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Evidence-Based Practice - Strengths & Levels of Evidence: Home

This tutorial describes the different types of evidence-based research studies, and how each of them can be considered to increasing or decreasing levels of strength in terms of the evidence they provide.

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Evidence Pyramid

The different types of evidence and their various 'strengths' are often depicted as a pyramid. The pyramid above is from the DePaul University Library's excellent Evidence-Based Nursing Research GuideIn this visual model, the strongest evidence is found at the top, with the weakest found at the bottom. The shape of the pyramid indicates that, in terms of sheer quantity, there are less higher strength sources than weaker sources for most topics. A few things to note:

  • Higher level sources typically go through more thorough critical appraisal and review, and also employ more stringent methodologies and quantitative analysis.
  • Lower level sources often use qualitative methodologies, or do not go through as rigorous critical evaluation than higher level sources.
  • It is important to understand that, depending on your research question, the 'highest quality' evidence you can find may not reach the very top of the pyramid. For example, a systematic review may not have been done on your topic. Or, it may not be possible to conduct a randomized controlled trial on your topic.

Definitions of Evidence Types

Systematic Review

A systematic review is a review of the evidence for a research question that uses systematic and clearly stated methods to identify, select and critically appraise relevant primary research. Data from studies included in the review are extracted and analyzed.


Meta Analysis

According to an article in BMJ Journals written by Allison Shorten and Brett Shorten, "Meta-analysis is a research process used to systematically synthesise or merge the findings of single, independent studies, using statistical methods to calculate an overall or ‘absolute’ effect. Meta-analysis does not simply pool data from smaller studies to achieve a larger sample size. Analysts use well recognised, systematic methods to account for differences in sample size, variability (heterogeneity) in study approach and findings (treatment effects) and test how sensitive their results are to their own systematic review protocol (study selection and statistical analysis)."


Evidence-Based Guideline

These can also be known as a clinical practice guideline. In the book Clinical Practice Guidelines We Can TrustThe Institute of Medicine defines them as, "statements that include recommendations, intended to optimize patient care, that are informed by a systematic review of evidence and an assessment of the benefits and harms of alternative care options".


Randomized Controlled Trial

The following definition comes from the article Designing a Research Project: Randomised Controlled Trials and their Principles by JM Kendall: "The randomised control trial (RCT) is a trial in which subjects are randomly assigned to one of two groups: one (the experimental group) receiving the intervention that is being tested, and the other (the comparison group or control) receiving an alternative (conventional) treatment (fig 1). The two groups are then followed up to see if there are any differences between them in outcome. The results and subsequent analysis of the trial are used to assess the effectiveness of the intervention, which is the extent to which a treatment, procedure, or service does patients more good than harm".


Controlled Clinical Trial

Also known as a Non-Randomized Controlled Trial. The PubMed MeSH Heading definition is: "Work consisting of a clinical trial involving one or more test treatments, at least one control treatment, specified outcome measures for evaluating the studied intervention, and a bias-free method for assigning patients to the test treatment. The treatment may be drugs, devices, or procedures studied for diagnostic, therapeutic, or prophylactic effectiveness. Control measures include placebos, active medicine, no-treatment, dosage forms and regimens, historical comparisons, etc.".


Case Control Studies

The PubMed MeSH definition for case control studies is as follows: "Comparisons that start with the identification of persons with the disease or outcome of interest and a control (comparison, referent) group without the disease or outcome of interest. The relationship of an attribute is examined by comparing both groups with regard to the frequency or levels of outcome over time".


Cohort Studies

Also known as a prospective study. The PubMed MeSH definition is "Studies in which subsets of a defined population are identified. These groups may or may not be exposed to factors hypothesized to influence the probability of the occurrence of a particular disease or other outcome. Cohorts are defined populations which, as a whole, are followed in an attempt to determine distinguishing subgroup characteristics".


Qualitative Metasynthesis

This one is a little trickier to define. The best one I could find is from Understanding Qualitative Metasynthesis: Issues and Opportunities in Early Childhood Intervention Research by Elizabeth Erwin, Mary Jane Brotherson, and Jean Ann Summers. "Qualitative metasynthesis is an intentional and coherent approach to analyzing data across qualitative studies. It is a process that enables researchers to identify a specific research question and then search for, select, appraise, summarize, and combine qualitative evidence to address the research question".

Further Reading & Online Resources