Page Comparison

This appraisal instrument can be found in the JBI SUMARI software.

Review authors should discuss each item in the appraisal instrument for each study included in their review. In particular, discussions should focus on what is considered acceptable to the aims of the review in terms of the specific study characteristics. When appraising systematic reviews this discussion may include issues such as what represents an adequate search strategy or appropriate methods of synthesis. The reviewers should be clear on what constitutes acceptable levels of information to allocate a positive appraisal compared with a negative, or response of “unclear”. This discussion should ideally take place before the reviewers independently conduct the appraisal.

Within Umbrella reviews, quantitative or qualitative systematic reviews may be incorporated, as well as meta-analyses of existing research. The individual checklist is available in Appendix 109.1.

There are 11 questions to guide the appraisal of systematic reviews or meta-analyses. Each question should be answered as “yes”, “no”, or “unclear”. Not applicable “NA” is also provided as an option and may be appropriate in rare instances.

1. Is the review question clearly and explicitly stated?

The review question is an essential step in the systematic review process. A well-articulated question defines the scope of the review and aids in the development of the search strategy to locate the relevant evidence. An explicitly stated question, formulated around its PICO (Population, Intervention, Comparator, Outcome) elements aids both the review team in the conduct of the review and the reader in determining if they review has achieved its objectives. Ideally the review question should be articulated in a published protocol; however this will not always be the case with many reviews that are located.

2. Were the inclusion criteria appropriate  for the review question?

The inclusion criteria should be identifiable from and match the review question. The necessary elements of the PICO should be explicit and clearly defined. The inclusion criteria should be detailed and the included reviews should clearly be eligible when matched against the stated inclusion criteria. Appraisers of meta-analyses will find that inclusion criteria may encompass criteria around the ability to conduct statistical analyses which would not be the norm for a systematic review. The types of included studies should be relevant to the review question, for example, an Umbrella Review aiming to summarize a range of effective non-pharmacological interventions for aggressive behaviors amongst elderly patients with dementia will limit itself to including systematic reviews and meta-analyses that synthesize quantitative studies assessing the various interventions; qualitative or economic reviews would not be included.

3. Was the search strategy appropriate?

A systematic review should provide evidence of the search strategy that has been used to locate the evidence. This may be found in the methods section of the review report in some cases, or as an appendix that may be provided as supplementary information to the review publication. A systematic review should present a clear search strategy that addresses each of the identifiable PICO components of the review question. Some reviews may also provide a description of the approach to searching and how the terms that were ultimately used were derived, though due to limits on word counts in journals this may be more the norm in online only publications. There should be evidence of logical and relevant keywords and terms and also evidence that Subject Headings and Indexing terms have been used in the conduct of the search. Limits on the search and their potential impact should also be considered; for example, if a date limit was used, was this appropriate and/or justified? If only English language studies were included, will the language bias have an impact on the review? The response to these considerations will depend, in part, on the review question.

4. Were the sources and resources used to search for studies adequate?

A systematic review should attempt to identify “all” the available evidence and as such there should be evidence of a comprehensive search strategy. Multiple electronic databases should be searched including major bibliographic citation databases such as MEDLINE and CINAHL. Ideally, other databases that are relevant to the review question should also be searched, for example, a systematic review with a question about a physical therapy intervention should also look to search the PEDro database, whilst a review focusing on an educational intervention should also search the ERIC. Reviews of effectiveness should aim to search trial registries. A comprehensive search is the ideal way to minimize publication bias. As a result, a well conducted systematic review should also attempt to search for gray literature, or “unpublished” studies; this may involve searching websites relevant to the review question or thesis repositories.

5. Were the criteria for appraising studies appropriate?

The systematic review should present a clear statement that critical appraisal was conducted and provide details of the items that were used to assess the included studies. This may be presented in “Methods of the review”, as an appendix of supplementary information, or as a reference to a source that can be located. The tools or instruments used should be appropriate for the review question asked and the type of research conducted. For example, a systematic review of effectiveness should present a tool or instrument that addresses aspects of validity for experimental studies and randomized controlled trials such as randomization and blinding – if the review includes observational research to answer the same question, a different tool would be more appropriate. Similarly, a review assessing diagnostic test accuracy may refer to the recognized QUADAS tool (Whiting et al, 2003).

6. Was critical appraisal conducted  by two or more reviewers independently?

Critical appraisal or some similar assessment of the quality of the literature included in a systematic review is essential. A key characteristic to minimize bias or systematic error in the conduct of a systematic review is to have the critical appraisal of the included studies completed by members of the review team independently and in duplicate. The systematic review should present a clear statement that critical appraisal was conducted by at least two reviewers working independently from each other and conferring where necessary to reach a decision regarding study quality and eligibility on the basis of quality.

7. Were there methods to minimize errors in data extraction?

Efforts made by review authors during data extraction can also minimize bias or systematic errors in the conduct of a systematic review. Strategies to minimize bias may include conducting all data extraction in duplicate and independently, using specific tools or instruments to guide data extraction and some evidence of piloting or training around their use.

8. Were the methods used to combine studies appropriate?

A synthesis of the evidence is a key feature of a systematic review. The synthesis that is presented should be appropriate for the review question and the stated type of systematic review and evidence it refers to. If a meta-analysis has been conducted this needs to be reviewed carefully. Was it appropriate to combine the studies? Have the reviewers assessed heterogeneity statistically and provided some explanation for heterogeneity that may be present? Often, where heterogeneous studies are included in the systematic review, narrative synthesis will be an appropriate method for presenting the results of multiple studies. If a qualitative review, are the methods that have been used to synthesize findings congruent with the stated methodology of the review? Is there adequate descriptive and explanatory information to support the final synthesized findings that have been constructed from the findings sourced from the original research?

9. Was the likelihood of publication bias assessed?

As mentioned, a comprehensive search strategy is the best means by which a review author may alleviate the impact of publication bias on the results of the review. Reviews may also present statistical tests such as Egger’s test or funnel plots to also assess the potential presence of publication bias and its potential impact on the results of the review. This question should be considered N/A for JBI qualitative reviews.

10. Were recommendations for policy and/or practice supported  by the reported data?

Whilst the first nine questions specifically look to identify potential bias in the conduct of a systematic review, the final questions are more indicators of review quality rather than validity. Ideally a  review should  present recommendations for  policy  and  practice.  Where these recommendations are made there should be a clear link to the results of the review. Is there evidence that the strength of the findings and the quality of the research have been considered in the formulation of review recommendations?

11. Were the specific directives for new research appropriate?

The systematic review process is recognized for its ability to identify gaps in the research, or knowledge base, around a particular topic. Most systematic review authors will provide some indication, often in the discussion section of the report, of future research direction. Where evidence is scarce or sample sizes that support overall estimates of effect are small and effect estimates are imprecise, repeating similar research to those identified by the review may be necessary and appropriate. In other instances, the case for new research questions to investigate the topic may be warranted.

P Whiting, AWS Rutjes, JB Reitsma, PMM Bossuyt, J Kleijnen. The development of QUADAS: a tool for the quality assessment of studies of diagnostic accuracy included in systematic reviews BMC Medical Research Methodology 2003, 3:2