Bias, robustness and certainty

Assess trustworthiness of findings

Study risk of bias, sensitivity analysis and outcome-level certainty are distinct activities. Select appropriate tools and state their versions rather than assigning an unexplained quality score.

Flow diagram

Steps

Choose appraisal approach

Select methods appropriate to study designs and review questions.

Study bias assessment

Assess result-specific domains with supporting evidence and independent reviewers.

Resolve judgments

Document disagreements and adjudication before synthesis.

Inform synthesis

Prespecify how study limitations affect inclusion, grouping and sensitivity analyses.

Heterogeneity and missing evidence

Assess clinical and methodological differences, selective reporting and unavailable results.

Sensitivity comparisons

Compare justified alternative inclusion and model assumptions with the main synthesis.

Assess certainty of evidence

Judge certainty per outcome, considering limitations, inconsistency, indirectness, imprecision and missing evidence.

Interpret and document

Record reasons and limits of conclusions; no statistical test proves absence of bias.