Systematic reviews in health care: Investigating and dealing with publication and other biases in meta-analysis

doi:10.1136/bmj.323.7304.101

BMJ 2001;323:101-105 ( 14 July )

Education and debate

Systematic reviews in health care

Investigating and dealing with publication and other biases in meta-analysis

This is the second in a series of four articles

Jonathan A C Sterne, senior lecturer in medical statistics, Matthias Egger, senior lecturer in epidemiology and public health medicine, George Davey Smith, professor of clinical epidemiology.

Medical Research Council Health Services Research Collaboration, Department of Social Medicine, University of Bristol, Bristol BS8 2PR

Correspondence to: J A C Sterne jonathan.sterne@bristol.ac.uk

The first 150 words of the full text of this article appear below.

Studies that show a significant effect of treatment are more likely to be published, be published in English, be cited byother authors, and produce multiple publications than other studies.^1-8Such studies are therefore also more likely to be identified andincluded in systematic reviews, which may introduce bias.⁹Low methodological quality of studies included in a systematicreview is another important source of bias.¹⁰

All these biases are more likely to affect small studies than large ones. The smaller a study the larger the treatment effectnecessary for the results to be significant. The greater investmentof time and money in larger studies means that they are more likelyto be of high methodological quality and published even if theirresults are negative. Bias in a systematic review may thereforebecome evident through an association between the size of thetreatment effect and study size $---$ such associations may be . . . [Full text of this article]

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