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13.1.2  Why consider non-randomized studies?

The Cochrane Collaboration focuses particularly on systematic reviews of randomized trials because they are more likely to provide unbiased information than other study designs about the differential effects of alternative forms of health care. Reviews of NRS are only likely to be undertaken when the question of interest cannot be answered by a review of randomized trials. The NRSMG believes that review authors may be justified in including NRS which are moderately susceptible to bias. Broadly, the NRSMG considers that there are three main reasons for including NRS in a Cochrane review:

a)      To examine the case for undertaking a randomized trial by providing an explicit evaluation of the weaknesses of available NRS. The findings of a review of NRS may also be useful to inform the design of a subsequent randomized trial, e.g. through the identification of relevant subgroups.

b)      To provide evidence of the effects (benefit or harm) of interventions that cannot be randomized, or which are extremely unlikely to be studied in randomized trials. In these contexts, a disinterested (free from bias and partiality) review that systematically reports the findings and limitations of available NRS can be useful.

c)      To provide evidence of effects (benefit or harm) that cannot be adequately studied in randomized trials, such as long-term and rare outcomes, or outcomes that were not known to be important when existing, major randomized trials were conducted.


Three other reasons are often cited in support of systematic reviews of NRS but are poor justifications:

d)      Studying effects in patient groups not recruited to randomized trials (such as children, pregnant women, the elderly). Although it is important to consider whether the results of trials can be generalized to people who are excluded from them, it is not clear that this can be achieved by consideration of non-randomized studies. Regardless of whether estimates from NRS agree or disagree with those of randomized trials, there is always potential for bias in the results of the NRS, such that misleading conclusions are drawn.

e)   To supplement existing randomized trial evidence. Adding non-randomized to randomized evidence may change an imprecise but unbiased estimate into a precise but biased estimate, i.e. an exchange of undesirable uncertainty for unacceptable error.

f)    When an intervention effect is really large. Implicitly, this is a result-driven or post hoc justification, since the review (or some other synthesis of the evidence) needs to be undertaken to observe the likely size of the effects. Whilst it is easier to argue that large effects are less likely to be completely explained by bias than small effects (Glasziou 2007), for the practice of health care it is still important to obtain unbiased estimates of the magnitude of large effects to make clinical and economic decisions (Reeves 2006). Thus randomized trials are still needed for large effects (and they need not be large if the effects are truly large). There may be ethical opposition to randomized trials of interventions already suspected to be associated with a large benefit as a result of a  systematic review of NRS, making it difficult to randomize participants, and interventions postulated to have large effects may also be difficult to randomize for other reasons (e.g. surgery vs. no surgery). However, the justification for a  systematic review of NRS in these circumstances should be classified as (b), i.e. interventions that are unlikely to be randomized, rather than as (f).