Andrea Cipriani, PhD; Julian P.T. Higgins, PhD; John R. Geddes, MD; Georgia Salanti, PhD
Acknowledgment: The authors thank Anna Chaimani for her help and support in drafting Figure 3 and Appendix Figure 1.
Grant Support: By the European Research Council (grant 260559 IMMA; Dr. Salanti).
Potential Conflicts of Interest: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M12-3072.
Requests for Single Reprints: Andrea Cipriani, PhD, Department of Public Health and Community Medicine, University of Verona, Policlinico G.B. Rossi, Piazzale L.A. Scuro 10, 37134 Verona, Italy; e-mail, firstname.lastname@example.org.
Current Author Addresses: Dr. Cipriani: Department of Public Health and Community Medicine, University of Verona, Policlinico G.B. Rossi, Piazzale L.A. Scuro 10, 37134 Verona, Italy.
Dr. Higgins: School of Social and Community Medicine, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol BS8 2PS, United Kingdom.
Dr. Geddes: Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford OX3 7JX, United Kingdom.
Dr. Salanti: Department of Hygiene and Epidemiology, University of Ioannina School of Medicine, University Campus Ioannina, 45110 Ioannina, Greece.
Author Contributions: Conception and design: A. Cipriani, J.R. Geddes, G. Salanti.
Analysis and interpretation of the data: A. Cipriani, J.R. Geddes, G. Salanti.
Drafting of the article: A. Cipriani, J.P.T. Higgins, J.R. Geddes, G. Salanti.
Critical revision of the article for important intellectual content: J.P.T. Higgins, J.R. Geddes, G. Salanti.
Final approval of the article: J.P.T. Higgins, J.R. Geddes, G. Salanti.
Statistical expertise: J.P.T. Higgins, G. Salanti.
Collection and assembly of data: A. Cipriani, G. Salanti.
Cipriani A, Higgins JP, Geddes JR, Salanti G. Conceptual and Technical Challenges in Network Meta-analysis. Ann Intern Med. 2013;159:130-137. doi: 10.7326/0003-4819-159-2-201307160-00008
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Published: Ann Intern Med. 2013;159(2):130-137.
The increase in treatment options creates an urgent need for comparative effectiveness research. Randomized, controlled trials comparing several treatments are usually not feasible, so other methodological approaches are needed. Meta-analyses provide summary estimates of treatment effects by combining data from many studies. However, an important drawback is that standard meta-analyses can compare only 2 interventions at a time. A new meta-analytic technique, called network meta-analysis (or multiple treatments meta-analysis or mixed-treatment comparison), allows assessment of the relative effectiveness of several interventions, synthesizing evidence across a network of randomized trials. Despite the growing prevalence and influence of network meta-analysis in many fields of medicine, several issues need to be addressed when constructing one to avoid conclusions that are inaccurate, invalid, or not clearly justified. This article explores the scope and limitations of network meta-analysis and offers advice on dealing with heterogeneity, inconsistency, and potential sources of bias in the available evidence to increase awareness among physicians about some of the challenges in interpretation.
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