As a final step on the Scoring Instrument, Study Reviewers provide an assessment as to their overall confidence in the study design. If both Study Reviewers agree, and the Lead Researcher concurs, that there is a fundamental flaw in the study design (not captured in the Design Quality dimension) that raises serious concerns about the study’s results, the study is removed from the evidence base and not factored into the Evidence Rating. This final determination serves as an additional safeguard to ensure that only the most rigorous studies comprise the evidence base. The study citation will be listed among the program’s additional references. See Program Review and Rating from Start to Finish for more information.