What is PRISMA?

"PRISMA stands for Preferred Reporting Items for Systematic Reviews and Meta-Analyses”.
It is an evidence-based minimum set of items for reporting in systematic reviews and
meta-analyses.
The aim of the PRISMA Statement is to help authors improve the reporting of systematic
reviews and meta-analyses. We have focused on randomized trials, but PRISMA can also be used
as a basis for reporting systematic reviews of other types of research, particularly evaluations of
interventions. PRISMA may also be useful for critical appraisal of published systematic reviews,
although it is not a quality assessment instrument to gauge the quality of a systematic review. The
PRISMA Statement consists of a 27-item checklist and a 4-phase(category) flow
diagram."
The PRISMA Flow Diagram is a tool that can be used to record different stages of the
literature search process--across multiple resources--and clearly show how a researcher
went from, 'These are the databases I searched for my terms', to, 'These are the papers I'm
going to talk about'.

What is included in a PRISMA flow diagram?

A PRISMA flow diagram includes several elements and provides a visual representation of
the study selection process in a systematic review or meta-analysis. Blow are the key
components typically included in a PRISMA flow diagram:
1) Identification
The flow diagram starts with the initial number of records identified through various sources
such as literature databases, manual searches, or other means.

Flow diagram from: Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow
CD, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic
reviews. BMJ 2021;372:n71. doi: 10.1136/bmj.n71. For more information, visit:
http://www.prisma-statement.org/
2) Screening
It shows the number of records remaining after removing duplicates. This stage involves
screening the titles and abstracts of the identified records to assess their relevance to the
research question or objective.
3) Eligibility
The flow diagram indicates the number of studies that passed the initial screening and
proceeded to the next stage. At this stage, full-text articles of potentially relevant studies
are assessed against predetermined eligibility criteria.
4) Inclusion/Exclusion
It presents the number of studies included in the systematic review or meta-analysis. These
studies have met the predefined eligibility criteria and are considered suitable for further
analysis. The flow diagram highlights the number of studies excluded at different
stages and the reasons for their exclusion. Common reasons for exclusion include
irrelevance to the research question, inadequate study design, insufficient data, or
failure to meet specific inclusion criteria.

Flow diagram from: Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow
CD, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic
reviews. BMJ 2021;372:n71. doi: 10.1136/bmj.n71. For more information, visit:
http://www.prisma-statement.org/
5) Data Extraction
Depending on the study design and objectives, the flow diagram may include a stage for
data extraction, where the number of studies included for data extraction is recorded. Data
extraction involves extracting relevant information from the included studies, such as study
characteristics, outcomes, and effect sizes.
6) Synthesis
While not always included in the flow diagram, some flow diagrams may show the number
of studies included in the synthesis or analysis phase. This stage involves synthesizing the
findings of the included studies, often through statistical methods, to draw overall
conclusions.

Flow diagram from: Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow
CD, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic
reviews. BMJ 2021;372:n71. doi: 10.1136/bmj.n71. For more information, visit:
http://www.prisma-statement.org/

PRISMA flow diagram examples and templates

Examples of and templates for PRISMA flow diagrams can be found on the PRISMA
webpage.

PRISMA flow chart best practices

When creating a PRISMA flow diagram, it is important to follow certain best practices to
ensure accuracy, clarity, and adherence to the PRISMA guidelines.
Before creating the flow diagram, thoroughly read and understand the PRISMA guidelines.
Familiarize yourself with the recommended reporting items and the flow diagram structure
specified in the guidelines.
Avoid overcrowding the flow diagram with excessive text or unnecessary details. Use
concise and clear descriptions for each stage, ensuring that readers can easily follow the
flow of information.
Include the necessary information in each step of the flow chart. This typically includes the
number of studies or records at each stage (n= ), reasons for exclusion (if applicable), and
the final number of studies included in the analysis.
Use consistent terminology throughout the flow diagram. Ensure that the terms used in the
flow diagram match those used in the text.
If possible, provide detailed information on the reasons for excluding studies at each stage.
This can include specific eligibility criteria not met, study design limitations, or any other
relevant details that justify exclusion. However, be mindful of space constraints and the
need for readability.
Double-check the accuracy of the flow diagram by cross-referencing it with the study
selection process described in the text. Ensure that the flow diagram accurately represents
the steps taken and the number of studies at each stage.
If any changes occur during the review process (e.g., updated searches, additional
screening rounds), update the flow diagram accordingly to reflect the most current
information accurately.

Challenges with PRISMA flow diagrams

While PRISMA flow diagrams have several benefits, there are also some challenges
associated with their creation and interpretation. Here are some common challenges:

 Complexity of the study selection process: The study selection process in

systematic reviews or meta-analyses can be complex, involving multiple screening
rounds, eligibility criteria, and decision-making criteria. Representing this complexity
in a concise and clear flow diagram can be challenging, especially when dealing with
a large number of studies.
 Space constraints: Journals often have limitations on the space available for figures
and flow diagrams. PRISMA flow diagrams need to be designed to fit within these
limitations, which can make it difficult to include all relevant information and maintain
readability.
 Limited information in the flow diagram: PRISMA flow charts provide a summary
of the study selection process but may not capture all the details and nuances of the
inclusion and exclusion decisions. The flow diagram alone may not fully explain the
reasons behind each decision, which may require referring to the main text for more
comprehensive information.
 Evolving review process: Systematic reviews and meta-analyses can be iterative
processes, involving ongoing updates, additional searches, or changes in
inclusion/exclusion criteria. Keeping the flow diagram up to date with these changes
can be challenging, especially if multiple versions of the flow diagram exist.
 Interpretation challenges: Readers and reviewers may interpret the flow diagram
differently, leading to potential misunderstandings or misinterpretations. The flow
diagram should be designed and described in a way that minimizes ambiguity and
maximizes clarity.

The PRISMA concept

There are a few important things to note while formulating PRISMA. The PRISMA is
based on the 27-item quality checklist broadly divided into:

 Title,

 Abstract,

 Introduction,

 Methods,

 Results,

 Discussion and,

 Funds (Moher, 2013).

The PRISMA checklist

Sl. Level of
Section/topic Checklist item
No. importance

Identify the report as a systematic review, meta-analysis, or

Title 1 High
both, or the type of paper and the title scope.

Clarity of the study with; background, aim, methods used,

Abstract 2 High
findings, conclusion and other relevant information.

Introduction 3 Must have a rationale. High

4 Must mention the objectives of the study High

Methods 5 Protocol registration. Low

 6 Eligibility criteria mentioned. Moderate

7 Information sources or the data collection sources. High

8 Search strategies or the research paradigm/philosophy. Moderate

9 Study selection or the research approach. Moderate

10 Data collection process or the sample size. High

11 Data items. Moderate

12 Risk of bias in individual studies. Low

13 Summary measures or the tools of analysis High

14 Synthesis of results or the methods of analysis High

15 Risk of bias across studies Low

16 Additional analyses Low

Results 17 Study selection of the key findings High

18 Study characteristics or statistical presentations High

19 Risk of bias within studies Low

 Results of individual studies or graphs and tabular
20 High
presentations

21 Synthesis of results Low

22 Risk of bias across studies Low

23 Additional analysis Low

Discussion 24 Summary of evidence Moderate

25 Limitations High

26 Conclusions High

Funding 27 Information about funding or author conflict Low

It is not mandatory to use all the checklist items; however, the inclusion and exclusion
criteria are mostly based on the checklist items. The main role of the PRISMA checklist
is to identify the quality of the papers identified using search strategies and databases.
In addition, the flow chart of PRISMA is based on 4 (category)stages:
1. identification,
2. screening,
3. eligibility and,
4. included.
Preparing the PRISMA flowchart
1. Identify the total number of papers collected from different papers and mention the
sources.

2. Presenting the excluded and the included from the 1 st screening and mention the
reason for exclusion.
3. Again presenting the excluded papers while keeping in count that the number of
included papers now is n=2153. Check the eligibility of the papers elected on the basis
of the quality checklist items and present the reason for excluding the papers.

4. Repeat the step if needed where the number of papers included stands at 368.
5. Present the final number of papers included.

6. Include the eligibility and screening test again if the study further focuses on Meta-
analysis.