what type of evidence is a literature review

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Evidence-Based Research: Levels of Evidence Pyramid

Introduction.

One way to organize the different types of evidence involved in evidence-based practice research is the levels of evidence pyramid. The pyramid includes a variety of evidence types and levels.

• systematic reviews
• critically-appraised topics
• critically-appraised individual articles
• randomized controlled trials
• cohort studies
• case-controlled studies, case series, and case reports
• Background information, expert opinion

Levels of evidence pyramid

The levels of evidence pyramid provides a way to visualize both the quality of evidence and the amount of evidence available. For example, systematic reviews are at the top of the pyramid, meaning they are both the highest level of evidence and the least common. As you go down the pyramid, the amount of evidence will increase as the quality of the evidence decreases.

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Filtered Resources

Filtered resources appraise the quality of studies and often make recommendations for practice. The main types of filtered resources in evidence-based practice are:

Scroll down the page to the Systematic reviews , Critically-appraised topics , and Critically-appraised individual articles sections for links to resources where you can find each of these types of filtered information.

Systematic reviews

Authors of a systematic review ask a specific clinical question, perform a comprehensive literature review, eliminate the poorly done studies, and attempt to make practice recommendations based on the well-done studies. Systematic reviews include only experimental, or quantitative, studies, and often include only randomized controlled trials.

You can find systematic reviews in these filtered databases :

• Cochrane Database of Systematic Reviews Cochrane systematic reviews are considered the gold standard for systematic reviews. This database contains both systematic reviews and review protocols. To find only systematic reviews, select Cochrane Reviews in the Document Type box.
• JBI EBP Database (formerly Joanna Briggs Institute EBP Database) This database includes systematic reviews, evidence summaries, and best practice information sheets. To find only systematic reviews, click on Limits and then select Systematic Reviews in the Publication Types box. To see how to use the limit and find full text, please see our Joanna Briggs Institute Search Help page .

You can also find systematic reviews in this unfiltered database :

To learn more about finding systematic reviews, please see our guide:

• Filtered Resources: Systematic Reviews

Critically-appraised topics

Authors of critically-appraised topics evaluate and synthesize multiple research studies. Critically-appraised topics are like short systematic reviews focused on a particular topic.

You can find critically-appraised topics in these resources:

• Annual Reviews This collection offers comprehensive, timely collections of critical reviews written by leading scientists. To find reviews on your topic, use the search box in the upper-right corner.
• Guideline Central This free database offers quick-reference guideline summaries organized by a new non-profit initiative which will aim to fill the gap left by the sudden closure of AHRQ’s National Guideline Clearinghouse (NGC).
• JBI EBP Database (formerly Joanna Briggs Institute EBP Database) To find critically-appraised topics in JBI, click on Limits and then select Evidence Summaries from the Publication Types box. To see how to use the limit and find full text, please see our Joanna Briggs Institute Search Help page .
• National Institute for Health and Care Excellence (NICE) Evidence-based recommendations for health and care in England.
• Filtered Resources: Critically-Appraised Topics

Critically-appraised individual articles

Authors of critically-appraised individual articles evaluate and synopsize individual research studies.

You can find critically-appraised individual articles in these resources:

• EvidenceAlerts Quality articles from over 120 clinical journals are selected by research staff and then rated for clinical relevance and interest by an international group of physicians. Note: You must create a free account to search EvidenceAlerts.
• ACP Journal Club This journal publishes reviews of research on the care of adults and adolescents. You can either browse this journal or use the Search within this publication feature.
• Evidence-Based Nursing This journal reviews research studies that are relevant to best nursing practice. You can either browse individual issues or use the search box in the upper-right corner.

To learn more about finding critically-appraised individual articles, please see our guide:

• Filtered Resources: Critically-Appraised Individual Articles

Unfiltered resources

You may not always be able to find information on your topic in the filtered literature. When this happens, you'll need to search the primary or unfiltered literature. Keep in mind that with unfiltered resources, you take on the role of reviewing what you find to make sure it is valid and reliable.

Note: You can also find systematic reviews and other filtered resources in these unfiltered databases.

The Levels of Evidence Pyramid includes unfiltered study types in this order of evidence from higher to lower:

You can search for each of these types of evidence in the following databases:

TRIP database

Background information & expert opinion.

Background information and expert opinions are not necessarily backed by research studies. They include point-of-care resources, textbooks, conference proceedings, etc.

• Family Physicians Inquiries Network: Clinical Inquiries Provide the ideal answers to clinical questions using a structured search, critical appraisal, authoritative recommendations, clinical perspective, and rigorous peer review. Clinical Inquiries deliver best evidence for point-of-care use.
• Harrison, T. R., & Fauci, A. S. (2009). Harrison's Manual of Medicine . New York: McGraw-Hill Professional. Contains the clinical portions of Harrison's Principles of Internal Medicine .
• Lippincott manual of nursing practice (8th ed.). (2006). Philadelphia, PA: Lippincott Williams & Wilkins. Provides background information on clinical nursing practice.
• Medscape: Drugs & Diseases An open-access, point-of-care medical reference that includes clinical information from top physicians and pharmacists in the United States and worldwide.
• Virginia Henderson Global Nursing e-Repository An open-access repository that contains works by nurses and is sponsored by Sigma Theta Tau International, the Honor Society of Nursing. Note: This resource contains both expert opinion and evidence-based practice articles.
• Previous Page: Phrasing Research Questions
• Next Page: Evidence Types
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Systematic Reviews

• Levels of Evidence
• Evidence Pyramid
• Joanna Briggs Institute

The evidence pyramid is often used to illustrate the development of evidence. At the base of the pyramid is animal research and laboratory studies – this is where ideas are first developed. As you progress up the pyramid the amount of information available decreases in volume, but increases in relevance to the clinical setting.

Meta Analysis  – systematic review that uses quantitative methods to synthesize and summarize the results.

Systematic Review  – summary of the medical literature that uses explicit methods to perform a comprehensive literature search and critical appraisal of individual studies and that uses appropriate st atistical techniques to combine these valid studies.

Randomized Controlled Trial – Participants are randomly allocated into an experimental group or a control group and followed over time for the variables/outcomes of interest.

Cohort Study – Involves identification of two groups (cohorts) of patients, one which received the exposure of interest, and one which did not, and following these cohorts forward for the outcome of interest.

Case Control Study – study which involves identifying patients who have the outcome of interest (cases) and patients without the same outcome (controls), and looking back to see if they had the exposure of interest.

Case Series   – report on a series of patients with an outcome of interest. No control group is involved.

• Levels of Evidence from The Centre for Evidence-Based Medicine
• The JBI Model of Evidence Based Healthcare
• How to Use the Evidence: Assessment and Application of Scientific Evidence From the National Health and Medical Research Council (NHMRC) of Australia. Book must be downloaded; not available to read online.

When searching for evidence to answer clinical questions, aim to identify the highest level of available evidence. Evidence hierarchies can help you strategically identify which resources to use for finding evidence, as well as which search results are most likely to be "best".                                             

Image source: Evidence-Based Practice: Study Design from Duke University Medical Center Library & Archives. This work is licensed under a Creativ e Commons Attribution-ShareAlike 4.0 International License .

The hierarchy of evidence (also known as the evidence-based pyramid) is depicted as a triangular representation of the levels of evidence with the strongest evidence at the top which progresses down through evidence with decreasing strength. At the top of the pyramid are research syntheses, such as Meta-Analyses and Systematic Reviews, the strongest forms of evidence. Below research syntheses are primary research studies progressing from experimental studies, such as Randomized Controlled Trials, to observational studies, such as Cohort Studies, Case-Control Studies, Cross-Sectional Studies, Case Series, and Case Reports. Non-Human Animal Studies and Laboratory Studies occupy the lowest level of evidence at the base of the pyramid.

• Finding Evidence-Based Answers to Clinical Questions – Quickly & Effectively A tip sheet from the health sciences librarians at UC Davis Libraries to help you get started with selecting resources for finding evidence, based on type of question.
• << Previous: What is a Systematic Review?
• Next: Locating Systematic Reviews >>
• Getting Started
• What is a Systematic Review?
• Locating Systematic Reviews
• Searching Systematically
• Developing Answerable Questions
• Identifying Synonyms & Related Terms
• Using Truncation and Wildcards
• Identifying Search Limits/Exclusion Criteria
• Keyword vs. Subject Searching
• Where to Search
• Search Filters
• Sensitivity vs. Precision
• Core Databases
• Other Databases
• Clinical Trial Registries
• Conference Presentations
• Databases Indexing Grey Literature
• Web Searching
• Handsearching
• Citation Indexes
• Documenting the Search Process
• Managing your Review

Research Support

• Last Updated: Feb 29, 2024 3:16 PM
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• Literature Review Types, Taxonomies

Evidence Synthesis, Systematic Review Services : Literature Review Types, Taxonomies

• Develop a Protocol
• Develop Your Research Question
• Select Databases
• Select Gray Literature Sources
• Write a Search Strategy
• Manage Your Search Process
• Register Your Protocol
• Citation Management
• Article Screening
• Risk of Bias Assessment
• Synthesize, Map, or Describe the Results
• Find Guidance by Discipline
• Manage Your Research Data
• Browse Evidence Portals by Discipline
• Additional Resources

Choosing a Literature Review Methodology

Growing interest in evidence-based practice has driven an increase in review methodologies. Your choice of review methodology (or literature review type) will be informed by the intent (purpose, function) of your research project and the time and resources of your team. 

• Decision Tree (What Type of Review is Right for You?) Developed by Cornell University Library staff, this "decision-tree" guides the user to a handful of review guides given time and intent.

Types of Evidence Synthesis*

Critical Review - Aims to demonstrate writer has extensively researched literature and critically evaluated its quality. Goes beyond mere description to include degree of analysis and conceptual innovation. Typically results in hypothesis or model.

Mapping Review (Systematic Map) - Map out and categorize existing literature from which to commission further reviews and/or primary research by identifying gaps in research literature.

Meta-Analysis - Technique that statistically combines the results of quantitative studies to provide a more precise effect of the results.

Mixed Studies Review (Mixed Methods Review) - Refers to any combination of methods where one significant component is a literature review (usually systematic). Within a review context it refers to a combination of review approaches for example combining quantitative with qualitative research or outcome with process studies.

Narrative (Literature) Review - Generic term: published materials that provide examination of recent or current literature. Can cover wide range of subjects at various levels of completeness and comprehensiveness.

Overview - Generic term: summary of the [medical] literature that attempts to survey the literature and describe its characteristics.

Qualitative Systematic Review or Qualitative Evidence Synthesis - Method for integrating or comparing the findings from qualitative studies. It looks for ‘themes’ or ‘constructs’ that lie in or across individual qualitative studies.

Rapid Review - Assessment of what is already known about a policy or practice issue, by using systematic review methods to search and critically appraise existing research.

Scoping Review or Evidence Map - Preliminary assessment of potential size and scope of available research literature. Aims to identify nature and extent of research.

State-of-the-art Review - Tend to address more current matters in contrast to other combined retrospective and current approaches. May offer new perspectives on issue or point out area for further research.

Systematic Review - Seeks to systematically search for, appraise and synthesis research evidence, often adhering to guidelines on the conduct of a review. (An emerging subset includes Living Reviews or Living Systematic Reviews - A [review or] systematic review which is continually updated, incorporating relevant new evidence as it becomes available.)

Systematic Search and Review - Combines strengths of critical review with a comprehensive search process. Typically addresses broad questions to produce ‘best evidence synthesis.’

Umbrella Review - Specifically refers to review compiling evidence from multiple reviews into one accessible and usable document. Focuses on broad condition or problem for which there are competing interventions and highlights reviews that address these interventions and their results.

*These definitions are in Grant & Booth's "A Typology of Reviews: An Analysis of 14 Review Types and Associated Methodologies."

Literature Review Types/Typologies, Taxonomies

Grant, M. J., and A. Booth. "A Typology of Reviews: An Analysis of 14 Review Types and Associated Methodologies."  Health Information and Libraries Journal  26.2 (2009): 91-108.  DOI: 10.1111/j.1471-1842.2009.00848.x  Link

Munn, Zachary, et al. “Systematic Review or Scoping Review? Guidance for Authors When Choosing between a Systematic or Scoping Review Approach.” BMC Medical Research Methodology , vol. 18, no. 1, Nov. 2018, p. 143. DOI: 10.1186/s12874-018-0611-x. Link

Sutton, A., et al. "Meeting the Review Family: Exploring Review Types and Associated Information Retrieval Requirements."  Health Information and Libraries Journal  36.3 (2019): 202-22.  DOI: 10.1111/hir.12276  Link

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Literature Reviews

• What is a literature review?
• Steps in the Literature Review Process
• Define your research question
• Determine inclusion and exclusion criteria
• Choose databases and search
• Review Results
• Synthesize Results
• Analyze Results
• Librarian Support

What is a Literature Review?

A literature or narrative review is a comprehensive review and analysis of the published literature on a specific topic or research question. The literature that is reviewed contains: books, articles, academic articles, conference proceedings, association papers, and dissertations. It contains the most pertinent studies and points to important past and current research and practices. It provides background and context, and shows how your research will contribute to the field. 

A literature review should: 

• Provide a comprehensive and updated review of the literature;
• Explain why this review has taken place;
• Articulate a position or hypothesis;
• Acknowledge and account for conflicting and corroborating points of view

From  S age Research Methods

Purpose of a Literature Review

A literature review can be written as an introduction to a study to:

• Demonstrate how a study fills a gap in research
• Compare a study with other research that's been done

Or it can be a separate work (a research article on its own) which:

• Organizes or describes a topic
• Describes variables within a particular issue/problem

Limitations of a Literature Review

Some of the limitations of a literature review are:

• It's a snapshot in time. Unlike other reviews, this one has beginning, a middle and an end. There may be future developments that could make your work less relevant.
• It may be too focused. Some niche studies may miss the bigger picture.
• It can be difficult to be comprehensive. There is no way to make sure all the literature on a topic was considered.
• It is easy to be biased if you stick to top tier journals. There may be other places where people are publishing exemplary research. Look to open access publications and conferences to reflect a more inclusive collection. Also, make sure to include opposing views (and not just supporting evidence).

Source: Grant, Maria J., and Andrew Booth. “A Typology of Reviews: An Analysis of 14 Review Types and Associated Methodologies.” Health Information & Libraries Journal, vol. 26, no. 2, June 2009, pp. 91–108. Wiley Online Library, doi:10.1111/j.1471-1842.2009.00848.x.

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Periodically, UT Libraries runs a workshop covering the basics and library support for literature reviews. While we try to offer these once per academic year, we find providing the recording to be helpful to community members who have missed the session. Following is the most recent recording of the workshop, Conducting a Literature Review. To view the recording, a UT login is required.

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Literature Review – Types Writing Guide and Examples

Table of Contents

Literature Review

Definition:

A literature review is a comprehensive and critical analysis of the existing literature on a particular topic or research question. It involves identifying, evaluating, and synthesizing relevant literature, including scholarly articles, books, and other sources, to provide a summary and critical assessment of what is known about the topic.

Types of Literature Review

Types of Literature Review are as follows:

• Narrative literature review : This type of review involves a comprehensive summary and critical analysis of the available literature on a particular topic or research question. It is often used as an introductory section of a research paper.
• Systematic literature review: This is a rigorous and structured review that follows a pre-defined protocol to identify, evaluate, and synthesize all relevant studies on a specific research question. It is often used in evidence-based practice and systematic reviews.
• Meta-analysis: This is a quantitative review that uses statistical methods to combine data from multiple studies to derive a summary effect size. It provides a more precise estimate of the overall effect than any individual study.
• Scoping review: This is a preliminary review that aims to map the existing literature on a broad topic area to identify research gaps and areas for further investigation.
• Critical literature review : This type of review evaluates the strengths and weaknesses of the existing literature on a particular topic or research question. It aims to provide a critical analysis of the literature and identify areas where further research is needed.
• Conceptual literature review: This review synthesizes and integrates theories and concepts from multiple sources to provide a new perspective on a particular topic. It aims to provide a theoretical framework for understanding a particular research question.
• Rapid literature review: This is a quick review that provides a snapshot of the current state of knowledge on a specific research question or topic. It is often used when time and resources are limited.
• Thematic literature review : This review identifies and analyzes common themes and patterns across a body of literature on a particular topic. It aims to provide a comprehensive overview of the literature and identify key themes and concepts.
• Realist literature review: This review is often used in social science research and aims to identify how and why certain interventions work in certain contexts. It takes into account the context and complexities of real-world situations.
• State-of-the-art literature review : This type of review provides an overview of the current state of knowledge in a particular field, highlighting the most recent and relevant research. It is often used in fields where knowledge is rapidly evolving, such as technology or medicine.
• Integrative literature review: This type of review synthesizes and integrates findings from multiple studies on a particular topic to identify patterns, themes, and gaps in the literature. It aims to provide a comprehensive understanding of the current state of knowledge on a particular topic.
• Umbrella literature review : This review is used to provide a broad overview of a large and diverse body of literature on a particular topic. It aims to identify common themes and patterns across different areas of research.
• Historical literature review: This type of review examines the historical development of research on a particular topic or research question. It aims to provide a historical context for understanding the current state of knowledge on a particular topic.
• Problem-oriented literature review : This review focuses on a specific problem or issue and examines the literature to identify potential solutions or interventions. It aims to provide practical recommendations for addressing a particular problem or issue.
• Mixed-methods literature review : This type of review combines quantitative and qualitative methods to synthesize and analyze the available literature on a particular topic. It aims to provide a more comprehensive understanding of the research question by combining different types of evidence.

Parts of Literature Review

Parts of a literature review are as follows:

Introduction

The introduction of a literature review typically provides background information on the research topic and why it is important. It outlines the objectives of the review, the research question or hypothesis, and the scope of the review.

Literature Search

This section outlines the search strategy and databases used to identify relevant literature. The search terms used, inclusion and exclusion criteria, and any limitations of the search are described.

Literature Analysis

The literature analysis is the main body of the literature review. This section summarizes and synthesizes the literature that is relevant to the research question or hypothesis. The review should be organized thematically, chronologically, or by methodology, depending on the research objectives.

Critical Evaluation

Critical evaluation involves assessing the quality and validity of the literature. This includes evaluating the reliability and validity of the studies reviewed, the methodology used, and the strength of the evidence.

The conclusion of the literature review should summarize the main findings, identify any gaps in the literature, and suggest areas for future research. It should also reiterate the importance of the research question or hypothesis and the contribution of the literature review to the overall research project.

The references list includes all the sources cited in the literature review, and follows a specific referencing style (e.g., APA, MLA, Harvard).

How to write Literature Review

Here are some steps to follow when writing a literature review:

• Define your research question or topic : Before starting your literature review, it is essential to define your research question or topic. This will help you identify relevant literature and determine the scope of your review.
• Conduct a comprehensive search: Use databases and search engines to find relevant literature. Look for peer-reviewed articles, books, and other academic sources that are relevant to your research question or topic.
• Evaluate the sources: Once you have found potential sources, evaluate them critically to determine their relevance, credibility, and quality. Look for recent publications, reputable authors, and reliable sources of data and evidence.
• Organize your sources: Group the sources by theme, method, or research question. This will help you identify similarities and differences among the literature, and provide a structure for your literature review.
• Analyze and synthesize the literature : Analyze each source in depth, identifying the key findings, methodologies, and conclusions. Then, synthesize the information from the sources, identifying patterns and themes in the literature.
• Write the literature review : Start with an introduction that provides an overview of the topic and the purpose of the literature review. Then, organize the literature according to your chosen structure, and analyze and synthesize the sources. Finally, provide a conclusion that summarizes the key findings of the literature review, identifies gaps in knowledge, and suggests areas for future research.
• Edit and proofread: Once you have written your literature review, edit and proofread it carefully to ensure that it is well-organized, clear, and concise.

Examples of Literature Review

Here’s an example of how a literature review can be conducted for a thesis on the topic of “ The Impact of Social Media on Teenagers’ Mental Health”:

• Start by identifying the key terms related to your research topic. In this case, the key terms are “social media,” “teenagers,” and “mental health.”
• Use academic databases like Google Scholar, JSTOR, or PubMed to search for relevant articles, books, and other publications. Use these keywords in your search to narrow down your results.
• Evaluate the sources you find to determine if they are relevant to your research question. You may want to consider the publication date, author’s credentials, and the journal or book publisher.
• Begin reading and taking notes on each source, paying attention to key findings, methodologies used, and any gaps in the research.
• Organize your findings into themes or categories. For example, you might categorize your sources into those that examine the impact of social media on self-esteem, those that explore the effects of cyberbullying, and those that investigate the relationship between social media use and depression.
• Synthesize your findings by summarizing the key themes and highlighting any gaps or inconsistencies in the research. Identify areas where further research is needed.
• Use your literature review to inform your research questions and hypotheses for your thesis.

For example, after conducting a literature review on the impact of social media on teenagers’ mental health, a thesis might look like this:

“Using a mixed-methods approach, this study aims to investigate the relationship between social media use and mental health outcomes in teenagers. Specifically, the study will examine the effects of cyberbullying, social comparison, and excessive social media use on self-esteem, anxiety, and depression. Through an analysis of survey data and qualitative interviews with teenagers, the study will provide insight into the complex relationship between social media use and mental health outcomes, and identify strategies for promoting positive mental health outcomes in young people.”

Reference: Smith, J., Jones, M., & Lee, S. (2019). The effects of social media use on adolescent mental health: A systematic review. Journal of Adolescent Health, 65(2), 154-165. doi:10.1016/j.jadohealth.2019.03.024

Reference Example: Author, A. A., Author, B. B., & Author, C. C. (Year). Title of article. Title of Journal, volume number(issue number), page range. doi:0000000/000000000000 or URL

Applications of Literature Review

some applications of literature review in different fields:

• Social Sciences: In social sciences, literature reviews are used to identify gaps in existing research, to develop research questions, and to provide a theoretical framework for research. Literature reviews are commonly used in fields such as sociology, psychology, anthropology, and political science.
• Natural Sciences: In natural sciences, literature reviews are used to summarize and evaluate the current state of knowledge in a particular field or subfield. Literature reviews can help researchers identify areas where more research is needed and provide insights into the latest developments in a particular field. Fields such as biology, chemistry, and physics commonly use literature reviews.
• Health Sciences: In health sciences, literature reviews are used to evaluate the effectiveness of treatments, identify best practices, and determine areas where more research is needed. Literature reviews are commonly used in fields such as medicine, nursing, and public health.
• Humanities: In humanities, literature reviews are used to identify gaps in existing knowledge, develop new interpretations of texts or cultural artifacts, and provide a theoretical framework for research. Literature reviews are commonly used in fields such as history, literary studies, and philosophy.

Role of Literature Review in Research

Here are some applications of literature review in research:

• Identifying Research Gaps : Literature review helps researchers identify gaps in existing research and literature related to their research question. This allows them to develop new research questions and hypotheses to fill those gaps.
• Developing Theoretical Framework: Literature review helps researchers develop a theoretical framework for their research. By analyzing and synthesizing existing literature, researchers can identify the key concepts, theories, and models that are relevant to their research.
• Selecting Research Methods : Literature review helps researchers select appropriate research methods and techniques based on previous research. It also helps researchers to identify potential biases or limitations of certain methods and techniques.
• Data Collection and Analysis: Literature review helps researchers in data collection and analysis by providing a foundation for the development of data collection instruments and methods. It also helps researchers to identify relevant data sources and identify potential data analysis techniques.
• Communicating Results: Literature review helps researchers to communicate their results effectively by providing a context for their research. It also helps to justify the significance of their findings in relation to existing research and literature.

Purpose of Literature Review

Some of the specific purposes of a literature review are as follows:

• To provide context: A literature review helps to provide context for your research by situating it within the broader body of literature on the topic.
• To identify gaps and inconsistencies: A literature review helps to identify areas where further research is needed or where there are inconsistencies in the existing literature.
• To synthesize information: A literature review helps to synthesize the information from multiple sources and present a coherent and comprehensive picture of the current state of knowledge on the topic.
• To identify key concepts and theories : A literature review helps to identify key concepts and theories that are relevant to your research question and provide a theoretical framework for your study.
• To inform research design: A literature review can inform the design of your research study by identifying appropriate research methods, data sources, and research questions.

Characteristics of Literature Review

Some Characteristics of Literature Review are as follows:

• Identifying gaps in knowledge: A literature review helps to identify gaps in the existing knowledge and research on a specific topic or research question. By analyzing and synthesizing the literature, you can identify areas where further research is needed and where new insights can be gained.
• Establishing the significance of your research: A literature review helps to establish the significance of your own research by placing it in the context of existing research. By demonstrating the relevance of your research to the existing literature, you can establish its importance and value.
• Informing research design and methodology : A literature review helps to inform research design and methodology by identifying the most appropriate research methods, techniques, and instruments. By reviewing the literature, you can identify the strengths and limitations of different research methods and techniques, and select the most appropriate ones for your own research.
• Supporting arguments and claims: A literature review provides evidence to support arguments and claims made in academic writing. By citing and analyzing the literature, you can provide a solid foundation for your own arguments and claims.
• I dentifying potential collaborators and mentors: A literature review can help identify potential collaborators and mentors by identifying researchers and practitioners who are working on related topics or using similar methods. By building relationships with these individuals, you can gain valuable insights and support for your own research and practice.
• Keeping up-to-date with the latest research : A literature review helps to keep you up-to-date with the latest research on a specific topic or research question. By regularly reviewing the literature, you can stay informed about the latest findings and developments in your field.

Advantages of Literature Review

There are several advantages to conducting a literature review as part of a research project, including:

• Establishing the significance of the research : A literature review helps to establish the significance of the research by demonstrating the gap or problem in the existing literature that the study aims to address.
• Identifying key concepts and theories: A literature review can help to identify key concepts and theories that are relevant to the research question, and provide a theoretical framework for the study.
• Supporting the research methodology : A literature review can inform the research methodology by identifying appropriate research methods, data sources, and research questions.
• Providing a comprehensive overview of the literature : A literature review provides a comprehensive overview of the current state of knowledge on a topic, allowing the researcher to identify key themes, debates, and areas of agreement or disagreement.
• Identifying potential research questions: A literature review can help to identify potential research questions and areas for further investigation.
• Avoiding duplication of research: A literature review can help to avoid duplication of research by identifying what has already been done on a topic, and what remains to be done.
• Enhancing the credibility of the research : A literature review helps to enhance the credibility of the research by demonstrating the researcher’s knowledge of the existing literature and their ability to situate their research within a broader context.

Limitations of Literature Review

Limitations of Literature Review are as follows:

• Limited scope : Literature reviews can only cover the existing literature on a particular topic, which may be limited in scope or depth.
• Publication bias : Literature reviews may be influenced by publication bias, which occurs when researchers are more likely to publish positive results than negative ones. This can lead to an incomplete or biased picture of the literature.
• Quality of sources : The quality of the literature reviewed can vary widely, and not all sources may be reliable or valid.
• Time-limited: Literature reviews can become quickly outdated as new research is published, making it difficult to keep up with the latest developments in a field.
• Subjective interpretation : Literature reviews can be subjective, and the interpretation of the findings can vary depending on the researcher’s perspective or bias.
• Lack of original data : Literature reviews do not generate new data, but rather rely on the analysis of existing studies.
• Risk of plagiarism: It is important to ensure that literature reviews do not inadvertently contain plagiarism, which can occur when researchers use the work of others without proper attribution.

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• What is a Systematic Review?

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• 1. Assemble Your Team
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Review Typologies

There are many types of evidence synthesis projects, including systematic reviews as well as others. The selection of review type is wholly dependent on the research question. Not all research questions are well-suited for systematic reviews.

• Review Typologies (from LITR-EX) This site explores different review methodologies such as, systematic, scoping, realist, narrative, state of the art, meta-ethnography, critical, and integrative reviews. The LITR-EX site has a health professions education focus, but the advice and information is widely applicable.

Review the table to peruse review types and associated methodologies. Librarians can also help your team determine which review type might be appropriate for your project. 

Reproduced from Grant, M. J. and Booth, A. (2009), A typology of reviews: an analysis of 14 review types and associated methodologies. Health Information & Libraries Journal, 26: 91-108.  doi:10.1111/j.1471-1842.2009.00848.x

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• Research Process

Levels of evidence in research

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Table of Contents

Level of evidence hierarchy

When carrying out a project you might have noticed that while searching for information, there seems to be different levels of credibility given to different types of scientific results. For example, it is not the same to use a systematic review or an expert opinion as a basis for an argument. It’s almost common sense that the first will demonstrate more accurate results than the latter, which ultimately derives from a personal opinion.

In the medical and health care area, for example, it is very important that professionals not only have access to information but also have instruments to determine which evidence is stronger and more trustworthy, building up the confidence to diagnose and treat their patients.

5 levels of evidence

With the increasing need from physicians – as well as scientists of different fields of study-, to know from which kind of research they can expect the best clinical evidence, experts decided to rank this evidence to help them identify the best sources of information to answer their questions. The criteria for ranking evidence is based on the design, methodology, validity and applicability of the different types of studies. The outcome is called “levels of evidence” or “levels of evidence hierarchy”. By organizing a well-defined hierarchy of evidence, academia experts were aiming to help scientists feel confident in using findings from high-ranked evidence in their own work or practice. For Physicians, whose daily activity depends on available clinical evidence to support decision-making, this really helps them to know which evidence to trust the most.

So, by now you know that research can be graded according to the evidential strength determined by different study designs. But how many grades are there? Which evidence should be high-ranked and low-ranked?

There are five levels of evidence in the hierarchy of evidence – being 1 (or in some cases A) for strong and high-quality evidence and 5 (or E) for evidence with effectiveness not established, as you can see in the pyramidal scheme below:

Level 1: (higher quality of evidence) – High-quality randomized trial or prospective study; testing of previously developed diagnostic criteria on consecutive patients; sensible costs and alternatives; values obtained from many studies with multiway sensitivity analyses; systematic review of Level I RCTs and Level I studies.

Level 2: Lesser quality RCT; prospective comparative study; retrospective study; untreated controls from an RCT; lesser quality prospective study; development of diagnostic criteria on consecutive patients; sensible costs and alternatives; values obtained from limited stud- ies; with multiway sensitivity analyses; systematic review of Level II studies or Level I studies with inconsistent results.

Level 3: Case-control study (therapeutic and prognostic studies); retrospective comparative study; study of nonconsecutive patients without consistently applied reference “gold” standard; analyses based on limited alternatives and costs and poor estimates; systematic review of Level III studies.

Level 4: Case series; case-control study (diagnostic studies); poor reference standard; analyses with no sensitivity analyses.

Level 5: (lower quality of evidence) – Expert opinion.

By looking at the pyramid, you can roughly distinguish what type of research gives you the highest quality of evidence and which gives you the lowest. Basically, level 1 and level 2 are filtered information – that means an author has gathered evidence from well-designed studies, with credible results, and has produced findings and conclusions appraised by renowned experts, who consider them valid and strong enough to serve researchers and scientists. Levels 3, 4 and 5 include evidence coming from unfiltered information. Because this evidence hasn’t been appraised by experts, it might be questionable, but not necessarily false or wrong.

Examples of levels of evidence

As you move up the pyramid, you will surely find higher-quality evidence. However, you will notice there is also less research available. So, if there are no resources for you available at the top, you may have to start moving down in order to find the answers you are looking for.

• Systematic Reviews: -Exhaustive summaries of all the existent literature about a certain topic. When drafting a systematic review, authors are expected to deliver a critical assessment and evaluation of all this literature rather than a simple list. Researchers that produce systematic reviews have their own criteria to locate, assemble and evaluate a body of literature.
• Meta-Analysis: Uses quantitative methods to synthesize a combination of results from independent studies. Normally, they function as an overview of clinical trials. Read more: Systematic review vs meta-analysis .
• Critically Appraised Topic: Evaluation of several research studies.
• Critically Appraised Article: Evaluation of individual research studies.
• Randomized Controlled Trial: a clinical trial in which participants or subjects (people that agree to participate in the trial) are randomly divided into groups. Placebo (control) is given to one of the groups whereas the other is treated with medication. This kind of research is key to learning about a treatment’s effectiveness.
• Cohort studies: A longitudinal study design, in which one or more samples called cohorts (individuals sharing a defining characteristic, like a disease) are exposed to an event and monitored prospectively and evaluated in predefined time intervals. They are commonly used to correlate diseases with risk factors and health outcomes.
• Case-Control Study: Selects patients with an outcome of interest (cases) and looks for an exposure factor of interest.
• Background Information/Expert Opinion: Information you can find in encyclopedias, textbooks and handbooks. This kind of evidence just serves as a good foundation for further research – or clinical practice – for it is usually too generalized.

Of course, it is recommended to use level A and/or 1 evidence for more accurate results but that doesn’t mean that all other study designs are unhelpful or useless. It all depends on your research question. Focusing once more on the healthcare and medical field, see how different study designs fit into particular questions, that are not necessarily located at the tip of the pyramid:

• Questions concerning therapy: “Which is the most efficient treatment for my patient?” >> RCT | Cohort studies | Case-Control | Case Studies
• Questions concerning diagnosis: “Which diagnose method should I use?” >> Prospective blind comparison
• Questions concerning prognosis: “How will the patient’s disease will develop over time?” >> Cohort Studies | Case Studies
• Questions concerning etiology: “What are the causes for this disease?” >> RCT | Cohort Studies | Case Studies
• Questions concerning costs: “What is the most cost-effective but safe option for my patient?” >> Economic evaluation
• Questions concerning meaning/quality of life: “What’s the quality of life of my patient going to be like?” >> Qualitative study

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Methodology

• Systematic Review | Definition, Example, & Guide

Systematic Review | Definition, Example & Guide

Published on June 15, 2022 by Shaun Turney . Revised on November 20, 2023.

A systematic review is a type of review that uses repeatable methods to find, select, and synthesize all available evidence. It answers a clearly formulated research question and explicitly states the methods used to arrive at the answer.

They answered the question “What is the effectiveness of probiotics in reducing eczema symptoms and improving quality of life in patients with eczema?”

In this context, a probiotic is a health product that contains live microorganisms and is taken by mouth. Eczema is a common skin condition that causes red, itchy skin.

Table of contents

What is a systematic review, systematic review vs. meta-analysis, systematic review vs. literature review, systematic review vs. scoping review, when to conduct a systematic review, pros and cons of systematic reviews, step-by-step example of a systematic review, other interesting articles, frequently asked questions about systematic reviews.

A review is an overview of the research that’s already been completed on a topic.

What makes a systematic review different from other types of reviews is that the research methods are designed to reduce bias . The methods are repeatable, and the approach is formal and systematic:

• Formulate a research question
• Develop a protocol
• Search for all relevant studies
• Apply the selection criteria
• Extract the data
• Synthesize the data
• Write and publish a report

Although multiple sets of guidelines exist, the Cochrane Handbook for Systematic Reviews is among the most widely used. It provides detailed guidelines on how to complete each step of the systematic review process.

Systematic reviews are most commonly used in medical and public health research, but they can also be found in other disciplines.

Systematic reviews typically answer their research question by synthesizing all available evidence and evaluating the quality of the evidence. Synthesizing means bringing together different information to tell a single, cohesive story. The synthesis can be narrative ( qualitative ), quantitative , or both.

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Systematic reviews often quantitatively synthesize the evidence using a meta-analysis . A meta-analysis is a statistical analysis, not a type of review.

A meta-analysis is a technique to synthesize results from multiple studies. It’s a statistical analysis that combines the results of two or more studies, usually to estimate an effect size .

A literature review is a type of review that uses a less systematic and formal approach than a systematic review. Typically, an expert in a topic will qualitatively summarize and evaluate previous work, without using a formal, explicit method.

Although literature reviews are often less time-consuming and can be insightful or helpful, they have a higher risk of bias and are less transparent than systematic reviews.

Similar to a systematic review, a scoping review is a type of review that tries to minimize bias by using transparent and repeatable methods.

However, a scoping review isn’t a type of systematic review. The most important difference is the goal: rather than answering a specific question, a scoping review explores a topic. The researcher tries to identify the main concepts, theories, and evidence, as well as gaps in the current research.

Sometimes scoping reviews are an exploratory preparation step for a systematic review, and sometimes they are a standalone project.

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A systematic review is a good choice of review if you want to answer a question about the effectiveness of an intervention , such as a medical treatment.

To conduct a systematic review, you’ll need the following:

• A precise question , usually about the effectiveness of an intervention. The question needs to be about a topic that’s previously been studied by multiple researchers. If there’s no previous research, there’s nothing to review.
• If you’re doing a systematic review on your own (e.g., for a research paper or thesis ), you should take appropriate measures to ensure the validity and reliability of your research.
• Access to databases and journal archives. Often, your educational institution provides you with access.
• Time. A professional systematic review is a time-consuming process: it will take the lead author about six months of full-time work. If you’re a student, you should narrow the scope of your systematic review and stick to a tight schedule.
• Bibliographic, word-processing, spreadsheet, and statistical software . For example, you could use EndNote, Microsoft Word, Excel, and SPSS.

A systematic review has many pros .

• They minimize research bias by considering all available evidence and evaluating each study for bias.
• Their methods are transparent , so they can be scrutinized by others.
• They’re thorough : they summarize all available evidence.
• They can be replicated and updated by others.

Systematic reviews also have a few cons .

• They’re time-consuming .
• They’re narrow in scope : they only answer the precise research question.

The 7 steps for conducting a systematic review are explained with an example.

Step 1: Formulate a research question

Formulating the research question is probably the most important step of a systematic review. A clear research question will:

• Allow you to more effectively communicate your research to other researchers and practitioners
• Guide your decisions as you plan and conduct your systematic review

A good research question for a systematic review has four components, which you can remember with the acronym PICO :

• Population(s) or problem(s)
• Intervention(s)
• Comparison(s)

You can rearrange these four components to write your research question:

• What is the effectiveness of I versus C for O in P ?

Sometimes, you may want to include a fifth component, the type of study design . In this case, the acronym is PICOT .

• Type of study design(s)
• The population of patients with eczema
• The intervention of probiotics
• In comparison to no treatment, placebo , or non-probiotic treatment
• The outcome of changes in participant-, parent-, and doctor-rated symptoms of eczema and quality of life
• Randomized control trials, a type of study design

Their research question was:

• What is the effectiveness of probiotics versus no treatment, a placebo, or a non-probiotic treatment for reducing eczema symptoms and improving quality of life in patients with eczema?

Step 2: Develop a protocol

A protocol is a document that contains your research plan for the systematic review. This is an important step because having a plan allows you to work more efficiently and reduces bias.

Your protocol should include the following components:

• Background information : Provide the context of the research question, including why it’s important.
• Research objective (s) : Rephrase your research question as an objective.
• Selection criteria: State how you’ll decide which studies to include or exclude from your review.
• Search strategy: Discuss your plan for finding studies.
• Analysis: Explain what information you’ll collect from the studies and how you’ll synthesize the data.

If you’re a professional seeking to publish your review, it’s a good idea to bring together an advisory committee . This is a group of about six people who have experience in the topic you’re researching. They can help you make decisions about your protocol.

It’s highly recommended to register your protocol. Registering your protocol means submitting it to a database such as PROSPERO or ClinicalTrials.gov .

Step 3: Search for all relevant studies

Searching for relevant studies is the most time-consuming step of a systematic review.

To reduce bias, it’s important to search for relevant studies very thoroughly. Your strategy will depend on your field and your research question, but sources generally fall into these four categories:

• Databases: Search multiple databases of peer-reviewed literature, such as PubMed or Scopus . Think carefully about how to phrase your search terms and include multiple synonyms of each word. Use Boolean operators if relevant.
• Handsearching: In addition to searching the primary sources using databases, you’ll also need to search manually. One strategy is to scan relevant journals or conference proceedings. Another strategy is to scan the reference lists of relevant studies.
• Gray literature: Gray literature includes documents produced by governments, universities, and other institutions that aren’t published by traditional publishers. Graduate student theses are an important type of gray literature, which you can search using the Networked Digital Library of Theses and Dissertations (NDLTD) . In medicine, clinical trial registries are another important type of gray literature.
• Experts: Contact experts in the field to ask if they have unpublished studies that should be included in your review.

At this stage of your review, you won’t read the articles yet. Simply save any potentially relevant citations using bibliographic software, such as Scribbr’s APA or MLA Generator .

• Databases: EMBASE, PsycINFO, AMED, LILACS, and ISI Web of Science
• Handsearch: Conference proceedings and reference lists of articles
• Gray literature: The Cochrane Library, the metaRegister of Controlled Trials, and the Ongoing Skin Trials Register
• Experts: Authors of unpublished registered trials, pharmaceutical companies, and manufacturers of probiotics

Step 4: Apply the selection criteria

Applying the selection criteria is a three-person job. Two of you will independently read the studies and decide which to include in your review based on the selection criteria you established in your protocol . The third person’s job is to break any ties.

To increase inter-rater reliability , ensure that everyone thoroughly understands the selection criteria before you begin.

If you’re writing a systematic review as a student for an assignment, you might not have a team. In this case, you’ll have to apply the selection criteria on your own; you can mention this as a limitation in your paper’s discussion.

You should apply the selection criteria in two phases:

• Based on the titles and abstracts : Decide whether each article potentially meets the selection criteria based on the information provided in the abstracts.
• Based on the full texts: Download the articles that weren’t excluded during the first phase. If an article isn’t available online or through your library, you may need to contact the authors to ask for a copy. Read the articles and decide which articles meet the selection criteria.

It’s very important to keep a meticulous record of why you included or excluded each article. When the selection process is complete, you can summarize what you did using a PRISMA flow diagram .

Next, Boyle and colleagues found the full texts for each of the remaining studies. Boyle and Tang read through the articles to decide if any more studies needed to be excluded based on the selection criteria.

When Boyle and Tang disagreed about whether a study should be excluded, they discussed it with Varigos until the three researchers came to an agreement.

Step 5: Extract the data

Extracting the data means collecting information from the selected studies in a systematic way. There are two types of information you need to collect from each study:

• Information about the study’s methods and results . The exact information will depend on your research question, but it might include the year, study design , sample size, context, research findings , and conclusions. If any data are missing, you’ll need to contact the study’s authors.
• Your judgment of the quality of the evidence, including risk of bias .

You should collect this information using forms. You can find sample forms in The Registry of Methods and Tools for Evidence-Informed Decision Making and the Grading of Recommendations, Assessment, Development and Evaluations Working Group .

Extracting the data is also a three-person job. Two people should do this step independently, and the third person will resolve any disagreements.

They also collected data about possible sources of bias, such as how the study participants were randomized into the control and treatment groups.

Step 6: Synthesize the data

Synthesizing the data means bringing together the information you collected into a single, cohesive story. There are two main approaches to synthesizing the data:

• Narrative ( qualitative ): Summarize the information in words. You’ll need to discuss the studies and assess their overall quality.
• Quantitative : Use statistical methods to summarize and compare data from different studies. The most common quantitative approach is a meta-analysis , which allows you to combine results from multiple studies into a summary result.

Generally, you should use both approaches together whenever possible. If you don’t have enough data, or the data from different studies aren’t comparable, then you can take just a narrative approach. However, you should justify why a quantitative approach wasn’t possible.

Boyle and colleagues also divided the studies into subgroups, such as studies about babies, children, and adults, and analyzed the effect sizes within each group.

Step 7: Write and publish a report

The purpose of writing a systematic review article is to share the answer to your research question and explain how you arrived at this answer.

Your article should include the following sections:

• Abstract : A summary of the review
• Introduction : Including the rationale and objectives
• Methods : Including the selection criteria, search method, data extraction method, and synthesis method
• Results : Including results of the search and selection process, study characteristics, risk of bias in the studies, and synthesis results
• Discussion : Including interpretation of the results and limitations of the review
• Conclusion : The answer to your research question and implications for practice, policy, or research

To verify that your report includes everything it needs, you can use the PRISMA checklist .

Once your report is written, you can publish it in a systematic review database, such as the Cochrane Database of Systematic Reviews , and/or in a peer-reviewed journal.

In their report, Boyle and colleagues concluded that probiotics cannot be recommended for reducing eczema symptoms or improving quality of life in patients with eczema. Note Generative AI tools like ChatGPT can be useful at various stages of the writing and research process and can help you to write your systematic review. However, we strongly advise against trying to pass AI-generated text off as your own work.

If you want to know more about statistics , methodology , or research bias , make sure to check out some of our other articles with explanations and examples.

• Student’s  t -distribution
• Normal distribution
• Null and Alternative Hypotheses
• Chi square tests
• Confidence interval
• Quartiles & Quantiles
• Cluster sampling
• Stratified sampling
• Data cleansing
• Reproducibility vs Replicability
• Peer review
• Prospective cohort study

Research bias

• Implicit bias
• Cognitive bias
• Placebo effect
• Hawthorne effect
• Hindsight bias
• Affect heuristic
• Social desirability bias

A literature review is a survey of scholarly sources (such as books, journal articles, and theses) related to a specific topic or research question .

It is often written as part of a thesis, dissertation , or research paper , in order to situate your work in relation to existing knowledge.

A literature review is a survey of credible sources on a topic, often used in dissertations , theses, and research papers . Literature reviews give an overview of knowledge on a subject, helping you identify relevant theories and methods, as well as gaps in existing research. Literature reviews are set up similarly to other  academic texts , with an introduction , a main body, and a conclusion .

An  annotated bibliography is a list of  source references that has a short description (called an annotation ) for each of the sources. It is often assigned as part of the research process for a  paper .  

A systematic review is secondary research because it uses existing research. You don’t collect new data yourself.

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Literature Reviews, Critiquing, & Synthesizing Literature

• Literature Review

Types of Literature Reviews

Literature review types -- comparing, learning about study designs, critically appraised topics -- writing, integrative lit review.

• Literature Review Steps Videos
• Critiquing Literature / Critical Review
• Synthesizing Literature
• Summarizing Articles

Types of Literature Reviews:

Critically Appraised Topic (CATs) :  A critically appraised topic (or CAT) is a short summary of evidence on a topic of interest, usually focused around a clinical question. A CAT is like a shorter and less rigorous version of a systematic review, summarizing the best available research evidence on a topic.

Integrative Review: A review via a systematic approach that uses a detailed search strategy to find relevant evidence to answer a targeted clinical question. Evidence can come from RCTs, observational studies, qualitative research, clinical experts, and other types of evidence. Does not use summary statistics.

Meta-analysis:  a quantitative statistical analysis of several separate but similar experiments or studies in order to test the pooled data for statistical significance.

Narrative or Traditional Review:  Critical research summary on a topic of interest, often to put a research problem into context. Captures a “snapshot” of the clinical problem or issue.

Rapid Review :  A rapid literature review (RLR) is an alternative to systematic literature review (SLR) that can speed up the analysis of newly published data.

Scoping Review  A s coping review is a descriptive approach, designed to chart the literature around a particular topic. It involves an extensive literature search and often uses structured mapping or charting of the literature.

Systematic Review : Comprehensive search strategies and rigorous research appraisal methods surrounding a clinical issue or question. Evidence is primarily based upon  RCTs . Used to summarize, appraise, & communicate contradictory results or unmanageable amounts of research.

Umbrella Review : An umbrella review is a systematic collection and assessment of multiple systematic reviews and meta-analyses on a specific research topic

• Lit Review vs Systematic Rev vs Meta Analysis
• A typology of reviews: an analysis of 14 review types and associated methodologies. Grant, M. J., & Booth, A. (2009). A typology of reviews: an analysis of 14 review types and associated methodologies. Health information and libraries journal, 26(2), 91–108. https://doi.org/10.1111/j.1471-1842.2009.00848.x
• Chart comparing Systematic Review Vs Literature Review Chart explaining differences. Chart by L. Kysh, MLIS from U. Ca
• Conducting umbrella reviews Belbasis, L., Bellou, V., & Ioannidis, J. P. (2022). Conducting umbrella reviews. BMJ medicine, 1(1).
• Meeting the review family: exploring review types and associated information retrieval requirements. Sutton, A., Clowes, M., Preston, L., & Booth, A. (2019). Meeting the review family: exploring review types and associated information retrieval requirements. Health Information & Libraries Journal, 36(3), 202-222.
• Part 1: Difference between systematic reviews and rapid reviews (4:43) Cochrane Training video.
• Rapid literature review: definition and methodology Smela, B., Toumi, M., Świerk, K., Francois, C., Biernikiewicz, M., Clay, E., & Boyer, L. (2023). Rapid literature review: definition and methodology. Journal of market access & health policy, 11(1), 2241234. https://doi.org/10.1080/20016689.2023.2241234
• Reviewing Research: Literature Reviews, Scoping Reviews, Systematic Reviews: Differentiating the Three Review Types University of Buffalo LibGuide
• Scoping reviews, systematic reviews, and meta-analysis: Applications in veterinary medicine Sargeant, J. M., & O'Connor, A. M. (2020). Scoping reviews, systematic reviews, and meta-analysis: Applications in veterinary medicine. Frontiers in Veterinary Science, 7, 11-11. https://doi.org/10.3389/fvets.2020.00011
• Systematic review or scoping review? Guidance for authors when choosing between a systematic or scoping review approach Munn, Z., Peters, M.D.J., Stern, C. et al. Systematic review or scoping review? Guidance for authors when choosing between a systematic or scoping review approach. BMC Med Res Methodol 18, 143 (2018). https://doi.org/10.1186/s12874-018-0611-x
• Systematic Review Service: What Type of Review is Right for You? University of Maryland Health Sciences and Human Services Library Decide with type of review. Decision Tree included.
• Systematic vs. Scoping vs. Integrative References Getting Help Systematic vs. Scoping vs. Integrative Review Duquesne University
• What Type of Review is Right for You? Cornell University Library Flowchart to decide about which review to use.
• Study Design 101 Tutorial by George Washington University. Describes different study designs.

Critically Appraised Topics (CATs)

• CEBMa Guideline for Critically Appraised Topics in Management and Organizations Barends, E., Rousseau, D. M., & Briner, R. B. (2017). CEBMa guideline for critically appraised topics in management and organizations. Center for Evidence-Based Management. https://cebma. org/wp-content/uploads/CEBMa-CAT-Guidelines. pdf.
• Critical Appraisal Skills Programme (CASP) The Critical Appraisal Skills Programme (CASP) was developed in Oxford in 1993 and has since helped to develop an evidence based approach in health and social care, working with local, national and international partner organisations.
• Evidence Based Medicine IV: how to find an evidence-based answer to a clinical question? Make a critically appraised topic! Beckers, G. M. A., Herbst, K., Kaefer, M., Harper, L., Castagnetti, M., Bagli, D., Kalfa, N., Fossum, M., & ESPU Research Committee. (2019). Evidence based medicine IV: How to find an evidence-based answer to a clinical question? make a critically appraised topic. Journal of Pediatric Urology, 15(4), 409-411. https://doi.org/10.1016/j.jpurol.2019.05.009
• EXAMPLE: The Use of Orthotic Insoles to Prevent Lower Limb Overuse Injuries: A Critically Appraised Topic Kelly JL, Valier AR. The Use of Orthotic Insoles to Prevent Lower Limb Overuse Injuries: A Critically Appraised Topic. J Sport Rehabil. 2018 Nov 1;27(6):591-595. doi: 10.1123/jsr.2016-0142. Epub 2018 Oct 13. PMID: 28952905.
• How to Perform a Critically Appraised Topic: Part 1, Ask, Search, and Apply Aine Marie Kelly and Paul Cronin American Journal of Roentgenology November 2011, Volume 197, Number 5
• How to Perform a Critically Appraised Topic: Part 2, Appraise, Evaluate, Generate, and Recommend Aine Marie Kelly and Paul Cronin American Journal of Roentgenology November 2011, Volume 197, Number 5
• How to write a critically appraised topic (CAT) Sadigh, G., Parker, R., Kelly, A. M., & Cronin, P. (2012). How to write a critically appraised topic (CAT). Academic radiology, 19(7), 872–888. https://doi.org/10.1016/j.acra.2012.02.005
• How to write a Critically Appraised Topic: evidence to underpin routine clinical practice Callander J, Anstey AV, Ingram JR, Limpens J, Flohr C, Spuls PI. How to write a Critically Appraised Topic: evidence to underpin routine clinical practice. Br J Dermatol. 2017 Oct;177(4):1007-1013. doi: 10.1111/bjd.15873. Epub 2017 Oct 1. PMID: 28967117.
• What is a Critically Appraised Topic (CAT) Physiopedia

Integrative Review:  A review via a systematic approach that uses a detailed search strategy to find relevant evidence to answer a targeted clinical question. Evidence can come from RCTs, observational studies, qualitative research, clinical experts, and other types of evidence. Does not use summary statistics.

• Conducting integrative reviews: a guide for novice nursing researchers Dhollande S, Taylor A, Meyer S, Scott M. Conducting integrative reviews: a guide for novice nursing researchers. J Res Nurs. 2021 Aug;26(5):427-438. doi: 10.1177/1744987121997907. Epub 2021 Aug 5. PMID: 35251272; PMCID: PMC8894639.
• The integrative review: Updated methodology. Whittemore, R., & Knafl, K. (2005). The integrative review: Updated methodology. Journal of Advanced Nursing, 52(5), 546-553. https://doi.org/10.1111/j.1365-2648.2005.03621.x
• Strategies for completing a successful integrative review Oermann, M. H., & Knafl, K. A. (2021). Strategies for completing a successful integrative review. Nurse Author & Editor, 31(3-4), 65-68.
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Resources listed on these guides are compiled by librarians at the R.A. Williams Library. We accept content recommendations, and after review, may include suggested resources on a guide. Our time is limited, so we generally do not reply to unsolicited recommendations from individuals not affiliated with AdventHealth University or notify them regarding whether or not we have linked to suggested content.

• About Covidence and systematic reviews

What are the different types of review?

Systematic literature reviews (slrs).

SLR’s attempt to collate all empirical evidence that fit pre-specified eligibility criteria in order to answer a specific clearly-formulated research question.  A SLR uses explicit and reproducible systematic methods that are selected with a view to minimizing bias, thus providing more reliable findings from which conclusions can be drawn and decisions made.

The process starts with a research question and a protocol or research plan. A review team searches for studies to answer the question using a highly sensitive search strategy. The retrieved studies are then screened for eligibility using pre-specified inclusion and exclusion criteria (this is done by at least two people working independently). Next, the reviewers extract the relevant data and assess the quality of the included studies. Finally, the review team synthesizes the extracted study data and presents the results. 

A SLR may contain meta-analyses (statistical analysis). A SLR which is continually updated, incorporating relevant new evidence as it becomes available is often known as a living SLR.

Rapid reviews

Rapid reviews aim to produce a rigorous synthesis quickly (due to time constraints/urgency), based on a pre-defined research question. The review process for rapid reviews is the same as for a more traditional systematic review: the emphasis is on a replicable pre-specified search, and screening methods that minimize the risk of bias, although potentially isn’t as stringent as a formal systematic review.

The process operates within pre-specified limits (for example, by restricting searches to articles published during a specific timeframe) and is usually run by a multidisciplinary team with expertise in systematic review methods.

Umbrella reviews or Overview of reviews

An umbrella review is a review of multiple systematic reviews. The process uses explicit and systematic methods to search for, and identify, systematic reviews on related research questions in the same topic area. The purpose of an umbrella review is to synthesize the results of the systematic reviews across important outcomes. 

Scoping reviews

Scoping reviews are exploratory and they typically address a broad question, compared to a systematic review that typically has a more targeted question. 

Researchers conduct scoping reviews to assess the extent of the available evidence, to organize it into groups and to highlight gaps. If a scoping review finds no studies, this might help researchers to decide that a systematic review is likely to be of limited value and that resources could be better directed elsewhere.

Literature reviews or narrative reviews

Literature, or narrative, reviews provide an overview of what is known about a particular topic. They evaluate the material, rather than simply restating it, but the methods used to do this are not usually prespecified and they are not described in detail in the review. The search might be comprehensive but it does not aim to be exhaustive. Literature reviews are often topic based  and can take the form of a discussion. Literature reviews lack precision and replicability and can  present their findings in the context of what has come before. Often, this sort of synthesis does not attempt to control for the author’s own bias. The results or conclusion of a literature review is likely to be presented in a narrative format rather than statistical methods.

Take a look at the articles about the different types of review on the Covidence blog:

• Systematic review types: meet the family
• The difference between a systematic review and a literature review
• The difference between a systematic review and a meta-analysis

• Schools & departments

Literature review

A general guide on how to conduct and write a literature review.

Please check course or programme information and materials provided by teaching staff, including your project supervisor, for subject-specific guidance.

What is a literature review?

A literature review is a piece of academic writing demonstrating knowledge and understanding of the academic literature on a specific topic placed in context.  A literature review also includes a critical evaluation of the material; this is why it is called a literature review rather than a literature report. It is a process of reviewing the literature, as well as a form of writing.

To illustrate the difference between reporting and reviewing, think about television or film review articles.  These articles include content such as a brief synopsis or the key points of the film or programme plus the critic’s own evaluation.  Similarly the two main objectives of a literature review are firstly the content covering existing research, theories and evidence, and secondly your own critical evaluation and discussion of this content. 

Usually a literature review forms a section or part of a dissertation, research project or long essay.  However, it can also be set and assessed as a standalone piece of work.

What is the purpose of a literature review?

…your task is to build an argument, not a library. Rudestam, K.E. and Newton, R.R. (1992) Surviving your dissertation: A comprehensive guide to content and process. California: Sage, p49.

In a larger piece of written work, such as a dissertation or project, a literature review is usually one of the first tasks carried out after deciding on a topic.  Reading combined with critical analysis can help to refine a topic and frame research questions.  Conducting a literature review establishes your familiarity with and understanding of current research in a particular field before carrying out a new investigation. After doing a literature review, you should know what research has already been done and be able to identify what is unknown within your topic.

When doing and writing a literature review, it is good practice to:

• summarise and analyse previous research and theories;
• identify areas of controversy and contested claims;
• highlight any gaps that may exist in research to date.

Conducting a literature review

Focusing on different aspects of your literature review can be useful to help plan, develop, refine and write it.  You can use and adapt the prompt questions in our worksheet below at different points in the process of researching and writing your review.  These are suggestions to get you thinking and writing.

Developing and refining your literature review (pdf)

Developing and refining your literature review (Word)

Developing and refining your literature review (Word rtf)

Writing a literature review has a lot in common with other assignment tasks.  There is advice on our other pages about thinking critically, reading strategies and academic writing.  Our literature review top tips suggest some specific things you can do to help you submit a successful review.

Literature review top tips (pdf)

Literature review top tips (Word rtf)

Our reading page includes strategies and advice on using books and articles and a notes record sheet grid you can use.

Reading at university

The Academic writing page suggests ways to organise and structure information from a range of sources and how you can develop your argument as you read and write.

Academic writing

The Critical thinking page has advice on how to be a more critical researcher and a form you can use to help you think and break down the stages of developing your argument.

Critical thinking

As with other forms of academic writing, your literature review needs to demonstrate good academic practice by following the Code of Student Conduct and acknowledging the work of others through citing and referencing your sources.  

Good academic practice

As with any writing task, you will need to review, edit and rewrite sections of your literature review.  The Editing and proofreading page includes tips on how to do this and strategies for standing back and thinking about your structure and checking the flow of your argument.

Editing and proofreading

Guidance on literature searching from the University Library

The Academic Support Librarians have developed LibSmart I and II, Learn courses to help you develop and enhance your digital research skills and capabilities; from getting started with the Library to managing data for your dissertation.

Searching using the library’s DiscoverEd tool: DiscoverEd

Finding resources in your subject: Subject guides

The Academic Support Librarians also provide one-to-one appointments to help you develop your research strategies.

1 to 1 support for literature searching and systematic reviews

Advice to help you optimise use of Google Scholar, Google Books and Google for your research and study: Using Google

Managing and curating your references

A referencing management tool can help you to collect and organise and your source material to produce a bibliography or reference list. 

Referencing and reference management

Information Services provide access to Cite them right online which is a guide to the main referencing systems and tells you how to reference just about any source (EASE log-in may be required).

Cite them right

Published study guides

There are a number of scholarship skills books and guides available which can help with writing a literature review.  Our Resource List of study skills guides includes sections on Referencing, Dissertation and project writing and Literature reviews.

Study skills guides

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The Levels of Evidence and their role in Evidence-Based Medicine

Patricia b. burns.

1 Research Associate, Section of Plastic Surgery, Department of Surgery, The University of Michigan Health System

Rod J. Rohrich

2 Professor of Surgery, Department of Plastic Surgery, University of Texas Southwestern Medical Center

Kevin C. Chung

3 Professor of Surgery, Section of Plastic Surgery, Department of Surgery, The University of Michigan Health System

As the name suggests, evidence-based medicine (EBM), is about finding evidence and using that evidence to make clinical decisions. A cornerstone of EBM is the hierarchical system of classifying evidence. This hierarchy is known as the levels of evidence. Physicians are encouraged to find the highest level of evidence to answer clinical questions. Several papers published in Plastic Surgery journals concerning EBM topics have touched on this subject. 1 – 6 Specifically, previous papers have discussed the lack of higher level evidence in PRS and need to improve the evidence published in the journal. Before that can be accomplished, it is important to understand the history behind the levels and how they should be interpreted. This paper will focus on the origin of levels of evidence, their relevance to the EBM movement and the implications for the field of plastic surgery as well as the everyday practice of plastic surgery.

History of Levels of Evidence

The levels of evidence were originally described in a report by the Canadian Task Force on the Periodic Health Examination in 1979. 7 The report’s purpose was to develop recommendations on the periodic health exam and base those recommendations on evidence in the medical literature. The authors developed a system of rating evidence ( Table 1 ) when determining the effectiveness of a particular intervention. The evidence was taken into account when grading recommendations. For example, a Grade A recommendation was given if there was good evidence to support a recommendation that a condition be included in the periodic health exam. The levels of evidence were further described and expanded by Sackett 8 in an article on levels of evidence for antithrombotic agents in 1989 ( Table 2 ). Both systems place randomized controlled trials (RCT) at the highest level and case series or expert opinions at the lowest level. The hierarchies rank studies according to the probability of bias. RCTs are given the highest level because they are designed to be unbiased and have less risk of systematic errors. For example, by randomly allocating subjects to two or more treatment groups, these types of studies also randomize confounding factors that may bias results. A case series or expert opinion is often biased by the author’s experience or opinions and there is no control of confounding factors.

Canadian Task Force on the Periodic Health Examination’s Levels of Evidence *

Levels of Evidence from Sackett *

Modification of levels

Since the introduction of levels of evidence, several other organizations and journals have adopted variation of the classification system. Diverse specialties are often asking different questions and it was recognized that the type and level of evidence needed to be modified accordingly. Research questions are divided into the categories: treatment, prognosis, diagnosis, and economic/decision analysis. For example, Table 3 shows the levels of evidence developed by the American Society of Plastic Surgeons (ASPS) for prognosis 9 and Table 4 shows the levels developed by the Centre for Evidence Based Medicine (CEBM) for treatment. 10 The two tables highlight the types of studies that are appropriate for the question (prognosis versus treatment) and how quality of data is taken into account when assigning a level. For example, RCTs are not appropriate when looking at the prognosis of a disease. The question in this instance is: “What will happen if we do nothing at all”? Because a prognosis question does not involve comparing treatments, the highest evidence would come from a cohort study or a systematic review of cohort studies. The levels of evidence also take into account the quality of the data. For example, in the chart from CEBM, poorly designed RCTs have the same level of evidence as a cohort study.

Levels of Evidence for Prognostic Studies *

Levels of Evidence for Therapeutic Studies *

A grading system that provides strength of recommendations based on evidence has also changed over time. Table 5 shows the Grade Practice Recommendations developed by ASPS. The grading system provides an important component in evidence-based medicine and assists in clinical decision making. For example, a strong recommendation is given when there is level I evidence and consistent evidence from Level II, III and IV studies available. The grading system does not degrade lower level evidence when deciding recommendations if the results are consistent.

Grade Practice Recommendations *

Interpretation of levels

Many journals assign a level to the papers they publish and authors often assign a level when submitting an abstract to conference proceedings. This allows the reader to know the level of evidence of the research but the designated level of evidence does always guarantee the quality of the research. It is important that readers not assume that level 1 evidence is always the best choice or appropriate for the research question. This concept will be very important for all of us to understand as we evolve into the field of EBM in Plastic Surgery. By design, our designated surgical specialty will always have important articles that may have a lower level of evidence due to the level of innovation and technique articles which are needed to move our surgical specialty forward.

Although RCTs are the often assigned the highest level of evidence, not all RCTs are conducted properly and the results should be carefully scrutinized. Sackett 8 stressed the importance of estimating types of errors and the power of studies when interpreting results from RCTs. For example, a poorly conducted RCT may report a negative result due to low power when in fact a real difference exists between treatment groups. Scales such as the Jadad scale have been developed to judge the quality of RCTs. 11 Although physicians may not have the time or inclination to use a scale to assess quality, there are some basic items that should be taken into account. Items used for assessing RCTs include: randomization, blinding, a description of the randomization and blinding process, description of the number of subjects who withdrew or drop out of the study; the confidence intervals around study estimates; and a description of the power analysis. For example, Bhandari et al. 12 published a paper assessing the quality of surgical RCTs. The authors evaluated the quality of RCTs reported in the Journal of Bone and Joint Surgery (JBJS) from 1988–2000. Papers with a score of > 75% were deemed high quality and 60% of the papers had a score < 75%. The authors identified 72 RCTs during this time period and the mean score was 68%. The main reason for the low quality score was lack of appropriate randomization, blinding, and a description of patient exclusion criteria. Another paper found the same quality score of papers in JBJS with a level 1 rating compared to level 2. 13 Therefore, one should not assume that level 1 studies have higher quality than level 2.

A resource for surgeons when appraising levels of evidence are the users’ guides published in the Canadian Journal of Surgery 14 , 15 and the Journal of Bone and Joint Surgery. 16 Similar papers that are not specific to surgery have been published in the Journal of the American Medical Association (JAMA). 17 , 18

Plastic surgery and EBM

The field of plastic surgery has been slow to adopt evidence-based medicine. This was demonstrated in a paper examining the level of evidence of papers published in PRS. 19 The authors assigned levels of evidence to papers published in PRS over a 20 year period. The majority of studies (93% in 1983) were level 4 or 5, which denotes case series and case reports. Although the results are disappointing, there was some improvement over time. By 2003 there were more level 1studies (1.5%) and fewer level 4 and 5 studies (87%). A recent analysis looked at the number of level 1 studies in 5 different plastic surgery journals from 1978–2009. The authors defined level 1 studies as RCTs and meta-analysis and restricted their search to these studies. The number of level 1 studies increased from 1 in 1978 to 32 by 2009. 20 From these results, we see that the field of plastic surgery is improving the level of evidence but still has a way to go, especially in improving the quality of studies published. For example, approximately a third of the studies involved double blinding, but the majority did not randomize subjects, describe the randomization process, or perform a power analysis. Power analysis is another area of concern in plastic surgery. A review of the plastic surgery literature found that the majority of published studies have inadequate power to detect moderate to large differences between treatment groups. 21 No matter what the level of evidence for a study, if it is under powered, the interpretation of results is questionable.

Although the goal is to improve the overall level of evidence in plastic surgery, this does not mean that all lower level evidence should be discarded. Case series and case reports are important for hypothesis generation and can lead to more controlled studies. Additionally, in the face of overwhelming evidence to support a treatment, such as the use of antibiotics for wound infections, there is no need for an RCT.

Clinical examples using levels of evidence

In order to understand how the levels of evidence work and aid the reader in interpreting levels, we provide some examples from the plastic surgery literature. The examples also show the peril of medical decisions based on results from case reports.

An association was hypothesized between lymphoma and silicone breast implants based on case reports. 22 – 27 The level of evidence for case reports, depending on the scale used, is 4 or 5. These case reports were used to generate the hypothesis that a possible association existed. Because of these results, several large retrospective cohort studies from the United States, Canada, Denmark, Sweden and Finland were conducted. 28 – 32 The level of evidence for a retrospective cohort is 2. All of these studies had many years of follow-up for a large number of patients. Some of the studies found an elevated risk and others no risk for lymphoma. None of the studies reached statistical significance. Therefore, higher level evidence from cohort studies does not provide evidence of any risk of lymphoma. Finally, a systematic review was performed that combined the evidence from the retrospective cohorts. 27 The results found an overall standardized incidence ratio of 0.89 (95% CI 0.67–1.18). Because the confidence intervals include 1, the results indicate there is no increased incidence. The level of evidence for the systematic review is 1. Based on the best available evidence, there is no association between lymphoma and silicone implants. This example shows how low level evidence studies were used to generate a hypothesis, which then led to higher level evidence that disproved the hypothesis. This example also demonstrates that RCTs are not feasible for rare events such as cancer and the importance of observational studies for a specific study question. A case-control study is a better option and provides higher evidence for testing the prognosis of the long-term effect of silicone breast implants.

Another example is the injection of epinephrine in fingers. Based on case reports prior to 1950, physicians were advised that epinephrine injection can result in finger ischemia. 33 We see in this example in which level 4 or 5 evidence was accepted as fact and incorporated into medical textbooks and teaching. However, not all physicians accepted this evidence and are performing injections of epinephrine into the fingers with no adverse effects on the hand. Obviously, it was time for higher level evidence to resolve this issue. An in-depth review of the literature from 1880 to 2000 by Denkler, 33 identified 48 cases of digital infarction of which 21 were injected with epinephrine. Further analysis found that the addition of procaine to the epinephrine injection was the cause of the ischemia. 34 The procaine used in these injections included toxic acidic batches that were recalled in 1948. In addition, several cohort studies found no complications from the use of epinephrine in the fingers and hand. 35 , 36 , 37 The results from these cohort studies increased the level of evidence. Based on the best available evidence from these studies, the hypothesis that epinephrine injection will harm fingers was rejected. This example highlights the biases inherent in case reports. It also shows the risk when spurious evidence is handed down and integrated into medical teaching.

Obtaining the best evidence

We have established the need for RCTs to improve evidence in plastic surgery but have also acknowledged the difficulties, particularly with randomization and blinding. Although RCTs may not be appropriate for many surgical questions, well designed and conducted cohort or case-control studies could boost the level of evidence. Many of the current studies tend to be descriptive and lack a control group. The way forward seems clear. Plastic surgery researchers need to consider utilizing a cohort or case-control design whenever an RCT is not possible. If designed properly, the level of evidence for observational studies can approach or surpass those from an RCT. In some instances, observation studies and RCTs have found similar results. 38 If enough cohort or case-control studies become available, this increases the prospect of systematic reviews of these studies that will increase overall evidence levels in plastic surgery.

The levels of evidence are an important component of EBM. Understanding the levels and why they are assigned to publications and abstracts helps the reader to prioritize information. This is not to say that all level 4 evidence should be ignored and all level 1 evidence accepted as fact. The levels of evidence provide a guide and the reader needs to be cautious when interpreting these results.

Acknowledgments

Supported in part by a Midcareer Investigator Award in Patient-Oriented Research (K24 AR053120) from the National Institute of Arthritis and Musculoskeletal and Skin Diseases (to Dr. Kevin C. Chung).

Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

• Finding Systematic Review Articles in the Databases

Finding Evidence-Based Articles: Systematic Reviews

The databases listed below are very useful for finding EBP research, including systematic reviews: 

An overview of formulating a PICO question and search strategy to find evidence-base practice literature in CINAHL Complete:

How to Search a PICO Question in PubMed:

• Tips for Using PubMed A two-page handout on the basics of PubMed from the National Library of Medlcine.

Cochrane Library Basic Search Tutorial from Drexel University Library:

• JBI This link opens in a new window Joanna Briggs Institute EBP Database is an online resource for healthcare professionals to rapidly access the best available evidence on a wide range of clinical topics at the point of care. Globally acknowledged as a leading producer of evidence-based care, practice guidance and other resources, JBI includes 4500+ JBI Evidence Summaries, Recommended Practices and Best Practice Information Sheets.

How to Read a Systematic Review and Meta-Analysis and Apply the Results to Patient Care: Users’ Guides to the Medical Literature

Murad, M. H., Montori, V. M., Ioannidis, J. P. A., Jaeschke, R., Devereaux, P. J., Prasad, K., Neumann, I., Carrasco-Labra, A., Agoritsas, T., Hatala, R., Meade, M. O., Wyer, P., Cook, D. J., & Guyatt, G. (2014). How to read a systematic review and meta-analysis and apply the results to patient care: Users’ guides to the medical literature .  JAMA : the Journal of the American Medical Association ,  312 (2), 171–179. https://doi.org/10.1001/jama.2014.5559

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How Do We Know Climate Change Is Real?

There is unequivocal evidence that Earth is warming at an unprecedented rate. Human activity is the principal cause.

• While Earth’s climate has changed throughout its history , the current warming is happening at a rate not seen in the past 10,000 years.
• According to the Intergovernmental Panel on Climate Change ( IPCC ), "Since systematic scientific assessments began in the 1970s, the influence of human activity on the warming of the climate system has evolved from theory to established fact." 1
• Scientific information taken from natural sources (such as ice cores, rocks, and tree rings) and from modern equipment (like satellites and instruments) all show the signs of a changing climate.
• From global temperature rise to melting ice sheets, the evidence of a warming planet abounds.

The rate of change since the mid-20th century is unprecedented over millennia.

Earth's climate has changed throughout history. Just in the last 800,000 years, there have been eight cycles of ice ages and warmer periods, with the end of the last ice age about 11,700 years ago marking the beginning of the modern climate era — and of human civilization. Most of these climate changes are attributed to very small variations in Earth’s orbit that change the amount of solar energy our planet receives.

The current warming trend is different because it is clearly the result of human activities since the mid-1800s, and is proceeding at a rate not seen over many recent millennia. 1 It is undeniable that human activities have produced the atmospheric gases that have trapped more of the Sun’s energy in the Earth system. This extra energy has warmed the atmosphere, ocean, and land, and widespread and rapid changes in the atmosphere, ocean, cryosphere, and biosphere have occurred.

Related Reading

Do scientists agree on climate change?

Yes, the vast majority of actively publishing climate scientists – 97 percent – agree that humans are causing global warming and climate change.

Earth-orbiting satellites and new technologies have helped scientists see the big picture, collecting many different types of information about our planet and its climate all over the world. These data, collected over many years, reveal the signs and patterns of a changing climate.

Scientists demonstrated the heat-trapping nature of carbon dioxide and other gases in the mid-19th century. 2 Many of the science instruments NASA uses to study our climate focus on how these gases affect the movement of infrared radiation through the atmosphere. From the measured impacts of increases in these gases, there is no question that increased greenhouse gas levels warm Earth in response.

"Scientific evidence for warming of the climate system is unequivocal." — Intergovernmental Panel on Climate Change

Ice cores drawn from Greenland, Antarctica, and tropical mountain glaciers show that Earth’s climate responds to changes in greenhouse gas levels. Ancient evidence can also be found in tree rings, ocean sediments, coral reefs, and layers of sedimentary rocks. This ancient, or paleoclimate, evidence reveals that current warming is occurring roughly 10 times faster than the average rate of warming after an ice age. Carbon dioxide from human activities is increasing about 250 times faster than it did from natural sources after the last Ice Age. 3

The Evidence for Rapid Climate Change Is Compelling:

Global temperature is rising.

The planet's average surface temperature has risen about 2 degrees Fahrenheit (1 degrees Celsius) since the late 19th century, a change driven largely by increased carbon dioxide emissions into the atmosphere and other human activities. 4 Most of the warming occurred in the past 40 years, with the seven most recent years being the warmest. The years 2016 and 2020 are tied for the warmest year on record. 5

The Ocean Is Getting Warmer

The ocean has absorbed much of this increased heat, with the top 100 meters (about 328 feet) of ocean showing warming of 0.67 degrees Fahrenheit (0.33 degrees Celsius) since 1969. 6 Earth stores 90% of the extra energy in the ocean.

The Ice Sheets Are Shrinking

The Greenland and Antarctic ice sheets have decreased in mass. Data from NASA's Gravity Recovery and Climate Experiment show Greenland lost an average of 279 billion tons of ice per year between 1993 and 2019, while Antarctica lost about 148 billion tons of ice per year. 7

Glaciers Are Retreating

Glaciers are retreating almost everywhere around the world — including in the Alps, Himalayas, Andes, Rockies, Alaska, and Africa. 8

Snow Cover Is Decreasing

Satellite observations reveal that the amount of spring snow cover in the Northern Hemisphere has decreased over the past five decades and the snow is melting earlier. 9

Sea Level Is Rising

Global sea level rose about 8 inches (20 centimeters) in the last century. The rate in the last two decades, however, is nearly double that of the last century and accelerating slightly every year. 10

Arctic Sea Ice Is Declining

Both the extent and thickness of Arctic sea ice has declined rapidly over the last several decades. 11

Extreme Events Are Increasing in Frequency

The number of record high temperature events in the United States has been increasing, while the number of record low temperature events has been decreasing, since 1950. The U.S. has also witnessed increasing numbers of intense rainfall events. 12

Ocean Acidification Is Increasing

Since the beginning of the Industrial Revolution, the acidity of surface ocean waters has increased by about 30%. 13 , 14 This increase is due to humans emitting more carbon dioxide into the atmosphere and hence more being absorbed into the ocean. The ocean has absorbed between 20% and 30% of total anthropogenic carbon dioxide emissions in recent decades (7.2 to 10.8 billion metric tons per year). 1 5 , 16

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Ambulatory total hip and knee arthroplasty: a literature review and perioperative considerations

Arthroplastie totale de la hanche et du genou en ambulatoire : revue de la littérature et considérations périopératoires

• Continuing Professional Development
• Published: 19 March 2024

Cite this article

• Vivian H. Y. Ip MBChB, FRCA   ORCID: orcid.org/0000-0001-6158-4415 1 ,
• Vishal Uppal MBBS, FRCA   ORCID: orcid.org/0000-0001-7263-2072 2 ,
• Kwesi Kwofie MD, FRCPC   ORCID: orcid.org/0000-0002-0509-4064 2 ,
• Ushma Shah MBBS, FRCA   ORCID: orcid.org/0000-0002-5630-5124 3 &
• Patrick B. Y. Wong MD, FRCPC   ORCID: orcid.org/0000-0001-7261-8764 4  

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Total joint arthroplasty (TJA), particularly for the hip and knee, is one of the most commonly performed surgical procedures. The advancement/evolution of surgical and anesthesia techniques have allowed TJA to be performed on an ambulatory / same-day discharge basis. In this Continuing Professional Development module, we synthesize the perioperative evidence that may aid the development of successful ambulatory TJA pathways.

We searched MEDLINE, Embase, CENTRAL, and the Cochrane Database of Systematic Reviews for ambulatory or fast-track TJA articles. In the absence of direct evidence for the ambulatory setting, we extrapolated the evidence from the in-patient TJA literature.

Principal findings

Patient selection encompassing patient, medical, and social factors is fundamental for successful same-day discharge of patients following TJA. Evidence for the type of intraoperative anesthesia favours neuraxial technique for achieving same day discharge criteria and reduced perioperative complications. Availability of short-acting local anesthetic for neuraxial anesthesia would affect the anesthetic choice. Nonetheless, modern general anesthesia with multimodal analgesia and antithrombotics in a well selected population can be considered. Regional analgesia forms an integral part of the multimodal analgesia regime to reduce opioid consumption and facilitate same-day hospital discharge, reducing hospital readmission. For ambulatory total knee arthroplasty, a combination of adductor canal block with local anesthetic periarticular infiltration provided is a suitable regional analgesic regimen.

Anesthesia for TJA has evolved as such that same-day discharge will become the norm for selected patients. It is essential to establish pathways for early discharge to prevent adverse effects and readmission in this population. As more data are generated from an increased volume of ambulatory TJA, more robust evidence will emerge for the ideal anesthetic components to optimize outcomes.

L’arthroplastie par prothèse totale (APT), en particulier de la hanche et du genou, constitue l’une des interventions chirurgicales les plus couramment pratiquées. L’avancement et l’évolution des techniques chirurgicales et d’anesthésie ont permis de réaliser une APT en ambulatoire / sur la base d’un congé le jour même. Dans ce module de développement professionnel continu, nous proposons une synthèse des données probantes périopératoires qui pourraient contribuer à l’élaboration de trajectoires réussies pour l’APT en ambulatoire.

Nous avons réalisé des recherches dans MEDLINE, Embase, CENTRAL et dans la base de données Cochrane des revues systématiques à la recherche d’articles sur les APT ambulatoires ou accélérées. En l’absence de données probantes directes dans un contexte ambulatoire, nous avons extrapolé les données probantes à partir de la littérature sur les APT en milieu hospitalier.

Constatations principales

La sélection des patient·es englobant les facteurs patient·es, médicaux et sociaux est fondamentale pour un congé réussi le jour même après une APT. Les données probantes portant sur le type d’anesthésie peropératoire privilégient la technique neuraxiale pour respecter les critères de congé le jour même et réduire les complications périopératoires. La disponibilité d’un anesthésique local à courte durée d’action pour l’anesthésie neuraxiale affecterait le choix de l’anesthésique. Néanmoins, dans une population bien sélectionnée, l’anesthésie générale moderne avec analgésie multimodale et antithrombotiques peut être envisagée. L’analgésie régionale fait partie intégrante d’un régime d’analgésie multimodale visant à réduire la consommation d’opioïdes et à faciliter le congé de l’hôpital le jour même, ce qui réduit le nombre de réadmissions. En ce qui concerne l’arthroplastie totale du genou en ambulatoire, la combinaison d’un bloc du canal des adducteurs et d’une infiltration périarticulaire d’anesthésique local constitue un régime approprié d’analgésie régionale.

L’anesthésie pour les APT a évolué de telle sorte que le congé le jour même deviendra la norme pour certain·es patient·es. Il est essentiel d’établir des trajectoires de congé précoce afin de prévenir les effets indésirables et la réadmission dans cette population. Au fur et à mesure que davantage de données seront générées à partir d’un volume accru d’APT en ambulatoire, des données probantes plus solides émergeront pour appuyer les composantes idéales de l’anesthésie pour optimiser les devenirs.

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Acknowledgments

We would like to thank Ms. Leah Boulos, MLIS (Evidence Synthesis Coordinator, Maritime SPOR SUPPORT Unit, Halifax) and Ms. Kendell Fitzgerald for helping us with the literature search.

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This submission was handled by Dr. Kathryn Sparrow, CPD Editor, Canadian Journal of Anesthesia .

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Nous tenons à remercier Mme Leah Boulos, MLIS (coordonnatrice de la synthèse des données probantes, Unité maritime SPOR SUPPORT, Halifax) et Mme Kendell Fitzgerald pour leur aide dans la recherche documentaire.

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Cet article a été traité par Dre Kathryn Sparrow, rédactrice des DPC, Journal canadien d’anesthésie.

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Department of Anesthesia, Perioperative and Pain Medicine, University of Calgary, Calgary, AB, Canada

Vivian H. Y. Ip MBChB, FRCA

Department of Anesthesia, Pain Management & Perioperative Medicine, Dalhousie University, Halifax, NS, Canada

Vishal Uppal MBBS, FRCA & Kwesi Kwofie MD, FRCPC

Department of Anesthesia & Perioperative Medicine, Western University, London, ON, Canada

Ushma Shah MBBS, FRCA

Department of Anesthesiology and Pain Medicine, University of Ottawa, 501 Smyth Rd, CCW 1401, Ottawa, ON, K1H 8L6, Canada

Patrick B. Y. Wong MD, FRCPC

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Ip, V.H.Y., Uppal, V., Kwofie, K. et al. Ambulatory total hip and knee arthroplasty: a literature review and perioperative considerations. Can J Anesth/J Can Anesth (2024). https://doi.org/10.1007/s12630-024-02699-0

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Received : 09 October 2021

Revised : 04 October 2023

Accepted : 25 October 2023

Published : 19 March 2024

DOI : https://doi.org/10.1007/s12630-024-02699-0

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• hip arthroplasty
• knee arthroplasty
• perioperative
• ambulatoire
• arthroplastie de la hanche
• arthroplastie du genou
• périopératoire

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