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Hamza T, Schwarzer G, Salanti G. crossnma: An R package to synthesize cross-design evidence and cross-format data using network meta-analysis and network meta-regression. BMC Med Res Methodol 2024; 24:169. [PMID: 39103781 DOI: 10.1186/s12874-023-02130-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Accepted: 12/19/2023] [Indexed: 08/07/2024] Open
Abstract
BACKGROUND Although aggregate data (AD) from randomised clinical trials (RCTs) are used in the majority of network meta-analyses (NMAs), other study designs (e.g., cohort studies and other non-randomised studies, NRS) can be informative about relative treatment effects. The individual participant data (IPD) of the study, when available, are preferred to AD for adjusting for important participant characteristics and to better handle heterogeneity and inconsistency in the network. RESULTS We developed the R package crossnma to perform cross-format (IPD and AD) and cross-design (RCT and NRS) NMA and network meta-regression (NMR). The models are implemented as Bayesian three-level hierarchical models using Just Another Gibbs Sampler (JAGS) software within the R environment. The R package crossnma includes functions to automatically create the JAGS model, reformat the data (based on user input), assess convergence and summarize the results. We demonstrate the workflow within crossnma by using a network of six trials comparing four treatments. CONCLUSIONS The R package crossnma enables the user to perform NMA and NMR with different data types in a Bayesian framework and facilitates the inclusion of all types of evidence recognising differences in risk of bias.
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Affiliation(s)
- Tasnim Hamza
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland.
- Graduate School for Health Sciences, University of Bern, Bern, Switzerland.
| | - Guido Schwarzer
- Institute of Medical Biometry and Statistics, Faculty of Medicine and Medical Center, University of Freiburg, Freiburg, Germany
| | - Georgia Salanti
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
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Ades AE, Welton NJ, Dias S, Phillippo DM, Caldwell DM. Twenty years of network meta-analysis: Continuing controversies and recent developments. Res Synth Methods 2024. [PMID: 38234221 DOI: 10.1002/jrsm.1700] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 12/15/2023] [Accepted: 12/18/2023] [Indexed: 01/19/2024]
Abstract
Network meta-analysis (NMA) is an extension of pairwise meta-analysis (PMA) which combines evidence from trials on multiple treatments in connected networks. NMA delivers internally consistent estimates of relative treatment efficacy, needed for rational decision making. Over its first 20 years NMA's use has grown exponentially, with applications in both health technology assessment (HTA), primarily re-imbursement decisions and clinical guideline development, and clinical research publications. This has been a period of transition in meta-analysis, first from its roots in educational and social psychology, where large heterogeneous datasets could be explored to find effect modifiers, to smaller pairwise meta-analyses in clinical medicine on average with less than six studies. This has been followed by narrowly-focused estimation of the effects of specific treatments at specific doses in specific populations in sparse networks, where direct comparisons are unavailable or informed by only one or two studies. NMA is a powerful and well-established technique but, in spite of the exponential increase in applications, doubts about the reliability and validity of NMA persist. Here we outline the continuing controversies, and review some recent developments. We suggest that heterogeneity should be minimized, as it poses a threat to the reliability of NMA which has not been fully appreciated, perhaps because it has not been seen as a problem in PMA. More research is needed on the extent of heterogeneity and inconsistency in datasets used for decision making, on formal methods for making recommendations based on NMA, and on the further development of multi-level network meta-regression.
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Affiliation(s)
- A E Ades
- Population Health Sciences, Bristol Medical School, Bristol, UK
| | - Nicky J Welton
- Population Health Sciences, Bristol Medical School, Bristol, UK
| | - Sofia Dias
- Centre for Reviews and Dissemination, University of York, York, UK
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Yao M, Wang Y, Ren Y, Jia Y, Zou K, Li L, Sun X. Comparison of statistical methods for integrating real-world evidence in a rare events meta-analysis of randomized controlled trials. Res Synth Methods 2023; 14:689-706. [PMID: 37309821 DOI: 10.1002/jrsm.1648] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2022] [Revised: 04/27/2023] [Accepted: 05/06/2023] [Indexed: 06/14/2023]
Abstract
Rare events meta-analyses of randomized controlled trials (RCTs) are often underpowered because the outcomes are infrequent. Real-world evidence (RWE) from non-randomized studies may provide valuable complementary evidence about the effects of rare events, and there is growing interest in including such evidence in the decision-making process. Several methods for combining RCTs and RWE studies have been proposed, but the comparative performance of these methods is not well understood. We describe a simulation study that aims to evaluate an array of alternative Bayesian methods for including RWE in rare events meta-analysis of RCTs: the naïve data synthesis, the design-adjusted synthesis, the use of RWE as prior information, the three-level hierarchical models, and the bias-corrected meta-analysis model. The percentage bias, root-mean-square-error, mean 95% credible interval width, coverage probability, and power are used to measure performance. The various methods are illustrated using a systematic review to evaluate the risk of diabetic ketoacidosis among patients using sodium/glucose co-transporter 2 inhibitors as compared with active-comparators. Our simulations show that the bias-corrected meta-analysis model is comparable to or better than the other methods in terms of all evaluated performance measures and simulation scenarios. Our results also demonstrate that data solely from RCTs may not be sufficiently reliable for assessing the effects of rare events. In summary, the inclusion of RWE could increase the certainty and comprehensiveness of the body of evidence of rare events from RCTs, and the bias-corrected meta-analysis model may be preferable.
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Affiliation(s)
- Minghong Yao
- Institute of Integrated Traditional Chinese and Western Medicine and Chinese Evidence-Based Medicine Center and Cochrane China Center and MAGIC China Center, West China Hospital, Sichuan University, Chengdu, China
- NMPA Key Laboratory for Real World Data Research and Evaluation in Hainan, West China Hospital, Sichuan University, Chengdu, China
- Sichuan Center of Technology Innovation for Real World Data, West China Hospital, Sichuan Univertisy, Chengdu, China
| | - Yuning Wang
- Institute of Integrated Traditional Chinese and Western Medicine and Chinese Evidence-Based Medicine Center and Cochrane China Center and MAGIC China Center, West China Hospital, Sichuan University, Chengdu, China
- NMPA Key Laboratory for Real World Data Research and Evaluation in Hainan, West China Hospital, Sichuan University, Chengdu, China
- Sichuan Center of Technology Innovation for Real World Data, West China Hospital, Sichuan Univertisy, Chengdu, China
| | - Yan Ren
- Institute of Integrated Traditional Chinese and Western Medicine and Chinese Evidence-Based Medicine Center and Cochrane China Center and MAGIC China Center, West China Hospital, Sichuan University, Chengdu, China
- NMPA Key Laboratory for Real World Data Research and Evaluation in Hainan, West China Hospital, Sichuan University, Chengdu, China
- Sichuan Center of Technology Innovation for Real World Data, West China Hospital, Sichuan Univertisy, Chengdu, China
| | - Yulong Jia
- Institute of Integrated Traditional Chinese and Western Medicine and Chinese Evidence-Based Medicine Center and Cochrane China Center and MAGIC China Center, West China Hospital, Sichuan University, Chengdu, China
- NMPA Key Laboratory for Real World Data Research and Evaluation in Hainan, West China Hospital, Sichuan University, Chengdu, China
- Sichuan Center of Technology Innovation for Real World Data, West China Hospital, Sichuan Univertisy, Chengdu, China
| | - Kang Zou
- Institute of Integrated Traditional Chinese and Western Medicine and Chinese Evidence-Based Medicine Center and Cochrane China Center and MAGIC China Center, West China Hospital, Sichuan University, Chengdu, China
- NMPA Key Laboratory for Real World Data Research and Evaluation in Hainan, West China Hospital, Sichuan University, Chengdu, China
- Sichuan Center of Technology Innovation for Real World Data, West China Hospital, Sichuan Univertisy, Chengdu, China
| | - Ling Li
- Institute of Integrated Traditional Chinese and Western Medicine and Chinese Evidence-Based Medicine Center and Cochrane China Center and MAGIC China Center, West China Hospital, Sichuan University, Chengdu, China
- NMPA Key Laboratory for Real World Data Research and Evaluation in Hainan, West China Hospital, Sichuan University, Chengdu, China
- Sichuan Center of Technology Innovation for Real World Data, West China Hospital, Sichuan Univertisy, Chengdu, China
| | - Xin Sun
- Institute of Integrated Traditional Chinese and Western Medicine and Chinese Evidence-Based Medicine Center and Cochrane China Center and MAGIC China Center, West China Hospital, Sichuan University, Chengdu, China
- NMPA Key Laboratory for Real World Data Research and Evaluation in Hainan, West China Hospital, Sichuan University, Chengdu, China
- Sichuan Center of Technology Innovation for Real World Data, West China Hospital, Sichuan Univertisy, Chengdu, China
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Hamza T, Chalkou K, Pellegrini F, Kuhle J, Benkert P, Lorscheider J, Zecca C, Iglesias-Urrutia CP, Manca A, Furukawa TA, Cipriani A, Salanti G. Synthesizing cross-design evidence and cross-format data using network meta-regression. Res Synth Methods 2023; 14:283-300. [PMID: 36625736 DOI: 10.1002/jrsm.1619] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 10/28/2022] [Accepted: 12/01/2022] [Indexed: 01/11/2023]
Abstract
In network meta-analysis (NMA), we synthesize all relevant evidence about health outcomes with competing treatments. The evidence may come from randomized clinical trials (RCT) or non-randomized studies (NRS) as individual participant data (IPD) or as aggregate data (AD). We present a suite of Bayesian NMA and network meta-regression (NMR) models allowing for cross-design and cross-format synthesis. The models integrate a three-level hierarchical model for synthesizing IPD and AD into four approaches. The four approaches account for differences in the design and risk of bias (RoB) in the RCT and NRS evidence. These four approaches variously ignoring differences in RoB, using NRS to construct penalized treatment effect priors and bias-adjustment models that control the contribution of information from high RoB studies in two different ways. We illustrate the methods in a network of three pharmacological interventions and placebo for patients with relapsing-remitting multiple sclerosis. The estimated relative treatment effects do not change much when we accounted for differences in design and RoB. Conducting network meta-regression showed that intervention efficacy decreases with increasing participant age. We also re-analysed a network of 431 RCT comparing 21 antidepressants, and we did not observe material changes in intervention efficacy when adjusting for studies' high RoB. We re-analysed both case studies accounting for different study RoB. In summary, the described suite of NMA/NMR models enables the inclusion of all relevant evidence while incorporating information on the within-study bias in both observational and experimental data and enabling estimation of individualized treatment effects through the inclusion of participant characteristics.
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Affiliation(s)
- Tasnim Hamza
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland.,Graduate School for Health Sciences, University of Bern, Bern, Switzerland
| | - Konstantina Chalkou
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland.,Graduate School for Health Sciences, University of Bern, Bern, Switzerland
| | | | - Jens Kuhle
- Department of Neurology, University Hospital Basel, University of Basel, Basel, Switzerland.,Departments of Biomedicine and Clinical Research, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Pascal Benkert
- Department of Clinical Research, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Johannes Lorscheider
- Departments of Biomedicine and Clinical Research, University Hospital Basel, University of Basel, Basel, Switzerland.,Research Center for Clinical Neuroimmunology and Neuroscience Basel (RC2NB), University Hospital Basel, University of Basel, Basel, Switzerland
| | - Chiara Zecca
- Multiple Sclerosis Center, Neurocenter of Southern Switzerland, EOC, Lugano, Switzerland.,Faculty of Biomedical Sciences, Università della Svizzera Italiana, Lugano, Switzerland
| | | | - Andrea Manca
- Centre for Health Economics, University of York, York, UK
| | - Toshi A Furukawa
- Department of Health Promotion and Human Behavior, Graduate School of Medicine/School of Public Health, Kyoto University, Kyoto, Japan.,Department of Clinical Epidemiology, Graduate School of Medicine/School of Public Health, Kyoto University, Kyoto, Japan
| | - Andrea Cipriani
- Department of Psychiatry, University of Oxford, Oxford, UK.,Oxford Health NHS Foundation Trust, Warneford Hospital, Oxford, UK
| | - Georgia Salanti
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
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Yao M, Wang Y, Mei F, Zou K, Li L, Sun X. Methods for the Inclusion of Real-World Evidence in a Rare Events Meta-Analysis of Randomized Controlled Trials. J Clin Med 2023; 12:jcm12041690. [PMID: 36836227 PMCID: PMC9964527 DOI: 10.3390/jcm12041690] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Revised: 02/10/2023] [Accepted: 02/17/2023] [Indexed: 02/22/2023] Open
Abstract
BACKGROUND Many rare events meta-analyses of randomized controlled trials (RCTs) have lower statistical power, and real-world evidence (RWE) is becoming widely recognized as a valuable source of evidence. The purpose of this study is to investigate methods for including RWE in a rare events meta-analysis of RCTs and the impact on the level of uncertainty around the estimates. METHODS Four methods for the inclusion of RWE in evidence synthesis were investigated by applying them to two previously published rare events meta-analyses: the naïve data synthesis (NDS), the design-adjusted synthesis (DAS), the use of RWE as prior information (RPI), and the three-level hierarchical models (THMs). We gauged the effect of the inclusion of RWE by varying the degree of confidence placed in RWE. RESULTS This study showed that the inclusion of RWE in a rare events meta-analysis of RCTs could increase the precision of the estimates, but this depended on the method of inclusion and the level of confidence placed in RWE. NDS cannot consider the bias of RWE, and its results may be misleading. DAS resulted in stable estimates for the two examples, regardless of whether we placed high- or low-level confidence in RWE. The results of the RPI approach were sensitive to the confidence level placed in RWE. The THM was effective in allowing for accommodating differences between study types, while it had a conservative result compared with other methods. CONCLUSION The inclusion of RWE in a rare events meta-analysis of RCTs could increase the level of certainty of the estimates and enhance the decision-making process. DAS might be appropriate for inclusion of RWE in a rare event meta-analysis of RCTs, but further evaluation in different scenarios of empirical or simulation studies is still warranted.
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Affiliation(s)
- Minghong Yao
- Chinese Evidence-Based Medicine Center and MAGIC China Center, West China Hospital, Sichuan University, Chengdu 610041, China
- NMPA Key Laboratory for Real World Data Research and Evaluation in Hainan, Chengdu 610041, China
- Sichuan Center of Technology Innovation for Real World Data, Chengdu 610041, China
| | - Yuning Wang
- Chinese Evidence-Based Medicine Center and MAGIC China Center, West China Hospital, Sichuan University, Chengdu 610041, China
- NMPA Key Laboratory for Real World Data Research and Evaluation in Hainan, Chengdu 610041, China
- Sichuan Center of Technology Innovation for Real World Data, Chengdu 610041, China
| | - Fan Mei
- Chinese Evidence-Based Medicine Center and MAGIC China Center, West China Hospital, Sichuan University, Chengdu 610041, China
- NMPA Key Laboratory for Real World Data Research and Evaluation in Hainan, Chengdu 610041, China
- Sichuan Center of Technology Innovation for Real World Data, Chengdu 610041, China
| | - Kang Zou
- Chinese Evidence-Based Medicine Center and MAGIC China Center, West China Hospital, Sichuan University, Chengdu 610041, China
- NMPA Key Laboratory for Real World Data Research and Evaluation in Hainan, Chengdu 610041, China
- Sichuan Center of Technology Innovation for Real World Data, Chengdu 610041, China
| | - Ling Li
- Chinese Evidence-Based Medicine Center and MAGIC China Center, West China Hospital, Sichuan University, Chengdu 610041, China
- NMPA Key Laboratory for Real World Data Research and Evaluation in Hainan, Chengdu 610041, China
- Sichuan Center of Technology Innovation for Real World Data, Chengdu 610041, China
- Correspondence: (L.L.); (X.S.); Tel.: +86-02885164187 (L.L.)
| | - Xin Sun
- Chinese Evidence-Based Medicine Center and MAGIC China Center, West China Hospital, Sichuan University, Chengdu 610041, China
- NMPA Key Laboratory for Real World Data Research and Evaluation in Hainan, Chengdu 610041, China
- Sichuan Center of Technology Innovation for Real World Data, Chengdu 610041, China
- Correspondence: (L.L.); (X.S.); Tel.: +86-02885164187 (L.L.)
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Lack of Efficacy of Bone Void Filling Materials in Medial Opening-Wedge High Tibial Osteotomy: A Systematic Review and Network Meta-Analysis. Arthroscopy 2022:S0749-8063(22)00835-0. [PMID: 36581002 DOI: 10.1016/j.arthro.2022.11.039] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Revised: 11/22/2022] [Accepted: 11/30/2022] [Indexed: 12/27/2022]
Abstract
PURPOSE To systematically review the clinical and radiologic outcomes of isolated medial opening-wedge high tibial osteotomies with different bone void filling materials and to compare the outcomes by network meta-analysis. METHODS This systematic review and network meta-analysis included searches of Medline, Embase, Cochrane Library, Web of Science, and Scopus from inception to July 30, 2022, for clinical comparative studies comparing 2 or more bone void filling materials in patients undergoing medial opening-wedge high tibial osteotomies. We performed Bayesian random-effect network meta-analyses to summarize the evidence and applied the Grading of Recommendations Assessment, Development, and Evaluation frameworks to rate the certainty of evidence, calculate the absolute effects, and present the findings. Cochrane Risk of Bias Tool 2.0 and modified Newcastle-Ottawa Scale were used to assess the risk of bias. RESULTS In total, 2,755 citations were identified by our search, of which 25 eligible trials, including 10 randomized controlled trials and 15 nonrandomized comparative trials (NCTs) enrolled 1,420 participants and 6 different interventions (autografts, allografts, synthetic grafts, mixed grafts, xenografts, and without grafts). There were some concerns on the risk of bias assessment among randomized controlled trials, and the median Newcastle-Ottawa Scale score was 6 for NCTs. All fillers showed no significantly superior treatment effects when compared with unfilled group in final Knee Society Scoring, Western Ontario and McMasters Universities score, time to bone union (TBU), and loss of correction (LOC). Exceptionally, moderate-certainty evidence suggested that autograft would produce superior incidence of complete bone union (CBU) than the unfilled at postoperative 1 year (odds ratio [OR] 13.0, 95% confidence interval [CI] 1.60-95.6), whereas low- to very low-certainty evidence suggested allografts (OR 0.2, 95% CI 0.06-0.52) and synthetic grafts (OR 0.29, 95% CI 0.10-0.68) would result in inferior CBU. Low-certainty evidence suggested allografts would result in larger LOC angle than unfilled group (mean difference 1.1, 95% CI 0.1-2.3). As for TBU, low-certainty evidence suggested mixed grafts would take longer time to reach clinical bone union (mean difference -14.04, 95% CI -21.0 to -6.9). CONCLUSIONS There is a lack of efficacy for different bone void filling materials to result better outcomes in Knee Society Scoring, Western Ontario and McMasters Universities score, TBU, and LOC than without graft. Although applying the autografts would produce a superior possibility of radiologic CBU than other fillers, because of the inclusion of NCTs, the overall certainty of the evidence synthesis is low. LEVEL OF EVIDENCE Level Ⅲ, meta-analysis of Level I randomized controlled trials and Level Ⅱ∼Ⅲ non-randomized comparative trails.
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Shin IS, Rim CH. Stepwise-Hierarchical Pooled Analysis for Synergistic Interpretation of Meta-analyses Involving Randomized and Observational Studies: Methodology Development. J Med Internet Res 2021; 23:e29642. [PMID: 34315697 PMCID: PMC8446840 DOI: 10.2196/29642] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Revised: 06/09/2021] [Accepted: 07/27/2021] [Indexed: 12/28/2022] Open
Abstract
Background The necessity of including observational studies in meta-analyses has been discussed in the literature, but a synergistic analysis method for combining randomized and observational studies has not been reported. Observational studies differ in validity depending on the degree of the confounders’ influence. Combining interpretations may be challenging, especially if the statistical directions are similar but the magnitude of the pooled results are different between randomized and observational studies (the ”gray zone”). Objective To overcome these hindrances, in this study, we aim to introduce a logical method for clinical interpretation of randomized and observational studies. Methods We designed a stepwise-hierarchical pooled analysis method to analyze both distribution trends and individual pooled results by dividing the included studies into at least three stages (eg, all studies, balanced studies, and randomized studies). Results According to the model, the validity of a hypothesis is mostly based on the pooled results of randomized studies (the highest stage). Ascending patterns in which effect size and statistical significance increase gradually with stage strengthen the validity of the hypothesis; in this case, the effect size of the observational studies is lower than that of the true effect (eg, because of the uncontrolled effect of negative confounders). Descending patterns in which decreasing effect size and statistical significance gradually weaken the validity of the hypothesis suggest that the effect size and statistical significance of the observational studies is larger than the true effect (eg, because of researchers’ bias). Conclusions We recommend using the stepwise-hierarchical pooled analysis approach for meta-analyses involving randomized and observational studies.
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Affiliation(s)
- In-Soo Shin
- Graduate School of Education, Dongguk University, Seoul, Republic of Korea
| | - Chai Hong Rim
- Department of Radiation Oncology, Ansan Hospital, Korea University, Gyeonggido, Republic of Korea
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