Figure 1. Overall process for determining updating status. Includes the search protocols to identify candidate new trials, application of criteria from the original review to identify eligible new trials, meta-analytic pooling of new results with previous meta-analytic results, and identification of new systematic reviews on the same topic or "pivotal trials" (published in 1 of the 5 highest-impact general medical journals or more than 3 times the sample size of the previous largest trial) that met any of our criteria for qualitative signals for updating. An individual reviewer reached a tentative conclusion about the presence of quantitative and qualitative signals for updating, but each review was discussed in detail by the project team to reach a final consensus decision. For reviews that did not have any signals for updating, the group also decided whether the searches had been adequate or whether more comprehensive searching for new trials might be required, including more detailed electronic searching and hand-searching of ACP Journal Club for new trials relevant to the original review.

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