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In Reply: In response to Drs García and Tenias, we agree that observational studies pose a greater risk for bias and confounding than do well-conducted randomized clinical trials. While we sought to identify randomized clinical trials on this topic, we could find only observational studies. Nonetheless, observational studies can help to inform clinical practice, and methods to minimize bias when conducting systematic reviews of observational studies are well accepted.¹ We used these methods (the MOOSE recommendations) in the conduct of our systematic review and included a detailed discussion of the potential biases of our review.

We limited our review to English-language articles because we did not have the resources to translate articles and because the evidence suggests that this introduces minimal bias.² Furthermore, we remain unaware of any non-English-language article that would provide evidence contrary to our findings. We identified qualitative but not quantitative heterogeneity among studies for hospital mortality. . . . [Full Text of this Article]

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