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How to Report an Umbrella Review UMBRELLA REVIEW AN OVERVIEW ON REASONS, METHODOLOGY AND STYLE OF REPORT Farid Najafi Department of Epidemiology School of Public Health Kermanshah University of Medical Sciences INTRODUCTION • Systematic review and meta-analysis are key for evidence-based medicine • The number of such studies are on increase: 11 studies published every day. pubmed - meta-analysis[Title/Abstract] count 25000 20000 15000 10000 5000 0 1977 2004 1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2006 2008 2010 2012 2014 2016 2018 2020 REVIEW ARTICLES Traditional Review Articles (Narrative Review) Systematic Review (Meta-analysis) REVIEW ARTICLE REVIEW ARTICLE REASONS FOR DOING UMBRELLA REVIEW • There is a need for reviewing of reviews: umbrella review, reviews of reviews, overviews of reviews, summary of systematic reviews and synthesis of reviews • Whatever the name, there is one common feature: Systematic review and meta-analysis is the only study type that is included • Principle reason: 1-number of systematic reviews are on increase 2-providing a summary from available research syntheses 3-to highlight whether the evidence around a topic is consistent or contradictory, and to explore the reasons for for the findings 4- A useful tool for doing a rapid review on title with a broad area INTRODUCTION • The aim of an umbrella review is not to repeat the searches, assessment of study eligibility, assessment of risk of bias or meta-analysis from included reviews, but rather to provide an overall picture of findings for particular questions • Comparison of one treatment vs. multiple treatment • Analyses of different interventions for the same condition • Investigation of the same intervention and condition, but with different outcomes EXAMPLE DIFFERENT INTERVENTIONS FOR THE SAME CONDITION THE SAME INTERVENTION AND CONDITION, BUT WITH DIFFERENT OUTCOMES WORKING GROUP FOR WRITING THIS PROTOCOL • In 2013, a methodology working group was formed by the Joanna Briggs Institute • Four type of participants in the working group: systematic review authors, researchers, clinicians and journal editors • From four countries: Australia, the USA, Canada and Thailand METHODOLOGY AND SUMMARY OF EVIDENCE FROM RESEARCH SYNTHESIS • Each umbrella review should be preceded by an a priori, peer-reviewed protocol, and should include articulated question(s), detailed inclusion criteria, a structured search process to locate and select relevant existing reviews, methods for critical appraisal of included reviews and a formal process of data extraction and finally the methods for summarizing and presenting the data • The aim of an umbrella review is not to re-synthesize the original articles or included reviews by meta-analysis OBJECTIVES AND INCLUSION CRITERIA • Objectives and questions need to be clearly stated • Is usually very broad • The effect of alcohol consumption on incidence of different type of cancers • The preventive effect of aspirin on cancer • The inclusion criteria need to be specified clearly • Which review types will be included a priori in the protocol • Review that incorporate theoretical studies or published opinion should not be included • PICO (for assessment of intervention in quantitative studies) and PICo (for qualitative studies: population, phenomenon of interest and context) must be defined • All elements of question (PICO and PICo) need to be defined clearly OBJECTIVES AND INCLUSION CRITERIA • Type of participants: age and other qualifying criteria of participants should be clearly defined • Intervention/phenomena of interest: may be focused, for example, only one pharmacological management, or broad, including both pharmacological and other interventions • Exercise as a treatment for sarcopenia • Risk factors for postpartum depression OBJECTIVES AND INCLUSION CRITERIA • Context/setting: should be clearly defined and may include, geographic location or other cultural factors or racial or sex-based charecteristics • Outcome: should be included in the description and report both beneficial and adverse outcomes • Measurement of quality of life using the 36-item Short Form Health Survey • Type of studies: the only study type is systematic review and meta-analysis • Someone may limit the umbrella review to the systematic review of RCTs and not observational study SEARCH STRATEGY • Should be comprehensive to find all relevant systematic review and meta-analyses • Detailed search filters employed should be presented sequentially in the single appendix for all the databases • Medline or Pubmed, Embase and CINAHL, other sources such as JBI Database of Systematic Reviews and Implementation Reports, the Cochrane Database of systematic Reviews, Database of Abstracts of Reviews of Effects and the PROSPERO register • Use of predefined filters or searching “systematic” or “meta-analysis” in title or abstract • Search of grey literature • No need to extend the search prior to 1990 PRESENTATION OF THE RESULTS • A narrative description of the review process accompanied by a flowchart as stipulated in PRISMA • Overall description of the included reviews need to be described with reference to the relevant table. • Specific items or points of interest from individual reviews may also be highlighted here. ALCOHOL CONSUMPTION AND RISK OF CANCER METHODOLOGICAL QUALITY • Critical appraisal of searched reviews is critical for all umbrella reviews • There are some checklist and tools available • AMSTAR • ROBIS • Check list by JBI scored by “met”, “not met”, “unclear” or “not applicable” • Two independent reviewers must run the appraisal • Decision on cut-off need to be made in advance • The quality score of each included study need to be indicated in the review AMSTAR2 • A 16-item assessment tool for systematic review of randomized and non- randomized health interventions • There is no general score • There are some critical domains • There are some advise for interpretation of the result of assessment • Decision is based on the judgment of reviewers and the aspects that is more important for the review AMSTAR2 FOR ASSESSMENT OF SYSTEMATIC REVIEW OF RANDOMIZED AND NON-RANDOMIZED HEALTH INTERVENTION INTERPRETATION ROBIS A TOOL FOR ASSESSING RISK OF BIAS UNIVERSITY OF BRISTOL • The tool is completed in 3 phases 1. Assess relevance (optional) 2. Identify concerns with the review process 3. Judge risk of bias • Phase 2 covers four domains through which bias may be introduced into a systematic review • Study eligibility criteria • Identification and selection of studies • Data collection and study appraisal • Synthesis and findings FINDINGS OF THE UMBRELLA REVIEW • A standardized data extraction tool should be employed by two independent reviewers • Extracted information should include followings: • Citation details, objectives of the included review, type of review, participants details, setting and context, number of searched database, date range of searching, number of studies, type of studies and country of origin of studies including in each review, tools for appraisal, reported outcomes, method of synthesis • Heterogeneity FINDINGS OF THE UMBRELLA REVIEW • Overlap of original/primary research studies in each of the included studies should be presented in the umbrella review • When overall effect estimate has been presented for each meta-analysis, tabular presentation of findings is recommended • The number of reviews that inform the outcome, number of participants (from included reviews) and statistical heterogeneity should be reported FOREST PLOT PRESENTATION Summary of retrieved meta-analyses Association between the use of metformin and risk of cancer Study ID ES (95% CI) New meta-analysis (Ping Wong, Shujuan Ma) (Up to 2017 (Hepatocellular/ Liver)) 0.59 (0.47, 0.74) New meta-analysis (Zheng Wang, Hu, H) (Up to 2016 (Pancreatic)) 0.59 (0.50, 0.69) Wen, Q (August 15, 2018 (Cervical)) 0.60 (0.43, 0.83) Contanza Saka Herran (2012-2017 (Head and Neck)) 0.71 (0.61, 0.83) Hiroshi Noto (Until 2011 (Stomach/Gastric)) 0.72 (0.26, 1.99) Deng, M (2019 (Colorectal)) 0.73 (0.59, 0.91) Deng, M (2019 (Colorectal adenoma)) 0.75 (0.65, 0.86) Shi, J (Up to August 2018 (Ovarian)) 0.76 (0.62, 0.93) T. Rokkas (Until 2015 (Colon)) 0.79 (0.69, 0.91) Monica Franciosi (1966-2012 (Esophagus)) 0.90 (0.83, 0.98) New meta-analysis of (Long Yao, Shu-ping Nie) (Up to 2018 (Lung)) 0.92 (0.85, 0.99) Grace H. Tang (Inception to Nov 2016 (Breast)) 0.93 (0.84, 1.02) New meta-analysis of (Christopher B. Chen , Zhaohan Feng) (Up to 2018 (Prostate)) 0.94 (0.85, 1.04) Hiroshi Noto (Until 2011 (Bladder)) 0.94 (0.64, 1.38) Chu, D (Between 1980 and July 2016 (Endometrial)) 1.05 (0.82, 1.35) NOTE: Weights are from random effects analysis .261 1 3.83 CHARACTERISTICS OF AN UMBRELLA REVIEW • In an umbrella review, the knowledge base at the primary research level is not being examined • It should not revert to reporting of the evidence from included reviews in turn • Authors should look to present outcomes or concepts across the included reviews in order to summarize the evidence in a user-friendly manner for the reader ACKNOWLEDGEMENT • This presentation has been prepared on the basis or report by the Umbrella Review Methodology workshop held at the Joanna Briggs Convention in October 2013 and also the Joanna Briggs Institute Scientific Committee, published in International Journal of Evidence-Based Healthcare Bastian H, Glasziou P, Chalmers I. Seventy-five trials and eleven systematic reviews a day: how will we ever keep up? PLoS medicine. 2010;7(9):e1000326. Aromataris E, Fernandez R, Godfrey CM, Holly C, Khalil H, Tungpunkom P. Summarizing systematic reviews: methodological development, conduct and reporting of an umbrella review approach. International journal of evidence-based healthcare. 2015;13(3):132-40..
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