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9.7  Sensitivity analyses

The process of undertaking a systematic review involves a sequence of decisions. Whilst many of these decisions are clearly objective and non-contentious, some will be somewhat arbitrary or unclear. For instance, if inclusion criteria involve a numerical value, the choice of value is usually arbitrary: for example, defining groups of older people may reasonably have lower limits of 60, 65, 70 or 75 years, or any value in between. Other decisions may be unclear because a study report fails to include the required information. Some decisions are unclear because the included studies themselves never obtained the information required: for example, the outcomes of those who unfortunately were lost to follow-up. Further decisions are unclear because there is no consensus on the best statistical method to use for a particular problem.


It is desirable to prove that the findings from a systematic review are not dependent on such arbitrary or unclear decisions. A sensitivity analysis is a repeat of the primary analysis or meta-analysis, substituting alternative decisions or ranges of values for decisions that were arbitrary or unclear. For example, if the eligibility of some studies in the meta-analysis is dubious because they do not contain full details, sensitivity analysis may involve undertaking the meta-analysis twice: first, including all studies and second, only including those that are definitely known to be eligible. A sensitivity analysis asks the question, “Are the findings robust to the decisions made in the process of obtaining them?”.


There are many decision nodes within the systematic review process which can generate a need for a sensitivity analysis. Examples include:


Searching for studies:


Eligibility criteria:


What data should be analysed?


Analysis methods:


Some sensitivity analyses can be pre-specified in the study protocol, but many issues suitable for sensitivity analysis are only identified during the review process where the individual peculiarities of the studies under investigation are identified. When sensitivity analyses show that the overall result and conclusions are not affected by the different decisions that could be made during the review process, the results of the review can be regarded with a higher degree of certainty. Where sensitivity analyses identify particular decisions or missing information that greatly influence the findings of the review, greater resources can be deployed to try and resolve uncertainties and obtain extra information, possibly through contacting trial authors and obtained individual patient data. If this cannot be achieved, the results must be interpreted with an appropriate degree of caution. Such findings may generate proposals for further investigations and future research.


Reporting of sensitivity analyses in a systematic review may best be done by producing a summary table. Rarely is it informative to produce individual forest plots for each sensitivity analysis undertaken.


Sensitivity analyses are sometimes confused with subgroup analysis. Although some sensitivity analyses involve restricting the analysis to a subset of the totality of studies, the two methods differ in two ways. First, sensitivity analyses do not attempt to estimate the effect of the intervention in the group of studies removed from the analysis, whereas in subgroup analyses, estimates are produced for each subgroup. Second, in sensitivity analyses, informal comparisons are made between different ways of estimating the same thing, whereas in subgroup analyses, formal statistical comparisons are made across the subgroups.