Department of Anaesthesia and Surgery, Graduate Entry Medicine, University of Nottingham, Nottingham, UK.
Department of Medicine, University of Copenhagen, Copenhagen, Denmark; Department of Anaesthesia, Zealand University Hospital, Køge, Denmark.
Br J Anaesth. 2021 Apr;126(4):903-911. doi: 10.1016/j.bja.2021.01.004. Epub 2021 Feb 6.
Systematic reviews and meta-analyses (SRMAs) are increasing in popularity, but should they be used to inform clinical decision-making in anaesthesia? We present evidence that the certainty of evidence from SRMAs in anaesthesia (and in general) may be unacceptably low because of risks of bias exaggerating treatment effects, unexplained heterogeneity reducing certainty in estimates, random errors, and widespread prevalence of publication bias. We also present the latest methodological advances to help improve the certainty of evidence from SRMAs. The target audience includes both review authors and practising clinicians to help with SRMA appraisal. Issues discussed include minimising risks of bias from included trials, trial sequential analysis to reduce random error, updated methods for presenting effect estimates, and novel publication bias tests for commonly used outcome measures. These methods can help to reduce spurious conclusions on clinical significance, explain statistical heterogeneity, and reduce false positives when evaluating small-study effects. By reducing concerns in these domains of Grading of Recommendations, Assessment, Development and Evaluation, it should help improve the certainty of evidence from SRMAs used for decision-making in anaesthesia, pain, and perioperative medicine.
系统评价和荟萃分析（SRMAs）越来越受欢迎，但它们是否应该用于指导麻醉学中的临床决策？我们提出的证据表明，由于偏倚风险夸大了治疗效果、无法解释的异质性降低了估计的确定性、随机误差以及广泛存在的发表偏倚，来自麻醉学（以及一般来说）的 SRMA 的证据确定性可能低得令人无法接受。我们还介绍了最新的方法学进展，以帮助提高来自 SRMA 的证据的确定性。目标受众包括综述作者和执业临床医生，以帮助进行 SRMA 评估。讨论的问题包括：从纳入的试验中最小化偏倚风险、试验序贯分析以减少随机误差、更新呈现效果估计的方法，以及针对常用结局指标的新型发表偏倚检验。这些方法有助于减少对临床意义的虚假结论、解释统计异质性，并在评估小样本效应时减少假阳性。通过减少这些推荐、评估、制定和评价领域的担忧，应该有助于提高用于指导麻醉、疼痛和围手术期医学决策的 SRMA 的证据确定性。
