David Moher and colleagues introduce PRISMA, an update of the QUOROM guidelines for reporting systematic reviews and meta-analyses

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Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement

Systematic reviews and meta-analyses have become increasingly important in health care. Clinicians read them to keep up to date with their field,1,2 and they are often used as a starting point for developing clinical practice guidelines. Granting agencies may require a systematic review to ensure there is justification for further research,3 and some health care journals are moving in this direction.4 As with all research, the value of a systematic review depends on what was done, what was found, and the clarity of reporting. As with other publications, the reporting quality of systematic reviews varies, limiting readers' ability to assess the strengths and weaknesses of those reviews.

Several early studies evaluated the quality of review reports. In 1987, Mulrow examined 50 review articles published in 4 leading medical journals in 1985 and 1986 and found that none met all 8 explicit scientific criteria, such as a quality assessment of included studies.5 In 1987, Sacks and colleagues6 evaluated the adequacy of reporting of 83 meta-analyses on 23 characteristics in 6 domains. Reporting was generally poor; between 1 and 14 characteristics were adequately reported (mean = 7.7; standard deviation = 2.7). A 1996 update of this study found little improvement.7

In 1996, to address the suboptimal reporting of meta-analyses, an international group developed a guidance called the QUOROM Statement (QUality Of Reporting Of Meta-analyses), which focused on the reporting of meta-analyses of randomized controlled trials.8 In this article, we summarize a revision of these guidelines, renamed PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses), which have been updated to address several conceptual and practical advances in the science of systematic reviews (Box 1).



Box 1

Conceptual issues in the evolution from QUOROM to PRISMA

Preferred reporting items for systematic reviews and meta-analyses: the PRISMA Statement.

Preferred reporting items for systematic reviews and meta-analyses: The PRISMA statement

Systematic reviews and meta-analyses are essential to summarize evidence relating to efficacy and safety of health care interventions accurately and reliably. The clarity and transparency of these reports, however, is not optimal. Poor reporting of systematic reviews diminishes their value to clinicians, policy makers, and other users.

Since the development of the QUOROM (QUality Of Reporting Of Meta-analysis) Statement—a reporting guideline published in 1999—there have been several conceptual, methodological, and practical advances regarding the conduct and reporting of systematic reviews and meta-analyses. Also, reviews of published systematic reviews have found that key information about these studies is often poorly reported. Realizing these issues, an international group that included experienced authors and methodologists developed PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) as an evolution of the original QUOROM guideline for systematic reviews and meta-analyses of evaluations of health care interventions.

The PRISMA Statement consists of a 27-item checklist and a four-phase flow diagram. The checklist includes items deemed essential for transparent reporting of a systematic review. In this Explanation and Elaboration document, we explain the meaning and rationale for each checklist item. For each item, we include an example of good reporting and, where possible, references to relevant empirical studies and methodological literature. The PRISMA Statement, this document, and the associated Web site (http://www.prisma-statement.org/) should be helpful resources to improve reporting of systematic reviews and meta-analyses.

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The PRISMA Statement for Reporting Systematic Reviews and Meta-Analyses of Studies That Evaluate Health Care Interventions: Explanation and Elaboration

Moher and colleagues introduce PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses), an update of the QUOROM guidelines for reporting systematic reviews and meta-analyses. Us...

/pdf/preferred-reporting-items-for-systematic-reviews-and-meta-5c1h0wv2gs.pdf

Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement

Background Clinicians should consider the clinical impact of anticoagulant-related bleeding when deciding on the duration of anticoagulant therapy in patients with venous thromboembolism. Purpose To provide reliable estimates of the clinical impact of anticoagulant-related bleeding, defined as the case-fatality rate of major bleeding and the risk for intracranial bleeding. Data sources MEDLINE (January 1989 to May 2003), Cochrane Controlled Trial Registry, thromboembolism experts, and reference lists; English-language literature only. Study selection Randomized, controlled trials and prospective cohort studies that investigated patients with venous thromboembolism who received oral anticoagulant therapy (target international normalized ratio, 2.0 to 3.0) for at least 3 months and that reported major bleeding and death as primary study outcomes. Data extraction Two reviewers independently extracted data on the number of anticoagulant-related major and intracranial bleeding episodes and on whether these events were fatal or nonfatal. Data synthesis The authors analyzed 33 studies involving 4374 patient-years of oral anticoagulant therapy. For all patients, the case-fatality rate of major bleeding was 13.4% (95% CI, 9.4% to 17.4%) and the rate of intracranial bleeding was 1.15 per 100 patient-years (CI, 1.14 to 1.16 per 100 patient-years). For patients who received anticoagulant therapy for more than 3 months, the case-fatality rate of major bleeding was 9.1% (CI, 2.5% to 21.7%), and the rate of intracranial bleeding was 0.65 per 100 patient-years (CI, 0.63 to 0.68 per 100 patient-years) after the initial 3 months of anticoagulation. Conclusion The clinical impact of anticoagulant-related major bleeding in patients with venous thromboembolism is considerable, and clinicians should take this into account when deciding whether to continue long-term oral anticoagulant therapy in an individual patient.

Clinical impact of bleeding in patients taking oral anticoagulant therapy for venous thromboembolism: a meta-analysis.

ObjectiveTo systematically review the effects of isotonic crystalloids compared with colloids in fluid resuscitation.Data SourcesComputerized bibliographic search of published research and citation review of relevant articles.Study SelectionAll randomized clinical trials of adult patients requiring

Crystalloids vs. colloids in fluid resuscitation: a systematic review.

Postoperative cardiac morbidity and mortality continue to pose considerable risks to surgical patients. Postoperative epidural analgesia is considered to have beneficial effects on cardiac outcomes. The use in high-risk cardiac patients remains controversial. No study has shown that postoperative ep

Epidural analgesia reduces postoperative myocardial infarction: a meta-analysis.

Objective To determine the effect of perioperative β blocker treatment in patients having non-cardiac surgery Design Systematic review and meta-analysis Data sources Seven search strategies, including searching two bibliographic databases and hand searching seven medical journals Study selection and outcomes We included randomised controlled trials that evaluated β blocker treatment in patients having non-cardiac surgery Perioperative outcomes within 30 days of surgery included total mortality, cardiovascular mortality, non-fatal myocardial infarction, non-fatal cardiac arrest, non-fatal stroke, congestive heart failure, hypotension needing treatment, bradycardia needing treatment, and bronchospasm Results Twenty two trials that randomised a total of 2437 patients met the eligibility criteria Perioperative β blockers did not show any statistically significant beneficial effects on any of the individual outcomes and the only nominally statistically significant beneficial relative risk was 044 (95% confidence interval 020 to 097, 99% confidence interval 016 to 124) for the composite outcome of cardiovascular mortality, non-fatal myocardial infarction, and non-fatal cardiac arrest Methods adapted from formal interim monitoring boundaries applied to cumulative meta-analysis showed that the evidence failed, by a considerable degree, to meet standards for forgoing additional studies The individual safety outcomes in patients treated with perioperative β blockers showed a relative risk for bradycardia needing treatment of 227 (95% CI 153 to 336, 99% CI 136 to 380) and a nominally statistically significant relative risk for hypotension needing treatment of 127 (95% CI 104 to 156, 99% CI 097 to 166) Conclusion The evidence that perioperative β blockers reduce major cardiovascular events is encouraging but too unreliable to allow definitive conclusions to be drawn

https://www.bmj.com/content/bmj/331/7512/313.full.pdf

How strong is the evidence for the use of perioperative β blockers in non-cardiac surgery? Systematic review and meta-analysis of randomised controlled trials

Purpose
Postdural puncture headache (PDPH) is an iatrogenic complication of neuraxial blockade. We systematically reviewed the literature on parturients to determine the frequency onset, and duration of PDPH.

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Peter T. Choi

Papers

Clinical impact of bleeding in patients taking oral anticoagulant therapy for venous thromboembolism: a meta-analysis.

Crystalloids vs. colloids in fluid resuscitation: a systematic review.

Epidural analgesia reduces postoperative myocardial infarction: a meta-analysis.

How strong is the evidence for the use of perioperative β blockers in non-cardiac surgery? Systematic review and meta-analysis of randomised controlled trials

PDPH is a common complication of neuraxial blockade in parturients: a meta-analysis of obstetrical studies