Benjamin Rouse, MHS; Andrea Cipriani, MD, PhD; Qiyuan Shi, MHS; Anne L. Coleman, MD, PhD; Kay Dickersin, MA, PhD; Tianjing Li, MD, MHS, PhD
Acknowledgment: The authors thank Laurie Bagley for providing the 1989–2006 versions of the American Academy of Ophthalmology's Primary Open Angle Glaucoma Preferred Practice Patterns; Hwanhee Hong for her help in developing the models used in this study; Alfred Sommer for providing information about the history of the Primary Open-Angle Glaucoma Preferred Practice Pattern guidelines; Roberta Scherer for her feedback on previous versions of the manuscript; and Georgia Salanti, Huseyin Naci, Deborah Caldwell, Stefan K. Leucht, and Toshiaki A. Furukawa for contributing insights to the design of the project.
Grant Support: By grant 1 RC1 EY020140 and grant 1 U01 EY020522, National Eye Institute, National Institutes of Health (principal investigator: Dr. Kay Dickersin). Dr. Andrea Cipriani is supported by the National Institute for Health Research Oxford Cognitive Health Clinical Research Facility.
Disclosures: Mr. Rouse and Mr. Shi report grants from the National Eye Institute, National Institutes of Health, during the conduct of the study. Dr. Dickersin reports grants from National Eye Institute during the conduct of the study. Authors not named here have disclosed no conflicts of interest. Disclosures can also be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M15-2367.
Editors' Disclosures: Christine Laine, MD, MPH, Editor in Chief, reports that she has no financial relationships or interests to disclose. Darren B. Taichman, MD, PhD, Executive Deputy Editor, reports that he has no financial relationships or interests to disclose. Cynthia D. Mulrow, MD, MSc, Senior Deputy Editor, reports that she has no relationships or interests to disclose. Deborah Cotton, MD, MPH, Deputy Editor, reports that she has no financial relationships or interest to disclose. Jaya K. Rao, MD, MHS, Deputy Editor, reports that she has stock holdings/options in Eli Lilly and Pfizer. Sankey V. Williams, MD, Deputy Editor, reports that he has no financial relationships or interests to disclose. Catharine B. Stack, PhD, MS, Deputy Editor for Statistics, reports that she has stock holdings in Pfizer and Johnson & Johnson.
Requests for Single Reprints: Tianjing Li, MD, MHS, PhD, Center for Clinical Trials and Evidence Synthesis, Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 North. Wolfe Street, Room E6011, Baltimore, MD 21205; e-mail, firstname.lastname@example.org.
Current Author Address: Mr. Rouse and Drs. Dickersin and Li: Center for Clinical Trials and Evidence Synthesis, Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 North Wolfe Street, Room E6006, Baltimore, MD 21205.
Dr. Cipriani: Department of Psychiatry, University of Oxford, Warneford Lane, Oxford OX3 7JX, United Kingdom.
Mr. Shi: International Vaccine Access Center, Department of International Health, Johns Hopkins Bloomberg School of Public Health, 415 North Washington Street, 553, Baltimore, MD 21231.
Dr. Coleman: Jules Stein Eye Institute, David Geffen School of Medicine at University of California, Los Angeles, 100 Stein Plaza, Box 957000, Los Angeles, CA 90095.
Author Contributions: Conception and design: B. Rouse, A. Cipriani, T. Li.
Analysis and interpretation of the data: B. Rouse, A. Cipriani, Q. Shi, A.L. Coleman, K. Dickersin, T. Li.
Drafting of the article: B. Rouse, A. Cipriani, T. Li.
Critical revision of the article for important intellectual content: B. Rouse, A. Cipriani, A.L. Coleman, K. Dickersin, T. Li.
Final approval of the article: A. Cipriani, A.L. Coleman, K. Dickersin, T. Li.
Provision of study materials or patients: T. Li.
Statistical expertise: T. Li.
Obtaining of funding: K. Dickersin.
Administrative, technical, or logistic support: T. Li.
Collection and assembly of data: B. Rouse, Q. Shi, T. Li.
Rouse B, Cipriani A, Shi Q, Coleman AL, Dickersin K, Li T. Network Meta-analysis for Clinical Practice Guidelines: A Case Study on First-Line Medical Therapies for Primary Open-Angle Glaucoma. Ann Intern Med. 2016;164:674-682. doi: 10.7326/M15-2367
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Published: Ann Intern Med. 2016;164(10):674-682.
Published at www.annals.org on 19 April 2016
Network meta-analysis compares multiple treatment options for the same condition and may be useful for developing clinical practice guidelines.
To compare treatment recommendations for first-line medical therapy for primary open angle-glaucoma (POAG) from major updates of American Academy of Ophthalmology (AAO) guidelines with the evidence available at the time, using network meta-analysis.
MEDLINE, Embase, and the Cochrane Library were searched on 11 March 2014 for randomized, controlled trials (RCTs) of glaucoma monotherapies compared with placebo, vehicle, or no treatment or other monotherapies. The AAO Web site was searched in August 2014 to identify AAO POAG guidelines.
Eligible RCTs were selected by 2 independent reviewers, and guidelines were selected by 1 person.
One person abstracted recommendations from guidelines and a second person verified. Two people independently abstracted data from included RCTs.
Guidelines were grouped together on the basis of literature search dates, and RCTs that existed at 1991, 1995, 1999, 2004, and 2009 were analyzed. The outcome of interest was intraocular pressure (IOP) at 3 months. Only the latest guideline made a specific recommendation: prostaglandins. Network meta-analyses showed that all treatments were superior to placebo in decreasing IOP at 3 months. The mean reductions (95% credible intervals [CrIs]) for the highest-ranking class compared with placebo were as follows: 1991: β-blockers, 4.01 (CrI, 0.48 to 7.43); 1995: α2-adrenergic agonists, 5.64 (CrI, 1.73 to 9.50); 1999: prostaglandins, 5.43 (CrI, 3.38 to 7.38); 2004: prostaglandins, 4.75 (CrI, 3.11 to 6.44); 2009: prostaglandins, 4.58 (CrI, 2.94 to 6.24).
When comparisons are informed by a small number of studies, the treatment effects and rankings may not be stable.
For timely recommendations when multiple treatment options are available, guidelines developers should consider network meta-analysis.
National Eye Institute, National Institutes of Health.
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