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Katrina Abuabara , MD, MA 1 Esther E Freeman MD, PhD 2 ; Robert Dellavalle , MD, PhD, MSPH 3

Research Techniques Made Simple : The Role of Systematic Reviews and Meta-Analysis in Dermatology. Katrina Abuabara , MD, MA 1 Esther E Freeman MD, PhD 2 ; Robert Dellavalle , MD, PhD, MSPH 3

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Katrina Abuabara , MD, MA 1 Esther E Freeman MD, PhD 2 ; Robert Dellavalle , MD, PhD, MSPH 3

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  1. Research Techniques Made Simple: The Role of Systematic Reviews and Meta-Analysis in Dermatology Katrina Abuabara, MD, MA1 Esther E Freeman MD, PhD2; Robert Dellavalle, MD, PhD, MSPH3 Affiliations:1Department of Dermatology, University of Pennsylvania; 2Department of Dermatology, Harvard Combined Dermatology Residency Program, Massachusetts General Hospital; 3Dermatology Service, Denver VA Medical Center

  2. Summary Points • A systematic review is a comprehensive summary of available data pertaining to a specific question, organized through a rigorous design. Systematic reviews often contain a meta-analysis, which is a statistical method for synthesizing data from multiple studies. • These techniques are used to answer specific research questions and may minimize bias, improve precision of intervention estimates, and increase the statistical power of identifying a real effect. They can also help to settle controversy when individual studies show conflicting results, and they may identify research gaps.

  3. Study design methodology • The PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) Statement describes criteria for developing, carrying out, and evaluating these types of studies. • Formulating an appropriate and specific research question is critical. • Eligibility criteria should be prespecified and a search strategy for included studies should be comprehensive and clearly described; these are often presented in a flow diagram.

  4. Example of a Flow Diagram *Originally published with the PRISMA Statement (Liberati A, Altman DG, Tetzlaff J, et al. (2009) PLoS Medicine 6:e1000100)

  5. Assessing Risk of Bias in Individual Studies • A descriptive approach of assessed methodological components such as selection bias, performance bias, detection bias, attrition bias, and reporting bias is recommended.

  6. Statistical Meta-analysis • Meta-analysis allows data from multiple studies to be statistically combined. • First, a summary statistic is calculated for each study. • Next, an overall intervention effect estimate is calculated. • Finally, to ensure that the results are valid and robust, researchers typically test for heterogeneity and publication bias and perform sensitivity analyses. • Results are often presented in a forest plot.

  7. Forest Plot • Used topresent the results of a meta-analysis. • The summary statistic for each study is shown as a square with a horizontal line indicating the confidence interval. • At the bottom of the graphic the overall intervention effect estimate is represented by a diamond, with the center showing the point estimate and the horizontal tips illustrating the confidence interval. • The significance of each study and the overall estimate are highlighted by whether they cross a vertical line of no effect.

  8. Example of a Forest Plot *Originally published with the PRISMA Statement. (Liberati A, Altman DG, Tetzlaff J, et al. (2009) PLoS Medicine 6:e1000100)

  9. Limitations of Systematic Reviewsand Meta-analyses • Limitations include the risk of misleading results if individual studies are biased or their reporting is not standardized. • Although often useful for summarizing an intervention effect from randomized controlled trials, systematic reviews and meta-analyses are less effective for capturing adverse effects or summarizing observational studies.

  10. Rating the Strength of Recommendations • GRADE • Used by the World Health Organization in its guideline development process • Classifies strength of recommendations into strong or weak. A strong recommendation means that based on the available evidence, clinicians are very certain that that benefits either do or do not outweigh the risks of an intervention. • Website: http://www.gradeworkinggroup.org/intro.htm • SORT • Used by the American Academy of Dermatology • Grades strength of recommendation into A, B, and C, with A-level evidence based on consistent, good-quality, patient-oriented evidence and C based on consensus, usual practice, or opinion. • Website: http://www.aad.org/education-and-quality-care/clinical-guidelines/guideline-development-process

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