Meta-analyses that combine the results of multiple randomized clinical trials (RCTs) are considered to provide the gold standard with regard to scientific evidence. Unfortunately, RCTs are not feasible, practical, or ethical to evaluate interventions for most medical and surgical research topics. Observational studies are the most common type of study design used in clinical research, and nearly two-thirds of published systematic reviews include evidence from cohort, case-control, and/or cross-sectional studies.^1,2 These types of study designs are particularly relied on to evaluate the safety or effectiveness of surgical interventions in real-world practice, identify and summarize rare adverse events, and include more clinically heterogenous patient populations. While it is estimated that more than 90% of surgical evidence is generated from observational data, nonetheless, the quality of these studies can vary more widely when compared with RCTs.³