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Williams MJ, Vogel JP, Gallos ID, Ramson JA, Chou D, Oladapo OT. The use of network meta-analysis in updating WHO living maternal and perinatal health recommendations. BMJ Glob Health 2023; 8:e013109. [PMID: 38084476 PMCID: PMC10711830 DOI: 10.1136/bmjgh-2023-013109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 10/21/2023] [Indexed: 12/18/2023] Open
Abstract
Drawing on two recent examples of WHO living guidelines in maternal and perinatal health, this paper elucidates a pragmatic, stepwise approach to using network meta-analysis (NMA) in guideline development in the presence of multiple treatment options. NMA has important advantages. These include the ability to compare multiple interventions in a single coherent analysis, provide direct estimates of the relative effects of all available interventions, infer indirect effect estimates for interventions not directly compared and generate rankings of the available treatment options. It can be difficult to harness these advantages in the face of a lack of current guidance on using NMA evidence in guideline development, with several challenges emerging. Challenges include the choice of conceptual approach, the volume and complexity of the evidence, the contribution of treatment rankings, and the fact that the preferable treatment is not always obvious. This paper describes a layered approach to resolving these challenges, which supports systematic guideline decision-making and development of trustworthy clinical guidelines when multiple treatment options are available.
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Affiliation(s)
| | - Joshua P Vogel
- Maternal, Child and Adolescent Health Program, Burnet Institute, Melbourne, Victoria, Australia
| | - Ioannis D Gallos
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - Jenny A Ramson
- Maternal, Child and Adolescent Health Program, Burnet Institute, Melbourne, Victoria, Australia
| | - Doris Chou
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - Olufemi T Oladapo
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva, Switzerland
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Chiocchia V, Furukawa TA, Schneider-Thoma J, Siafis S, Cipriani A, Leucht S, Salanti G. Estimating and visualising the trade-off between benefits and harms on multiple clinical outcomes in network meta-analysis. Syst Rev 2023; 12:209. [PMID: 37951949 PMCID: PMC10638812 DOI: 10.1186/s13643-023-02376-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Accepted: 10/24/2023] [Indexed: 11/14/2023] Open
Abstract
BACKGROUND The relative treatment effects estimated from network meta-analysis can be employed to rank treatments from the most preferable to the least preferable option. These treatment hierarchies are typically based on ranking metrics calculated from a single outcome. Some approaches have been proposed in the literature to account for multiple outcomes and individual preferences, such as the coverage area inside a spie chart, that, however, does not account for a trade-off between efficacy and safety outcomes. We present the net-benefit standardised area within a spie chart, [Formula: see text] to explore the changes in treatment performance with different trade-offs between benefits and harms, according to a particular set of preferences. METHODS We combine the standardised areas within spie charts for efficacy and safety/acceptability outcomes with a value λ specifying the trade-off between benefits and harms. We derive absolute probabilities and convert outcomes on a scale between 0 and 1 for inclusion in the spie chart. RESULTS We illustrate how the treatments in three published network meta-analyses perform as the trade-off λ varies. The decrease of the [Formula: see text] quantity appears more pronounced for some drugs, e.g. haloperidol. Changes in treatment performance seem more frequent when SUCRA is employed as outcome measures in the spie charts. CONCLUSIONS [Formula: see text] should not be interpreted as a ranking metric but it is a simple approach that could help identify which treatment is preferable when multiple outcomes are of interest and trading-off between benefits and harms is important.
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Affiliation(s)
- Virginia Chiocchia
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland.
- Graduate School of Health Sciences, University of Bern, Bern, Switzerland.
| | - Toshi A Furukawa
- Department of Health Promotion and Human Behavior, Kyoto University Graduate School of Medicine/School of Public Health, Kyoto, Japan
| | - Johannes Schneider-Thoma
- Department of Psychiatry and Psychotherapy, School of Medicine, Technical University of Munich, Munich, Germany
| | - Spyridon Siafis
- Department of Psychiatry and Psychotherapy, School of Medicine, Technical University of Munich, Munich, Germany
| | - Andrea Cipriani
- Department of Psychiatry, University of Oxford, Oxford, UK
- Oxford Health NHS Foundation Trust, Warneford Hospital, Oxford, UK
- Oxford Precision Psychiatry Lab, Oxford Health Biomedical Research Centre, Oxford, UK
| | - Stefan Leucht
- Department of Psychiatry and Psychotherapy, School of Medicine, Technical University of Munich, Munich, Germany
| | - Georgia Salanti
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
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Yu DSF, Li PWC, Lin RSY, Kee F, Chiu A, Wu W. Effects of non-pharmacological interventions on loneliness among community-dwelling older adults: A systematic review, network meta-analysis, and meta-regression. Int J Nurs Stud 2023; 144:104524. [PMID: 37295285 DOI: 10.1016/j.ijnurstu.2023.104524] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Revised: 05/05/2023] [Accepted: 05/09/2023] [Indexed: 06/12/2023]
Abstract
BACKGROUND The highly prevalent late-life loneliness, together with its deleterious health impacts, calls for increasing attention to the need for effective interventions targeting on this growing public health problem. With the increasing evidence on interventions for combating loneliness, it is timely to identify their comparative effectiveness. OBJECTIVE This systematic review, meta-analysis and network meta-analysis was to identify and compare the effects of various non-pharmacological interventions on loneliness in community-dwelling older adults. METHODS Systematic search was conducted in nine electronic databases from inception to 30th March 2023 for studies investigating the effects of non-pharmacological interventions on loneliness among community-dwelling older adults. The interventions were categorized according to the nature and purpose of use. Pairwise meta-analysis and network meta-analyses were sequentially performed to identify the effects of each category of interventions and their comparative intervention effectiveness, respectively. Meta-regression was performed to examine any influence of study design and participants' characteristics on the intervention effectiveness. The study protocol was registered at PROSPERO (CRD42022307621). RESULTS A total of 60 studies with 13,295 participants were included. The interventions were categorized as psychological interventions, social support interventions (by digital and non-digital means), behavioral activation, exercise intervention with and without social engagement, multi-component intervention and health promotion. Pairwise meta-analysis identified the positive effect of psychological interventions (Hedges' g = -2.33; 95%CI [-4.40, -0.25]; Z = -2.20, p = 0.003), non-digital social support interventions (Hedges' g = -0.63; 95%CI [-1.16, -0.10]; Z = 2.33, p = 0.02) and multi-component interventions (Hedges' g = -0.28 95%CI [-0.54, -0.03]; Z = -2.15, p = 0.03) on reducing loneliness. Subgroup analysis provided additional insights: i) social support and exercise interventions which integrated active strategies to optimize the social engagement demonstrated more promising intervention effects; ii) behavioral activation and multicomponent interventions worked better for older adults who were male or reported loneliness, respectively, and iii) counseling-based psychological interventions was more effective than mind-body practice. Network meta-analysis consistently pointed to the greatest therapeutic benefits of psychological interventions, and this was followed by exercise-based interventions, non-digital social support interventions and behavioral activation. Meta-regression further suggested that the therapeutic effects of the tested interventions were independent of the various factors relating to study design and participants' characteristics. CONCLUSIONS This review highlights the more superior effects of psychological interventions in improving loneliness among older adults. Interventions which have an attribute to optimize social dynamic and connectivity may also be effective. TWEETABLE ABSTRACT Psychological intervention is the best to beat late-life loneliness, but increasing social dynamic and connectivity may add an impact.
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Affiliation(s)
- Doris Sau-Fung Yu
- School of Nursing, Li Ka Shing Faculty of Medicine, the University of Hong Kong, Hong Kong.
| | - Polly Wai-Chi Li
- School of Nursing, Li Ka Shing Faculty of Medicine, the University of Hong Kong, Hong Kong
| | - Rose Sin-Yi Lin
- School of Nursing, University of Rochester, United States of America
| | - Frank Kee
- School of Medicine, Dentistry and Biomedical Sciences, Centre for Public Health, Queen's University Belfast, United Kingdom of Great Britain and Northern Ireland
| | - Alice Chiu
- Improving Health Outcomes Together Team, Alberta Health Services, Calgary, Alberta, Canada
| | - Wendy Wu
- School of Nursing, Li Ka Shing Faculty of Medicine, the University of Hong Kong, Hong Kong
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Duan R, Tong J, Sutton AJ, Asch DA, Chu H, Schmid CH, Chen Y. Origami plot: a novel multivariate data visualization tool that improves radar chart. J Clin Epidemiol 2023; 156:85-94. [PMID: 36822444 PMCID: PMC10599795 DOI: 10.1016/j.jclinepi.2023.02.020] [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: 09/20/2022] [Revised: 02/07/2023] [Accepted: 02/15/2023] [Indexed: 02/23/2023]
Abstract
OBJECTIVES We propose the origami plot, which maintains the original functionality of a radar chart and avoids potential misuse of its connected regions, with newly added features to better assist multicriteria decision-making. STUDY DESIGN AND SETTING Built upon a radar chart, the origami plot adds additional auxiliary axes and points such that the area of the connected region of all dots is invariant to the ordering of axes. As such, it enables ranking different individuals by the overall performance for multicriteria decision-making while maintaining the intuitive visual appeal of the radar chart. We develop extensions of the origami plot, including the weighted origami plot, which allows reweighting of each attribute to define the overall performance, and the pairwise origami plot, which highlights comparisons between two individuals. RESULTS We illustrate the different versions of origami plots using the hospital compare database developed by the Centers for Medicare & Medicaid Services (CMS). The plot shows individual hospital's performance on mortality, readmission, complication, and infection, as well as patient experience and timely and effective care, as well as their overall performance across these metrics. The weighted origami plot allows weighing the attributes differently when some are more important than others. We illustrate the potential use of the pairwise origami plot in electronic health records (EHR) system to monitor five clinical measures (body mass index [BMI]), fasting glucose level, blood pressure, triglycerides, and low-density lipoprotein ([LDL] cholesterol) of a patient across multiple hospital visits. CONCLUSION The origami plot is a useful visualization tool to assist multicriteria decision making. It improves radar charts by avoiding potential misuse of the connected regions. It has several new features and allows flexible customization.
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Affiliation(s)
- Rui Duan
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA, USA.
| | - Jiayi Tong
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Philadelphia, PA, USA
| | - Alex J Sutton
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - David A Asch
- Division of General Internal Medicine, University of Pennsylvania, Philadelphia, PA, USA; Leonard Davis Institute of Health Economics, Philadelphia, PA, USA
| | - Haitao Chu
- Division of Biostatistics, University of Minnesota, Minneapolis, MN, USA; Statistical Research and Innovation, Global Biometrics and Data Management, Pfizer Inc., New York, NY, USA
| | | | - Yong Chen
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Philadelphia, PA, USA; Leonard Davis Institute of Health Economics, Philadelphia, PA, USA.
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Ostinelli EG, Efthimiou O, Naci H, Furukawa TA, Leucht S, Salanti G, Wainwright L, Zangani C, De Crescenzo F, Smith K, Stevens K, Liu Q, Cipriani A. Vitruvian plot: a visualisation tool for multiple outcomes in network meta-analysis. EVIDENCE-BASED MENTAL HEALTH 2022; 25:e65-e70. [PMID: 35613849 PMCID: PMC9811072 DOI: 10.1136/ebmental-2022-300457] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Accepted: 05/10/2022] [Indexed: 01/17/2023]
Abstract
OBJECTIVE A network meta-analysis (NMA) usually assesses multiple outcomes across several treatment comparisons. The Vitruvian plot aims to facilitate communication of multiple outcomes from NMAs to patients and clinicians. METHODS We developed this tool following the recommendations on the communication of benefit-risk information from the available literature. We collected and implemented feedback from researchers, statisticians, methodologists, clinicians and people with lived experience of physical and mental health issues. RESULTS We present the Vitruvian plot, which graphically presents absolute estimates and relative performance of competing interventions against a common comparator for several outcomes of interest. We use two alternative colour schemes to highlight either the strength of statistical evidence or the confidence in the evidence. Confidence in the evidence is evaluated across six domains (within-study bias, reporting bias, indirectness, imprecision, heterogeneity and incoherence) using the Confidence in Network Meta-Analysis (CINeMA) system. CONCLUSIONS The Vitruvian plot allows reporting of multiple outcomes from NMAs, with colourings appropriate to inform credibility of the presented evidence.
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Affiliation(s)
- Edoardo Giuseppe Ostinelli
- Department of Psychiatry, University of Oxford, Oxford, UK,Oxford Precision Psychiatry Lab, NIHR Oxford Health Biomedical Research Centre, Oxford, UK,Oxford Health NHS Foundation Trust, Warneford Hospital, Oxford, UK
| | - Orestis Efthimiou
- Department of Psychiatry, University of Oxford, Oxford, UK,Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland,Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Huseyin Naci
- Department of Health Policy, London School of Economics and Political Science, London, UK
| | - Toshi A Furukawa
- Department of Health Promotion and Human Behavior, School of Public Health, Kyoto, Japan
| | - Stefan Leucht
- Department of Psychiatry and Psychotherapy, Technical University of Munich, Munchen, Germany
| | - Georgia Salanti
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Laurence Wainwright
- Oxford Precision Psychiatry Lab, NIHR Oxford Health Biomedical Research Centre, Oxford, UK
| | - Caroline Zangani
- Department of Psychiatry, University of Oxford, Oxford, UK,Oxford Precision Psychiatry Lab, NIHR Oxford Health Biomedical Research Centre, Oxford, UK,Oxford Health NHS Foundation Trust, Warneford Hospital, Oxford, UK
| | - Franco De Crescenzo
- Department of Psychiatry, University of Oxford, Oxford, UK,Oxford Precision Psychiatry Lab, NIHR Oxford Health Biomedical Research Centre, Oxford, UK
| | - Katharine Smith
- Department of Psychiatry, University of Oxford, Oxford, UK,Oxford Precision Psychiatry Lab, NIHR Oxford Health Biomedical Research Centre, Oxford, UK,Oxford Health NHS Foundation Trust, Warneford Hospital, Oxford, UK
| | - Katherine Stevens
- Oxford Precision Psychiatry Lab, NIHR Oxford Health Biomedical Research Centre, Oxford, UK
| | - Qiang Liu
- Department of Psychiatry, University of Oxford, Oxford, UK,Oxford Precision Psychiatry Lab, NIHR Oxford Health Biomedical Research Centre, Oxford, UK
| | - Andrea Cipriani
- Department of Psychiatry, University of Oxford, Oxford, UK,Oxford Precision Psychiatry Lab, NIHR Oxford Health Biomedical Research Centre, Oxford, UK,Oxford Health NHS Foundation Trust, Warneford Hospital, Oxford, UK
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Phillips MR, Sadeghirad B, Busse JW, Brignardello-Petersen R, Cuello-Garcia CA, Kenji Nampo F, Guo YJ, Bzovsky S, Bannuru RR, Thabane L, Bhandari M, Guyatt GH. Development and design validation of a novel network meta-analysis presentation tool for multiple outcomes: a qualitative descriptive study. BMJ Open 2022; 12:e056400. [PMID: 35688599 PMCID: PMC9189833 DOI: 10.1136/bmjopen-2021-056400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE The Grades of Recommendations, Assessment, Development and Evaluation working group recently developed an innovative approach to interpreting results from network meta-analyses (NMA) through minimally and partially contextualised methods; however, the optimal method for presenting results for multiple outcomes using this approach remains uncertain. We; therefore, developed and iteratively modified a presentation method that effectively summarises NMA results of multiple outcomes for clinicians using this new interpretation approach. DESIGN Qualitative descriptive study. SETTING A steering group of seven individuals with experience in NMA and design validation studies developed two colour-coded presentation formats for evaluation. Through an iterative process, we assessed the validity of both formats to maximise their clarity and ease of interpretation. PARTICIPANTS 26 participants including 20 clinicians who routinely provide patient care, 3 research staff/research methodologists and 3 residents. MAIN OUTCOME MEASURES Two team members used qualitative content analysis to independently analyse transcripts of all interviews. The steering group reviewed the analyses and responded with serial modifications of the presentation format. RESULTS To ensure that readers could easily discern the benefits and safety of each included treatment across all assessed outcomes, participants primarily focused on simple information presentations, with intuitive organisational decisions and colour coding. Feedback ultimately resulted in two presentation versions, each preferred by a substantial group of participants, and development of a legend to facilitate interpretation. CONCLUSION Iterative design validation facilitated the development of two novel formats for presenting minimally or partially contextualised NMA results for multiple outcomes. These presentation approaches appeal to audiences that include clinicians with limited familiarity with NMAs.
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Affiliation(s)
- Mark R Phillips
- Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Behnam Sadeghirad
- Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Anesthesia, McMaster University, Hamilton, Ontario, Canada
| | - Jason W Busse
- Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Anesthesia, McMaster University, Hamilton, Ontario, Canada
| | | | - Carlos A Cuello-Garcia
- Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Fernando Kenji Nampo
- Department of Latin-American Institute of Life and Nature science, Federal University of Latin-American Integration, Foz do Iguacu, Brazil
| | - Yu Jia Guo
- Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Sofia Bzovsky
- Department of Surgery - Division of Orthopaedics, McMaster University, Hamilton, Ontario, Canada
| | - Raveendhara R Bannuru
- Center for Treatment Comparison and Integrative Analysis, Tufts Medical Center, Boston, Massachusetts, USA
| | - Lehana Thabane
- Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Biostatistics Unit, St. Joseph's Healthcare, Hamilton, Ontario, Canada
| | - Mohit Bhandari
- Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Division of Orthopaedic Surgery, Mcmaster University, Hamilton, Ontario, Canada
| | - Gordon H Guyatt
- Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
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Chiocchia V, White IR, Salanti G. The complexity underlying treatment rankings: how to use them and what to look at. BMJ Evid Based Med 2022; 28:180-182. [PMID: 35501121 DOI: 10.1136/bmjebm-2021-111904] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/23/2022] [Indexed: 11/04/2022]
Affiliation(s)
- Virginia Chiocchia
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
- Graduate School of Health Sciences, University of Bern, Bern, Switzerland
| | - Ian R White
- Medical Research Council Clinical Trials Unit, University College London, London, UK
| | - Georgia Salanti
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
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