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Hierarchy of Evidence Factsheet v1 11042016 PDF

This document discusses the hierarchy of evidence, which ranks different types of quantitative research studies based on their strengths and weaknesses for providing evidence about a topic. Studies higher in the hierarchy, like systematic reviews and randomized controlled trials, are considered the "gold standard" because they have stronger research designs that minimize bias. However, other study types lower in the hierarchy, like case studies, can still provide useful information. It's important to consider both the type of study and its quality when evaluating evidence about a topic. The hierarchy helps determine what type of additional research may be most useful.

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Mirja Adiyaksa
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74 views

Hierarchy of Evidence Factsheet v1 11042016 PDF

This document discusses the hierarchy of evidence, which ranks different types of quantitative research studies based on their strengths and weaknesses for providing evidence about a topic. Studies higher in the hierarchy, like systematic reviews and randomized controlled trials, are considered the "gold standard" because they have stronger research designs that minimize bias. However, other study types lower in the hierarchy, like case studies, can still provide useful information. It's important to consider both the type of study and its quality when evaluating evidence about a topic. The hierarchy helps determine what type of additional research may be most useful.

Uploaded by

Mirja Adiyaksa
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as PDF, TXT or read online on Scribd
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Hierarchy of evidence

Aim of this factsheet


What is the hierarchy of evidence and why is it important to consider for research.

Introduction
The hierarchy of evidence is a weighting of evidence given to the design of a quantitative study. Those
studies that fall at the top of the hierarchy are considered to be ‘gold standard’; studies that have used these
designs provide the ‘best’ evidence for the researched area. This does not mean that those lower down the
hierarchy are necessarily inferior, as sometimes it is not possible to undertake a systematic review or
randomised controlled trial. For example, it would be unethical to experimentally test whether smoking
causes lung cancer using a randomised controlled trial, you can only observe whether being exposed to
tobacco causes lung cancer (using a cohort or case-control design). Consideration should always be given to
the quality of the study conducted; just because something is labelled as being at the top of the hierarchy
doesn’t mean it is entitled to be there if the conduct of the research was poor.

The hierarchy from a top down approach

Systematic review
(meta-analysis)

Randomised controlled trials

Cohort Studies

Non-randomised trials

Case-control studies

Cross sectional surveys

Case studies

Systematic reviews – These combine evidence from relevant studies; this may be in a particular disease area
or for a particular intervention dependent on the research question. Extracted data from all of the included
studies are combined to build up a broader picture of the evidence. Usually randomised controlled trials are
used but observational studies may be incorporated too. The quality of each of the studies included is
assessed systematically within the review and may be weighted accordingly. Numerical data from the
studies may be combined using a statistical method known as meta-analysis, where appropriate.

Randomised controlled trial (RCT) – These are experimental studies comparing groups (usually two) to
establish the effectiveness of specific interventions The most common design is to compare a new
intervention against the current best practice. Participants in the trials are randomly assigned to the
treatment groups to minimise bias (see trial design factsheet)

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Cohort studies - These are observational studies that identify participants who are exposed to a particular
risk factor. Participants are then followed forward in time (usually years) to determine if they develop the
disease under investigation.

Non-randomised trials – These trials are run when it is not ethical or possible to incorporate randomisation
into the design. There is an increased risk of biases being introduced into the research and this should be
considered carefully when analysis is reported.

Case-Control studies – These are observational studies that identify participants with a disease. Participants
are then tracked back in time (usually years), along with a matched group of control participants, to
determine if they were exposed to the risk factor under investigation.

Cross Sectional surveys – These provide data across a population at a single point in time. This provides an
indication of possible prevalence, events, behaviours and attitudes, but doesn’t give any idea of changes
over time, unless repeated (and here, an important question is whether the survey is distributed to the same
group or not). This data may be used in an exploratory fashion to investigate causal relationships.

Case studies – These studies are descriptive in nature and usually cover a particular presentation of a single
case. Despite these being the weakest form of evidence in the hierarchy they can still provide very useful
information particularly in the very early stages of research into an area.

Why consider the hierarchy of evidence?


When considering whether to conduct a piece of research it is important to be aware of what has already
been covered in the area. Ethically patients should have the best evidenced treatment available. Being
aware of what has already been done will also reduce research waste. Ideally, the next step of research
should be to add to the next level of evidence in the hierarchy. However, this may not always be possible,
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review or meta-analysis to be undertaken. Therefore it may be appropriate to continue research at the
current level of the hierarchy rather than to move to the next level prematurely.

It is also important to assess the quality of the evidence at each level of the given hierarchy. A poorly
conducted and reported RCT may provide less evidential value than the non-randomised trial that preceded
it. The GRADE (Grading of Recommendations Assessment, Development and Evaluation) working group has
produced a common, sensible approach to grading quality of evidence and strength of recommendation
(now used in Cochrane reviews). The ability to critically appraise the conduct of any research study is a vital
skill for any researcher (see further links section).

Time to think – At what level of evidence should a study be conducted in the following scenarios?

 Multiple relevant RCTs of good quality have been conducted into a psycho-social intervention for
Alzheimer’s but not for Lewy body dementia.
 The presentation of a case within clinic is unlike anything within the current literature
 The understanding of the progression of Parkinson’s within a specific population is needed

Further links
http://www.gradeworkinggroup.org/publications/index.htm#BMJ2008
http://www.bmj.com/about-bmj/resources-readers/publications/how-read-paper

References
Understanding quantitative research: part 1. J. Hoare & Z. Hoare. Nursing Standard 2012, 27, 15-17.
http://www.gradeworkinggroup.org/index.htm

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