Course: Statistics
Module: Systematic reviews
Lecture 1: Introduction to systematic reviews
Description: Introduction to systematic reviews and how
to perform them
Author: Dr Susan D. Shenkin
Learning Objectives
On completion of this lecture, you should be able to:
define what a systematic review is
identify and use some useful resources
discuss the differences between systematic reviews
of randomised controlled trials and observational
studies
describe the process of how to perform a systematic
review
What is a systematic review?
collates all empirical evidence that fits pre-specified
eligibility criteria in order to answer a specific
research question
[Link]
What is a systematic review?
clearly stated objectives with pre-defined eligibility criteria
for studies
explicit, reproducible methodology
a systematic search that attempts to identify all studies
assessment of the validity of the findings of the included
studies (e.g. risk of bias)
systematic presentation, and synthesis, of the
characteristics and findings of the included studies
[Link]
What is a meta-analysis?
the use of statistical methods
to summarize the results of
independent studies
i.e. A specific type of systematic
review
Why are reviews needed?
Massive numbers of publications
Both print, and electronic media
Diverse languages
Different countries
Primary studies can appear contradictory
Psychology and social sciences predated medical
systematic reviews (1930s)
Why are systematic reviews needed?
Literature/narrative/critical review:
Often not replicable/updated
May be biased by prior beliefs
May be commissioned due to published opinion
Often miss small but important effects
Different reviewers reached different conclusions
Affected by subspecialty of reviewer
Little attempt to discuss heterogeneity
Why are systematic reviews needed?
Benefits of therapy not brought into clinical practice
e.g. Clot-busters/beta blockers for heart attacks
SR would have identified benefit in mid-1970s
Not in clinical practice till 1990s
Inadequate summaries of current knowledge
Omitted mention of effective treatment, or suggested only
as part of trials
Why are systematic reviews needed?
As part of student dissertation/PG thesis
To secure grant funding for research
To propose future research agenda
To establish clinical or cost-effectiveness
To establish feasibility of an intervention
To allow information to be assimilated quickly and easily
To reduce delay of research to clinical practice
Note this is as substantial a piece of work as original
research
Problems with systematic reviews
Vary in quality
Require updating (often by time of publication)
May not include all studies
o Non-English
o Grey literature
o Early literature
Quality assessment can still be subjective
Why are systematic reviews needed?
Mostly
o A substantive question
o Several primary studies
o Uncertainty
Can be of
o RCTs (randomised controlled trials) of intervention (vaccine,
drug, behaviour)
e.g. MMR, clot busters, exercise after stroke
o Observational studies
e.g. Birth weight and IQ, IQ and mortality, WMH and
morbidity/mortality
Hierarchy of evidence
RCTs or observational studies
RCTs
o gold standard for interventions
o Minimise bias
o Exposed/unexposed groups are comparable
o Bigger is better
[Link]
RCTs or observational studies
Observational studies
o The majority of studies
o When RCTs are not ethical/feasible/done
o Need clarity about design ?filter by method
o What search techniques are appropriate?
o Concern about bias, confounding (bigger not always
better)
o Difficult to combine different study designs
o May require original data
o Meta-analysis can be spuriously precise and misleading
[Link]
Introduction to Cochrane
Archie Cochrane (1909-88)
o British epidemiologist
o Advocated RCTs to inform healthcare practice
The School of Medicine,
Cardiff University and the
Cochrane Archive
Cochrane collaboration
o Cochrane Reviews (>4,000) registered
o Identify, appraise and synthesise research-
based evidence and present it in accessible
format; regularly updated
o Focus on interventions
o Outstanding general resource
[Link]
Introduction to Campbell Collaboration
Systematic reviews of the effects of social
interventions
Prepare, maintain and disseminate systematic
reviews in education, crime and justice, and social
welfare
Register relevant reviews
Links to useful methodology sites
o Effect sizes
o Campbell Collaboration Resource Centre
[Link]
Introduction to EPPI-Centre
Evidence for Policy and Practice Information and Co-
ordinating Centre
Systematic reviews of public policy
o Education, health promotion, employment, social care,
criminal justice
Online evidence library
Methods, tools and databases (quantitative and
qualitative)
EPPI-Centre (March 2007) EPPI-Centre methods for
conducting systematic reviews. London: EPPI-Centre,
Social Science Research Unit, Institute of Education,
University of London.
[Link]
Introduction to PROSPERO
Centre for Reviews and Dissemination, York
Evaluate the effects of health and social care interventions
and the delivery and organisation of health care
Guidance on systematic reviews
PROSPERO
o International prospective register of SRs
DARE
o abstracts of quality assessed systematic reviews and details
of all Cochrane reviews and protocols
NHS EED
HTA
[Link]
Introduction to EQUATOR
Enhancing the QUAlity and Transparency Of health
Research
Started March 2006
Grew from guideline development groups (including
CONSORT)
Aim to:
o provide resources and education enabling the improvement of
health research reporting
o monitor progress in the improvement of health research
reporting
[Link]
Introduction to EQUATOR
Detailed reporting guidelines
o CONSORT Statement (reporting of randomized controlled
trials)
o STARD (reporting of diagnostic accuracy studies)
o STROBE (reporting of observational studies in epidemiology)
o PRISMA (reporting of systematic reviews), which replaced
QUOROM
o MOOSE (reporting of meta-analyses of observational studies)
Minimum Information for Biological and Biomedical
Investigation (MIBBI) portal
o e.g. minimum dataset for fMRI studies
[Link]
How to do a systematic review?
1. Define a question
2. Search the literature
3. Assess the studies
4. Combine the results
5. Put the findings in context
How to do a systematic review?
1. Define a question
2. Search the literature
3. Assess the studies
4. Combine the results
5. Put the findings in context
How to do a systematic review?
1. Define a question
2. Search the literature
3. Assess the studies
4. Combine the results (Geoff Der)
5. Put the findings in context
Presenting and assessing results
Use the 27-point PRISMA checklist
Use the PRISMA flow diagram
Essential to ensure high quality reviews
Use other checklists for your primary studies
Moher D, Liberati A, Tetzlaff J, Altman DG,
The PRISMA Group (2009). Preferred Reporting Items for Systematic Reviews and Meta-Analyses:
The PRISMA Statement. PLoS Med 6(6): e1000097. doi:10.1371/journal.pmed1000097
PRISMA 2009 Checklist
Reported
Section/topic # Checklist item
on page #
Risk of bias across studies 15 Specify any assessment of risk of bias that may affect the cumulative evidence (e.g., publication bias, selective
reporting within studies).
Additional analyses 16 Describe methods of additional analyses (e.g., sensitivity or subgroup analyses, meta-regression), if done, indicating
which were pre-specified.
RESULTS
Study selection 17 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.
Study characteristics 18 For each study, present characteristics for which data were extracted (e.g., study size, PICOS, follow-up period) and
provide the citations.
Risk of bias within studies 19 Present data on risk of bias of each study and, if available, any outcome level assessment (see item 12).
Results of individual studies 20 For all outcomes considered (benefits or harms), present, for each study: (a) simple summary data for each
intervention group (b) effect estimates and confidence intervals, ideally with a forest plot.
Synthesis of results 21 Present results of each meta-analysis done, including confidence intervals and measures of consistency.
Risk of bias across studies 22 Present results of any assessment of risk of bias across studies (see Item 15).
Additional analysis 23 Give results of additional analyses, if done (e.g., sensitivity or subgroup analyses, meta-regression [see Item 16]).
DISCUSSION
Summary of evidence 24 Summarize the main findings including the strength of evidence for each main outcome; consider their relevance to
key groups (e.g., healthcare providers, users, and policy makers).
Limitations 25 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).
Conclusions 26 Provide a general interpretation of the results in the context of other evidence, and implications for future research.
FUNDING
Funding 27 Describe sources of funding for the systematic review and other support (e.g., supply of data); role of funders for the
systematic review.
From: Moher D, Liberati A, Tetzlaff J, Altman DG, The PRISMA Group (2009). Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement. PLoS Med 6(6): e1000097.
doi:10.1371/journal.pmed1000097
For more information, visit: [Link].
Page 2 of 2
Putting the results in context
Writing the paper:
Follow conventional structure
Be clear and comprehensive
Should be reproducible
Check with target journal (length?)
Very useful guide by Prof Joanna Wardlaw (SBIRC)
You have now reached the end of this lecture, and you
should be able to:
define what a systematic review is
identify and use some useful resources
discuss the differences between systematic
reviews of randomised controlled trials and
observational studies
describe the process of how to perform a
systematic review
Acknowledgements
[Link]
Division of Clinical Neurosciences (DCN), especially Prof Joanna Wardlaw
[Link]
The work was supported by The University of Edinburgh Centre for Cognitive Ageing
and Cognitive Epidemiology, part of the cross council Lifelong Health and Wellbeing
Initiative (G0700704/84698). Funding from the BBSRC, EPSRC, ESRC and MRC is
gratefully acknowledged.
