Systematic Review and Meta-analysis

By Dr. Omer Eladil MBBS, MD, MSc London

31 May 2012

EDC RESEARCH ACTIVITIES NO. 3

Objectives
By the end of this session, we are expecting to: 1. Define different terms used in Systematic Review (SR) and Metaanalysis (MA). 2. Explain why should we do SR &MA. 3. Show how to conduct SR & MA. 4. Undertake important steps of SR. 5. Pilot SR & MA for research

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The main reference

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Definitions

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 A systematic review is a review of a

clearly formulated question that uses systematic and explicit methods to identify, select, and critically appraise relevant research, and to collect and analyze data, statistical methods (metaanalysis) may or may not be used.
Meta-analysis: refers to the use of

statistical techniques in a systematic review to integrate the results of

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 Boolean operator: Combine terms when

conducting electronic searches. AND (narrow a search), OR (broaden a search) and NOT (exclude terms from a search).
Cochrane Collaboration: An international

organization helps to make well-informed decisions about health care by preparing, maintaining, updating and ensuring the accessibility of systematic reviews of the effects of healthcare interventions. systematic review examples.docx 31 May 2012

 Grey literature: A general term for the

kind of material that is not published in an easily accessible form or listed in standard bibliographic databases, for example conference proceedings, internal reports, theses and some books.
Handsearching: The process of

searching a journal page by page to identify relevant articles.

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 Indexing term: A word used to describe

the subject of, for example, a journal article. Ideally these terms will be assigned from a controlled vocabulary, for example MeSH.
Medical Subject Heading (MeSH):

controlled vocabulary indexing system used by the National Library of Medicine for indexing articles on Medline and some others.
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 Meta-analysis: Statistical techniques used to

combine the results of two or more studies and obtain a combined estimate of effect.
Truncation symbol: A symbol used when

searching electronic databases to retrieve words begin with a particular stem. For example, a search for child$ on Ovid MEDLINE.
Centre for Reviews and Dissemination
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Why SR & MA are important

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 Health care decisions taken by

practitioners and/or decision-makers for both individual patients and for public policy should be based on the evidences of: The best practice and the best latest research. However, this can be difficult given the large amounts generated by individual studies which may be biased, methodologically flawed, and can be misinterpreted and
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 SRs aim to identify, evaluate and

summarise the findings of all relevant individual studies, thereby making the available evidence more accessible to decision makers.
When appropriate, combining the results

of several studies gives a more reliable and precise estimate of an interventions effectiveness than one study alone
(Oxman in CD1993;118:A-13.)
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Common types of systematic reviews

1.

2.
3. 4. 5.

Health interventions. Clinical tests. Public health interventions. Adverse effects. Economic evaluations.

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Then How to Conduct SR & MA?

FRAME OF THE Systematic review.docx

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Check whether a new review is justified: It is on topics where a gap in knowledge has been identified, prioritised and a question posed. Check list of reviews.docx Check whether there are already existing or ongoing reviews. This achieved by searching the Database such as: Abstracts of Reviews of Effects for critical appraisals of systematic reviews of health interventions effects. 31 Cochrane Database of SystematicMay 2012
1.

 Other sites; include:

oNational Institute for Health and Clinical Excellence (NICE). oCampbell Collaboration website contains the Campbell Library of Systematic Reviews for full detailed completed and ongoing systematic reviews in education, crime and justice, and social welfare; and the Evidence for Policy and Practice Information. oPublic health database of systematic and non systematic reviews of public health interventions (DoPHER).31 May 2012

2.

Select the review team and advisory group. Design the Review Protocol: Review question: clear question, the answers to which will provide meaningful information that can be used to guide decision-making. Objectives. PICOS details: Population Interventions Comparators Outcomes Study design. PICOS.docx 31 May 2012 Inclusion and exclusion criteria.

3.

Methodological issues to be noted A. Language Language bias arises because studies with statistically significant results that have been conducted in non-English speaking countries may be more likely to be published in English language journals than those with non significant results.
4.

(Egger M. et al., Language bias in randomised controlled trials

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B. Publication type/status
Reports, book chapters, conference

abstracts, theses or they may be informally reported or remain unpublished.

(Mona a.alaziz, Post card SJPH, 2009)

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Identifying research evidence Specify the databases and additional sources that will be searched: Searching electronic databases Handsearching Contacting authors, experts, and other organisations Searching relevant Internet resources google scholar Citation searching by selecting a number of key papers 31 May 2012 Grey literature.
C.

D. Grey literature: identification of grey

literature, such as unpublished papers, is difficult, but some are included on: 1. Databases such as NTIS (National Technical Information Service) and HMIC (Health Management Information Consortium). 2. Libraries of specialist research organisations and professional societies

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Study selection
in two stages:

Initial screening of titles and abstracts against the inclusion criteria to identify potentially relevant papers. 2. Later screening of the full papers identified as possibly relevant in the initial screening.
1.

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Data extraction
The protocol should outline the

information that will be extracted from studies identified for inclusion in the review and provide details of any software to be used for recording the data. Procedures for data extraction including the number of researchers who will extract the data and how discrepancies will be resolved.
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Quality assessment
The protocol should provide details of

the method of study appraisal to be used, including examples of the specific quality criteria.

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Data synthesis
It should state whether a meta-analysis

is planned. It can be difficult to pre-specify full details of the planned synthesis. Is the meta-analysis a fixed or randomeffects model or both would be used. FRAME OF THE Systematic review.docx
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Dissemination
Dissemination of findings is an integral

part of the review process and fundamental to ensuring that the essential messages from the review reach the appropriate audiences.

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Reasons for meta-analysis

Combining the results of individual

studies in a meta-analysis increases power and precision in estimating intervention effects.

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Ann Intern Med. 2009;151:264-269.

One reason for changing the name from QUOROM (QUality Of Reporting Of Metaanalyses) to PRISMA (Preferred Reporting Items for Systematic reviews and Meta Analyses) was the desire to encompass both systematic reviews and meta-analyses.
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In summary
They are six steps:

1.
2. 3. 4.

5.
6.

FRAMING THE QUESTION. IDENTIFYING RELEVANT PUBLICATIONS. ASSESSING STUDY QUALITY. SUMMARIZING THE EVIDENCE. INTERPRETING THE FINDINGS. DISSEMINATION.
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Take home message

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Case definition

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