Anda di halaman 1dari 28

Chocrane Col.

systematic review and its appraisal

Why are systematic reviews important?


Systematic reviews of randomised controlled trials are considered the best level of evidence for answering questions about the effectiveness of healthcare interventions. In addition to the reduction in bias, one of the many advantages of systematic reviews is that they enable us to reduce the everincreasing torrent of both published and unpublished research literature into manageable portions

Advantage of meta-analysis
Pooling of data from individual studies leads to an increase in sample size, and an increase in power which is particularly important when the size of effect is small or there is a relatively low event rate. The increase in sample size not only means an increase in power, but also an increase in the precision in the estimate of effect

Where to find systematic reviews?


The best solution is to search the Cochrane Library, which contains two databases dedicated to helping you locate the systematic review you need. The Cochrane Database of Systematic Reviews (CDSR) includes full text systematic reviews that have been completed to the exacting standards of the Cochrane Collaboration, and protocols of reviews that are underway. The Database of Abstracts of Reviews of Effectiveness (DARE) is a compilation of abstracts of systematic reviews that are published in paper journals, along with helpful commentary on their quality.

Critically appraising systematic reviews


1. What are the reviews objectives? To focus on well-defined questions, stating the populations, intervention/control groups, and outcomes to be included. 2. How comprehensive was the search strategy? To search for all the literature relevant to the question. Published and unpublished literature should be sought, any restrictions regarding language of publication should be stated and justified, as should the time period covered by the search. Ideally a systematic review needs to be up to date, incorporating all the recent literature.

Appraisal of SW
3. What were the inclusion/exclusion criteria? The criteria for selecting or rejecting studies should be clearly stated and appropriate. The process* by which articles are assessed for relevance should also be recorded. 4. How was the validity of the primary studies assessed? The process* by which validity assessment was undertaken and the criteria used to assess the quality of the primary studies should be clear. It should also be apparent how the results of the validity assessment are used within the reviews data synthesis.

Appraisal of SW
5. How were data extracted from the primary studies? The process* by which data was extracted from the primary studies should be transparent. 6. Are the characteristics of the included studies clearly displayed? A table illustrating the study characteristics of each included primary study should be presented.

Appraisal of SW
7. Does the review examine differences/similarities between the included studies and their results? Heterogeneity between studies should be explored and the reasons for any variations discussed. Heterogeneity can be explored statistically, graphically or through a narrative. 8. Was the synthesis of the data carried out appropriately? Was data pooled qualitatively or statistically? If statistical pooling (meta-analysis) was used, was it used appropriately? 9. Were the results interpreted appropriately? Any conclusions, implications for research or practice should follow on logically from the results.

How to produce a Systematic Review?

How is a systematic review conducted?


First step: to specify a tight question. population (group to whom the intervention will apply), intervention (the therapy, treatment or preventive policy to be carried out), comparison (what will the intervention be compared against it could be a common alternative intervention, a placebo or no intervention) and outcomes (what do we wish to measure at the end, what is important to us and to consumers?).

A clear protocol
Describing the background to the work, hypothesis to be tested and methodology to be used Allowing peer (and often consumer) review of the question to be asked, and methods to be used, so that these can be improved. It also limits vague inclusion criteria that may preferentially allow in studies with good results, and data dredging where lots of analyses are tried out, but only those with significant results reported.

Clear inclusion and exclusion criteria


Besides the population, intervention, comparison and outcomes that should be represented in the inclusion and exclusion criteria, it is important to specify the type of studies that will offer the least biased evidence for the review-- RCT Ideally the process of deciding on inclusion of studies is performed independently by at least two people, on a form specifically designed for the review, sometimes blinded to authors and results.

Transparent inclusive search strategy


To include all the published and preferably also unpublished data that exist. Ideally several types of searching are adopted, so that if one strategy misses a relevant study it may be picked up through another searching method. Search strategies generally include several of the following: structured searches of several electronic databases (including the Cochrane Library) Checking through the reference lists of included studies and relevant reviews Letters to relevant pharmaceutical companies and experts in the field asking about unpublished or ongoing work Handsearching of relevant journals or conference abstracts, Translation of foreign language articles.

Quality assessment of the included studies


Assessment of study validity (preferably independently duplicated) and some statement on how those biases may affect outcomes is essential in understanding the believability of the results of a systematic review Selection bias Attrition bias (where more participants drop out of one experimental arm for some reason), Performance bias (where those receiving the intervention and/or those caring for them are aware of the experimental allocation and may alter concurrent treatments accordingly) Detection bias (where those assessing outcomes are aware of the experimental allocation and may be open to biased outcome measurement).8

Extracting data
Ideally the process is independently duplicated, based on prior decisions (in the protocol), comprehensive (on a form designed for the review, and may involve contacting authors to fill in any gaps in published reports) Clearly tabulated to allow transparency and possibly corrections at a later date.

Pooling of data
Narrative or statistical pooling or metaanalysis? Narrative or meta-analytic comparisons and sub-groupings should be prespecified in the protocol (to avoid multiple analyses being carried out with only the statistically significant ones being published).

What is meta-analysis?
To pool extracted numerical data, weighted so that larger studies, or those with less variability, contribute more to the outcome. This pooling provides an answer with greater precision that each included study on its own The pictorial representation of a metaanalysis is called a forest plot (see example).

Forest plot of continuous data

Statistical analysis
Fixed effects (where it is assumed that the true outcomes of the various studies are the same) Random effects methodologies (where the true outcomes are assumed to vary a little with differing study inclusion, dose, duration etc). Where fixed effects meta-analysis produces a result that is statistically heterogeneous it is usual to switch to random effects meta-analysis. Statistical heterogeneity of studies (large differences in their results, suggesting differing true outcomes) is ideally explored through subgrouping or metaregression.

How can I perform a meta-analysis?


A meta-analysis is a very good way of summarising data from a group of studies. However, this is only useful where the set of studies is representative of the whole body of literature, so should generally be restricted to use within systematic reviews. Meta-analyses can be performed by hand or with a calculator, but are usually completed with the help of specialised computer software (that may also create a forest plot). There are many very good types of software available, but for those embarking on a Cochrane review the free Review Manager software (downloadable from the main Cochrane website) is excellent, creating forest plots

Cochrane Collaboration Cochrane Library and Oral Health Group

Background of the Cochrane Collaboration


In 1972, the British epidemiologist Archie Cochrane published an influential book Effectiveness and Efficiency. Random Reflections on Health Services. It is surely a great criticism of our profession that we have not organised a critical summary, by speciality or subspecialty, updated periodically, of all relevant randomised controlled trials (Archie Cochrane)

Structure of the Cochrane Collaboration


Cochrane Collaboration was formed in October 1993. The Cochrane Collaboration aims to help people make well-informed decisions about health care by preparing, maintaining, and promoting the accessibility of systematic reviews of the effects of health care interventions. Over the last ten years it has grown into an international organisation, currently over 6,000 people contributing from over 60 countries. What is remarkable about the Cochrane Collaboration is that the majority of these contributors undertake their Cochrane work in their own time.

The Cochrane Library


The main product of the Cochrane Collaboration is The Cochrane Database of Systematic Reviews that forms part of The Cochrane Library, a quarterly electronic publication. It contains the full text of more than 1350 regularly updated systematic reviews and more than 1,000 protocols for reviews in progress. Several hundred reviews and protocols are added annually.

CL policy
It is Cochrane policy that reviewers revisit their review and update it within two years of it being published on The Cochrane Library. There are several stages to the Cochrane peer review process, including the assessment of protocols, evaluation of the reviews methodology and content by editors, peer reviewers and potential end users / consumers. It has been suggested that the existence of such a thorough refereeing process ultimately leads to Cochrane reviews being less prone to bias than systematic reviews and meta-analysis published in paper-based journals.

Cochrane Oral Health Group


Responsible for preparing and maintaining systematic reviews within the scope of oral health. Oral health is broadly conceived to include the prevention, treatment and rehabilitation or oral, dental and craniofacial diseases and disorders. Alexia Antczak-Bouckoms initially set up the OHG in New England (USA) in 1994. The group moved to Manchester (UK) in 1996 and secured National Health Service (NHS) funding for the editorial base in 1997. The editorial base is situated in the Manchester Dental Education Centre, University Dental Hospital of Manchester under the Co-ordinating Editorship of Professor William Shaw and Dr Helen Worthington.

OHGs Specialised Register of Trials


It currently holds over 13,400 reports of oral health related trials (RCTs, CCTs) and related references from a wide range of bibliographical sources including MEDLINE, EMBASE, CINAHL, CANCERLIT, PSYCLIT, and the Cochrane Controlled Trials Register in addition to conference proceedings. The register is continually growing as a result of on-going electronic searching and the OHGs organised programme of handsearching the oral health literature. This handsearching programme also contributes to the Cochrane Collaborations worldwide handsearching programme co-ordinated by the New England Cochane Centre, USA. This collection of references from various sources makes the Specialised Register a unique and valuable resource and the best starting point for anyone considering a systematic review with the oral health field.

Ways to contribute
The Oral Health Group welcomes all those interested in contributing to the work of the group. There are several options for participation, either as a lead reviewer, assisting as a co-reviewer, handsearching a journal to identify RCTs, or by becoming a member of the panel of peer reviewers or consumers. For further details or an information pack please refer to the groups website: www.cochrane-oral.man.ac.uk Contact: Emma Tavender, Co-ordinator, Cochrane Oral Health Group, MANDEC, University Dental Hospital of Manchester, Higher Cambridge Street, Manchester M15 6FH. Tel: +44 161 275 7818, Fax: +44 161 275 7815, Email: emma.tavender@man.ac.uk

Anda mungkin juga menyukai