Systematic review

by: Nehal Gamal Eldeen Abosamra

Contents:
• Introduction
• Comparison between Systematic & narrative review
• Definition of systematic review
• What is the significance of Systematic Reviews?
• Why are Systematic Reviews Necessary?
• Key Characteristics of Systematic Reviews
• Steps in a systematic review
• Example on systematic review
• PRISMA checklist
Literature review:
The general term for all attempts to
synthesize the results and conclusions of two
or more publications on a given topic .
A review may or may not be systematic.
Levels of literature review
• Narrative review
Traditional expert review; usually subjective in nature.

• Systematic review
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 from the studies that are included in the
review.
• Meta- analysis
• Quantitative evidence
• Use of statistical methods to combine the
results of various independent, similar
studies
• More precise calculation of one estimate of
treatment effect than could be achieved by
any of the individual , contributing studies
Systematic Review History:
• Astronomers claim to be the first
users of this method.
• Explosion of SRs in health sciences
in mid 1980s.
• Term “systematic review” was
coined by health care researchers.
• SR became a significant tool for“
evidence- based medicine” or “
evidence- based practice”
• Growth of SR s in health sciences.
 Systematic review Traditional narrative review
Deciding Start with clear question May also start with clear
on review to be answered or question to be answered,
question hypothesis to be tested but they more often involve
general discussion of subject
with no stated hypothesis

Searching Strive to locate all Do not usually attempt to

for relevant published and locate all relevant literature
relevant unpublished studies to
studies limit impact of
publication and other
biases
 Systematic review Traditional narrative review

Deciding which Involve explicit description of what Usually do not describe

studies to types of studies are to be included why certain studies are
include and to limit selection bias on behalf of included and other
exclude
reviewer excluded

Assessing Examine in systematic manner methods Often do not consider

study quality used in primary studies, differences in study
and investigate potential biases in these methods or study quality
studies and sources of heterogeneity

Synthesizing Base their conclusion on those Often do not differentiate

study results studied which are most between methodologically
methodologically sound sound and unsound
Hierarchy of
scientific
evidence
 What is a Systematic Review?
• “A review that is conducted according to
clearly stated, scientific research methods,
and is designed to minimize biases and
errors inherent to traditional, narrative
reviews.”
SR (Another definition):
A systematic review attempts
• To collate all empirical evidence that fits
prespecified eligibility criteria .
• In order to answer a specific research question.
• It uses explicit, systematic methods that are selected
with a view to minimizing bias.
• Thus providing more reliable findings from which
conclusions can be drawn and decisions made.
What is the significance of Systematic Reviews?
• The large amount of medical literature requires
clinicians and researchers alike to rely on systematic
reviews in order to make an informed decision.
• Systematic Reviews minimize bias.
• “A systematic review is a more scientific method of
summarizing literature because specific protocols
are used to determine which studies will be included
in the review.”
Kevin C. Chung, MD, Patricia B. Burns, MPH, H. Myra Kim, ScD, “Clinical Perspective: A Practical Guide to Meta-Analysis.” The Journal of Hand Surgery. Vol. 31A No.10 December 2006. p.1671
 Why are Systematic Reviews Necessary?
• “The volume of published material makes it
impractical for an individual clinician to remain up to
date on a variety of common conditions.
• This is further complicated when individual studies
report conflicting conclusions, a problem that is
prevalent when small patient samples and
retrospective designs are used.”
Margaliot, Zvi, Kevin C. Chung. “Systematic Reviews: A Primer for Plastic Surgery Research”. PRS Journal. 120/7 (2007) p.1834
Key Characteristics of Systematic Reviews
• Clearly stated title and set of objectives with
predefined eligibility criteria for studies.
• Comprehensive strategy to search for relevant
studies (unpublished and published)
• Assessment of the validity of the findings of the
included studies.
• Explicit and justified criteria for the inclusion or
exclusion of any study.
• Clear presentation of characteristics of each study
included and an analysis of methodological quality
• Comprehensive list of all studies excluded and
justification for exclusion.

Linda N. Meurer, MD, MPH Department of Family and Community Medicine. “Systematic Synthesis of the Literature: Introduction to Meta-
analysis”. Power Point Presentation.
• Clear analysis of the results of the eligible studies
–statistical synthesis of data (meta-analysis) if
appropriate and possible;
–or qualitative synthesis
• Structured report of the review clearly stating the
aims, describing the methods and materials and
reporting the results.

Linda N. Meurer, MD, MPH Department of Family and Community Medicine. “Systematic Synthesis of the Literature:
Introduction to Meta-analysis”. Power Point Presentation.
Steps in a systematic review
• Build a review team.
• Develop a protocol or plan.
• Formulate review question.
• Define inclusion and exclusion criteria.
• Locate studies .
• Select studies.
• Assess study quality.
• Extract data.
• Analysis/summary and synthesis of relevant studies.
• Present results.
• Interpret results/determining the applicability of results.
Review team:
• Normally a team work
• Key skills:
Managing research projects
(Leading, coordinating)
Expertise in the topic
Methodological expertise
(planning, searching, managing information,
coding, analysing, synthesizing, writing.
Steps in a systematic review
• Build a review team.
• Develop a protocol or plan.
• Formulate review question.
• Define inclusion and exclusion criteria.
• Locate studies .
• Select studies.
• Assess study quality.
• Extract data.
• Analysis/summary and synthesis of relevant studies.
• Present results.
• Interpret results/determining the applicability of results.
Protocol:
• What is the title?
• What is the context and what are the conceptual
issues?
• What is the aim?
• What is the research question?
• What is the search strategy?
• What are the inclusion/exclusion criteria?
• How will the data be extracted and analysed?
• How will the quality of studies be assessed?
Steps in a systematic review
• Build a review team.
• Develop a protocol or plan.
• Formulate review question.
• Define inclusion and exclusion criteria.
• Locate studies .
• Select studies.
• Assess study quality.
• Extract data.
• Analysis/summary and synthesis of relevant studies.
• Present results.
• Interpret results/determining the applicability of results.
PICO- question components in medicine:
• P----Population
Patients(Demographic factors, socioeconomic factors,
setting, etc)
• I-----Intervention
Drug, procedure, etc.
• C-----Comparison
Alternative to compare with intervention( Placebo or active)
• O------Outcome
• Improvement, effect, measure, etc.
PICO- question example
Steps in a systematic review
• Build a review team.
• Develop a protocol or plan.
• Formulate review question.
• Define inclusion and exclusion criteria.
• Locate studies .
• Select studies.
• Assess study quality.
• Extract data.
• Analysis/summary and synthesis of relevant studies.
• Present results.
• Interpret results/determining the applicability of results.
inclusion/exclusion criteria-example
Steps in a systematic review
• Build a review team.
• Develop a protocol or plan.
• Formulate review question.
• Define inclusion and exclusion criteria.
• Locate studies .
• Select studies.
• Assess study quality.
• Extract data.
• Analysis/summary and synthesis of relevant studies.
• Present results.
• Interpret results/determining the applicability of results.
Searching literature
• Identifying major concepts
• Keywords, controlled vocabulary
• Combination of concepts
 Boolean operators, string, truncation, proximity, etc.
• Identifying where to search
• Search strategy
 Varies in different databases
• Export citations to reference management software
 EndNote, etc.
• Documenting your search
 Database name, date of searching, number of results
Source of literature
• Electronic databases ( General vs. subject)
• Grey literature
Conference proceedings, theses, reports,
websites
• Browsing issues of topical journals
• Backward and forward citations of the most
relevant articles
• Conversation with experts in the field
Search strategy --example
Steps in a systematic review
• Build a review team.
• Develop a protocol or plan.
• Formulate review question.
• Define inclusion and exclusion criteria.
• Locate studies .
• Select studies.
• Assess study quality.
• Extract data.
• Analysis/summary and synthesis of relevant studies.
• Present results.
• Interpret results/determining the applicability of results.
Study selection
An initial assessment that occurs following the search
• It addresses the question “should the paper be retrieved?”
• It is essential to use two assessors in both the
selection and critical appraisal processes to limit the
risk of error
• Select only those studies that address the review
question and that match the inclusion criteria
• Scan titles and abstracts
• If uncertain? Retrieve- scan full text
PRISMA flow diagram
Steps in a systematic review
• Build a review team.
• Develop a protocol or plan.
• Formulate review question.
• Define inclusion and exclusion criteria.
• Locate studies .
• Select studies.
• Assess study quality.
• Extract data.
• Analysis/summary and synthesis of relevant studies.
• Present results.
• Interpret results/determining the applicability of results.
Study quality assessment
• Choose appropriate checklist
 related to study design
• It is better to use more reviewers
 inter-reviewer reliability
Quality assessment criteria
Quality assessment results
Steps in a systematic review
• Build a review team.
• Develop a protocol or plan.
• Formulate review question.
• Define inclusion and exclusion criteria.
• Locate studies .
• Select studies.
• Assess study quality.
• Extract data.
• Analysis/summary and synthesis of relevant studies.
• Present results.
• Interpret results/determining the applicability of results.
Data extraction
• Think about what data you need to
extract from included studies to answer
the questions
• Pilot a draft data extraction form
Data extraction form
Steps in a systematic review
• Build a review team.
• Develop a protocol or plan.
• Formulate review question.
• Define inclusion and exclusion criteria.
• Locate studies .
• Select studies.
• Assess study quality.
• Extract data.
• Analysis/summary and synthesis of relevant studies.
• Present results.
• Interpret results/determining the applicability of results.
Summary table of evidence
Data synthesis
• Will results be pooled/ how?
• How will differences between
studies be taken into account?
• Can subgroups of data be made?
• How will results be displayed?
Example of systematic review
Meta-analysis
Meta-analyses can be used to
• To establish statistical significance with studies that have conflicting results
• To develop a more correct and precise estimate of effect magnitude by
increasing statistical power
• To examine potential reasons for variability or heterogeneity in study
- results
• To examine subgroups with individual numbers that are not statistically
significant
The final pooled effect estimate is the key outcome
The most common measures of effect used for dichotomous data are the risk
ratio (also called relative risk) and the odds ratio
The dominant method used for continuous data are standardized mean
difference (SMD) estimation
Methods used in meta-analysis for post analysis of findings
include :
• Heterogeneity analysis
• Sensitivity analysis, and
• Evaluation of publication bias
Heterogeneity analysis is to determine statistical heterogeneity
which might result from clinical or methodological heterogeneity
Clinical diversity  variability in the participants,
interventions, and outcomes
Methodological diversity  variability in study design
and risk of bias
Typically used heterogeneity metrics include the Cochran's
Q statistic, a chi-squared (χ2) test of heterogeneity with k-1
degrees of freedom and the inconsistency index I2, which
describes the percentage of total variation across studies
Some ways to investigate reasons for heterogeneity are
subgroup analysis and meta-regression
Sensitivity analyses can also examine effects of studies
identified as being aberrant concerning conduct or result
Refences list:
1-(Bruce, 1994, p. 218).
2-(Nunan, 1992, p. 217)
3-(Rudestam and Newton, 2007, p. 63).
4- Kevin C. Chung, MD, Patricia B. Burns, MPH, H. Myra Kim, ScD,
“Clinical Perspective: A Practical Guide to Meta-Analysis.” The
Journal of Hand Surgery. Vol. 31A No.10 December 2006. p.1671
 5-Margaliot, Zvi, Kevin C. Chung. “Systematic Reviews: A Primer for
Plastic Surgery Research”. PRS Journal. 120/7 (2007) p.1834
6- Linda N. Meurer, MD, MPH Department of Family and Community
Medicine. “Systematic Synthesis of the Literature: Introduction to
Meta-analysis”. Power Point Presentation
7-(Haidich, 2010).
8-Wagle M, et al. BMJ Open 2018;8:e018556. doi:10.1136/bmjopen-2017-
018556

9-Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et
al. The PRISMA 2020 statement: an updated guideline for reporting systematic
reviews. BMJ 2021;372:n71. doi: 10.1136/bmj.n71
Thank you