Before using the tool, please note that you will be prompted to answer a series of questions related to your planned knowledge synthesis. We recommend that you conduct a preliminary search to gain background on the relevant literature.
Please note that some of the suggested combination(s) of evidence synthesis methods are theoretically possible, but not currently used in practice (i.e., we could not locate published examples in the literature). In these cases, we advise users of the tool to use their own judgement when deciding whether or not to proceed with a given method.
For guidance on using this tool, please refer to our Explanation and Elaboration document and/or the tool tips icon found beside each question.
“Background: Anaesthesia in morbidly obese people is challenging with a high dose of opioid consumption.
Objective: This systematic review and meta-analysis of randomised controlled trials (RCTs) summaries evidence comparing ketamine to placebo for pain management after bariatric surgery.”1
“Background: Rapid adoption of robotic-assisted general surgery procedures . . . continues while questions remain about its benefits and utility.”
Objective: “To compare the clinical effectiveness of robot-assisted cholecystectomy for benign gallbladder disease as compared with the laparoscopic approach.”2
“Background: Carpal tunnel syndrome (CTS) is a compression neuropathy of the median nerve causing pain and numbness and tingling typically in the thumb, index and middle finger . . . Splinting the wrist . . . using an orthosis is usually offered to people with mild-to-moderate findings, but its effectiveness remains unclear.
“Background: Carpal tunnel syndrome (CTS) is a compression neuropathy of the median nerve causing pain and numbness and tingling typically in the thumb, index and middle finger . . . Splinting the wrist . . . using an orthosis is usually offered to people with mild-to-moderate findings, but its effectiveness remains unclear.3
“Background: The comparative effectiveness of localized prostate cancer treatments is largely unknown.
Objectives: To compare the effectiveness and harms of treatments for localized prostate cancer.”4
“Background: Non-fatal self-harm frequently leads to non-fatal repetition and sometimes to suicide. We need to quantify these two outcomes of self-harm to help us to develop and test effective interventions.
Objectives: To estimate rates of fatal and non-fatal repetition of self-harm.”5
Background: Khat (Catha edulis) is a woody plant cultivated predominantly in north east Africa and the Arabian Peninsula . . . The traditional use of khat may be considered largely functional – to assist with religious studies, arduous work demands, food shortages, and social cohesion, and to self medicate for a range of ailments including depression.
Objectives: To collate and evaluate systematically evidence relating to physiological harms (physical and mental) caused by, or associated with, khat use in the UK. To compare evidence of societal harms caused by/ associated with khat use between countries where khat is legal and countries where it is controlled. To distinguish between evidence of causal relationships and evidence of associative relationships pertaining to khat harms. To identify evidence gaps relating to harms caused by/associated with khat use in the UK.6
Background: “Atrial fibrillation (AF) is the most common cardiac arrhythmia, with an increasing incidence and prevalence because of progressively aging populations. Costs related to AF are both direct and indirect.”
Objectives: “This systematic review aims to identify the main cost drivers of the illness, assess the potential economic impact resulting from changes in care strategies, and propose interventions where they are most needed.”7
Background: “A hygienic environment is essential to provide quality patient care and prevent healthcare-acquired infections. Understanding costs is important to budget for service delivery, but costs evidence for environmental health services (EHS) in healthcare facilities (HCFs) is lacking.”
Objective: “To evaluate the costs of establishing, operating, and maintaining EHS in HCFs in low- and middle-income countries (LMICs).”8
Background: “Chikungunya (CHIK) is a re-emerging viral infection endemic in tropical and subtropical areas. While the typical clinical presentation is an acute febrile syndrome, long-term articular complications and even death can occur.”
Objective: “This review characterizes the global epidemiological and economic burden of chikungunya.”9
“Background: Alzheimer's disease (AD) is the most common neurodegenerative disease worldwide, and an updated quantification of its impact on morbidity, disability, and mortality is warranted . . .”
“Background: Alzheimer's disease (AD) is the most common neurodegenerative disease worldwide, and an updated quantification of its impact on morbidity, disability, and mortality is warranted . . .”10
“Background: Given the uncertainty in attributions of patient benefits to healthcare workers (HCW) vaccination, having strong evidence of the direct effectiveness of vaccination on healthcare workers and the cost-effectiveness of these campaigns in reducing the incidence of illness and absenteeism among HCW is important. Previously, a systematic review evaluated the direct effectiveness of influenza vaccination of HCWs but failed to provide any conclusions due to the limited number of included studies [16]. Moreover, only epidemiological effects were examined, and no systematic review has summarized economic evidence despite the substantial costs involved in implementing HCW vaccination.
Objectives: The specific objective in this review was to synthesize evidence to whether influenza vaccines reduced influenza related morbidity among HCWs, which includes incidence rate and absenteeism, and the associated costs of these programs.”11
Objective: “To perform a systematic review of the cost-effectiveness of colorectal cancer screening for the U.S. Preventive Services Task Force.”12
Objective: “To systematically identify and appraise the international literature on the cost-effectiveness of metabolic surgery for the treatment of comorbid type 2 diabetes (T2D) and obesity.”13
“Objective: To analyse preterm birth rates worldwide to assess the incidence of this public health problem, map the regional distribution of preterm births and gain insight into existing assessment strategies.”14
Background: “Evidence regarding the adverse burden of severe neonatal jaundice (SNJ) in hospitalized neonates in resource-constrained settings is sparse.”
Objective: “We attempted to determine the prevalence of SNJ, described using clinical outcome markers, in all World Health Organization (WHO) regions in the world.”15
“Objectives: This study aimed to estimate the prevalence of genital, anal and oral HPV infection in Brazil through systematic review and meta-analysis.”16
“Background: Studies of the association between obesity, and total mortality and cardiovascular events in patients with coronary artery disease (CAD) have shown contradictory results.
Objectives: Our aim was to undertake a systematic review of cohort studies and perform a meta-analysis to better estimate the effect of bodyweight and other measures of obesity on total mortality, cardiovascular mortality, re-infarction, and revascularization in patients with established CAD.”17
“Background: Prolonged pregnancy is a known risk factor for stillbirth. To avoid this adverse outcome, women are routinely offered induction of labour after 41 weeks gestation . . . However, 1 in 3 stillbirths occur prior to 41 weeks gestation. The stillbirth risks before 41 weeks are not routinely discussed with women who have no clinical indication for delivery . . .
Objectives: We undertook a systematic review to evaluate the additional weekly risks of stillbirth in term pregnancies that continue versus deliver at various gestational ages. We also assessed the week-specific risks of neonatal death by gestational age at birth.”18
Objective: “To provide a comprehensive overview of cardiovascular disease (CVD) risk prediction models for women and models that include female-specific predictors.”19
“Background: Many observational studies have reported clinical and non-clinical risk factors associated with necrotizing enterocolitis (NEC), but the prognostic value usually is unclear . . . To identify independent risk factors for a complex disease as NEC, a (preferably prospective) prognostic cohort design with multivariable analysis including multiple co-variates is considered most appropriate.
Objectives: The aim of this study was to provide a systematic review of the literature on prognostic studies reporting on independent risk factors for NEC in neonates.”20
“Background: Many observational studies have reported clinical and non-clinical risk factors associated with necrotizing enterocolitis (NEC), but the prognostic value usually is unclear . . . To identify independent risk factors for a complex disease as NEC, a (preferably prospective) prognostic cohort design with multivariable analysis including multiple co-variates is considered most appropriate.
Objectives: To assess whether anticholinergic burden is a prognostic factor for future cognitive decline or dementia in cognitively unimpaired older adults.”21
“Background: CT is being used as a staging tool in the FOxTROT trial, but it remains unclear what the accuracy of CT is for selection of these high-risk colon cancer tumors . . .”
Objectives: The purpose of this article is to determine the accuracy of CT in the detection of tumor invasion beyond the bowel wall and nodal involvement of colon carcinomas.”22
“Objective: To examine the validity and findings of studies that examine the accuracy of algorithm based smartphone applications to assess risk of skin cancer in suspicious skin lesions.”23
“Background: Appendicitis remains a difficult disease to diagnose, and imaging adjuncts are commonly employed. Magnetic resonance imaging (MRI) is an imaging test that can be used to diagnose appendicitis . . . As it does not expose patients to radiation, it is an attractive imaging modality, particularly in women and children.
Objectives: The primary objective was to determine the diagnostic accuracy of MRI for detecting appendicitis in all patients . . .”24
“Background: Primary care physicians can play a unique role in recognizing and treating patients with alcohol problems.
Objectives: To evaluate the accuracy of screening methods for alcohol problems in primary care.”25
“Background: Several studies have reported the presence of electroencephalography (EEG) abnormalities or altered evoked potentials (EPs) during sepsis. However, the role of these tests in the diagnosis and prognostic assessment of sepsis-associated encephalopathy remains unclear.
Objectives: The aim of our study was to answer the following questions:
“Background: In order to advance pharmacovigilance . . . is being researched as a potential to supplement traditional drug safety surveillance systems. Three reviews have been recently published to explore the breadth of evidence on the methods and use of social media data for pharmacovigilance; however, none of the reviews found rigorous evaluations of the reliability and validity of the data.
Objectives: To assess the utility of social media data for detecting adverse events related to health products, including pharmaceuticals, medical devices, and natural health products.
The specific research questions were:
Background: Deprescribing (medication dose reduction or cessation) is an integral component of appropriate prescribing. The extent to which de-prescribing recommendations are included in clinical practice guidelines is unclear.
Objectives: To identify guidelines that contain de-prescribing recommendations, qualitatively explore the content and format of de-prescribing recommendations and estimate the proportion of guidelines that contain de-prescribing recommendations.29
“Background: Opportunities for social connection between generations in the UK have diminished over the last few decades because of changes in the way that we live and work . . . Evidence suggests that intergenerational activity can have a positive impact on participants, for example, in reducing loneliness and exclusion for both older people and children and young people, improving mental health, increasing mutual understanding and addressing important issues such as ageism, housing and care. There are currently no other EGMs that exist that address this type of intervention; however, it would complement existing EGMs addressing child welfare.
Objectives: To identify, appraise and bring together the evidence on the use of intergenerational practice, to answer the following specific research questions:
“Background: The NHS currently faces increasing demands on accident and emergency departments. Concern has been expressed regarding whether the needs of vulnerable groups are being handled appropriately or whether alternative methods of service delivery may provide more appropriate emergency and urgent care services for particular groups.
Objective: Our objective was to identify what interventions exist to manage use of the emergency and urgent care system by people from a prespecified list of vulnerable groups. We aimed to describe the characteristics of these interventions and examine service delivery outcomes (for patients and the health service) resulting from these interventions.”31
“Background: Nursing home residents (NHR) are characterized by increasing frailty, multimorbidity and care dependency. These conditions result in frequent hospital transfers which can lead to negative effects on residents' health status and are often avoidable. Reasons for emergency department (ED) visits or hospital admissions are complex. Prior research indicated factors influencing transfer decisions in view of nursing staff and general practitioners.
Objectives: The aim of this systematic review is to explore how family members experience and influence transfers from nursing home (NH) to hospital and how they are involved in the transfer decision.”34
Objectives: “This systematic review synthesized the qualitative evidence on factors influencing obesogenic behaviours in adolescent girls and women of reproductive age in low- and middle-income countries (LMICs).”35
“Background: Coronary artery disease including acute coronary syndrome (ACS) constitutes the most common cause of death in people with cardiovascular disease. Prompt diagnosis and early initiation of treatment significantly impact on patient outcomes. Positive patient experience with their initial care is linked to positive clinical outcomes.
Objective: This qualitative review aimed to investigate patients' experience of care provision and the challenges faced by them during their different stages of care following an ACS.”36
Objective: Although knowledge on athlete motivation had already been developed before the review, the authors explicitly frame it in a holistic context.38
“Background: Qualitative research on women's experiences participating in yoga after a cancer diagnosis is growing; systematic synthesis and integration of results are necessary to facilitate the transfer and implementation of knowledge among researchers and end-users.
Objectives: This review integrates findings from qualitative studies, compares and contrasts findings to elucidate patterns or contradictions in conclusions, and develops an overarching interpretation of women's experiences participating in yoga after a cancer diagnosis.”39
“Background: The authors identified determinants of independent active free play related to child characteristics, parental restrictions, neighborhood and physical environment, societal changes, and policy issues. They created an ecological model depicting these factors, and the relationships therein. This model may be viewed as a contribution to theory building.40
Objective: To produce a meta-study by completing a systematic review of qualitative research examining determinants of independent active free play in children.”40
“Background: Comprehending the significance of legacy in end-of-life (EoL) situations helps palliative care professionals enhance person-centered outcomes for those with a life-threatening illness and their families.
Objective: Our purpose was to conduct a concept analysis of legacy in EoL care. By employing Walker and Avant’s approach, we identified the concept’s defining characteristics. Subsequently, we established the antecedents, consequences, and empirical referents.”41
“Background: Patients with chronic disease may experience complicated management plans requiring significant personal investment. This has been termed 'treatment burden' and has been associated with unfavourable outcomes.
Objective: The aim of this systematic review is to examine the qualitative literature on treatment burden in stroke from the patient perspective.”43
Background: Adolescent girls and women of reproductive age are particularly vulnerable to malnutrition . . . due to poor dietary intakes, inequitable distribution of food within households, dietary taboos and gender inequality.35
Objective: This review synthesized the qualitative evidence on factors influencing obesogenic behaviours in adolescent girls and women of reproductive age in low- and middle-income countries (LMICs). It followed the framework synthesis approach to extract, analyse and synthesize data.35
“Background: Although the barriers to using health data have been relatively well studied and point to insufficient skills in data use core competencies among health workers, lack of trust in data due to poor quality, and inadequate availability because of fragmented data across multiple sources, among others, to date there is no formal review of evidence from existing efforts to strengthen immunization data use.
Objectives: To address this gap, we conducted a realist systematic review of existing research evidence on immunization data use interventions in low- and middle-income countries (LMICs). Our review was designed to answer two specific research questions: 1. What are the most effective interventions to improve the use of data for immunization program and policy decision-making? 2. Why do these interventions produce the outcomes that they do?”45
Background: An evidence base that addresses issues of complexity and context is urgently needed for large-system transformation and health care reform. Fundamental conceptual and methodological challenges also must be addressed.46
Objective: This review analyzes examples of successful and less successful transformation initiatives, synthesizes knowledge of the underlying mechanisms, clarifies the role of government, and outlines options for evaluation.46
Objective: “To identify and describe the breast cancer-specific health-related quality of life (HRQoL) instruments with evidence of validation in the breast cancer population for potential use in patients treated for breast cancer (excluding surgery).”48
“Background: Patient-reported outcome (PRO) measures are commonly used to capture patient experience with dysphagia and to evaluate treatment effectiveness. Inappropriate application can lead to distorted results in clinical studies.
Objectives: A systematic review of the literature on dysphagia-related PRO measures was performed to (1) identify all currently available measures and (2) to evaluate each for the presence of important measurement properties that would affect their applicability.”49
“Background: Parent responses can have a major impact on their child’s pain.
Objectives: The purpose of this systematic review is to (a) identify and describe measures assessing pain-related cognitive, affective, and behavioral responses in parents of children with chronic pain and (b) meta-analyze reported correlations between parent constructs and child outcomes (i.e., pain intensity, functional disability, and school functioning).”50
“Objective: To identify types of nurse-led interventions for multimorbidity and which outcomes are positively affected by them.”52
“Objective: To evaluate healthcare workers' knowledge, attitudes and practices level of prevention and management of catheter-associated urinary tract infection.”53
This question is referring to the number of interventions or diagnostic tests that will be assessed in your review. It is only relevant if your goals and objectives involved interventions (i.e., your answer to question 1 is “Assess the effectiveness and/or safety of interventions”, “Assess the burden of illness, monetary costs alone or the cost-effectiveness of interventions”, or diagnostic tests (i.e., your answer to question 1 is “Assess a diagnostic test for precision and accuracy”). This question is not about the number of comparisons, subgroups or outcomes you will be evaluating.
This systematic review compares early intervention versus treatment as usual for early-phase psychosis services.54
“This systematic review and meta-analysis of randomised controlled trials (RCTs) summaries evidence comparing ketamine to placebo for pain management after bariatric surgery.”1
This systematic review evaluated the diagnostic accuracy of two point-of-care tests, natriuretic peptide testing (B-type natriuretic peptide (BNP) or N terminal fragment pro B-type natriuretic peptide (NTproBNP)), against any relevant reference standard, including echocardiography, clinical examination, or combinations of these, in humans55.
In this systematic review, 21 antidepressant drugs were assessed56.
This systematic review aimed to compare ipilimumab-nivolumab, pembrolizumab-axitinib, and avelumab-axitinib as treatments for metastatic renal cell carcinoma57.
In this systematic review, three diagnostic tests were assessed: endoscopic ultrasonography, magnetic resonance imaging, and computed tomography molecular rapid diagnostic testing58.
This rapid review assesses the effectiveness of universal screening for SARS-CoV-2 infection compared with no screening, and the accuracy of universal screening in people who have not presented to clinical care for symptoms of COVID-1959.
As part of this rapid review, the accuracy of various screening modalities were assessed relative to a reference reverse transcriptase polymerase chain reaction (RT-PCR) test, including single point-in-time screening; screening using direct temperature measurement, international travel history, exposure to known infected people, or suspected infected people, and a combination of these screening modalities.59
Select this answer response if your answer response to question 1 does not involve interventions or diagnostic tests.
A systematic review attempts to collate all empirical evidence that fits pre-specified eligibility criteria in order to answer a specific research question. Specifically, the unit of synthesis in a systematic review is a primary study (as defined below).
This review provides a summary of findings from systematic reviews of interventions for adolescent mental health60.
This is an overview of Cochrane systematic reviews on the effectiveness and risks of interventions to treat overweight and obesity in children and adolescents60.
Primary studies refer to research studies in which data were often collected from individuals, such as patients. Specifically, the unit of analysis in a primary study is an individual and you would only consider primary studies as eligible sources to be included in your review.
This systematic review includes randomized controlled trials only.61
This systematic review includes randomized controlled trials only.3
Select this answer response if you plan to use both systematic reviews and primary studies in your review.
This review included systematic reviews, quantitative studies, qualitative studies, mixed‐methods studies, scoping reviews, literature reviews, quality improvement projects, as well as opinion and discussion papers.62
“We conducted a global systematic umbrella review to assess the evidence on prevention, early detection and rehabilitation interventions for child functioning outcomes related to developmental disabilities in children under 5 years. We focused on prevalent disabilities worldwide and identified evidence-based interventions.”63
“We anticipated that performing any meta‐analyses would not be possible as a result of few studies reporting specific dietary interventions with available data. A narrative synthesis of the results was conducted by one investigator using the Synthesis Without Meta‐analysis guideline to guide on reporting and presentation . . .”64
“A charting form was developed to capture data on study characteristics, population characteristics and outcomes of interest . . . The review findings were summarized descriptively using summary tables.”65
“We summarized the findings narratively or in tables. Because this was a scoping review, we did not run any data analysis or risk of bias appraisal for the included studies.”66
“We performed a systematic review and meta-analysis that evaluated the prophylactic effect of aspirin during pregnancy . . . Relative risks of the prophylactic effects were calculated with their 95% confidence intervals.”67
• One of the outcomes used to assess the effectiveness of ketamine was opioid consumption during the first 24 h after surgery . . . Meta-analysis was used to estimate mean differences in opioid consumption between treatment groups.
“We used the RevMan 5.3.5 statistical package from the Cochrane collaboration for meta-analyses. We selected the mean difference (MD) as an effective measure for continuous data. For dichotomous variables, odds ratios (OR) with 95% confidence intervals (95% CI) were calculated. Random effects model was used. The threshold of statistical significance was set to 0.05.”1
Known comparisons: A vs. B and B vs. C
Unknown comparison: A vs. C
Method: A vs. C = (A vs. B) – (B vs. C)
“We included placebo-controlled and head-to-head trials of 21 antidepressants used for the acute treatment of adults (≥18 years old and of both sexes) with major depressive disorder . . . We estimated summary odds ratios (ORs) using pairwise and network meta-analysis with random effects.”56
“Three drug combinations, ipilimumab-nivolumab (Ipi-Nivo), pembrolizumab-axitinib (Pembro-Axi), and avelumab-axitinib (Ave-Axi), have received regulatory approval in the USA and Europe for the treatment of metastatic renal cell carcinoma with clear cell component (mRCC).”57
“However, since no clinical trial has provided any head-to-head comparison data of these combinations, we conducted a network meta-analysis (NMA) to indirectly compare their efficacies in terms of progression-free survival (PFS), overall survival (OS), and objective response rate (ORR) in the first-line setting for patients with mRCC.”58
“Data were extracted using the standardized data extraction tool from JBI. Data synthesis following the JBI approach was performed.”36
“For all papers, two reviewers each independently extracted data and coded Results data against the a priori framework. This coding was then supplemented by secondary thematic analysis of any data not captured by the framework.”69
The authors included 73 studies that used quantitative methods, and 22 studies used qualitative or mixed methods; the majority were based on cross-sectional data.70
The authors included 21 trials, and 12 studies used qualitative methods.71
A fixed question can have elements of the PICO (Population, Intervention, Comparison, and Outcome) approach that is used in a quantitative evidence synthesis of interventions (e.g., systematic review and meta-analysis).42
Frameworks for articulating a question to be answered by qualitative research include:
A fixed question is defined by the elements that serve to “anchor” a synthesis. For example, you could use these elements as concepts to generate lists of keywords for each concept to identify relevant studies and aggregate the findings.42
Research Question: “What are the factors that support (enablers) and inhibit (barriers) the implementation of interventions aimed at improving chronic disease care for Indigenous people within a primary health care setting?”72
Research Question: “Thus, the primary objective of this research was to explore physician and surgeon sensemaking when presented with electronic health data associated with their clinical performance.”73
Objective: “. . . to compare the clinical effectiveness of robot-assisted cholecystectomy for benign gallbladder disease as compared with the laparoscopic approach.”2
An emergent question generally does not have a set of pre-defined parameters. We can restate an emergent review question as a review objective, which serves as a “compass” that offers a general direction for the conduct of the qualitative evidence synthesis.74
Research Objective: “To understand factors considered important by patients, caregivers and health care providers in contributing to tuberculosis medication adherence.”74
Research Objective: “To assess the current available evidence, extract findings and highlight key themes that may help to guide midwifery and medical management, training of key healthcare workers and development of support services dealing with bereaved parents going through a stillbirth.”75
Research Problem: Social prescribing is an approach which seeks to address non-medical and health-related social needs through taking a holistic person-centred and community-based approach. This involves connecting people with and supporting them to access groups and organisations within their local communities . . . Despite growing literature on the implementation of social prescribing, to date there has been no synthesis that develops a theoretical understanding of the factors that shape link workers' experiences of their role.
If you expect the included studies will be rich in concepts and theories, respond “Yes” to this question.
If you expect the included studies will report little data on concepts and theories, respond “No” to this question.
Select this response if your review team consists of members who have expertise in qualitative research.
Select this response if your review team does not have expertise in qualitative research.
“ . . . In order to provide decision-makers with timely results, a rapid review approach was collectively agreed on with a 6-week timeline for completion. Rapid reviews tailor the systematic review process to produce information that is relevant to decision-maker needs in an abbreviated period of time. The streamlined steps followed in this review included limiting: the study design to randomised clinical trials (RCTs), search dates to a period of 10 years and language of publication to English.”85
If neither of the above apply to your review, select “No” as your answer response.
This question refers to living systematic reviews, which involves: (i) continual, active monitoring of the evidence (i.e. monthly searches); (ii) immediately including any new important evidence (meaning data, studies or information); and, (iii) are supported by up-to-date communication about the status of the review, and any new evidence being incorporated.87
If you anticipate that an update to review will be required, select “Yes” as your answer response
“This systematic review will be maintained as a living review with periodic literature searches and updates as new studies emerge. The reviewers will consider quantitative and qualitative factors, such as CoE [certainty of evidence], balance between benefits and harms, and contextual considerations in assessing whether the new evidence may lead to meaningful changes to the recommendations and an update is warranted.”88
If you do not anticipate updating the review, select “No” as your answer response
“Although pre-clinical results are promising, to date there is a dearth of evidence to support the efficacy of chloroquine and hydroxychloroquine (CQ) in preventing COVID-19. Considering potential safety issues and the likelihood of imparting a false sense of security, prophylaxis with CQ against COVID-19 needs to be thoroughly evaluated in observational studies or high-quality randomized controlled studies.”89