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      The rough guide to systematic reviews and meta-analyses

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          Abstract

          The hierarchy of evidence based medicine postulates that systematic reviews of homogenous randomized trials represent one of the uppermost levels of clinical evidence. Indeed, the current overwhelming role of systematic reviews, meta-analyses and meta-regression analyses in evidence based heath care calls for a thorough knowledge of the pros and cons of these study designs, even for the busy clinician. Despite this sore need, few succinct but thorough resources are available to guide users or would-be authors of systematic reviews. This article provides a rough guide to reading and, summarily, designing and conducting systematic reviews and meta-analyses

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          Most cited references 23

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          Cochrane Handbook for Systematic Reviews of Interventions

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            The results of direct and indirect treatment comparisons in meta-analysis of randomized controlled trials.

            When little or no data directly comparing two treatments are available, investigators often rely on indirect comparisons from studies testing the treatments against a control or placebo. One approach to indirect comparison is to pool findings from the active treatment arms of the original controlled trials. This approach offers no advantage over a comparison of observational study data and is prone to bias. We present an alternative model that evaluates the differences between treatment and placebo in two sets of clinical trials, and preserves the randomization of the originally assigned patient groups. We apply the method to data on sulphamethoxazole-trimethoprim or dapsone/pyrimethamine as prophylaxis against Pneumocystis carinii in HIV infected patients. The indirect comparison showed substantial increased benefit from the former (odds ratio 0.37, 95% CI 0.21 to 0.65), while direct comparisons from randomized trials suggests a much smaller difference (risk ratio 0.64, 95% CI 0.45 to 0.90; p-value for difference of effect = 0.11). Direct comparisons of treatments should be sought. When direct comparisons are unavailable, indirect comparison meta-analysis should evaluate the magnitude of treatment effects across studies, recognizing the limited strength of inference.
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              External Validation of a Measurement Tool to Assess Systematic Reviews (AMSTAR)

              Background Thousands of systematic reviews have been conducted in all areas of health care. However, the methodological quality of these reviews is variable and should routinely be appraised. AMSTAR is a measurement tool to assess systematic reviews. Methodology AMSTAR was used to appraise 42 reviews focusing on therapies to treat gastro-esophageal reflux disease, peptic ulcer disease, and other acid-related diseases. Two assessors applied the AMSTAR to each review. Two other assessors, plus a clinician and/or methodologist applied a global assessment to each review independently. Conclusions The sample of 42 reviews covered a wide range of methodological quality. The overall scores on AMSTAR ranged from 0 to 10 (out of a maximum of 11) with a mean of 4.6 (95% CI: 3.7 to 5.6) and median 4.0 (range 2.0 to 6.0). The inter-observer agreement of the individual items ranged from moderate to almost perfect agreement. Nine items scored a kappa of >0.75 (95% CI: 0.55 to 0.96). The reliability of the total AMSTAR score was excellent: kappa 0.84 (95% CI: 0.67 to 1.00) and Pearson's R 0.96 (95% CI: 0.92 to 0.98). The overall scores for the global assessment ranged from 2 to 7 (out of a maximum score of 7) with a mean of 4.43 (95% CI: 3.6 to 5.3) and median 4.0 (range 2.25 to 5.75). The agreement was lower with a kappa of 0.63 (95% CI: 0.40 to 0.88). Construct validity was shown by AMSTAR convergence with the results of the global assessment: Pearson's R 0.72 (95% CI: 0.53 to 0.84). For the AMSTAR total score, the limits of agreement were −0.19±1.38. This translates to a minimum detectable difference between reviews of 0.64 ‘AMSTAR points’. Further validation of AMSTAR is needed to assess its validity, reliability and perceived utility by appraisers and end users of reviews across a broader range of systematic reviews.
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                Author and article information

                Journal
                HSR Proc Intensive Care Cardiovasc Anesth
                HSR Proc Intensive Care Cardiovasc Anesth
                2037-0504
                hsrp
                HSR Proceedings in Intensive Care & Cardiovascular Anesthesia
                EDIMES Edizioni Internazionali Srl
                2037-0504
                2037-0512
                2011
                : 3
                : 3
                : 161-173
                Affiliations
                [1 ]Division of Cardiology, University of Modena and Reggio Emilia, Modena, Italy
                [2 ]Meta-analysis and Evidence-based medicine Training in Cardiology (METCARDIO), Ospedaletti, Italy
                [3 ]Heart Failure and Cardiac Rehabilitation Unit, Catholic University of the Sacred Heart, Rome, Italy
                [4 ]Department of Anesthesia and Intensive Care, Università Vita-Salute San Raffaele, Milan, Italy
                Author notes
                Giuseppe Biondi-Zoccai, MD Division of Cardiology, University of Modena and Reggio Emilia, Via Del Pozzo, 71 - 41124 Modena, Italy; E-mail: gbiondizoccai@ 123456gmail.com
                Article
                201103161
                3484632
                23439862
                Copyright © 2011, HSR Proceedings in Intensive Care and Cardiovascular Anesthesia

                This is an open-access article distributed under the terms of the Creative Commons Attribution Non-commercial License 3.0, which permits use, distribution, and reproduction in any medium, provided the original work is properly cited, the use is non commercial and is otherwise in compliance with the license. See: http://creativecommons.org/licenses/by-nc/3.0/ and http://creativecommons.org/licenses/by-nc/3.0/legalcode.

                Categories
                Review-Article

                systematic review, meta-regression, meta-analysis

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