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Review
. 2019 May 28;4(5):213-220.
doi: 10.1302/2058-5241.4.180049. eCollection 2019 May.

How to prepare and manage a systematic review and meta-analysis of clinical studies

James R Berstock  1 , Michael R Whitehouse  2   3
Affiliations
Review

How to prepare and manage a systematic review and meta-analysis of clinical studies

James R Berstock et al. EFORT Open Rev. .

Abstract

Use the PICO framework to formulate a specific clinical question.Formulate a search strategy.Prospectively register the review protocol.Execute the literature search.Apply eligibility criteria to exclude irrelevant studies.Extract data and appraise each study for risk of bias and external validity.Provide a narrative review.If appropriate data are available, perform a meta-analysis.Report the review findings in the context of the risk of bias assessment, any sensitivity analyses and the analysis of risk of publication bias.Useful resources include the Cochrane Handbook, PROSPERO, GRADE and PRISMA. Cite this article: EFORT Open Rev 2019;4:213-220. DOI: 10.1302/2058-5241.4.180049.

Keywords: meta-analysis; orthopaedics; review; systematic review.

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Conflict of interest statement

ICMJE Conflict of interest statement: JRB reports that he works for North Bristol NHS trust as an Orthopaedic Surgeon and is not employed elsewhere. MRW reports that he has received a grant from National Institute for Health Research (NIHR) and that this study was supported by the NIHR Biomedical Research Centre at University Hospitals Bristol NHS Foundation Trust and the University of Bristol. The views expressed in this publication are those of the author(s) and not necessarily those of the NHS, the NIHR or the Department of Health and Social Care. He reports he has received a grant from Stryker investigate the outcome of the Triathlon total knee replacement. He has received payment for lectures including service on speakers’ bureaus from Heraeus, DePuy and that his institution receives payment at market rates for teaching on basic science and cemented joint replacement delivered to trainees and consultants.

Figures

Fig. 1
Fig. 1
Example study flow diagram.
Fig. 2
Fig. 2
Forest plot of return of active straight leg raise following either subvastus or medial parapatellar approach to total knee replacement. Pooled data from eight RCTs show that SLR returns 1.19 days earlier with use of the subvastus approach, (95% CI 0.97 to 1.42, p < 0.00001). Data from: Berstock JR, Murray JR, Whitehouse MR, Blom AW, Beswick AD. Medial subvastus versus the medial parapatellar approach for total knee replacement: A systematic review and meta-analysis of randomized controlled trials. EFORT Open Rev 2018;3:78–84.
Fig. 3
Fig. 3
A theoretical funnel plot demonstrating an absence of small studies reporting a negative effect, suggestive of a publication bias. The central vertical line shows the pooled effect size and each circle represents a study. Larger studies with a smaller standard error are located at the apex of the triangle. Smaller studies are expected to distribute on both sides of the overall effect size line, but in this example do not.
Fig. 4
Fig. 4
Simplified forest plot of 30-day mortality following total knee replacement. Pooled data from 1.8 million total knee replacements, 30-day mortality 0.19% (95% CI 0.15 to 0.23).
Fig. 5
Fig. 5
Meta-regression of data presented in Fig. 4. Each individual study is represented by a circle, the size of which correlates to the weighting of each study. The straight line shows that mortality is seen to decrease with time, with the lines above and below representing 95% CIs, which get tighter where more data exist. For this meta-regression R2 = 70%, suggesting that 70% of the variation between studies is explained by the year of data collection. Data with permission from: Berstock JR, Beswick AD, López-López JA, Whitehouse MR, Blom AW. Mortality after total knee arthroplasty: a systematic review of incidence, temporal trends, and risk factors. J Bone Joint Surg Am 2018;100:1064–1070.
Fig. 6
Fig. 6
Schematic of comparisons possible via network meta-analysis.
See this image and copyright information in PMC

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