title: Consensus-based recommendations for investigating clinical heterogeneity in systematic reviews.
abstract: BACKGROUND
  Critics of systematic reviews have argued that these studies often fail to inform clinical decision making because their results are far too general, that the data are sparse, such that findings cannot be applied to individual patients or for other decision making. While there is some consensus on methods for investigating statistical and methodological heterogeneity, little attention has been paid to clinical aspects of heterogeneity. Clinical heterogeneity, true effect heterogeneity, can be defined as variability among studies in the participants, the types or timing of outcome measurements, and the intervention characteristics. The objective of this project was to develop recommendations for investigating clinical heterogeneity in systematic reviews.
  
  
  METHODS
  We used a modified Delphi technique with three phases: (1) pre-meeting item generation; (2) face-to-face consensus meeting in the form of a modified Delphi process; and (3) post-meeting feedback. We identified and invited potential participants with expertise in systematic review methodology, systematic review reporting, or statistical aspects of meta-analyses, or those who published papers on clinical heterogeneity.
  
  
  RESULTS
  Between April and June of 2011, we conducted phone calls with participants. In June 2011 we held the face-to-face focus group meeting in Ann Arbor, Michigan. First, we agreed upon a definition of clinical heterogeneity: Variations in the treatment effect that are due to differences in clinically related characteristics. Next, we discussed and generated recommendations in the following 12 categories related to investigating clinical heterogeneity: the systematic review team, planning investigations, rationale for choice of variables, types of clinical variables, the role of statistical heterogeneity, the use of plotting and visual aids, dealing with outlier studies, the number of investigations or variables, the role of the best evidence synthesis, types of statistical methods, the interpretation of findings, and reporting.
  
  
  CONCLUSIONS
  Clinical heterogeneity is common in systematic reviews. Our recommendations can help guide systematic reviewers in conducting valid and reliable investigations of clinical heterogeneity. Findings of these investigations may allow for increased applicability of findings of systematic reviews to the management of individual patients.
authors.affiliation: Department of Orthopaedic Surgery, University of Michigan, MedSport, 24 Frank Lloyd Wright Drive, Ann Arbor, MI 48106, USA. jgagnier@umich.edu.
authors.forename: Joel J
authors.initials: JJ
authors.lastname: Gagnier
authors.forename: Hal
authors.initials: H
authors.lastname: Morgenstern
authors.forename: Doug G
authors.initials: DG
authors.lastname: Altman
authors.forename: Jesse
authors.initials: J
authors.lastname: Berlin
authors.forename: Stephanie
authors.initials: S
authors.lastname: Chang
authors.forename: Peter
authors.initials: P
authors.lastname: McCulloch
authors.forename: Xin
authors.initials: X
authors.lastname: Sun
authors.forename: David
authors.initials: D
authors.lastname: Moher
mesh_terms: D032921:Consensus; D003697:Delphi Technique; D019317:Evidence-Based Medicine; D006801:Humans; D015201:Meta-Analysis as Topic; D016032:Randomized Controlled Trials as Topic; D012196:Review Literature as Topic; D016896:Treatment Outcome