , or the provision of feeding assistance , provision of enhanced menus , use of a de central ised food service , enhanced nutritional screening combined with increased dietetic time .  Conclusion There is moderate ( Level 3 ) evidence to support each of the interventions appraised in this review . Implication s for Practice There is moderate support that warrants consideration of the interventions listed above . Careful monitoring of weight of individual residents would help to determine the effectiveness of any such change in delivery of care . Implication s for Research Future research into interventions to improve eating and minimise undernutrition in older people with dementia should feature the following : inclusion of reliable outcome measures , full details of interventions , r and omisation of participants , inclusion of control groups , adequate sample sizes , longitudinal follow up , consideration of baseline demographics of intervention groups , and experimental design that allows the determination of the effectiveness of individual definable changes in delivery of care
The Frailty Index was examined in almost all these dimensions , with the exception of reliability , and its diagnostic and predictive characteristics were shown to be satisfactory .
Gait speed showed high sensitivity , but only moderate specificity , and excellent predictive ability for future disability in activities of daily living .
The Tilburg Frailty Indicator was shown to be a reliable and valid measure for frailty screening , but its diagnostic accuracy was not evaluated .
Screening Letter , Timed-up- and -go test and PRISMA 7 ( Preferred Reporting Items for Systematic Review s and Meta-Analyses ) demonstrated high sensitivity and moderate specificity for identifying frailty .
In general , low physical activity , variously measured , was one of the most powerful predictors of future decline in activities of daily living .
Conclusion Only a few frailty measures seem to be demonstrably valid , reliable and diagnostically accurate , and have good predictive ability .
Nevertheless , it was clear that no suitable tool for assessing frailty appropriately in emergency departments was identified
Background A scoping search identified systematic review s on diagnostic accuracy and predictive ability of frailty measures in older adults .
In most cases , research was confined to specific assessment measures related to a specific clinical model .
Objectives To summarize the best available evidence from systematic review s in relation to reliability , validity , diagnostic accuracy and predictive ability of frailty measures in older adults .