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8.2.1  ‘Bias’ and ‘risk of bias’

A bias is a systematic error, or deviation from the truth, in results or inferences. Biases can operate in either direction: different biases can lead to underestimation or overestimation of the true intervention effect. Biases can vary in magnitude: some are small (and trivial compared with the observed effect) and some are substantial (so that an apparent finding may be entirely due to bias). Even a particular source of bias may vary in direction: bias due to a particular design flaw (e.g. lack of allocation concealment) may lead to underestimation of an effect in one study but overestimation in another study. It is usually impossible to know to what extent biases have affected the results of a particular study, although there is good empirical evidence that particular flaws in the design, conduct and analysis of randomized clinical trials lead to bias (see Section 8.2.3). Because the results of a study may in fact be unbiased despite a methodological flaw, it is more appropriate to consider risk of bias.


Differences in risks of bias can help explain variation in the results of the studies included in a systematic review (i.e. can explain heterogeneity of results). More rigorous studies are more likely to yield results that are closer to the truth. Meta-analysis of results from studies of variable validity can result in false positive conclusions (erroneously concluding an intervention is effective) if the less rigorous studies are biased toward overestimating an intervention’s effect. They might also come to false negative conclusions (erroneously concluding no effect) if the less rigorous studies are biased towards underestimating an intervention’s effect (Detsky 1992).


It is important to assess risk of bias in all studies in a review irrespective of the anticipated variability in either the results or the validity of the included studies. For instance, the results may be consistent among studies but all the studies may be flawed. In this case, the review’s conclusions should not be as strong as if a series of rigorous studies yielded consistent results about an intervention’s effect. In a Cochrane review, this appraisal process is described as the assessment of risk of bias in included studies. A tool that has been developed and implemented in RevMan for this purpose is described in Section 8.5. The rest of this chapter provides the rationale for this tool as well as explaining how bias assessments should be summarized and incorporated in analyses (Sections 8.6 to 8.8). Sections 8.9 to 8.15 provide background considerations to assist review authors in using the tool.


Bias should not be confused with imprecision. Bias refers to systematic error, meaning that multiple replications of the same study would reach the wrong answer on average. Imprecision refers to random error, meaning that multiple replications of the same study will produce different effect estimates because of sampling variation even if they would give the right answer on average. The results of smaller studies are subject to greater sampling variation and hence are less precise. Imprecision is reflected in the confidence interval around the intervention effect estimate from each study and in the weight given to the results of each study in a meta-analysis. More precise results are given more weight.