Having taken a position of advocacy for the use of the three synthesis methods in the first sixteen chapters, this chapter identifies the serious limitations of the methods both theoretical and practical. It begins by discussing the limitations of systematic review and meta-analysis based on empiric studies of the quality, reproducibility, and predictive validity published up to the year 2000. The overall conclusion of the early literature—that studies using systematic review and meta-analysis were uneven in quality of conduct and reporting—has not changed in the interval since this book was published. The chapter goes on to define framing effects and the implications of the existence of framing effects for conclusions based on decision analysis. Criticisms of the use of QALYs in making clinical and policy decisions are delineated. League tables are described and their use is critiqued. The chapter ends by identifying the situations in which each method is most useful and the situations in which they may be misleading or wrong.
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