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Systematic review


Systematic review

A systematic review (also systematic literature review or structured literature review, SLR) is a literature review focused on a research question that tries to identify, appraise, select and synthesize all high quality research evidence relevant to that question. Systematic reviews of high-quality randomized controlled trials are crucial to evidence-based medicine.[1] An understanding of systematic reviews and how to implement them in practice is becoming mandatory for all professionals involved in the delivery of health care. Besides health interventions, systematic reviews may concern clinical tests, public health interventions, social interventions, adverse effects, and economic evaluations.[2][3] Systematic reviews are not limited to medicine and are quite common in all other sciences where data are collected, published in the literature, and an assessment of methodological quality for a precisely defined subject would be helpful.[4]

This diagram illustrates in a visual way and in plain language what review authors actually do in the process of undertaking a systematic review.


  • Characteristics 1
  • Cochrane Collaboration 2
  • Strengths and weaknesses 3
  • See also 4
  • References 5
  • External links 6


A systematic review aims to provide an exhaustive summary of current literature relevant to a research question. The first step of a systematic review is a thorough search of the literature for relevant papers. The Methodology section of the review will list the databases and citation indexes searched, such as Web of Science, Embase, and PubMed, as well as any hand-searched individual journals. Next, the titles and the abstracts of the identified articles are checked against pre-determined criteria for eligibility and relevance. This list will always depend on the research problem. Each included study may be assigned an objective assessment of methodological quality preferably using a method conforming to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement (the current guideline)[5] or the high quality standards of Cochrane collaboration.[6]

Systematic reviews often, but not always, use statistical techniques (meta-analysis) to combine results of the eligible studies, or at least use scoring of the levels of evidence depending on the methodology used. An additional rater may be consulted to resolve any scoring differences between raters.[4] Systematic review is often applied in the biomedical or healthcare context, but it can be applied in any field of research. Groups like the Campbell Collaboration are promoting the use of systematic reviews in policy-making beyond just healthcare.

A systematic review uses an objective and transparent approach for research synthesis, with the aim of minimizing bias. While many systematic reviews are based on an explicit quantitative meta-analysis of available data, there are also qualitative reviews which adhere to the standards for gathering, analyzing and reporting evidence. The EPPI-Centre has been influential in developing methods for combining both qualitative and quantitative research in systematic reviews.[7]

Recent developments in systematic reviews include realist reviews,[8] and the meta-narrative approach.[9][10] These approaches try to overcome the problems of methodological and epistemological heterogeneity in the diverse literatures existing on some subjects. The PRISMA statement[11] suggests a standardized way to ensure a transparent and complete reporting of systematic reviews, and is now required for this kind of research by more than 170 medical journals worldwide.[12]

Cochrane Collaboration

The Cochrane Collaboration is a group of over 31,000 specialists in healthcare who systematically review randomised trials of the effects of prevention, treatments and rehabilitation as well as health systems interventions. When appropriate, they also include the results of other types of research. Cochrane Reviews are published in The Cochrane Database of Systematic Reviews section of the Cochrane Library. The 2010 impact factor for The Cochrane Database of Systematic Reviews was 6.186, and it was ranked 10th in the “Medicine, General & Internal” category.[13] There are six types of Cochrane Review:[14][15][16][17]

  1. Intervention reviews assess the benefits and harms of interventions used in healthcare and health policy.
  2. Diagnostic test accuracy reviews assess how well a diagnostic test performs in diagnosing and detecting a particular disease.
  3. Methodology reviews address issues relevant to how systematic reviews and clinical trials are conducted and reported.
  4. Qualitative reviews synthesize qualitative evidence to address questions on aspects other than effectiveness.
  5. Prognosis reviews address the probable course or future outcome(s) of people with a health problem.
  6. Overviews of Systematic Reviews (OoRs) are a new type of study in order to compile multiple evidence from systematic reviews into a single document that is accessible and useful to serve as a friendly front end for the Cochrane Collaboration with regard to healthcare decision-making.

The Cochrane Collaboration provides a handbook for systematic reviewers of interventions which "provides guidance to authors for the preparation of Cochrane Intervention reviews."[18] The Cochrane Handbook outlines eight general steps for preparing a systematic review:[18]

  1. Defining the review question(s) and developing criteria for including studies
  2. Searching for studies
  3. Selecting studies and collecting data
  4. Assessing risk of bias in included studies
  5. Analysing data and undertaking meta-analyses
  6. Addressing reporting biases
  7. Presenting results and "summary of findings" tables
  8. Interpreting results and drawing conclusions

The Cochrane Handbook forms the basis of two sets of standards for the conduct and reporting of Cochrane Intervention Reviews (MECIR - Methodological Expectations of Cochrane Intervention Reviews)[19]

Strengths and weaknesses

While systematic reviews are regarded as the strongest form of medical evidence, a review of 300 studies found that not all systematic reviews were equally reliable, and that their reporting can be improved by a universally agreed upon set of standards and guidelines.[20] A further study by the same group found that of 100 systematic reviews monitored, 7% needed updating at the time of publication, another 4% within a year, and another 11% within 2 years; this figure was higher in rapidly changing fields of medicine, especially cardiovascular medicine.[21] A 2003 study suggested that extending searches beyond major databases, perhaps into grey literature, would increase the effectiveness of reviews.[22]

Roberts and colleagues highlighted the problems with systematic reviews, particularly those conducted by the Cochrane Collaboration, noting that published reviews are often biased, out of date and excessively long.[23] They criticized Cochrane reviews as not being sufficiently critical in the selection of trials and including too many of low quality. They proposed several solutions, including limiting studies in meta-analyses and reviews to registered clinical trials, requiring that original data be made available for statistical checking (a proposal that had been previously made by other researchers[24]), paying greater attention to sample size estimates, and eliminating dependence on only published data.

Some of these difficulties were noted early on as described by Altman: "much poor research arises because researchers feel compelled for career reasons to carry out research that they are ill equipped to perform, and nobody stops them."[25] Methodological limitations of meta-analysis have also been noted.[26] Another concern is that the methods used to conduct a systematic review are sometimes changed once researchers see the available trials they are going to include.[27] Bloggers have described retractions of systematic reviews and published reports of studies included in published systematic reviews.[28][29][30]

Systematic reviews are increasingly prevalent in other fields, such as international development research.[31] Subsequently, a number of donors – most notably the UK Department for International Development (DFID) and AusAid – are focusing more attention and resources on testing the appropriateness of systematic reviews in assessing the impacts of development and humanitarian interventions.[31]

See also


  1. ^ "What is EBM?".  
  2. ^ Systematic reviews: CRD's guidance for undertaking reviews in health care. York: University of York, Centre for Reviews and Dissemination, 2008. ISBN 978-1-900640-47-3. Retrieved 2011-06-17.
  3. ^ Petticrew M, Roberts H. Systematic reviews in the social sciences. Wiley Blackwell, 2006.
  4. ^ a b  
  5. ^ "PRISMA". Retrieved 2013-08-29. 
  6. ^ "Cochrane Handbook for Systematic Reviews of Interventions". Retrieved 2013-08-29. 
  7. ^ Thomas, J.; Harden, A; Oakley, A; Oliver, S; Sutcliffe, K; Rees, R; Brunton, G; Kavanagh, J (2004). "Integrating qualitative research with trials in systematic reviews". BMJ 328 (7446): 1010–2.  
  8. ^ Pawson, R.; Greenhalgh, T.; Harvey, G.; Walshe, K. (2005). "Realist review - a new method of systematic review designed for complex policy interventions". Journal of Health Services Research & Policy 10: 21.  
  9. ^ MacFarlane, Fraser; Kyriakidou, Olivia; Bate, Paul; Peacock, Richard;  
  10. ^  
  11. ^ Liberati, Alessandro; Altman, Douglas G.; Tetzlaff, Jennifer; Mulrow, Cynthia; Gøtzsche, Peter C.; Ioannidis, John P. A.; Clarke, Mike; Devereaux, P. J.; et al. (2009). "The PRISMA Statement for Reporting Systematic Reviews and Meta-Analyses of Studies That Evaluate Health Care Interventions: Explanation and Elaboration". PLoS Medicine 6 (7): e1000100.  
  12. ^ Endorsing PRISMA.
  13. ^ The Cochrane Library. 2010 impact factor. Cochrane Database of Systematic Reviews (CDSR). Frequently asked questions. Retrieved 2011-07-01.
  14. ^ Review Manager (RevMan) [Computer program]. Version 5.2. Copenhagen: The Nordic Cochrane Centre, The Cochrane Collaboration, 2012.
  15. ^ The Cochrane Library
  16. ^ Silva V, Grande AJ, Carvalho AP, Martimbianco AL, Riera R (2014). "Overview of systematic reviews - a new type of study. Part II". Sao Paulo Med J.  
  17. ^ Silva V, Grande AJ, Martimbianco AL, Riera R, Carvalho AP (2012). "Overview of systematic reviews - a new type of study. part I: why and for whom?". Sao Paulo Med J. 130 (6): 398–404.  
  18. ^ a b Higgins JPT, Green S (editors). Cochrane handbook for systematic reviews of interventions, version 5.1.0 (updated March 2011). The Cochrane Collaboration, 2011. Retrieved 2011-06-17.
  19. ^ "Methodological Expectations of Cochrane Intervention Reviews (MECIR)". Retrieved 6 October 2014. 
  20. ^ Moher, David; Tetzlaff, Jennifer; Tricco, Andrea C.; Sampson, Margaret; Altman, Douglas G. (2007). "Epidemiology and Reporting Characteristics of Systematic Reviews". PLoS Medicine 4 (3): e78.  
  21. ^ Shojania, Kaveh G.; Sampson, Margaret; Ansari, Mohammed T.; Ji, Jun; Doucette, Steve; Moher, David (2007). "How Quickly Do Systematic Reviews Go Out of Date? A Survival Analysis". Annals of Internal Medicine 147 (4): 224–33.  
  22. ^ Savoie, Isabelle; Helmer, Diane; Green, Carolyn J.; Kazanjian, Arminée (2003). "Beyond Medline: reducing bias through extended systematic review search". International Journal of Technology Assessment in Health Care 19 (1): 168–78.  
  23. ^ Roberts, I; Ker, K; Edwards, P; Beecher, D; Manno, D; Sydenham, E (3 June 2015). "The knowledge system underpinning healthcare is not fit for purpose and must change.". BMJ (Clinical research ed.) 350: h2463.  
  24. ^ Masters, Ken (Dec 2014). "A new level of evidence: Systematic literature reviews (SLRs) with meta-analyses of directly-accessed data (“MA of DAD”)". Medical Teacher 36 (12): 1080–1081.  
  25. ^ Altman, DG (29 January 1994). "The scandal of poor medical research.". BMJ (Clinical research ed.) 308 (6924): 283–4.  
  26. ^ Shapiro, S (1 November 1994). "Meta-analysis/Shmeta-analysis.". American journal of epidemiology 140 (9): 771–8.  
  27. ^ Page, MJ; McKenzie, JE; Kirkham, J; Dwan, K; Kramer, S; Green, S; Forbes, A (Oct 1, 2014). "Bias due to selective inclusion and reporting of outcomes and analyses in systematic reviews of randomised trials of healthcare interventions.". The Cochrane database of systematic reviews 10: MR000035.  
  28. ^ "Retraction Of Scientific Papers For Fraud Or Bias Is Just The Tip Of The Iceberg". IFL Science!. Retrieved 29 June 2015. 
  29. ^ "Retraction and republication for Lancet Resp Med tracheostomy paper". Retraction Watch. Retrieved 29 June 2015. 
  30. ^ "BioMed Central retracting 43 papers for fake peer review". Retraction Watch. 
  31. ^ a b Hagen-Zanker, Jessica; Duvendack, Maren; Mallett, Richard; Slater, Rachel; Carpenter, Samuel; Tromme, Mathieu (January 2012). "Making systematic reviews work for international development research".  

External links

  • Centre for Reviews and Dissemination, University of York.
  • Cochrane Collaboration
  • Evidence for Policy and Practice Information and Co-ordinating Centre (EPPI-Centre), University of London
  • MeSH: Review Literature—articles about the review process
  • MeSH: Review [Publication Type] - limit search results to reviews
  • PubMed search: "Review Literature" [MAJR]
  • Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Statement, "an evidence-based minimum set of items for reporting in systematic reviews and meta-analyses"
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