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The committee recommends the following standard for assessing and describing the quality of a body of evidence. As noted earlier, this overall assessment should be done once the qualitative and quantitative syntheses are completed (see Standards 4.2–4.4 below). The order of this chapter’s standards does not indicate the sequence in which the various steps should be conducted. Standard 4.1 is presented first to reflect the committee’s recommendation that the SR specifies its methods a priori in the research protocol.

Standard 4.1—Use a prespecified method to evaluate the body of evidence

Required elements:

If an SR is to be objective, it should use prespecified, analytic methods. If the SR’s assessment of the quality of a body of evidence is to be credible and true to scientific principles, it should be based on agreed-on concepts of study quality. If the SR is to be comprehensible, it should use unambiguous language, free from jar-

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gon, to describe the quality of evidence for each outcome. Decision makers—whether clinicians, patients, or others—should not have to decipher undefined and possibly conflicting terms and symbols in order to understand the methods and findings of SRs.

Clearly, the assessment of the quality of a body of evidence—for each outcome in the SR—must incorporate multiple dimensions of study quality. Without a sound conceptual framework for scrutinizing the body of evidence, the SR can lead to the wrong conclusions about an intervention’s effectiveness, with potentially serious implications for clinical practice.

The lack of an evidence-based system for assessing and characterizing the quality of a body of evidence is clearly problematic. A plethora of systems are in use, none have been evaluated, and all have their proponents and critics. The committee’s recommended quality characteristics are well-established concepts for evaluating quality; however, the SR field needs unambiguous, jargon-free language for systematically applying these concepts. GRADE merits consideration, but should be rigorously evaluated before it becomes a required component of SRs in the United States. Until a well-validated standard language is developed, SR authors should use their chosen lexicon and provide clear definitions of their terms.


As noted earlier, the term “synthesis” refers to the collation, combination, and summary of the results of an SR. The committee uses the term “qualitative synthesis” to refer to an assessment of the body of evidence that goes beyond factual descriptions or tables that, for example, simply detail how many studies were assessed, the reasons for excluding other studies, the range of study sizes and treatments compared, or quality scores of each study as measured by a risk of bias tool. While an accurate description of the body of evidence is essential, it is not sufficient (Atkins, 2007; Mulrow and Lohr, 2001).

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