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12.2.3  Factors that increase the quality level of a body of evidence

Although observational studies and downgraded randomized trials will generally yield a low rating for quality of evidence, there will be unusual circumstances in which authors could ‘upgrade’ such evidence to moderate or even high quality (Table 12.2.c).

1.       On rare occasions when methodologically well-done observational studies yield large, consistent and precise estimates of the magnitude of an intervention effect, one may be particularly confident in the results. A large effect (e.g. RR > 2 or RR < 0.5) in the absence of plausible confounders, or a very large effect (e.g. RR > 5 or RR < 0.2) in studies with no major threats to validity, might qualify for this.  In these situations, while the observational studies are likely to have provided an overestimate of the true effect, the weak study design may not explain all of the apparent observed benefit. Thus, despite reservations based on the observational study design, authors are confident that the effect exists. The magnitude of the effect in these studies may move the assigned quality of evidence from low to moderate (if the effect is large in the absence of other methodological limitations).  For example, a meta-analysis of observational studies showed that bicycle helmets reduce the risk of head injuries in cyclists by a large margin (odds ratio [OR] 0.31, 95%CI 0.26–0.37) (Thompson 2000).  This large effect, in the absence of obvious bias that could create the association, suggests a rating of moderate-quality evidence.

2.       On occasion, all plausible biases from observational or randomized studies may be working to underestimate an apparent intervention effect. For example, if only sicker patients receive an experimental intervention or exposure, yet they still fare better, it is likely that the actual intervention or exposure effect is larger than the data suggest.  For instance, a rigorous systematic review of observational studies including a total of 38 million patients demonstrated higher death rates in private for-profit versus private not-for-profit hospitals (Devereaux 2004).  One possible bias relates to different disease severity in patients in the two hospital types.  It is likely, however, that patients in the not-for-profit hospitals were sicker than those in the for-profit hospitals.  Thus, to the extent that residual confounding existed, it would bias results against the not-for-profit hospitals.  The second likely bias was the possibility that higher numbers of patients with excellent private insurance coverage could lead to a hospital having more resources and a spill-over effect that would benefit those without such coverage.  Since for-profit hospitals are likely to admit a larger proportion of such well-insured patients than not-for-profit hospitals, the bias is once again against the not-for-profit hospitals.  Because the plausible biases would all diminish the demonstrated intervention effect, one might consider the evidence from these observational studies as moderate rather than low quality. A parallel situation exists when observational studies have failed to demonstrate an association but all plausible biases would have increased an intervention effect. This situation will usually arise in the exploration of apparent harmful effects.  For example, because the hypoglycaemic drug phenformin causes lactic acidosis, the related agent metformin is under suspicion for the same toxicity.  Nevertheless, very large observational studies have failed to demonstrate an association (Salpeter 2007).  Given the likelihood that clinicians would be more alert to lactic acidosis in the presence of the agent and overreport its occurence, one might consider this moderate, or even high quality, evidence refuting a causal relationship between typical therapeutic doses of metformin and lactic acidosis.

3.       The presence of a dose-response gradient may also increase our confidence in the findings of observational studies and thereby enhance the assigned quality of evidence.  For example, our confidence in the result of observational studies that show an increased risk of bleeding in patients who have supratherapeutic anticoagulation levels is increased by the observation that there is a dose-response gradient between higher levels of the international normalized ratio (INR) and the increased risk of bleeding (Levine 2004).