Changes in Burnout and Satisfaction With Work-Life Integration in Physicians and the General US Working Population Between 2011 and 2017

OBJECTIVE

To evaluate the prevalence of burnout and satisfaction with work-life integration among physicians and other US workers in 2017 compared with 2011 and 2014.

PARTICIPANTS AND METHODS

Between October 12, 2017, and March 15, 2018, we surveyed US physicians and a probability-based sample of the US working population using methods similar to our 2011 and 2014 studies. A secondary survey with intensive follow-up was conducted in a sample of nonresponders to evaluate response bias. Burnout and work-life integration were measured using standard tools.

RESULTS

Of 30,456 physicians who received an invitation to participate, 5197 (17.1%) completed surveys. Among the 476 physicians in the secondary survey of nonresponders, 248 (52.1%) responded. A comparison of responders in the 2 surveys revealed no significant differences in burnout scores (P=.66), suggesting that participants were representative of US physicians. When assessed using the Maslach Burnout Inventory, 43.9% (2147 of 4893) of the physicians who completed the MBI reported at least one symptom of burnout in 2017 compared with 54.4% (3680 of 6767) in 2014 (P<.001) and 45.5% (3310 of 7227) in 2011 (P=.04). Satisfaction with work-life integration was more favorable in 2017 (42.7% [2056 of 4809]) than in 2014 (40.9% [2718 of 6651]; P<.001) but less favorable than in 2011 (48.5% [3512 of 7244]; P<.001). On multivariate analysis adjusting for age, sex, relationship status, and hours worked per week, physicians were at increased risk for burnout (odds ratio, 1.39; 95% CI, 1.26-1.54; P<.001) and were less likely to be satisfied with work-life integration (odds ratio, 0.77; 95% CI, 0.70-0.85; P<.001) than other working US adults.

CONCLUSION

Burnout and satisfaction with work-life integration among US physicians improved between 2014 and 2017, with burnout currently near 2011 levels. Physicians remain at increased risk for burnout relative to workers in other fields.

Sex Difference in Celiac Disease in Undiagnosed Populations: A Systematic Review and Meta-analysis

BACKGROUND & AIMS

A higher proportion of female vs male patients receive a diagnosis of celiac disease. Little is known about sex-based differences in the prevalence of celiac disease in undiagnosed populations. We aimed to address this knowledge gap with a systematic review and meta-analysis.

METHODS

We searched MEDLINE, Embase, Cochrane, and Scopus databases through 2017 for studies of screen-detected or undiagnosed celiac disease. Our final analysis included studies that included screening and confirmatory tests (either second serologic analysis or a small intestine biopsy) and provided information on the sex of participants. Studies were excluded if they were performed with specific, high-risk, or referral populations. The primary outcome was the percentage of undetected celiac disease among female and male patients.

RESULTS

We identified 4070 articles and analyzed data from 87. Our meta-analysis comprised data from 291,969 study participants. The pooled prevalence of undetected celiac disease in female participants was 0.589% (95% CI, 0.549%-0.629%) and in male participants was 0.415% (95% CI, 0.343%-0.487%). The risk of undetected celiac disease was higher among female than male participants (relative risk [RR], 1.42; 95% CI, 1.27-1.57; P < .00001). The I² was 5% (low heterogeneity among studies). In subgroup analyses, the RR of celiac disease for girls vs boys was 1.79 (95% CI, 1.44-2.22; P < .00001; I² = 18%), the RR for female vs male blood donors was 1.13 (95% CI, 0.76-1.69; P = .54; I² = 0), and the RR for women vs men with villous atrophy was 1.38 (95% CI, 1.07-1.79; P = .01; I² = 0).

CONCLUSIONS

In a systematic review and meta-analysis, we found a higher risk for celiac disease in women than men in an undiagnosed populations (identified through general population screening). The increased risk for celiac disease among girls and women should be considered for screening, diagnosis, and management strategies.

Association of Racial Bias With Burnout Among Resident Physicians

Importance

Burnout, a syndrome characterized by emotional exhaustion, depersonalization, and a decreased sense of efficacy, is common among resident physicians, and negative emotional states may increase the expression of prejudices, which are associated with racial disparities in health care. Whether racial bias varies by symptoms of burnout among resident physicians is unknown.

Objective

To assess the association between burnout and explicit and implicit racial biases toward black people in resident physicians.

Design, Setting, and Participants

This cohort study obtained data from surveys completed by first-year medical students and resident physicians in the United States as part of the Cognitive Habits and Growth Evaluation Study. Participants were followed up from enrollment in 2010 to 2011 through 2017. Participants completed questionnaires at year 4 of medical school as well as at the second and third years of residency. Only data from resident physicians who self-identified as belonging to a racial group other than black (n = 3392) were included in the analyses because of scarce evidence of racial bias in the care provided to black patients by black physicians. Resident physicians training in radiology or pathology were excluded because they provided less direct patient interaction.

Main Outcomes and Measures

Burnout symptoms were measured by 2 single-item measures from the Maslach Burnout Inventory. Explicit attitudes about white and black people were measured by a feeling thermometer (FT, from 0 to 100 points, ranging from very cold or unfavorable [lowest score] to very warm or favorable [highest score]; included in the second-year [R2] and third-year [R3] questionnaires). The R2 Questionnaire included a racial Implicit Association Test (IAT; range: -2 to 2).

Results

Among the 3392 nonblack resident physician respondents, 1693 (49.9%) were male, 1964 (57.9%) were younger than 30 years, and 2362 (69.6%) self-identified as belonging to the white race. In this cohort, 1529 of 3380 resident physicians (45.2%) had symptoms of burnout and 1394 of 3377 resident physicians (41.3%) had depression. From this group, 12 did not complete the burnout items and 15 did not complete the Patient-Reported Outcomes Measurement Information System (PROMIS) items. The mean (SD) FT score toward black people was 77.9 (21.0) and toward white people was 81.1 (20.1), and the mean (SD) racial IAT score was 0.4 (0.4). Burnout at the R2 Questionnaire time point was associated with greater explicit and implicit racial biases. In multivariable analyses adjusting for demographics, specialty, depression, and FT scores toward white people, resident physicians with burnout had greater explicit racial bias (difference in FT score, -2.40; 95% CI, -3.42 to -1.37; P < .001) and implicit racial bias (difference in IAT score, 0.05; 95% CI, 0.02-0.08; P = .002). A dose-response association was found between change in depersonalization from R2 to R3 Questionnaire and R3 Questionnaire explicit bias (for each 1-point increase the difference in R3 FT score decreased, -0.73; 95% CI, -1.23 to -0.23; P = .004) and change in explicit bias.

Conclusions and Relevance

Among resident physicians, symptoms of burnout appeared to be associated with greater explicit and implicit racial biases; given the high prevalence of burnout and the negative implications of bias for medical care, symptoms of burnout may be factors in racial disparities in health care.

The association of resistance training with mortality: A systematic review and meta-analysis

BACKGROUND

The benefits of aerobic exercise are well-studied; there is no consensus on the association between resistance training and major adverse cardiovascular outcomes. This systematic review and meta-analysis aimed to address this issue.

DESIGN AND METHODS

We searched for randomized trials and cohort studies that evaluated the association between resistance training and mortality and cardiovascular events. Two investigators screened the identified abstracts and full-texts independently and in duplicate. Cochrane tools were used to assess the risk of bias. We calculated hazard ratios and 95% confidence intervals using random effect models.

RESULTS

From the 1430 studies identified, 11 (one randomized trial and 10 cohort studies) met the inclusion criteria, totaling 370,256 participants with mean follow-up of 8.85 years. The meta-analysis showed that, compared with no exercise, resistance training was associated with 21% (hazard ratio (95% confidence interval (CI)), 0.79 (0.69-0.91)) and 40% (hazard ratio (95% CI), 0.60 (0.49-0.72)) lower all-cause mortality alone and when combined with aerobic exercise, respectively. Furthermore, resistance training had a borderline association with lower cardiovascular mortality (hazard ratio (95% CI), 0.83 (0.67-1.03)). In addition, resistance training showed no significant association with cancer mortality. Risk of bias was low to intermediate in the included studies. One cohort study looked at the effect of resistance training on coronary heart disease events in men and found a 23% risk reduction (risk ratio, 0.77, CI: 0.61-0.98).

CONCLUSION

Resistance training is associated with lower mortality and appears to have an additive effect when combined with aerobic exercise. There are insufficient data to determine the potential beneficial effect of resistance training on non-fatal events or the effect of substituting aerobic exercise with resistance training.

Physician Burnout, Well-being, and Work Unit Safety Grades in Relationship to Reported Medical Errors

OBJECTIVE

To evaluate physician burnout, well-being, and work unit safety grades in relationship to perceived major medical errors.

PARTICIPANTS AND METHODS

From August 28, 2014, to October 6, 2014, we conducted a population-based survey of US physicians in active practice regarding burnout, fatigue, suicidal ideation, work unit safety grade, and recent medical errors. Multivariate logistic regression and mixed-effects hierarchical models evaluated the associations among burnout, well-being measures, work unit safety grades, and medical errors.

RESULTS

Of 6695 responding physicians in active practice, 6586 provided information on the areas of interest: 3574 (54.3%) reported symptoms of burnout, 2163 (32.8%) reported excessive fatigue, and 427 (6.5%) reported recent suicidal ideation, with 255 of 6563 (3.9%) reporting a poor or failing patient safety grade in their primary work area and 691 of 6586 (10.5%) reporting a major medical error in the prior 3 months. Physicians reporting errors were more likely to have symptoms of burnout (77.6% vs 51.5%; P<.001), fatigue (46.6% vs 31.2%; P<.001), and recent suicidal ideation (12.7% vs 5.8%; P<.001). In multivariate modeling, perceived errors were independently more likely to be reported by physicians with burnout (odds ratio [OR], 2.22; 95% CI, 1.79-2.76) or fatigue (OR, 1.38; 95% CI, 1.15-1.65) and those with incrementally worse work unit safety grades (OR, 1.70; 95% CI, 1.36-2.12; OR, 1.92; 95% CI, 1.48-2.49; OR, 3.12; 95% CI, 2.13-4.58; and OR, 4.37; 95% CI, 2.06-9.28 for grades of B, C, D, and F, respectively), adjusted for demographic and clinical characteristics.

CONCLUSION

In this large national study, physician burnout, fatigue, and work unit safety grades were independently associated with major medical errors. Interventions to reduce rates of medical errors must address both physician well-being and work unit safety.

Impact of decision aids used during clinical encounters on clinician outcomes and consultation length: a systematic review

BACKGROUND

Clinicians' satisfaction with encounter decision aids is an important component in facilitating implementation of these tools. We aimed to determine the impact of decision aids supporting shared decision making (SDM) during the clinical encounter on clinician outcomes.

METHODS

We searched nine databases from inception to June 2017. Randomised clinical trials (RCTs) of decision aids used during clinical encounters with an unaided control group were eligible for inclusion. Due to heterogeneity among included studies, we used a narrative evidence synthesis approach.

RESULTS

Twenty-five papers met inclusion criteria including 22 RCTs and 3 qualitative or mixed-methods studies nested in an RCT, together representing 23 unique trials. These trials evaluated healthcare decisions for cardiovascular prevention and treatment (n=8), treatment of diabetes mellitus (n=3), treatment of osteoporosis (n=2), treatment of depression (n=2), antibiotics to treat acute respiratory infections (n=3), cancer prevention and treatment (n=4) and prenatal diagnosis (n=1). Clinician outcomes were measured in only a minority of studies. Clinicians' satisfaction with decision making was assessed in only 8 (and only 2 of them showed statistically significantly greater satisfaction with the decision aid); only three trials asked if clinicians would recommend the decision aid to colleagues and only five asked if clinicians would use decision aids in the future. Outpatient consultations were not prolonged when a decision aid was used in 9 out of 13 trials. The overall strength of the evidence was low, with the major risk of bias related to lack of blinding of participants and/or outcome assessors.

CONCLUSION

Decision aids can improve clinicians' satisfaction with medical decision making and provide helpful information without affecting length of consultation time. Most SDM trials, however, omit outcomes related to clinicians' perspective on the decision making process or the likelihood of using a decision aid in the future.

Implementing bedside rounds to improve patient-centred outcomes: a systematic review

BACKGROUND

Bedside rounds (BR) have been proposed as an ideal method to promote patient-centred hospital care, but there is substantial variation in their implementation and effects. Our objectives were to describe the implementation of BR in hospital settings and determine their effect on patient-centred outcomes.

METHODS

Data sources included Ovid MEDLINE, Ovid Embase, Scopus and Ovid Cochrane Central Registry of Clinical Trials from database inception through 28 July 2017. We included experimental studies comparing BR to another form of rounds in a hospital-based setting (ie, medical/surgical unit, intensive care unit (ICU)) and reporting a quantitative patient-reported or objectively measured clinical outcome. We used random effects models to calculate pooled Cohen's d effect size estimates for the patient knowledge and patient experience outcome domains.

RESULTS

Twenty-nine studies met inclusion criteria, including 20 from adult care (17 non-ICU, 3 ICU), and nine from paediatrics (5 non-ICU, 4 ICU), the majority of which (n=23) were conducted in the USA. Thirteen studies implemented BR with cointerventions as part of a 'bundle'. Studies most commonly reported outcomes in the domains of patient experience (n=24) and patient knowledge (n=10). We found a small, statistically significant improvement in patient experience with BR (summary Cohen's d=0.09, 95% CI 0.04 to 0.14, p<0.001, I²=56%), but no significant association between BR and patient knowledge (Cohen's d=0.21, 95% CI -0.004 to -0.43, p=0.054, I²=92%). Risk of bias was moderate to high, with methodological limitations most often relating to selective reporting, low adherence rates and missing data.

CONCLUSIONS

BR have been implemented in a variety of hospital settings, often 'bundled' with cointerventions. However, BR have demonstrated limited effect on patient-centred outcomes.

Physician burnout: contributors, consequences and solutions

Physician burnout, a work-related syndrome involving emotional exhaustion, depersonalization and a sense of reduced personal accomplishment, is prevalent internationally. Rates of burnout symptoms that have been associated with adverse effects on patients, the healthcare workforce, costs and physician health exceed 50% in studies of both physicians-in-training and practicing physicians. This problem represents a public health crisis with negative impacts on individual physicians, patients and healthcare organizations and systems. Drivers of this epidemic are largely rooted within healthcare organizations and systems and include excessive workloads, inefficient work processes, clerical burdens, work-home conflicts, lack of input or control for physicians with respect to issues affecting their work lives, organizational support structures and leadership culture. Individual physician-level factors also play a role, with higher rates of burnout commonly reported in female and younger physicians. Effective solutions align with these drivers. For example, organizational efforts such as locally developed practice modifications and increased support for clinical work have demonstrated benefits in reducing burnout. Individually focused solutions such as mindfulness-based stress reduction and small-group programmes to promote community, connectedness and meaning have also been shown to be effective. Regardless of the specific approach taken, the problem of physician burnout is best addressed when viewed as a shared responsibility of both healthcare systems and individual physicians. Although our understanding of physician burnout has advanced considerably in recent years, many gaps in our knowledge remain. Longitudinal studies of burnout's effects and the impact of interventions on both burnout and its effects are needed, as are studies of effective solutions implemented in combination. For medicine to fulfil its mission for patients and for public health, all stakeholders in healthcare delivery must work together to develop and implement effective remedies for physician burnout.

Abstract 20: The Effect of Resistance Training on Survival and Cardiovascular Outcomes: A Systematic Review and Meta-Analysis

Background: This is the first systematic review and meta-analysis to investigate the effect of resistance training (RT) on survival and other cardiovascular outcomes including ischemic heart disease events and stroke.

Methods: An experienced librarian searched databases up to September 25 th , 2017, for randomized trials and cohort studies that evaluated the effect of RT on survival and cardiovascular events in the general population. The databases included Ovid MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Scopus. Two investigators conducted the screening process independently and in duplicate. Cochrane tools were used to assess the risk of bias in clinical trials and observational studies. We calculated hazard ratios and 95% confidence intervals using RevMan and fixed and random effect models and had a subgroup analysis based on doses of RT and for the combination of RT and aerobic exercise (AE) vs no exercise.

Results: The search identified 1429 studies from which 10 (one randomized trial) met the inclusion criteria, including 338,254 participants with a mean follow up of 8.14 years. The meta-analysis showed that RT, in comparison with no exercises, is associated with 24% lower all-cause mortality and 48% lower mortality when combined with AE. Based on subgroup analysis, performing 1-2 sessions of RT/week is associated with lower all-cause mortality by 28% (HR 0.72, 95% CI 0.66-0.78) whereas > 5 sessions of RT/week has no association with all-cause mortality (HR 0.99, 95% CI 0.76-1.31). Further, RT alone or combined with AE is associated with lower CV mortality compared to no exercise (Figures). Finally, RT alone also showed a borderline association with lower all-cancer mortality. Heterogeneity was present for several comparisons, and subsequent analysis will explore sources of this variability. Using study design-specific Cochrane risk of bias tools, no major sources of bias were identified in the included studies. One cohort study looked at the effect of RT on coronary heart disease events and found 23% risk reduction in men, while no study specifically assessed the effect of RT on cerebrovascular outcomes.

Conclusion: RT is associated with lower all-cause, CV and all-cancer mortality. RT appears to have an additive effect when combined with AE.

Educational Technologies for Physician Continuous Professional Development: A National Survey

PURPOSE

To determine the past experiences with, current use of, and anticipated use of online learning and simulation-based education among practicing U.S. physicians, and how findings vary by age.

METHOD

The authors surveyed 4,648 randomly sampled board-certified U.S. physicians, September 2015 to April 2016, using Internet-based and paper questionnaires. Survey items (some optional) addressed past and current technology usage, perceived technology effectiveness, and anticipated future use of specific technology innovations.

RESULTS

Of 988 respondents, 444 completed optional items. Of these, 429/442 (97.1%) had used online learning and 372/442 (84.2%) had used simulation-based education in the past five years. Desire for more online learning was modest (mean [standard deviation], 4.6 [1.5]; 1 = strongly disagree, 7 = strongly agree), as was desire for more simulation-based education (4.2 [1.7]). Both online learning and simulation-based education were perceived as effective (5.2 [1.4]; 5.0 [1.4]). Physicians believed they possess adequate skills for online learning (5.8 [1.2]) and that point-of-care learning is vital to effective patient care (5.3 [1.3]). Only 39.0% used objective performance data to guide their learning choices, although 64.6% agreed that such information would be useful. The highest-rated innovations included a central repository for listing educational opportunities and tracking continuing education credits, an app to award credit for answering patient-focused questions, 5-minute and 20-minute clinical updates, and an e-mailed "question of the week." Responses to most survey items were similar across age groups.

CONCLUSIONS

Practicing physicians generally seem receptive and prepared to use a variety of educational technologies, regardless of age.

Professional Satisfaction and the Career Plans of US Physicians

OBJECTIVE

To evaluate the relationship between burnout, satisfaction with electronic health records and work-life integration, and the career plans of US physicians.

PARTICIPANTS AND METHODS

Physicians across all specialties in the United States were surveyed between August 28, 2014, and October 6, 2014. Physicians provided information regarding the likelihood of reducing clinical hours in the next 12 months and the likelihood of leaving current practice within the next 24 months.

RESULTS

Of 35,922 physicians contacted, 6880 (19.2%) returned surveys. Of the 6695 physicians in clinical practice at the time of the survey (97.3%), 1275 of the 6452 who responded (19.8%) reported it was likely or definite that they would reduce clinical work hours in the next 12 months, and 1726 of the 6496 who responded (26.6%) indicated it was likely or definite that they would leave their current practice in the next 2 years. Of the latter group, 126 (1.9% of the 6695 physicians in clinical practice at the time of the survey) indicated that they planned to leave practice altogether and pursue a different career. Burnout (odds ratio [OR], 1.81; 95% CI, 1.49-2.19; P<.001), dissatisfaction with work-life integration (OR, 1.65; 95% CI, 1.27-2.14; P<.001), and dissatisfaction with the electronic health record (OR, 1.44; 95% CI, 1.16-1.80; P=.001) were independent predictors of intent to reduce clinical work hours and leave current practice.

CONCLUSION

Nearly 1 in 5 US physicians intend to reduce clinical work hours in the next year, and roughly 1 in 50 intend to leave medicine altogether in the next 2 years to pursue a different career. If physicians follow through on these intentions, it could profoundly worsen the projected shortage of US physicians.

Medical Licensure Questions and Physician Reluctance to Seek Care for Mental Health Conditions

OBJECTIVE

To determine whether state medical licensure application questions (MLAQs) about mental health are related to physicians' reluctance to seek help for a mental health condition because of concerns about repercussions to their medical licensure.

METHODS

In 2016, we collected initial and renewal medical licensure application forms from 50 states and the District of Columbia. We coded MLAQs related to physicians' mental health as "consistent" if they inquired only about current impairment from a mental health condition or did not ask about mental health conditions. We obtained data on care-seeking attitudes for a mental health problem from a nationally representative convenience sample of 5829 physicians who completed a survey between August 28, 2014, and October 6, 2014. Analyses explored relationships between state of employment, MLAQs, and physicians' reluctance to seek formal medical care for treatment of a mental health condition because of concerns about repercussions to their medical licensure.

RESULTS

We obtained initial licensure applications from 51 of 51 (100%) and renewal applications from 48 of 51 (94.1%) medical licensing boards. Only one-third of states currently have MLAQs about mental health on their initial and renewal application forms that are considered consistent. Nearly 40% of physicians (2325 of 5829) reported that they would be reluctant to seek formal medical care for treatment of a mental health condition because of concerns about repercussions to their medical licensure. Physicians working in a state in which neither the initial nor the renewal application was consistent were more likely to be reluctant to seek help (odds ratio, 1.21; 95% CI, 1.07-1.37; P=.002 vs both applications consistent).

CONCLUSION

Our findings support that MLAQs regarding mental health conditions present a barrier to physicians seeking help.

Professional Development Perceptions and Practices Among U.S. Physicians: A Cross-Specialty National Survey

PURPOSE

Professional development (PD)-both for-credit continuing medical education (CME) and informal self-directed or point-of-care learning-is vital to all physicians. The authors sought to understand physicians' PD perceptions and practices and how these vary by specialty and practice type.

METHOD

The authors administered an Internet and paper survey, from September 2015 to April 2016, to randomly sampled U.S. physicians. Survey items addressed perceived PD needs and barriers and how physicians identify knowledge/skills gaps.

RESULTS

Of 4,648 invitees, 988 (21.6%) responded. Respondents believed that they already know what they need to learn (mean 5.8 [1 = strongly disagree; 7 = strongly agree]), can answer clinical questions using available resources (5.9), and want credit for learning during patient care (5.1). They did not strongly desire help identifying learning gaps (4.0) or indicate difficulty accumulating CME credits (3.1). Most PD was done during personal time (5.5). Competencies regarding medical knowledge/skills, wellness, informatics, and practice/systems improvement were rated the highest priority, while research, teaching, and professionalism were rated the lowest. The most important sources used to identify knowledge/skills gaps were immediate patient care needs (4.1 [1 = not important; 5 = extremely important]), personal awareness (3.8), and practice updates (3.7). The most important barriers were time (3.5) and cost (2.9). Differences by specialty and practice type were generally small and not statistically significant.

CONCLUSIONS

Physicians feel confident in identifying their own learning needs, perceive medical knowledge/skills as their highest-priority need, and desire more credit for learning during patient care.

Can Shared Decision Making Improve Physician Well-Being and Reduce Burnout?

There are many causes of physician burnout in today’s health care environment, including an ever increasing administrative workload, pressure to do more work in less time, and a drive to reduce costs and improve patient outcomes. Importantly, lack of meaning in work is a crucial documented driver of physician burnout. Clinical encounters perceived as meaningful by physicians could therefore potentially positively impact physician well-being. Here we reflect on the potential of interventions that aim to enhance the patient-physician interaction, such as shared decision making, to improve physician well-being by facilitating interactions with patients that are perceived as meaningful.

Methodological Standards for Meta-Analyses and Qualitative Systematic Reviews of Cardiac Prevention and Treatment Studies: A Scientific Statement From the American Heart Association

Meta-analyses are becoming increasingly popular, especially in the fields of cardiovascular disease prevention and treatment. They are often considered to be a reliable source of evidence for making healthcare decisions. Unfortunately, problems among meta-analyses such as the misapplication and misinterpretation of statistical methods and tests are long-standing and widespread. The purposes of this statement are to review key steps in the development of a meta-analysis and to provide recommendations that will be useful for carrying out meta-analyses and for readers and journal editors, who must interpret the findings and gauge methodological quality. To make the statement practical and accessible, detailed descriptions of statistical methods have been omitted. Based on a survey of cardiovascular meta-analyses, published literature on methodology, expert consultation, and consensus among the writing group, key recommendations are provided. Recommendations reinforce several current practices, including protocol registration; comprehensive search strategies; methods for data extraction and abstraction; methods for identifying, measuring, and dealing with heterogeneity; and statistical methods for pooling results. Other practices should be discontinued, including the use of levels of evidence and evidence hierarchies to gauge the value and impact of different study designs (including meta-analyses) and the use of structured tools to assess the quality of studies to be included in a meta-analysis. We also recommend choosing a pooling model for conventional meta-analyses (fixed effect or random effects) on the basis of clinical and methodological similarities among studies to be included, rather than the results of a test for statistical heterogeneity.