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Users' Guides to the Medical Literature |

How to Read a Systematic Review and Meta-analysis and Apply the Results to Patient Care:  Users’ Guides to the Medical Literature

Mohammad Hassan Murad, MD, MPH1; Victor M. Montori, MD, MSc2; John P. A. Ioannidis, MD, DSc3; Roman Jaeschke, MD, MSc4; P. J. Devereaux, MD, PhD5; Kameshwar Prasad, MD, DM, FRCPE6; Ignacio Neumann, MD, MSc7; Alonso Carrasco-Labra, DDS, MSc8; Thomas Agoritsas, MD9; Rose Hatala, MD, MSc10; Maureen O. Meade, MD11; Peter Wyer, MD12; Deborah J. Cook, MD, MSc13; Gordon Guyatt, MD, MSc14
[+] Author Affiliations
1Division of Preventive Medicine and Knowledge and Evaluation Research Unit, Mayo Clinic, Minnesota
2Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, Minnesota
3Departments of Medicine and Health Research and Policy, Stanford University School of Medicine; Department of Statistics, Stanford University School of Humanities and Sciences; and Meta-Research Innovation Center at Stanford (METRICS), Stanford University, Stanford, California
4Departments of Medicine and Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
5Departments of Medicine and Clinical Epidemiology and Biostatistics and Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
6All India Institute of Medical Sciences, New Delhi
7Department of Internal Medicine, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
8Evidence-Based Dentistry Unit, Faculty of Dentistry, Universidad de Chile, Santiago, Chile, and Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
9Department Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
10Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
11Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
12Columbia University Medical Center, New York, New York
13Departments of Medicine and Clinical Epidemiology and Biostatistics and Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
14Departments of Medicine and Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
JAMA. 2014;312(2):171-179. doi:10.1001/jama.2014.5559.
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Clinical decisions should be based on the totality of the best evidence and not the results of individual studies. When clinicians apply the results of a systematic review or meta-analysis to patient care, they should start by evaluating the credibility of the methods of the systematic review, ie, the extent to which these methods have likely protected against misleading results. Credibility depends on whether the review addressed a sensible clinical question; included an exhaustive literature search; demonstrated reproducibility of the selection and assessment of studies; and presented results in a useful manner. For reviews that are sufficiently credible, clinicians must decide on the degree of confidence in the estimates that the evidence warrants (quality of evidence). Confidence depends on the risk of bias in the body of evidence; the precision and consistency of the results; whether the results directly apply to the patient of interest; and the likelihood of reporting bias. Shared decision making requires understanding of the estimates of magnitude of beneficial and harmful effects, and confidence in those estimates.

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Figure.
Results of a Meta-analysis of the Outcomes of Nonfatal Infarction, Death, and Nonfatal Stroke in Patients Receiving Perioperative β-Blockers

Abbreviations: BBSA, Beta Blocker in Spinal Anesthesia study; DIPOM, Diabetic Postoperative Mortality and Morbidity trial; MaVS, Metoprolol after Vascular Surgery study; POBBLE, Perioperative β-blockade trial; POISE, Perioperative Ischemic Evaluation trial. Dotted line indicates no effect. Dashed line is centered on meta-analysis pooled estimate.

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