Paeds · professional-practice-and-evidence
Interpreting systematic reviews and clinical guidelines
Also known as Critical appraisal of systematic reviews and meta-analyses · Reading a forest plot and the PRISMA flow diagram · Appraising clinical practice guidelines with AGREE II · AMSTAR-2 and ROBIS for systematic reviews · GRADE Evidence-to-Decision and recommendation strength
Fellowship guide to interpreting systematic reviews, meta-analyses, network meta-analyses, and clinical practice guidelines in child health: reading the PRISMA 2020 flow and a forest plot, quantifying heterogeneity with I-squared, appraising a review with AMSTAR-2 and ROBIS, appraising a guideline with AGREE II, moving from GRADE certainty to recommendation with the Evidence-to-Decision framework, and judging applicability to the child — with ANZ, UK, US and Canada guidance.
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Target exams
Red flags
- Accepting a pooled estimate before checking heterogeneity, publication bias, and the risk of bias of the included studies
- Treating a network meta-analysis treatment ranking as if it came from head-to-head trials
- Following a weak or conditional guideline recommendation as though it were mandatory
- Applying an adult-derived recommendation to a neonate or infant without weighing indirectness
- Trusting an industry-funded or predatory-journal meta-analysis over an independent Cochrane review
- Quoting a relative pooled effect without the absolute baseline and the number needed to treat
Life stages
Care settings
Clinical exam formats
Board mappings
- General and Community Paediatrics
- Interpreting evidence synthesis and clinical guidelines
- Renewed curriculum — Learning goal 12: Critically appraising evidence and applying it to practice
- Scholarly activity and research methods
- Professional practice and ethics
- Written appraisal of a systematic review or guideline
- Structured discussion of a systematic review or clinical guideline
- Long Cases integrating synthesised evidence with patient values
- Short Cases on critical appraisal of a meta-analysis or guideline
- 2. Professional skills and knowledge: Evidence-based practice and research methodology
- Quality improvement and patient safety themes
- Safeguarding and screening themes
- Foundation of Practice (FOP)
- Applied Knowledge in Practice (AKP)
- Communication
- History taking and management
- Child development
- General Pediatrics Content Outline — evidence-based medicine, biostatistics, and critical appraisal
- General Pediatrics EPA: Applying synthesised evidence and guidelines to patient care
- Bioethics and professional conduct
- Practice-based Learning and Improvement: using systematic reviews and guidelines to guide care
- Systems-based Practice: implementing evidence-based recommendations appropriately
- Professionalism
- Scholar
- Medical Expert
- Collaborator
- Health Advocate
- Pediatrics EPA — applying evidence and guidelines to patient care
Two products that get confused
Systematic review
Clinical practice guideline
Ask — was the question focused and preregistered · Search — was it reproducible and exhaustive · Bias — AMSTAR-2 or ROBIS before the result · Heterogeneity — I-squared and its explanation · Applicability — does it fit my child. Remember it as A-S-B-H-A: question, search, bias, heterogeneity, applicability. Never read the pooled diamond before you have judged the method. [1] [2]
Overview & Definition
A parent hands you a printout of a meta-analysis that claims a preventive therapy halves the risk of their child's chronic illness, and a leaflet from a guideline body that recommends the same drug. Before you answer the clinical question, you face an evidence question: can the synthesis and the guideline be trusted, how large is the effect in absolute terms, and do the children in the studies look anything like yours. [10]
A systematic review answers a focused clinical question by assembling, appraising, and — when the studies are similar enough — pooling all the relevant evidence, using methods that another team could reproduce. A meta-analysis is the statistical pooling that may sit inside a systematic review; not every systematic review pools, and not every pooled number is justified. A clinical practice guideline turns the body of evidence into recommendations for practice, through a transparent process that names the certainty of the evidence and the strength of each recommendation. [1] [11]
This page owns the interpretation of synthesised evidence and of guidelines. The five-step engine of evidence-based practice, the PICO question, and the appraisal of single studies with RoB 2, ROBINS-I, and QUADAS-2 belong to the dedicated evidence-based medicine leaf, and the underlying statistics belong to the biostatistics and clinical epidemiology leaves. Read this page as the layer above them: what to do when the evidence arrives already pooled or already turned into a recommendation. [10]
References13ShowHide
- [1]Page MJ, McKenzie JE, Bossuyt PM, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ, 2021.PMID 33782057
- [2]Shea BJ, Reeves BC, Wells G, et al. AMSTAR 2: a critical appraisal tool for systematic reviews that include randomised or non-randomised studies of healthcare interventions, or both. BMJ, 2017.PMID 28935701
- [3]Whiting P, Savović J, Higgins JP, et al. ROBIS: A new tool to assess risk of bias in systematic reviews was developed. Journal of clinical epidemiology, 2016.PMID 26092286
- [4]Higgins JP, Thompson SG, Deeks JJ, Altman DG Measuring inconsistency in meta-analyses. BMJ, 2003.PMID 12958120
- [5]Cipriani A, Higgins JP, Geddes JR, Salanti G Conceptual and technical challenges in network meta-analysis. Annals of internal medicine, 2013.PMID 23856683
- [6]Al Khalifah R, Florez ID, Guyatt G, Thabane L Network meta-analysis: users' guide for pediatricians. BMC pediatrics, 2018.PMID 29843665
- [7]Alonso-Coello P, Oxman AD, Moberg J, et al. GRADE Evidence to Decision (EtD) frameworks: a systematic and transparent approach to making well informed healthcare choices. 1: Introduction. BMJ, 2016.PMID 27365494
- [8]Andrews J, Guyatt G, Oxman AD, et al. GRADE guidelines: 14. Going from evidence to recommendations: the significance and presentation of recommendations. Journal of clinical epidemiology, 2013.PMID 23312392
- [9]Andrews JC, Schünemann HJ, Oxman AD, et al. GRADE guidelines: 15. Going from evidence to recommendation-determinants of a recommendation's direction and strength. Journal of clinical epidemiology, 2013.PMID 23570745
- [10]Murad MH, Montori VM, Ioannidis JP, et al. How to read a systematic review and meta-analysis and apply the results to patient care: users' guides to the medical literature. JAMA, 2014.PMID 25005654
- [11]Guyatt GH, Oxman AD, Vist GE, et al. GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. BMJ, 2008.PMID 18436948
- [12]Moher D, Liberati A, Tetzlaff J, et al. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. Journal of clinical epidemiology, 2009.PMID 19631508
- [13]Simmonds M, Salanti G, McKenzie J, Elliott J Living systematic reviews: 3. Statistical methods for updating meta-analyses. Journal of clinical epidemiology, 2017.PMID 28912004