The PRISMA guideline for writing a systematic review and meta-analysis.
About this guideline
This guideline is based on the PRISMA statement; an evidence-based minimum set of items for reporting systematic reviews and meta-analyses. Although the guideline focuses on the reporting of reviews evaluating randomized trials, it can also be used for reporting systematic reviews of other types of research, particularly evaluations of interventions.
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Guidance
Approx. 3 min read
Title
Identify the report as a systematic review, meta-analysis, or both.
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Authors should identify their report as a systematic review or meta-analysis. Terms such as “review” or “overview” do not describe for readers whether the review was systematic or whether a meta-analysis was performed. A recent survey found that 50% of 300 authors did not mention the terms “systematic review” or “meta-analysis” in the title or abstract of their systematic review [3]. Although sensitive search strategies have been developed to identify systematic reviews [22], inclusion of the terms systematic review or meta-analysis in the title may improve indexing and identification.
We advise authors to use informative titles that make key information easily accessible to readers. Ideally, a title reflecting the PICOS approach (participants, interventions, comparators, outcomes, and study design) (see Item 11 and Box 2) may help readers as it provides key information about the scope of the review. Specifying the design(s) of the studies included, as shown in the examples, may also help some readers and those searching databases.
Some journals recommend “indicative titles” that indicate the topic matter of the review, while others require declarative titles that give the review’s main conclusion. Busy practitioners may prefer to see the conclusion of the review in the title, but declarative titles can oversimplify or exaggerate findings. Thus, many journals and methodologists prefer indicative titles as used in the examples above.
Examples
Recurrence rates of video-assisted thoracoscopic versus open surgery in the prevention of recurrent pneumothoraces: a systematic review of randomised and non-randomised trials
Mortality in randomized trials of antioxidant supplements for primary and secondary prevention: systematic review and meta-analysis
Abstract
Provide a structured summary including, as applicable: background; objectives; data sources; study eligibility criteria, participants, and interventions; study appraisal and synthesis methods; results; limitations; conclusions and implications of key findings; systematic review registration number
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Abstracts provide key information that enables readers to understand the scope, processes, and findings of a review and to decide whether to read the full report. The abstract may be all that is readily available to a reader, for example, in a bibliographic database. The abstract should present a balanced and realistic assessment of the review’s findings that mirrors, albeit briefly, the main text of the report.
We agree with others that the quality of reporting in abstracts presented at conferences and in journal publications needs improvement [24],[25]. While we do not uniformly favor a specific format over another, we generally recommend structured abstracts. Structured abstracts provide readers with a series of headings pertaining to the purpose, conduct, findings, and conclusions of the systematic review being reported [26],[27]. They give readers more complete information and facilitate finding information more easily than unstructured abstracts [28],[29],[30],[31],[32].
A highly structured abstract of a systematic review could include the following headings: Context (or Background); Objective (or Purpose); Data Sources; Study Selection (or Eligibility Criteria); Study Appraisal and Synthesis Methods (or Data Extraction and Data Synthesis); Results; Limitations; and Conclusions (or Implications). Alternatively, a simpler structure could cover but collapse some of the above headings (e.g., label Study Selection and Study Appraisal as Review Methods) or omit some headings such as Background and Limitations.
In the highly structured abstract mentioned above, authors use the Background heading to set the context for readers and explain the importance of the review question. Under the Objectives heading, they ideally use elements of PICOS (see Box 2) to state the primary objective of the review. Under a Data Sources heading, they summarize sources that were searched, any language or publication type restrictions, and the start and end dates of searches. Study Selection statements then ideally describe who selected studies using what inclusion criteria. Data Extraction Methods statements describe appraisal methods during data abstraction and the methods used to integrate or summarize the data. The Data Synthesis section is where the main results of the review are reported. If the review includes meta-analyses, authors should provide numerical results with confidence intervals for the most important outcomes. Ideally, they should specify the amount of evidence in these analyses (numbers of studies and numbers of participants). Under a Limitations heading, authors might describe the most important weaknesses of included studies as well as limitations of the review process. Then authors should provide clear and balanced Conclusions that are closely linked to the objective and findings of the review. Additionally, it would be helpful if authors included some information about funding for the review. Finally, although protocol registration for systematic reviews is still not common practice, if authors have registered their review or received a registration number, we recommend providing the registration information at the end of the abstract.
Taking all the above considerations into account, the intrinsic tension between the goal of completeness of the abstract and its keeping into the space limit often set by journal editors is recognized as a major challenge.
Examples
Context: The role and dose of oral vitamin D supplementation in nonvertebral fracture prevention have not been well established.
Objective: To estimate the effectiveness of vitamin D supplementation in preventing hip and nonvertebral fractures in older persons.
Data Sources: A systematic review of English and non-English articles using MEDLINE and the Cochrane Controlled Trials Register (1960–2005), and EMBASE (1991–2005). Additional studies were identified by contacting clinical experts and searching bibliographies and abstracts presented at the American Society for Bone and Mineral Research (1995–2004). Search terms included randomized controlled trial (RCT), controlled clinical trial, random allocation, double-blind method, cholecalciferol, ergocalciferol, 25-hydroxyvitamin D, fractures, humans, elderly, falls, and bone density.
Study Selection: Only double-blind RCTs of oral vitamin D supplementation (cholecalciferol, ergocalciferol) with or without calcium supplementation vs calcium supplementation or placebo in older persons (>60 years) that examined hip or nonvertebral fractures were included.
Data Extraction: Independent extraction of articles by 2 authors using predefined data fields, including study quality indicators.
Data Synthesis: All pooled analyses were based on random-effects models. Five RCTs for hip fracture (n = 9294) and 7 RCTs for nonvertebral fracture risk (n = 9820) met our inclusion criteria. All trials used cholecalciferol. Heterogeneity among studies for both hip and nonvertebral fracture prevention was observed, which disappeared after pooling RCTs with low-dose (400 IU/d) and higher-dose vitamin D (700–800 IU/d), separately. A vitamin D dose of 700 to 800 IU/d reduced the relative risk (RR) of hip fracture by 26% (3 RCTs with 5572 persons; pooled RR, 0.74; 95% confidence interval [CI], 0.61–0.88) and any nonvertebral fracture by 23% (5 RCTs with 6098 persons; pooled RR, 0.77; 95% CI, 0.68–0.87) vs calcium or placebo. No significant benefit was observed for RCTs with 400 IU/d vitamin D (2 RCTs with 3722 persons; pooled RR for hip fracture, 1.15; 95% CI, 0.88–1.50; and pooled RR for any nonvertebral fracture, 1.03; 95% CI, 0.86–1.24).
Conclusions: Oral vitamin D supplementation between 700 to 800 IU/d appears to reduce the risk of hip and any nonvertebral fractures in ambulatory or institutionalized elderly persons. An oral vitamin D dose of 400 IU/d is not sufficient for fracture prevention.
Introduction
Describe the rationale for the review in the context of what is already known.
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Readers need to understand the rationale behind the study and what the systematic review may add to what is already known. Authors should tell readers whether their report is a new systematic review or an update of an existing one. If the review is an update, authors should state reasons for the update, including what has been added to the evidence base since the previous version of the review.
An ideal background or introduction that sets context for readers might include the following. First, authors might define the importance of the review question from different perspectives (e.g., public health, individual patient, or health policy). Second, authors might briefly mention the current state of knowledge and its limitations. As in the above example, information about the effects of several different interventions may be available that helps readers understand why potential relative benefits or harms of particular interventions need review. Third, authors might whet readers’ appetites by clearly stating what the review aims to add. They also could discuss the extent to which the limitations of the existing evidence base may be overcome by the review.
Examples
Reversing the trend of increasing weight for height in children has proven difficult.
It is widely accepted that increasing energy expenditure and reducing energy intake form the theoretical basis for management. Therefore, interventions
aiming to increase physical activity and improve diet are the foundation of efforts
to prevent and treat childhood obesity. Such lifestyle interventions have been
supported by recent systematic reviews, as well as by the Canadian Paediatric
Society, the Royal College of Paediatrics and Child Health, and the American
Academy of Pediatrics. However, these interventions are fraught with poor
adherence. Thus, school-based interventions are theoretically appealing because
adherence with interventions can be improved. Consequently, many local
governments have enacted or are considering policies that mandate increased
physical activity in schools, although the effect of such interventions on body
composition has not been assessed
Provide an explicit statement of questions being addressed with reference to participants, interventions, comparisons, outcomes, and study design (PICOS).
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The questions being addressed, and the rationale for them, are one of the most critical parts of a systematic review. They should be stated precisely and explicitly so that readers can understand quickly the review’s scope and the potential applicability of the review to their interests [35]. Framing questions so that they include the following five “PICOS” components may improve the explicitness of review questions: (1) the patient population or disease being addressed (P), (2) the interventions or exposure of interest (I), (3) the comparators (C), (4) the main outcome or endpoint of interest (O), and (5) the study designs chosen (S). For more detail regarding PICOS, see Box 2.
Good review questions may be narrowly focused or broad, depending on the overall objectives of the review. Sometimes broad questions might increase the applicability of the results and facilitate detection of bias, exploratory analyses, and sensitivity analyses [35],[36]. Whether narrowly focused or broad, precisely stated review objectives are critical as they help define other components of the review process such as the eligibility criteria (Item 6) and the search for relevant literature (Items 7 and 8)
Examples
To examine whether topical or intraluminal antibiotics reduce catheter-related bloodstream infection, we reviewed randomized, controlled trials that assessed the efficacy of these antibiotics for primary prophylaxis against catheter-related bloodstream infection and mortality compared with no antibiotic therapy in adults undergoing hemodialysis
Methods
Indicate if a review protocol exists, if and where it can be accessed (e.g., Web address) and, if available, provide registration information including the registration number.
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A protocol is important because it pre-specifies the objectives and methods of the systematic review. For instance, a protocol specifies outcomes of primary interest, how reviewers will extract information about those outcomes, and methods that reviewers might use to quantitatively summarize the outcome data (see Item 13). Having a protocol can help restrict the likelihood of biased post hoc decisions in review methods, such as selective outcome reporting. Several sources provide guidance about elements to include in the protocol for a systematic review [16],[38],[39]. For meta-analyses of individual patient-level data, we advise authors to describe whether a protocol was explicitly designed and whether, when, and how participating collaborators endorsed it [40],[41].
Authors may modify protocols during the research, and readers should not automatically consider such modifications inappropriate. For example, legitimate modifications may extend the period of searches to include older or newer studies, broaden eligibility criteria that proved too narrow, or add analyses if the primary analyses suggest that additional ones are warranted. Authors should, however, describe the modifications and explain their rationale.
Although worthwhile protocol amendments are common, one must consider the effects that protocol modifications may have on the results of a systematic review, especially if the primary outcome is changed. Bias from selective outcome reporting in randomized trials has been well documented [42],[43]. An examination of 47 Cochrane reviews revealed indirect evidence for possible selective reporting bias for systematic reviews. Almost all (n = 43) contained a major change, such as the addition or deletion of outcomes, between the protocol and the full publication [44]. Whether (or to what extent) the changes reflected bias, however, was not clear. For example, it has been rather common not to describe outcomes that were not presented in any of the included studies.
Registration of a systematic review, typically with a protocol and registration number, is not yet common, but some opportunities exist [45],[46]. Registration may possibly reduce the risk of multiple reviews addressing the same question [45],[46],[47],[48], reduce publication bias, and provide greater transparency when updating systematic reviews. Of note, a survey of systematic reviews indexed in MEDLINE in November 2004 found that reports of protocol use had increased to about 46% [3] from 8% noted in previous surveys [49]. The improvement was due mostly to Cochrane reviews, which, by requirement, have a published protocol [3].
Examples
Methods of the analysis and inclusion criteria were specified in advance and documented in a protocol.
Specify study characteristics (e.g., PICOS, length of follow-up) and report characteristics (e.g., years considered, language, publication status) used as criteria for eligibility, giving rational
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Knowledge of the eligibility criteria is essential in appraising the validity, applicability, and comprehensiveness of a review. Thus, authors should unambiguously specify eligibility criteria used in the review. Carefully defined eligibility criteria inform various steps of the review methodology. They influence the development of the search strategy and serve to ensure that studies are selected in a systematic and unbiased manner.
A study may be described in multiple reports, and one report may describe multiple studies. Therefore, we separate eligibility criteria into the following two components: study characteristics and report characteristics. Both need to be reported. Study eligibility criteria are likely to include the populations, interventions, comparators, outcomes, and study designs of interest (PICOS; see Box 2), as well as other study-specific elements, such as specifying a minimum length of follow-up. Authors should state whether studies will be excluded because they do not include (or report) specific outcomes to help readers ascertain whether the systematic review may be biased as a consequence of selective reporting [42],[43].
Report eligibility criteria are likely to include language of publication, publication status (e.g., inclusion of unpublished material and abstracts), and year of publication. Inclusion or not of non-English language literature [51],[52],[53],[54],[55], unpublished data, or older data can influence the effect estimates in meta-analyses [56],[57],[58],[59]. Caution may need to be exercised in including all identified studies due to potential differences in the risk of bias such as, for example, selective reporting in abstracts [60],[61],[62].
Examples
Types of studies: “Randomised clinical trials studying the administration of hepatitis B vaccine to CRF [chronic renal failure] patients, with or without dialysis. No language, publication date, or publication status restrictions were imposed…”
Types of participants: “Participants of any age with CRF or receiving dialysis (haemodialysis or peritoneal dialysis) were considered. CRF was defined as serum creatinine greater than 200 µmol/L for a period of more than six months or individuals receiving dialysis (haemodialysis or peritoneal dialysis)…Renal transplant patients were excluded from this review as these individuals are immunosuppressed and are receiving immunosuppressant agents to prevent rejection of their transplanted organs, and they have essentially normal renal function…”
Types of intervention: “Trials comparing the beneficial and harmful effects of hepatitis B vaccines with adjuvant or cytokine co-interventions [and] trials comparing the beneficial and harmful effects of immunoglobulin prophylaxis. This review was limited to studies looking at active immunization. Hepatitis B vaccines (plasma or recombinant (yeast) derived) of all types, dose, and regimens versus placebo, control vaccine, or no vaccine…”
Types of outcome measures: “Primary outcome measures: Seroconversion, ie, proportion of patients with adequate anti-HBs response (>10 IU/L or Sample Ratio Units). Hepatitis B infections (as measured by hepatitis B core antigen (HBcAg) positivity or persistent HBsAg positivity), both acute and chronic. Acute (primary) HBV [hepatitis B virus] infections were defined as seroconversion to HBsAg positivity or development of IgM anti-HBc. Chronic HBV infections were defined as the persistence of HBsAg for more than six months or HBsAg positivity and liver biopsy compatible with a diagnosis or chronic hepatitis B. Secondary outcome measures: Adverse events of hepatitis B vaccinations…[and]…mortality.” [
Describe all information sources in the search (e.g., databases with dates of coverage, contact with study authors to identify additional studies) and date last searched.
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The National Library of Medicine’s MEDLINE database is one of the most comprehensive sources of health care information in the world. Like any database, however, its coverage is not complete and varies according to the field. Retrieval from any single database, even by an experienced searcher, may be imperfect, which is why detailed reporting is important within the systematic review.
At a minimum, for each database searched, authors should report the database, platform, or provider (e.g., Ovid, Dialog, PubMed) and the start and end dates for the search of each database. This information lets readers assess the currency of the review, which is important because the publication time-lag outdates the results of some reviews [64]. This information should also make updating more efficient [65]. Authors should also report who developed and conducted the search [66].
In addition to searching databases, authors should report the use of supplementary approaches to identify studies, such as hand searching of journals, checking reference lists, searching trials registries or regulatory agency Web sites [67], contacting manufacturers, or contacting authors. Authors should also report if they attempted to acquire any missing information (e.g., on study methods or results) from investigators or sponsors; it is useful to describe briefly who was contacted and what unpublished information was obtained.
Examples
Studies were identified by searching electronic databases, scanning reference lists of articles and consultation with experts in the field and drug companies…No limits were applied for language and foreign papers were translated. This search was applied to Medline (1966–Present), CancerLit (1975–Present), and adapted for Embase (1980–Present), Science Citation Index Expanded (1981–Present) and Pre-Medline electronic databases. Cochrane and DARE (Database of Abstracts of Reviews of Effectiveness) databases were reviewed…The last search was run on 19 June 2001. In addition, we handsearched contents pages of Journal of Clinical Oncology 2001, European Journal of Cancer 2001 and Bone 2001, together with abstracts printed in these journals 1999–2001. A limited update literature search was performed from 19 June 2001 to 31 December 2003.
Present full electronic search strategy for at least one database, including any limits used, such that it could be repeated.
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The search strategy is an essential part of the report of any systematic review. Searches may be complicated and iterative, particularly when reviewers search unfamiliar databases or their review is addressing a broad or new topic. Perusing the search strategy allows interested readers to assess the comprehensiveness and completeness of the search, and to replicate it. Thus, we advise authors to report their full electronic search strategy for at least one major database. As an alternative to presenting search strategies for all databases, authors could indicate how the search took into account other databases searched, as index terms vary across databases. If different searches are used for different parts of a wider question (e.g., questions relating to benefits and questions relating to harms), we recommend authors provide at least one example of a strategy for each part of the objective [69]. We also encourage authors to state whether search strategies were peer reviewed as part of the systematic review process [70].
We realize that journal restrictions vary and that having the search strategy in the text of the report is not always feasible. We strongly encourage all journals, however, to find ways, such as a “Web extra,” appendix, or electronic link to an archive, to make search strategies accessible to readers. We also advise all authors to archive their searches so that (1) others may access and review them (e.g., replicate them or understand why their review of a similar topic did not identify the same reports), and (2) future updates of their review are facilitated.
Several sources provide guidance on developing search strategies [71],[72],[73]. Most searches have constraints, for example relating to limited time or financial resources, inaccessible or inadequately indexed reports and databases, unavailability of experts with particular language or database searching skills, or review questions for which pertinent evidence is not easy to find. Authors should be straightforward in describing their search constraints. Apart from the keywords used to identify or exclude records, they should report any additional limitations relevant to the search, such as language and date restrictions (see also eligibility criteria, Item 6) [51].
Examples
In text: “We used the following search terms to search all trials registers and databases: immunoglobulin*; IVIG; sepsis; septic shock; septicaemia; and septicemia…”
In appendix:
Search strategy: MEDLINE (OVID)
immunoglobulins/
immunoglobulin$.tw.
ivig.tw.
1 or 2 or 3
sepsis/
sepsis.tw.
septic shock/
septic shock.tw.
septicemia/
septicaemia.tw.
septicemia.tw.
5 or 6 or 7 or 8 or 9 or 10 or 11
4 and 12
randomized controlled trials/
randomized-controlled-trial.pt.
controlled-clinical-trial.pt.
random allocation/
double-blind method/
single-blind method/
14 or 15 or 16 or 17 or 18 or 19
exp clinical trials/
clinical-trial.pt.
(clin$ adj trial$).ti,ab.
((singl$ or doubl$ or trebl$ or tripl\() adj (blind\))).ti,ab.
placebos/
placebo$.ti,ab.
random$.ti,ab.
21 or 22 or 23 or 24 or 25 or 26 or 27
research design/
comparative study/
exp evaluation studies/
follow-up studies/
prospective studies/
(control$ or prospective$ or volunteer$).ti,ab.
30 or 31 or 32 or 33 or 34
20 or 28 or 29 or 35
13 and 36
State the process for selecting studies (i.e., for screening, for determining eligibility, for inclusion in the systematic review, and, if applicable, for inclusion in the meta-analysis).
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There is no standard process for selecting studies to include in a systematic review. Authors usually start with a large number of identified records from their search and sequentially exclude records according to eligibility criteria. We advise authors to report how they screened the retrieved records (typically a title and abstract), how often it was necessary to review the full text publication, and if any types of record (e.g., letters to the editor) were excluded. We also advise using the PRISMA flow diagram to summarize study selection processes (see Item 17; Box 3).
Efforts to enhance objectivity and avoid mistakes in study selection are important. Thus authors should report whether each stage was carried out by one or several people, who these people were, and, whenever multiple independent investigators performed the selection, what the process was for resolving disagreements. The use of at least two investigators may reduce the possibility of rejecting relevant reports [75]. The benefit may be greatest for topics where selection or rejection of an article requires difficult judgments [76]. For these topics, authors should ideally tell readers the level of inter-rater agreement, how commonly arbitration about selection was required, and what efforts were made to resolve disagreements (e.g., by contact with the authors of the original studies).
Examples
Eligibility assessment…[was] performed independently in an unblinded standardized manner by 2 reviewers…Disagreements between reviewers were resolved by consensus
Describe the method of data extraction from reports (e.g., piloted forms, independently by two reviewers) and any processes for obtaining and confirming data from investigators.
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Reviewers extract information from each included study so that they can critique, present, and summarize evidence in a systematic review. They might also contact authors of included studies for information that has not been, or is unclearly, reported. In meta-analysis of individual patient data, this phase involves collection and scrutiny of detailed raw databases. The authors should describe these methods, including any steps taken to reduce bias and mistakes during data collection and data extraction [78] (Box 3).
Some systematic reviewers use a data extraction form that could be reported as an appendix or “Web extra” to their report. These forms could show the reader what information reviewers sought (see Item 11) and how they extracted it. Authors could tell readers if the form was piloted. Regardless, we advise authors to tell readers who extracted what data, whether any extractions were completed in duplicate, and, if so, whether duplicate abstraction was done independently and how disagreements were resolved.
Published reports of the included studies may not provide all the information required for the review. Reviewers should describe any actions they took to seek additional information from the original researchers (see Item 7). The description might include how they attempted to contact researchers, what they asked for, and their success in obtaining the necessary information. Authors should also tell readers when individual patient data were sought from the original researchers [41] (see Item 11) and indicate the studies for which such data were used in the analyses. The reviewers ideally should also state whether they confirmed the accuracy of the information included in their review with the original researchers, for example, by sending them a copy of the draft review [79].
Some studies are published more than once. Duplicate publications may be difficult to ascertain, and their inclusion may introduce bias [80],[81]. We advise authors to describe any steps they used to avoid double counting and piece together data from multiple reports of the same study (e.g., juxtaposing author names, treatment comparisons, sample sizes, or outcomes). We also advise authors to indicate whether all reports on a study were considered, as inconsistencies may reveal important limitations. For example, a review of multiple publications of drug trials showed that reported study characteristics may differ from report to report, including the description of the design, number of patients analyzed, chosen significance level, and outcomes [82]. Authors ideally should present any algorithm that they used to select data from overlapping reports and any efforts they used to solve logical inconsistencies across reports
Examples
We developed a data extraction sheet (based on the Cochrane Consumers and Communication Review Group’s data extraction template), pilot-tested it on ten randomly-selected included studies, and refined it accordingly. One review author extracted the following data from included studies and the second author checked the extracted data…Disagreements were resolved by discussion between the two review authors; if no agreement could be reached, it was planned a third author would decide. We contacted five authors for further information. All responded and one provided numerical data that had only been presented graphically in the published paper.
List and define all variables for which data were sought (e.g., PICOS, funding sources), and any assumptions and simplifications made.
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It is important for readers to know what information review authors sought, even if some of this information was not available [84]. If the review is limited to reporting only those variables that were obtained, rather than those that were deemed important but could not be obtained, bias might be introduced and the reader might be misled. It is therefore helpful if authors can refer readers to the protocol (see Item 5), and archive their extraction forms (see Item 10), including definitions of variables. The published systematic review should include a description of the processes used with, if relevant, specification of how readers can get access to additional materials.
We encourage authors to report whether some variables were added after the review started. Such variables might include those found in the studies that the reviewers identified (e.g., important outcome measures that the reviewers initially overlooked). Authors should describe the reasons for adding any variables to those already pre-specified in the protocol so that readers can understand the review process.
We advise authors to report any assumptions they made about missing or unclear information and to explain those processes. For example, in studies of women aged 50 or older it is reasonable to assume that none were pregnant, even if this is not reported. Likewise, review authors might make assumptions about the route of administration of drugs assessed. However, special care should be taken in making assumptions about qualitative information. For example, the upper age limit for “children” can vary from 15 years to 21 years, “intense” physiotherapy might mean very different things to different researchers at different times and for different patients, and the volume of blood associated with “heavy” blood loss might vary widely depending on the setting.
Examples
Information was extracted from each included trial on: (1) characteristics of trial participants (including age, stage and severity of disease, and method of diagnosis), and the trial’s inclusion and exclusion criteria; (2) type of intervention (including type, dose, duration and frequency of the NSAID [non-steroidal anti-inflammatory drug]; versus placebo or versus the type, dose, duration and frequency of another NSAID; or versus another pain management drug; or versus no treatment); (3) type of outcome measure (including the level of pain reduction, improvement in quality of life score (using a validated scale), effect on daily activities, absence from work or school, length of follow up, unintended effects of treatment, number of women requiring more invasive treatment)
Describe methods used for assessing risk of bias in individual studies (including specification of whether this was done at the study or outcome level, or both), and how this information is to be used in any data synthesis.
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The likelihood that the treatment effect reported in a systematic review approximates the truth depends on the validity of the included studies, as certain methodological characteristics may be associated with effect sizes [87],[88]. For example, trials without reported adequate allocation concealment exaggerate treatment effects on average compared to those with adequate concealment [88]. Therefore, it is important for authors to describe any methods that they used to gauge the risk of bias in the included studies and how that information was used [89]. Additionally, authors should provide a rationale if no assessment of risk of bias was undertaken. The most popular term to describe the issues relevant to this item is “quality,” but for the reasons that are elaborated in Box 4 we prefer to name this item as “assessment of risk of bias.”
Many methods exist to assess the overall risk of bias in included studies, including scales, checklists, and individual components [90],[91]. As discussed in Box 4, scales that numerically summarize multiple components into a single number are misleading and unhelpful [92],[93]. Rather, authors should specify the methodological components that they assessed. Common markers of validity for randomized trials include the following: appropriate generation of random allocation sequence [94]; concealment of the allocation sequence [93]; blinding of participants, health care providers, data collectors, and outcome adjudicators [95],[96],[97],[98]; proportion of patients lost to follow-up [99],[100]; stopping of trials early for benefit [101]; and whether the analysis followed the intention-to-treat principle [100],[102]. The ultimate decision regarding which methodological features to evaluate requires consideration of the strength of the empiric data, theoretical rationale, and the unique circumstances of the included studies.
Authors should report how they assessed risk of bias; whether it was in a blind manner; and if assessments were completed by more than one person, and if so, whether they were completed independently [103],[104]. Similarly, we encourage authors to report any calibration exercises among review team members that were done. Finally, authors need to report how their assessments of risk of bias are used subsequently in the data synthesis (see Item 16). Despite the often difficult task of assessing the risk of bias in included studies, authors are sometimes silent on what they did with the resultant assessments [89]. If authors exclude studies from the review or any subsequent analyses on the basis of the risk of bias, they should tell readers which studies they excluded and explain the reasons for those exclusions (see Item 6). Authors should also describe any planned sensitivity or subgroup analyses related to bias assessments (see Item 16).
Examples
To ascertain the validity of eligible randomized trials, pairs of reviewers working independently and with adequate reliability determined the adequacy of randomization and concealment of allocation, blinding of patients, health care providers, data collectors, and outcome assessors; and extent of loss to follow-up (i.e. proportion of patients in whom the investigators were not able to ascertain outcomes).
To explore variability in study results (heterogeneity) we specified the following hypotheses before conducting the analysis. We hypothesised that effect size may differ according to the methodological quality of the studies.
State the principal summary measures (e.g., risk ratio, difference in means).
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When planning a systematic review, it is generally desirable that authors pre-specify the outcomes of primary interest (see Item 5) as well as the intended summary effect measure for each outcome. The chosen summary effect measure may differ from that used in some of the included studies. If possible the choice of effect measures should be explained, though it is not always easy to judge in advance which measure is the most appropriate.
For binary outcomes, the most common summary measures are the risk ratio, odds ratio, and risk difference [108]. Relative effects are more consistent across studies than absolute effects [109],[110], although absolute differences are important when interpreting findings (see Item 24).
For continuous outcomes, the natural effect measure is the difference in means [108]. Its use is appropriate when outcome measurements in all studies are made on the same scale. The standardized difference in means is used when the studies do not yield directly comparable data. Usually this occurs when all studies assess the same outcome but measure it in a variety of ways (e.g., different scales to measure depression).
For time-to-event outcomes, the hazard ratio is the most common summary measure. Reviewers need the log hazard ratio and its standard error for a study to be included in a meta-analysis [111]. This information may not be given for all studies, but methods are available for estimating the desired quantities from other reported information [111]. Risk ratio and odds ratio (in relation to events occurring by a fixed time) are not equivalent to the hazard ratio, and median survival times are not a reliable basis for meta-analysis [112]. If authors have used these measures they should describe their methods in the report.
Examples
Relative risk of mortality reduction was the primary measure of treatment effect.
The meta-analyses were performed by computing relative risks (RRs) using random-effects model. Quantitative analyses were performed on an intention-to-treat basis and were confined to data derived from the period of follow-up. RR and 95% confidence intervals for each side effect (and all side effects) were calculated.
The primary outcome measure was the mean difference in log10 HIV-1 viral load comparing zinc supplementation to placebo…
Describe the methods of handling data and combining results of studies, if done, including measures of consistency (e.g., I2) for each meta-analysis.
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The data extracted from the studies in the review may need some transformation (processing) before they are suitable for analysis or for presentation in an evidence table. Although such data handling may facilitate meta-analyses, it is sometimes needed even when meta-analyses are not done. For example, in trials with more than two intervention groups it may be necessary to combine results for two or more groups (e.g., receiving similar but non-identical interventions), or it may be desirable to include only a subset of the data to match the review’s inclusion criteria. When several different scales (e.g., for depression) are used across studies, the sign of some scores may need to be reversed to ensure that all scales are aligned (e.g., so low values represent good health on all scales). Standard deviations may have to be reconstructed from other statistics such as p-values and t statistics [115],[116], or occasionally they may be imputed from the standard deviations observed in other studies [117]. Time-to-event data also usually need careful conversions to a consistent format [111]. Authors should report details of any such data processing.
Statistical combination of data from two or more separate studies in a meta-analysis may be neither necessary nor desirable (see Box 5 and Item 21). Regardless of the decision to combine individual study results, authors should report how they planned to evaluate between-study variability (heterogeneity or inconsistency) (Box 6). The consistency of results across trials may influence the decision of whether to combine trial results in a meta-analysis.
When meta-analysis is done, authors should specify the effect measure (e.g., relative risk or mean difference) (see Item 13), the statistical method (e.g., inverse variance), and whether a fixed- or random-effects approach, or some other method (e.g., Bayesian) was used (see Box 6). If possible, authors should explain the reasons for those choices.
Examples
We tested for heterogeneity with the Breslow-Day test, and used the method proposed by Higgins et al. to measure inconsistency (the percentage of total variation across studies due to heterogeneity) of effects across lipid-lowering interventions. The advantages of this measure of inconsistency (termed I2) are that it does not inherently depend on the number of studies and is accompanied by an uncertainty interval.
In very few instances, estimates of baseline mean or mean QOL [Quality of life] responses were obtained without corresponding estimates of variance (standard deviation [SD] or standard error). In these instances, an SD was imputed from the mean of the known SDs. In a number of cases, the response data available were the mean and variance in a pre study condition and after therapy. The within-patient variance in these cases could not be calculated directly and was approximated by assuming independence.
Specify any assessment of risk of bias that may affect the cumulative evidence (e.g., publication bias, selective reporting within studies).
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Reviewers should explore the possibility that the available data are biased. They may examine results from the available studies for clues that suggest there may be missing studies (publication bias) or missing data from the included studies (selective reporting bias) (see Box 7). Authors should report in detail any methods used to investigate possible bias across studies.
It is difficult to assess whether within-study selective reporting is present in a systematic review. If a protocol of an individual study is available, the outcomes in the protocol and the published report can be compared. Even in the absence of a protocol, outcomes listed in the methods section of the published report can be compared with those for which results are presented [120]. In only half of 196 trial reports describing comparisons of two drugs in arthritis were all the effect variables in the methods and results sections the same [82]. In other cases, knowledge of the clinical area may suggest that it is likely that the outcome was measured even if it was not reported. For example, in a particular disease, if one of two linked outcomes is reported but the other is not, then one should question whether the latter has been selectively omitted [121],[122].
Only 36% (76 of 212) of therapeutic systematic reviews published in November 2004 reported that study publication bias was considered, and only a quarter of those intended to carry out a formal assessment for that bias [3]. Of 60 meta-analyses in 24 articles published in 2005 in which formal assessments were reported, most were based on fewer than ten studies; most displayed statistically significant heterogeneity; and many reviewers misinterpreted the results of the tests employed [123]. A review of trials of antidepressants found that meta-analysis of only the published trials gave effect estimates 32% larger on average than when all trials sent to the drug agency were analyzed [67].
Examples
For each trial we plotted the effect by the inverse of its standard error. The symmetry of such ‘funnel plots’ was assessed both visually, and formally with Egger’s test, to see if the effect decreased with increasing sample size.
We assessed the possibility of publication bias by evaluating a funnel plot of the trial mean differences for asymmetry, which can result from the non publication of small trials with negative results…Because graphical evaluation can be subjective, we also conducted an adjusted rank correlation test and a regression asymmetry test as formal statistical tests for publication bias…We acknowledge that other factors, such as differences in trial quality or true study heterogeneity, could produce asymmetry in funnel plots.
Describe methods of additional analyses (e.g., sensitivity or subgroup analyses, meta-regression), if done, indicating which were pre-specified.
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Authors may perform additional analyses to help understand whether the results of their review are robust, all of which should be reported. Such analyses include sensitivity analysis, subgroup analysis, and meta-regression [125].
Sensitivity analyses are used to explore the degree to which the main findings of a systematic review are affected by changes in its methods or in the data used from individual studies (e.g., study inclusion criteria, results of risk of bias assessment). Subgroup analyses address whether the summary effects vary in relation to specific (usually clinical) characteristics of the included studies or their participants. Meta-regression extends the idea of subgroup analysis to the examination of the quantitative influence of study characteristics on the effect size [126]. Meta-regression also allows authors to examine the contribution of different variables to the heterogeneity in study findings. Readers of systematic reviews should be aware that meta-regression has many limitations, including a danger of over-interpretation of findings [127],[128].
Even with limited data, many additional analyses can be undertaken. The choice of which analysis to undertake will depend on the aims of the review. None of these analyses, however, are exempt from producing potentially misleading results. It is important to inform readers whether these analyses were performed, their rationale, and which were pre-specified.
Examples
Sensitivity analyses were pre-specified. The treatment effects were examined according to quality components (concealed treatment allocation, blinding of patients and caregivers, blinded outcome assessment), time to initiation of statins, and the type of statin. One post-hoc sensitivity analysis was conducted including unpublished data from a trial using cerivastatin
Results
Give numbers of studies screened, assessed for eligibility, and included in the review, with reasons for exclusions at each stage, ideally with a flow diagram.
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Authors should report, ideally with a flow diagram, the total number of records identified from electronic bibliographic sources (including specialized database or registry searches), hand searches of various sources, reference lists, citation indices, and experts. It is useful if authors delineate for readers the number of selected articles that were identified from the different sources so that they can see, for example, whether most articles were identified through electronic bibliographic sources or from references or experts. Literature identified primarily from references or experts may be prone to citation or publication bias [131],[132].
The flow diagram and text should describe clearly the process of report selection throughout the review. Authors should report: unique records identified in searches; records excluded after preliminary screening (e.g., screening of titles and abstracts); reports retrieved for detailed evaluation; potentially eligible reports that were not retrievable; retrieved reports that did not meet inclusion criteria and the primary reasons for exclusion; and the studies included in the review. Indeed, the most appropriate layout may vary for different reviews.
Authors should also note the presence of duplicate or supplementary reports so that readers understand the number of individual studies compared to the number of reports that were included in the review. Authors should be consistent in their use of terms, such as whether they are reporting on counts of citations, records, publications, or studies. We believe that reporting the number of studies is the most important.
A flow diagram can be very useful; it should depict all the studies included based upon fulfilling the eligibility criteria, whether or not data have been combined for statistical analysis. A recent review of 87 systematic reviews found that about half included a QUOROM flow diagram [133]. The authors of this research recommended some important ways that reviewers can improve the use of a flow diagram when describing the flow of information throughout the review process, including a separate flow diagram for each important outcome reported [133].
Examples
In text: A total of 10 studies involving 13 trials were identified for inclusion in the review. The search of Medline, PsycInfo and Cinahl databases provided a total of 584 citations. After adjusting for duplicates 509 remained. Of these, 479 studies were discarded because after reviewing the abstracts it appeared that these papers clearly did not meet the criteria. Three additional studies…were discarded because full text of the study was not available or the paper could not be feasibly translated into English. The full text of the remaining 27 citations was examined in more detail. It appeared that 22 studies did not meet the inclusion criteria as described. Five studies…met the inclusion criteria and were included in the systematic review. An additional five studies…that met the criteria for inclusion were identified by checking the references of located, relevant papers and searching for studies that have cited these papers. No unpublished relevant studies were obtained.
Example flow diagram of study selection.
DDW, Digestive Disease Week; UEGW, United European Gastroenterology Week. Reproduced with permission from https://doi.org/10.1371/journal.pmed.1000100.g002
For each study, present characteristics for which data were extracted (e.g., study size, PICOS, follow-up period) and provide the citation.
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For readers to gauge the validity and applicability of a systematic review’s results, they need to know something about the included studies. Such information includes PICOS (Box 2) and specific information relevant to the review question. For example, if the review is examining the long-term effects of antidepressants for moderate depressive disorder, authors should report the follow-up periods of the included studies. For each included study, authors should provide a citation for the source of their information regardless of whether or not the study is published. This information makes it easier for interested readers to retrieve the relevant publications or documents.
Reporting study-level data also allows the comparison of the main characteristics of the studies included in the review. Authors should present enough detail to allow readers to make their own judgments about the relevance of included studies. Such information also makes it possible for readers to conduct their own subgroup analyses and interpret subgroups, based on study characteristics.
Authors should avoid, whenever possible, assuming information when it is missing from a study report (e.g., sample size, method of randomization). Reviewers may contact the original investigators to try to obtain missing information or confirm the data extracted for the systematic review. If this information is not obtained, this should be noted in the report. If information is imputed, the reader should be told how this was done and for which items. Presenting study-level data makes it possible to clearly identify unpublished information obtained from the original researchers and make it available for the public record.
Typically, study-level characteristics are presented as a table as in the example in Table 2. Such presentation ensures that all pertinent items are addressed and that missing or unclear information is clearly indicated. Although paper-based journals do not generally allow for the quantity of information available in electronic journals or Cochrane reviews, this should not be accepted as an excuse for omission of important aspects of the methods or results of included studies, since these can, if necessary, be shown on a Web site.
Following the presentation and description of each included study, as discussed above, reviewers usually provide a narrative summary of the studies. Such a summary provides readers with an overview of the included studies. It may for example address the languages of the published papers, years of publication, and geographic origins of the included studies.
The PICOS framework is often helpful in reporting the narrative summary indicating, for example, the clinical characteristics and disease severity of the participants and the main features of the intervention and of the comparison group. For non-pharmacological interventions, it may be helpful to specify for each study the key elements of the intervention received by each group. Full details of the interventions in included studies were reported in only three of 25 systematic reviews relevant to general practice [84].
Examples
In text:
Characteristics of included studies
Methods: All four studies finally selected for the review were randomised controlled trials published in English. The duration of the intervention was 24 months for the RIO-North America and 12 months for the RIO-Diabetes, RIO-Lipids and RIO-Europe study. Although the last two described a period of 24 months during which they were conducted, only the first 12-months results are provided. All trials had a run-in, as a single blind period before the randomisation.
Participants: The included studies involved 6625 participants. The main inclusion criteria entailed adults (18 years or older), with a body mass index greater than 27 kg/m2 and less than 5 kg variation in body weight within the three months before study entry.
Intervention: All trials were multicentric. The RIO-North America was conducted in the USA and Canada, RIO-Europe in Europe and the USA, RIO-Diabetes in the USA and 10 other different countries not specified, and RIO-Lipids in eight unspecified different countries.
The intervention received was placebo, 5 mg of rimonabant or 20 mg of rimonabant once daily in addition to a mild hypocaloric diet (600 kcal/day deficit).
Outcomes:
Primary: In all studies the primary outcome assessed was weight change from baseline after one year of treatment and the RIO-North America study also evaluated the prevention of weight regain between the first and second year. All studies evaluated adverse effects, including those of any kind and serious events. Quality of life was measured in only one study, but the results were not described (RIO-Europe).
Secondary and additional outcomes: These included prevalence of metabolic syndrome after one year and change in cardiometabolic risk factors such as blood pressure, lipid profile, etc.
No study included mortality and costs as outcome.
The timing of outcome measures was variable and could include monthly investigations, evaluations every three months or a single final evaluation after one year.
In table:
Example Table: Summary of included studies evaluating the efficacy of antiemetic agents in acute gastroenteritis.
https://doi.org/10.1371/journal.pmed.1000100.t002
Present data on risk of bias of each study and, if available, any outcome-level assessment (see Item 12).
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We recommend that reviewers assess the risk of bias in the included studies using a standard approach with defined criteria (see Item 12). They should report the results of any such assessments [89].
Reporting only summary data (e.g., “two of eight trials adequately concealed allocation”) is inadequate because it fails to inform readers which studies had the particular methodological shortcoming. A more informative approach is to explicitly report the methodological features evaluated for each study. The Cochrane Collaboration’s new tool for assessing the risk of bias also requests that authors substantiate these assessments with any relevant text from the original studies [11]. It is often easiest to provide these data in a tabular format, as in the example. However, a narrative summary describing the tabular data can also be helpful for readers.
Examples
In table:
Example Table: Quality measures of the randomized controlled trials that failed to fulfill any one of six markers of validity.
https://doi.org/10.1371/journal.pmed.1000100.t003
For all outcomes considered (benefits and harms), present, for each study: (a) simple summary data for each intervention group and (b) effect estimates and confidence intervals, ideally with a forest plot.
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Publication of summary data from individual studies allows the analyses to be reproduced and other analyses and graphical displays to be investigated. Others may wish to assess the impact of excluding particular studies or consider subgroup analyses not reported by the review authors. Displaying the results of each treatment group in included studies also enables inspection of individual study features. For example, if only odds ratios are provided, readers cannot assess the variation in event rates across the studies, making the odds ratio impossible to interpret [138]. Additionally, because data extraction errors in meta-analyses are common and can be large [139], the presentation of the results from individual studies makes it easier to identify errors. For continuous outcomes, readers may wish to examine the consistency of standard deviations across studies, for example, to be reassured that standard deviation and standard error have not been confused [138].
For each study, the summary data for each intervention group are generally given for binary outcomes as frequencies with and without the event (or as proportions such as 12/45). It is not sufficient to report event rates per intervention group as percentages. The required summary data for continuous outcomes are the mean, standard deviation, and sample size for each group. In reviews that examine time-to-event data, the authors should report the log hazard ratio and its standard error (or confidence interval) for each included study. Sometimes, essential data are missing from the reports of the included studies and cannot be calculated from other data but may need to be imputed by the reviewers. For example, the standard deviation may be imputed using the typical standard deviations in the other trials [116],[117] (see Item 14). Whenever relevant, authors should indicate which results were not reported directly and had to be estimated from other information (see Item 13). In addition, the inclusion of unpublished data should be noted.
For all included studies it is important to present the estimated effect with a confidence interval. This information may be incorporated in a table showing study characteristics or may be shown in a forest plot [140]. The key elements of the forest plot are the effect estimates and confidence intervals for each study shown graphically, but it is preferable also to include, for each study, the numerical group-specific summary data, the effect size and confidence interval, and the percentage weight (see second example [Figure 3]). For discussion of the results of meta-analysis, see Item 21.
In principle, all the above information should be provided for every outcome considered in the review, including both benefits and harms. When there are too many outcomes for full information to be included, results for the most important outcomes should be included in the main report with other information provided as a Web appendix. The choice of the information to present should be justified in light of what was originally stated in the protocol. Authors should explicitly mention if the planned main outcomes cannot be presented due to lack of information. There is some evidence that information on harms is only rarely reported in systematic reviews, even when it is available in the original studies [141]. Selective omission of harms results biases a systematic review and decreases its ability to contribute to informed decision making.
Examples
In figure:
Example Figure: Overall failure (defined as failure of assigned regimen or relapse) with tetracycline-rifampicin versus tetracycline-streptomycin.
CI, confidence interval. Reproduced with permission from https://doi.org/10.1371/journal.pmed.1000100.g003
In table:
Example Table: Heterotopic ossification in trials comparing radiotherapy to non-steroidal anti-inflammatory drugs after major hip procedures and fractures.
https://doi.org/10.1371/journal.pmed.1000100.t004
Present the main results of the review. If meta-analyses are done, include for each, confidence intervals and measures of consistency.
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Results of systematic reviews should be presented in an orderly manner. Initial narrative descriptions of the evidence covered in the review (see Item 18) may tell readers important things about the study populations and the design and conduct of studies. These descriptions can facilitate the examination of patterns across studies. They may also provide important information about applicability of evidence, suggest the likely effects of any major biases, and allow consideration, in a systematic manner, of multiple explanations for possible differences of findings across studies.
If authors have conducted one or more meta-analyses, they should present the results as an estimated effect across studies with a confidence interval. It is often simplest to show each meta-analysis summary with the actual results of included studies in a forest plot (see Item 20) [140]. It should always be clear which of the included studies contributed to each meta-analysis. Authors should also provide, for each meta-analysis, a measure of the consistency of the results from the included studies such as I2 (heterogeneity; see Box 6); a confidence interval may also be given for this measure [145]. If no meta-analysis was performed, the qualitative inferences should be presented as systematically as possible with an explanation of why meta-analysis was not done, as in the second example above [143]. Readers may find a forest plot, without a summary estimate, helpful in such cases.
Authors should in general report syntheses for all the outcome measures they set out to investigate (i.e., those described in the protocol; see Item 4) to allow readers to draw their own conclusions about the implications of the results. Readers should be made aware of any deviations from the planned analysis. Authors should tell readers if the planned meta-analysis was not thought appropriate or possible for some of the outcomes and the reasons for that decision.
It may not always be sensible to give meta-analysis results and forest plots for each outcome. If the review addresses a broad question, there may be a very large number of outcomes. Also, some outcomes may have been reported in only one or two studies, in which case forest plots are of little value and may be seriously biased.
Of 300 systematic reviews indexed in MEDLINE in 2004, a little more than half (54%) included meta-analyses, of which the majority (91%) reported assessing for inconsistency in results.
Examples
Mortality data were available for all six trials, randomizing 311 patients and reporting data for 305 patients. There were no deaths reported in the three respiratory syncytial virus/severe bronchiolitis trials; thus our estimate is based on three trials randomizing 232 patients, 64 of whom died. In the pooled analysis, surfactant was associated with significantly lower mortality (relative risk = 0.7, 95% confidence interval = 0.4–0.97, P = 0.04). There was no evidence of heterogeneity (I2 = 0%).
Because the study designs, participants, interventions, and reported outcome measures varied markedly, we focused on describing the studies, their results, their applicability, and their limitations and on qualitative synthesis rather than meta-analysis.
We detected significant heterogeneity within this comparison (I2 = 46.6%; χ2 = 13.11, df = 7; P = 0.07). Retrospective exploration of the heterogeneity identified one trial that seemed to differ from the others. It included only small ulcers (wound area less than 5 cm2). Exclusion of this trial removed the statistical heterogeneity and did not affect the finding of no evidence of a difference in healing rate between hydrocolloids and simple low adherent dressings (relative risk = 0.98, [95% confidence interval] 0.85 to 1.12; I2 = 0%).
Present results of any assessment of risk of bias across studies (see Item 15).
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Authors should present the results of any assessments of risk of bias across studies. If a funnel plot is reported, authors should specify the effect estimate and measure of precision used, presented typically on the x-axis and y-axis, respectively. Authors should describe if and how they have tested the statistical significance of any possible asymmetry (see Item 15). Results of any investigations of selective reporting of outcomes within studies (as discussed in Item 15) should also be reported. Also, we advise authors to tell readers if any pre-specified analyses for assessing risk of bias across studies were not completed and the reasons (e.g., too few included studies).
Examples
Strong evidence of heterogeneity (I2 = 79%, P<0.001) was observed. To explore this heterogeneity, a funnel plot was drawn. The funnel plot in Figure 4 shows evidence of considerable asymmetry.
Example Figure 4: Example of a funnel plot showing evidence of considerable asymmetry. SE, standard error. Adapted with permission from. https://doi.org/10.1371/journal.pmed.1000100.g004
Specifically, four sertraline trials involving 486 participants and one citalopram trial involving 274 participants were reported as having failed to achieve a statistically significant drug effect, without reporting mean HRSD [Hamilton Rating Scale for Depression] scores. We were unable to find data from these trials on pharmaceutical company Web sites or through our search of the published literature. These omissions represent 38% of patients in sertraline trials and 23% of patients in citalopram trials. Analyses with and without inclusion of these trials found no differences in the patterns of results; similarly, the revealed patterns do not interact with drug type. The purpose of using the data obtained from the FDA was to avoid publication bias, by including unpublished as well as published trials. Inclusion of only those sertraline and citalopram trials for which means were reported to the FDA would constitute a form of reporting bias similar to publication bias and would lead to overestimation of drug–placebo differences for these drug types. Therefore, we present analyses only on data for medications for which complete clinical trials’ change was reported.
Give results of additional analyses, if done (e.g., sensitivity or subgroup analyses, meta-regression [see Item 16]).
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Authors should report any subgroup or sensitivity analyses and whether or not they were pre-specified (see Items 5 and 16). For analyses comparing subgroups of studies (e.g., separating studies of low- and high-dose aspirin), the authors should report any tests for interactions, as well as estimates and confidence intervals from meta-analyses within each subgroup. Similarly, meta-regression results (see Item 16) should not be limited to p-values, but should include effect sizes and confidence intervals [150], as the first example reported above does in a table. The amount of data included in each additional analysis should be specified if different from that considered in the main analyses. This information is especially relevant for sensitivity analyses that exclude some studies; for example, those with high risk of bias.
Importantly, all additional analyses conducted should be reported, not just those that were statistically significant. This information will help avoid selective outcome reporting bias within the review as has been demonstrated in reports of randomized controlled trials [42],[44],[121],[151],[152]. Results from exploratory subgroup or sensitivity analyses should be interpreted cautiously, bearing in mind the potential for multiple analyses to mislead.
Examples
…benefits of chondroitin were smaller in trials with adequate concealment of allocation compared with trials with unclear concealment (P for interaction = 0.050), in trials with an intention-to-treat analysis compared with those that had excluded patients from the analysis (P for interaction = 0.017), and in large compared with small trials (P for interaction = 0.022).
Subgroup analyses according to antibody status, antiviral medications, organ transplanted, treatment duration, use of antilymphocyte therapy, time to outcome assessment, study quality and other aspects of study design did not demonstrate any differences in treatment effects. Multivariate meta-regression showed no significant difference in CMV [cytomegalovirus] disease after allowing for potential confounding or effect-modification by prophylactic drug used, organ transplanted or recipient serostatus in CMV positive recipients and CMV negative recipients of CMV positive donors.
Discussion
Summarize the main findings, including the strength of evidence for each main outcome; consider their relevance to key groups (e.g., health care providers, users, and policy makers
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Authors should give a brief and balanced summary of the nature and findings of the review. Sometimes, outcomes for which little or no data were found should be noted due to potential relevance for policy decisions and future research. Applicability of the review’s findings, to different patients, settings, or target audiences, for example, should be mentioned. Although there is no standard way to assess applicability simultaneously to different audiences, some systems do exist [153]. Sometimes, authors formally rate or assess the overall body of evidence addressed in the review and can present the strength of their summary recommendations tied to their assessments of the quality of evidence (e.g., the GRADE system) [10].
Authors need to keep in mind that statistical significance of the effects does not always suggest clinical or policy relevance. Likewise, a non-significant result does not demonstrate that a treatment is ineffective. Authors should ideally clarify trade-offs and how the values attached to the main outcomes would lead different people to make different decisions. In addition, adroit authors consider factors that are important in translating the evidence to different settings and that may modify the estimates of effects reported in the review [153]. Patients and health care providers may be primarily interested in which intervention is most likely to provide a benefit with acceptable harms, while policy makers and administrators may value data on organizational impact and resource utilization.
Examples
Overall, the evidence is not sufficiently robust to determine the comparative effectiveness of angioplasty (with or without stenting) and medical treatment alone. Only 2 randomized trials with long-term outcomes and a third randomized trial that allowed substantial crossover of treatment after 3 months directly compared angioplasty and medical treatment…the randomized trials did not evaluate enough patients or did not follow patients for a sufficient duration to allow definitive conclusions to be made about clinical outcomes, such as mortality and cardiovascular or kidney failure events.
Some acceptable evidence from comparison of medical treatment and angioplasty suggested no difference in long-term kidney function but possibly better blood pressure control after angioplasty, an effect that may be limited to patients with bilateral atherosclerotic renal artery stenosis. The evidence regarding other outcomes is weak. Because the reviewed studies did not explicitly address patients with rapid clinical deterioration who may need acute intervention, our conclusions do not apply to this important subset of patients.
Discuss limitations at study and outcome level (e.g., risk of bias), and at review level (e.g., incomplete retrieval of identified research, reporting bias).
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A discussion of limitations should address the validity (i.e., risk of bias) and reporting (informativeness) of the included studies, limitations of the review process, and generalizability (applicability) of the review. Readers may find it helpful if authors discuss whether studies were threatened by serious risks of bias, whether the estimates of the effect of the intervention are too imprecise, or if there were missing data for many participants or important outcomes.
Limitations of the review process might include limitations of the search (e.g., restricting to English-language publications), and any difficulties in the study selection, appraisal, and meta-analysis processes. For example, poor or incomplete reporting of study designs, patient populations, and interventions may hamper interpretation and synthesis of the included studies [84]. Applicability of the review may be affected if there are limited data for certain populations or subgroups where the intervention might perform differently or few studies assessing the most important outcomes of interest; or if there is a substantial amount of data relating to an outdated intervention or comparator or heavy reliance on imputation of missing values for summary estimates (Item 14).
Examples
Outcome level:
The meta-analysis reported here combines data across studies in order to estimate treatment effects with more precision than is possible in a single study. The main limitation of this meta-analysis, as with any overview, is that the patient population, the antibiotic regimen and the outcome definitions are not the same across studies.
Study and review level:
Our study has several limitations. The quality of the studies varied. Randomization was adequate in all trials; however, 7 of the articles did not explicitly state that analysis of data adhered to the intention-to-treat principle, which could lead to overestimation of treatment effect in these trials, and we could not assess the quality of 4 of the 5 trials reported as abstracts. Analyses did not identify an association between components of quality and re-bleeding risk, and the effect size in favour of combination therapy remained statistically significant when we excluded trials that were reported as abstracts.
Publication bias might account for some of the effect we observed. Smaller trials are, in general, analyzed with less methodological rigor than larger studies, and an asymmetrical funnel plot suggests that selective reporting may have led to an overestimation of effect sizes in small trials.
Provide a general interpretation of the results in the context of other evidence, and implications for future research.
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Systematic reviewers sometimes draw conclusions that are too optimistic [157] or do not consider the harms equally as carefully as the benefits, although some evidence suggests these problems are decreasing [158]. If conclusions cannot be drawn because there are too few reliable studies, or too much uncertainty, this should be stated. Such a finding can be as important as finding consistent effects from several large studies.
Authors should try to relate the results of the review to other evidence, as this helps readers to better interpret the results. For example, there may be other systematic reviews about the same general topic that have used different methods or have addressed related but slightly different questions [159],[160]. Similarly, there may be additional information relevant to decision makers, such as the cost-effectiveness of the intervention (e.g., health technology assessment). Authors may discuss the results of their review in the context of existing evidence regarding other interventions.
We advise authors also to make explicit recommendations for future research. In a sample of 2,535 Cochrane reviews, 82% included recommendations for research with specific interventions, 30% suggested the appropriate type of participants, and 52% suggested outcome measures for future research [161]. There is no corresponding assessment about systematic reviews published in medical journals, but we believe that such recommendations are much less common in those reviews.
Clinical research should not be planned without a thorough knowledge of similar, existing research [162]. There is evidence that this still does not occur as it should and that authors of primary studies do not consider a systematic review when they design their studies [163]. We believe systematic reviews have great potential for guiding future clinical research.
Examples
Implications for practice:
Between 1995 and 1997 five different meta-analyses of the effect of antibiotic prophylaxis on infection and mortality were published. All confirmed a significant reduction in infections, though the magnitude of the effect varied from one review to another. The estimated impact on overall mortality was less evident and has generated considerable controversy on the cost effectiveness of the treatment. Only one among the five available reviews, however, suggested that a weak association between respiratory tract infections and mortality exists and lack of sufficient statistical power may have accounted for the limited effect on mortality.
Implications for research:
A logical next step for future trials would thus be the comparison of this protocol against a regimen of a systemic antibiotic agent only to see whether the topical component can be dropped. We have already identified six such trials but the total number of patients so far enrolled (n = 1056) is too small for us to be confident that the two treatments are really equally effective. If the hypothesis is therefore considered worth testing more and larger randomised controlled trials are warranted. Trials of this kind, however, would not resolve the relevant issue of treatment induced resistance. To produce a satisfactory answer to this, studies with a different design would be necessary. Though a detailed discussion goes beyond the scope of this paper, studies in which the intensive care unit rather than the individual patient is the unit of randomisation and in which the occurrence of antibiotic resistance is monitored over a long period of time should be undertaken.
Funding
Describe sources of funding or other support (e.g., supply of data) for the systematic review; role of funders for the systematic review.
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Authors of systematic reviews, like those of any other research study, should disclose any funding they received to carry out the review, or state if the review was not funded. Lexchin and colleagues [166] observed that outcomes of reports of randomized trials and meta-analyses of clinical trials funded by the pharmaceutical industry are more likely to favor the sponsor’s product compared to studies with other sources of funding. Similar results have been reported elsewhere [167],[168]. Analogous data suggest that similar biases may affect the conclusions of systematic reviews [169].
Given the potential role of systematic reviews in decision making, we believe authors should be transparent about the funding and the role of funders, if any. Sometimes the funders will provide services, such as those of a librarian to complete the searches for relevant literature or access to commercial databases not available to the reviewers. Any level of funding or services provided to the systematic review team should be reported. Authors should also report whether the funder had any role in the conduct or report of the review. Beyond funding issues, authors should report any real or perceived conflicts of interest related to their role or the role of the funder in the reporting of the systematic review [170].
In a survey of 300 systematic reviews published in November 2004, funding sources were not reported in 41% of the reviews [3]. Only a minority of reviews (2%) reported being funded by for-profit sources, but the true proportion may be higher [171].
Examples
Authors of systematic reviews, like those of any other research study, should disclose any funding they received to carry out the review, or state if the review was not funded. Lexchin and colleagues [166] observed that outcomes of reports of randomized trials and meta-analyses of clinical trials funded by the pharmaceutical industry are more likely to favor the sponsor’s product compared to studies with other sources of funding. Similar results have been reported elsewhere [167],[168]. Analogous data suggest that similar biases may affect the conclusions of systematic reviews [169].
Given the potential role of systematic reviews in decision making, we believe authors should be transparent about the funding and the role of funders, if any. Sometimes the funders will provide services, such as those of a librarian to complete the searches for relevant literature or access to commercial databases not available to the reviewers. Any level of funding or services provided to the systematic review team should be reported. Authors should also report whether the funder had any role in the conduct or report of the review. Beyond funding issues, authors should report any real or perceived conflicts of interest related to their role or the role of the funder in the reporting of the systematic review [170].
In a survey of 300 systematic reviews published in November 2004, funding sources were not reported in 41% of the reviews [3]. Only a minority of reviews (2%) reported being funded by for-profit sources, but the true proportion may be higher [171].