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You don’t have to look too far to see the benefits of systematic reviews and their summary results.
So the production and use of systematic reviews to inform clinical decision makers is both appropriate and well supported.
With clinical needs and finite budgets dictating the priorities in clinical research, systematic reviews can also reduce research waste. Identifying or carrying out a systematic review, before embarking on any new primary research, is increasingly seen by many research funders as an essential early step. Prospective applicants to NIHR funding are offered guidance notes to ensure that all primary research is informed by a review of the existing literature.
An earlier survey on the utilisation of Cochrane reviews in designing new studies showed that the proportion of study investigators using them was very limited.
A recent review of two sets of NIHR Health Technology Assessment (HTA) funded trials (those funded between 2006 and 2008 and those funded in 2013) sought to identify whether trial planning and design were informed by systematic reviews. National Institute for Health and Care Excellence (NICE) Technology Appraisal Guidance documents (TA), which include Technology Assessment Reports (TAR) based on reviews of the clinical and economic evidence (i.e.
Only five of the 47 trials that were funded in 2006-08 (cohort 1) did not refer to a systematic review, for which the authors found plausible reasons. However, few studies have explored how researchers use systematic reviews when planning new trials.
Scientific history already contains examples where a failure to consider, conduct, and use systematic reviews has led to patients being exposed to potential harm, as well as the waste of resources in carrying out unnecessary clinical trials.
Kamal R Mahtani is a GP and deputy director of the Centre for Evidence Based Medicine, Nuffield Department of Primary Care Health Sciences, University of Oxford. This blog has been cross posted from the NIHR School for Primary Care Research blog and the BMJ Blogs site.
Disclaimer: The views expressed are those of the author and not necessarily of the any of the institutions or organisations mentioned in the article. An updated Cochrane systematic review found inconsistent evidence of benefit for self-monitoring of blood glucose (SMBG) in people with type 2 diabetes who do not use insulin. The reviewers also looked at adverse events (including hypoglycemia), quality of life and cost outcomes.


The review included 12 studies, comprising 3,259 patients.  The reviewers found that for most of the analyses they planned, there was insufficient or inconsistent data. Any testing regime can only have benefit if it is accompanied by appropriate changes in treatment. I am an information scientist with an interest in making knowledge from systematic research more accessible to people who need it.
The well known Cochrane logo depicts a real example, highlighting the value of systematically pooling data for meta-analysis and in this case demonstrating the clear benefit of corticosteroids in accelerating lung maturation in preterm babies. A systematic review of rosiglitazone, which was developed to treat type 2 diabetes, showed an increased risk of myocardial infarction. Originally marketed as a safer alternative to existing non-steroidal anti-inflammatory drugs, it was withdrawn in 2004 after concerns emerged of a higher risk of cardiovascular events, notably myocardial infarction. One of the largest funders of research in the UK is the NHS National Institute for Health Research (NIHR). This may includeidentifying relevant, existing systematic reviews or carrying out an appropriate review and summarising the findings for the application. Only 11 of the 24 authors who responded to their survey were aware of the relevant Cochrane review at the time they designed their study. However, this has improved as a greater understanding ofthe need to begin (and end) new research with a systematic review has become more apparent. All the trials that were funded in 2013 (cohort 2) were informed by systematic reviews. A large change from before then, and perhaps not surprising, given the requirements of the funders.
The reasons the analysis found were varied, but by far the most common reason was to justify treatment comparisons. For example, we cannot guarantee that using a systematic review to inform new research automatically generates higher quality trials and more reliable outcomes. Researchers applying for funding of any new primary study should therefore ensure that they are well aware of existing evidence and the implications to their proposed work. The review formed part of the evidence that ultimately led to the suspension of the marketing authorisation for rosiglitazone by the European Medicines Agency, despite the drug having been available for over 10 years. Asystematic review of published clinical studies of rofecoxib, conducted before the September 2004 withdrawal, identified 18 randomised controlled trials, all sponsored by the manufacturer. The NIHR makes the production and promotion of systematic reviews a key investment in its infrastructure.


Judging the point at which justified replication is needed before it becomes wasteful duplication can be challenging. Cumulative meta-analysis of these trials showed that had a systematic review and meta-analysis of accumulating evidence been conducted by the end of 2000, it would have been clear that rofecoxib was associated with a higher incidence of myocardial infarction.
It has also been argued that reviews of small, poorly conducted, single-center trials exaggerate treatment effects, not seen in subsequent larger well conducted trials. So several thousands of participants, in the studies conducted after 2000, were randomised into trials when a clear harm could (and should) already have been detected.
However, as has been pointed out already, funders need assurance, even from reviews of smaller trials, that there is a need to support further research.
And a systematic review can provide this, as well as information to inform the design of the new research.
The report reminds us that type 2 diabetes “comprises the majority of people with diabetes around the world, and is largely the result of excess body weight and physical inactivity”. Increasingly, this includes children.The WHO report highlights the need to address gaps in the diabetes knowledge base. The reviewers conclude that multicomponent interventions may be effective for reducing body mass index and weight in overweight or obese children.
Other effects (good and bad) are unclear and the role of dietary interventions remains uncertain. As so often, the review highlights that much research is wasted because of shortcomings in the way studies are designed and reported.
Whilst there was not enough good evidence to say which intervention is more effective than another, the reviewers found that:“combined dietary, physical activity and behavioural component appears effective. Prevention of type 2 diabetes; a systematic review and meta- analysis of different intervention strategies.



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