Cited by 596Meta-analysis and systematic reviewsDelphi Technique in ResearchStatistical Methods in Clinical Trials

CINeMA: Software for semiautomated assessment of the confidence in the results of network meta‐analysis

Open access
Papakonstantinou, Theodoros, Nikolakopoulou, Adriani, Higgins, Julian P. T., Egger, Matthias, Salanti, Georgia·2020·Campbell Systematic Reviews

Abstract

Network meta‐analysis (NMA) compares several interventions that are linked in a network of comparative studies and estimates the relative treatment effects between all treatments, using both direct and indirect evidence. NMA is increasingly used for decision making in health care, however, a user‐friendly system to evaluate the confidence that can be placed in the results of NMA is currently lacking. This paper is a tutorial describing the Confidence In Network Meta‐Analysis (CINeMA) web application, which is based on the framework developed by Salanti et al (2014, PLOS One , 9, e99682) and refined by Nikolakopoulou et al (2019, bioRxiv ). Six domains that affect the level of confidence in the NMA results are considered: (a) within‐study bias, (b) reporting bias, (c) indirectness, (d) imprecision, (e) heterogeneity, and (f) incoherence. CINeMA is freely available and open‐source and no login is required. In the configuration step users upload their data, produce network plots and define the analysis and effect measure. The dataset should include assessments of study‐level risk of bias and judgments on indirectness. CINeMA calls the netmeta routine in R to estimate relative effects and heterogeneity. Users are then guided through a systematic evaluation of the six domains. In this way reviewers assess the level of concerns for each relative treatment effect from NMA as giving rise to “no concerns,” “some concerns,” or “major concerns” in each of the six domains, which are graphically summarized on the report page for all effect estimates. Finally, judgments across the domains are summarized into a single confidence rating (“high,” “moderate,” “low,” or “very low”). In conclusion, the user‐friendly web‐based CINeMA platform provides a transparent framework to evaluate evidence from systematic reviews with multiple interventions.

AI snapshot

Written from the paper’s full text.

TL;DR

CINeMA is a freely available, open-source web application that semiautomates assessment of confidence in network meta-analysis results using six domains: within-study bias, reporting bias, indirectness, imprecision, heterogeneity, and incoherence. It guides users from data upload and NMA configuration through domain judgments to a final confidence rating of high, moderate, low, or very low.

Key findings

  • CINeMA implements the Salanti et al. (2014) framework refined by Nikolakopoulou et al. (2019), with optional rules for automated domain judgments that users can partially or fully override.
  • In the worked example, the uploaded network included 22 randomized trials, 6 interventions, and 14 comparisons with direct data; the NMA found diabetes risk was lower with ARB and higher with diuretics than with placebo, with odds ratios of 0.827 (95% CI 0.691–0.990) for ARB versus placebo and 1.330 (95% CI 1.124–1.573) for diuretics versus placebo.
  • For within-study bias in ACE versus beta blockers, low-RoB studies contributed 53%, moderate-RoB studies 43%, and high-RoB studies 4%; the Majority, Average, and Highest rules yielded “No concerns,” “Some concerns,” and “Major concerns,” respectively.
  • For imprecision, with a clinically important odds ratio of 1.2, the diuretics-versus-placebo confidence interval of 1.12–1.57 was judged “No concerns”; for heterogeneity, beta blockers versus placebo had a confidence interval of 1.05–1.46 and prediction interval of 0.90–1.70, yielding “Some concerns,” with estimated between-study variance τ² = 0.016.

Methods

  • Design: tutorial describing the CINeMA web application, its data formats, default rules, and rationale, based on the CINeMA framework.
  • Data/sample: worked example using a network meta-analysis of antihypertensive drugs and diabetes incidence, including 22 randomized trials comparing ACE inhibitors, ARBs, calcium-channel blockers, beta blockers, diuretics, and placebo.
  • Analysis: CINeMA calls the netmeta routine in R to estimate relative effects and heterogeneity, calculates a contribution matrix, and applies semiautomated rules across six domains; judgments are summarized on a report page into an overall confidence rating.

Limitations

  • The paper states that subjectivity is inevitable in evidence evaluation, including interpretation of heterogeneity and definition of a clinically important effect size, and that a study examining CINeMA’s reproducibility would be of interest.
  • The paper states that CINeMA currently does not support multiple outcomes per project, multiple concurrent projects, or assessment of dependency between outcomes; time-to-event and rate data are also not supported, and the reporting bias domain is planned for further development.
  • The text makes evident that the worked example’s indirectness data are fictional, reporting bias judgments are illustrative, and the clinically important odds ratio of 1.2 is not justified by clinical or epidemiological reasoning.

Model-written summary. Check it against the paper before relying on it.

Integrity signals

Registry

Crossref · 10.1002/cl2.1080

Cites

26 of 26 references verified0 citation errors · 0 not checkable

Statistics

Nothing to recompute.

Claims the paper makes

0 of 27 cited sources checked · 0 supported · 0 flagged

  • Findingnone given

    CINeMA considers the per-study contribution matrix in conjunction with RoB assessments to evaluate each relative treatment effect with respect to within-study bias.

    “CINeMA considers the per‐study contribution matrix in conjunction with RoB assessments to evaluate each relative treatment effect with respect to within‐study bias.”
    Quote in the paperSubstantial claim
    • Rests on an assumption: High risk of bias should be associated with “Major concerns,” moderate risk of bias with “Some concerns,” and low risk of bias with “No concerns.”
  • Findingreasoning

    Three rules can be used to summarize the risk of within-study bias and of indirectness for each relative effect estimate and produce automated judgments.

    “Three rules can be used to summarize the risk of within‐study bias and of indirectness for each relative effect estimate and produce automated judgments.”
    Quote in the paperSubstantial claim
  • Premisecitation

    CINeMA is based on the framework developed by Salanti et al. (2014) and refined by Nikolakopoulou et al. (2019).

    “This paper is a tutorial describing the Confidence In Network Meta‐Analysis (CINeMA) web application, which is based on the framework developed by Salanti et al (2014, PLOS One, 9, e99682) and refined by Nikolakopoulou et al (2019, bioRxiv).”
    • Also stated in: § INTRODUCTION · plain
      “To evaluate the confidence in the results of NMA, a framework has been developed (Salanti, Del Giovane, Chaimani, Caldwell, & Higgins, 2014) and recently refined (Nikolakopoulou et al., 2019), which is called CINeMA (Confidence In Network Meta‐Analysis).”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites Salanti et al., 2014

      Not checked in the free run.

    • cites Nikolakopoulou et al., 2019

      Not checked in the free run.

  • Premisecitation

    The CINeMA framework considers six domains that affect the level of confidence in NMA results: within-study bias, reporting bias, indirectness, imprecision, heterogeneity, and incoherence.

    “Six domains that affect the level of confidence in the NMA results are considered: (a) within‐study bias, (b) reporting bias, (c) indirectness, (d) imprecision, (e) heterogeneity, and (f) incoherence.”
    • Also stated in: § INTRODUCTION · plain
      “The CINeMA framework considers six domains that affect the level of confidence in the NMA results: (a) within‐study bias, (b) reporting bias, (c) indirectness, (d) imprecision, (e) heterogeneity, and (f) incoherence.”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites Salanti et al., 2014

      Not checked in the free run.

    • cites Nikolakopoulou et al., 2019

      Not checked in the free run.

  • Interpretationreasoning

    The user-friendly web-based CINeMA platform provides a transparent framework to evaluate evidence from systematic reviews with multiple interventions.

    “In conclusion, the user‐friendly web‐based CINeMA platform provides a transparent framework to evaluate evidence from systematic reviews with multiple interventions.”
    Quote in the paperSubstantial claim
    • Rests on an assumption: A user-friendly system to evaluate the confidence that can be placed in the results of NMA is currently lacking.
  • Classified as probably not a substantial claim. 27
  • May combine two claims. 9
  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingnone given

    CINeMA does not permanently store the data or any other information related to uploaded projects; only temporary storage takes place.

    “CINeMA does not permanently store the data, or any other information related to the uploaded projects; only temporary storage takes place for the sake of the calculations or network efficiency.”
    Quote in the paperNot a substantial claim
  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Findingnone given

    CINeMA is freely available and open-source and no login is required.

    “CINeMA is freely available and open‐source and no login is required.”
    • Also stated in: § DISCUSSION · plain
      “CINeMA is freely available and open‐source and no login is required.”
    Quote in the paperNot a substantial claim
  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingcitation

    The CINeMA framework has been implemented in a user-friendly web application.

    “The CINeMA framework has been implemented in a user‐friendly web application (see https://cinema.ispm.unibe.ch/; CINeMA, 2017).”
    Quote in the paperNot a substantial claim
  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Findingown data

    In the worked example, CINeMA recognizes the file format (long) and outcome type (binary) and provides a summary of the dataset: 22 studies, 6 interventions, and 14 comparisons with direct data.

    “Uploading the network of antihypertensive drugs, CINeMA recognizes the file format (long) and outcome type (binary) and provides summary of the dataset: it includes 22 studies, 6 interventions, and 14 comparisons with direct data.”
    Quote in the paperNot a substantial claim
  • Classified as probably not a substantial claim.

    Findingnone given

    The rules for judging imprecision and heterogeneity are based on whether the confidence interval or prediction interval includes the line of no-effect and prespecified clinically important treatment effects.

    “The rules for judging imprecision and heterogeneity are based on whether the confidence interval or prediction interval includes the line of no‐effect and prespecified clinically important treatment effects.”
    Quote in the paperSubstantial claim
  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Findingown data

    In the worked example, studies at low RoB contribute 53% in the estimation of ACE versus Beta Blockers, 43% of the contribution comes from studies at moderate RoB, and studies at high RoB contribute the remaining 4%.

    “Studies at low RoB contribute 53% in the estimation of ACE versus Beta Blockers, 43% of the contribution comes from studies at moderate RoB, and studies at high RoB contribute the remaining 4%.”
    Quote in the paperNot a substantial claim
  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Findingreasoning

    In the worked example, these RoB contributions resolve into "No concerns," "Some concerns," and "Major concerns" using the "Majority RoB," "Average RoB," and "Highest RoB" rules respectively.

    “These RoB contributions resolve into “No concerns,” “Some concerns,” and “Major concerns” using the “Majority RoB,” “Average RoB,” and “Highest RoB” rules respectively.”
    Quote in the paperNot a substantial claim
    • Rests on an assumption: High risk of bias should be associated with “Major concerns,” moderate risk of bias with “Some concerns,” and low risk of bias with “No concerns.”
  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingnone given

    Currently, other types of outcomes, for example, time to event or rate data, are not supported by CINeMA.

    “Currently, other types of outcomes, for example, time to event or rate data, are not supported.”
    Quote in the paperNot a substantial claim
  • Classified as probably not a substantial claim.

    Findingreasoning

    CINeMA software can be used to facilitate evaluation of results of NMA.

    “We have outlined how CINeMA software can be used to facilitate evaluation of results of NMA.”
    Quote in the paperSubstantial claim
  • Classified as probably not a substantial claim.

    Premisecitation

    Reviewers assess the level of concerns for each relative treatment effect from NMA as giving rise to "no concerns," "some concerns," or "major concerns" in each of the six domains.

    “Reviewers assess the level of concerns for each relative treatment effect from NMA as giving rise to “no concerns,” “some concerns,” or “major concerns” in each of the six domains.”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites Salanti et al., 2014

      Not checked in the free run.

    • cites Nikolakopoulou et al., 2019

      Not checked in the free run.

  • Classified as probably not a substantial claim.

    Premisecitation

    Network meta-analysis (NMA) is increasingly used for decision making in health care.

    “Network meta‐analysis (NMA) is increasingly being used to make decisions about optimal interventions in health care (Kanters et al., 2016; Petropoulou et al., 2016).”
    • Also stated in: § Abstract · plain
      “NMA is increasingly used for decision making in health care”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites Kanters et al., 2016

      Not checked in the free run.

    • cites Petropoulou et al., 2016

      Not checked in the free run.

  • Classified as probably not a substantial claim.

    Premisecitation

    Judgments across the six domains are summarized into a single confidence rating: high, moderate, low, or very low.

    “Finally, judgments across the domains are summarized into a single confidence rating (“high,” “moderate,” “low,” or “very low”).”
    • Also stated in: § INTRODUCTION · plain
      “Then, judgments across the domains are summarized into a single confidence rating (“high,” “moderate,” “low,” or “very low”).”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites Salanti et al., 2014

      Not checked in the free run.

    • cites Nikolakopoulou et al., 2019

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    The NMA found that the risk of diabetes was lower with ARB, and higher with diuretics than with placebo.

    “The NMA found that the risk of diabetes was lower with ARB, and higher with diuretics than with placebo (Elliott and Meyer, 2007).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Elliott and Meyer, 2007

      Not checked in the free run.

  • Classified as probably not a substantial claim.

    Interpretationnone given

    CINeMA, with semiautomation of methods via a guided on-line process, greatly simplifies evaluation of NMA results, particularly for large networks.

    “CINeMA, with semiautomation of methods via a guided on‐line process greatly simplifies this process, particularly for large networks.”
    Quote in the paperSubstantial claim
  • Classified as probably not a substantial claim.

    Premisecitation

    Prediction intervals provide a range within which the true effect of a new study is likely to lie.

    “Prediction intervals provide a range within which the true effect of a new study is likely to lie (Riley, Higgins, & Deeks, 2011).”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites Riley, Higgins, & Deeks, 2011

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Interpretationnone given

    Imprecision and Heterogeneity are related as big heterogeneity will also affect the precision of relative treatment effects.

    ““Imprecision” and “Heterogeneity” are also related as big heterogeneity will also affect the precision of relative treatment effects.”
    Quote in the paperNot a substantial claim
  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Study-level RoB would normally summarize considerations on selection, performance, attrition, detection, and reporting bias.

    “Study‐level RoB would normally summarize considerations on selection, performance, attrition, detection, and reporting bias (Higgins et al., 2011), while study‐level indirectness refers to deviations between the data and the targeted research question.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Higgins et al., 2011

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Interpretationcitation

    While the main guiding principles of the CINeMA framework have been established, specific methods, recommendations, and implementation of automated rules in CINeMA software are evolving.

    “While the main guiding principles of the CINeMA framework have been established (Nikolakopoulou et al., 2019; Salanti et al., 2014), specific methods, recommendations, and implementation of automated rules in CINeMA software are evolving.”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites Nikolakopoulou et al., 2019

      Not checked in the free run.

    • cites Salanti et al., 2014

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    The design-by-treatment interaction test is a global method to assess incoherence.

    “the first is a global method to assess incoherence, the design‐by‐treatment interaction test (Higgins et al., 2012; White et al., 2012).”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites Higgins et al., 2012

      Not checked in the free run.

    • cites White et al., 2012

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S2 (checkable). May combine two claims.

    Interpretationreasoning

    The clearly defined criteria on which judgments are based should increase reproducibility and the fact that CINeMA is open-source ensures transparency.

    “The clearly defined criteria on which judgments are based should increase reproducibility and the fact that CINeMA is open‐source ensures transparency.”
    Quote in the paperNot a substantial claim
  • Probably not a substantial claim: may not pass S4 (based).

    Premisenone given

    Assuming that transitivity holds implies that consistency-which refers to the agreement of the estimated treatment effects-also holds.

    “Assuming that transitivity holds implies that consistency—which refers to the agreement of the estimated treatment effects—also holds.”
    Quote in the paperNot a substantial claim
  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Early applications of CINeMA have appeared in the literature.

    “Early applications of CINeMA have appeared in the literature (Cipriani et al., 2018; Schwingshackl et al., 2018).”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites Cipriani et al., 2018

      Not checked in the free run.

    • cites Schwingshackl et al., 2018

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Reference quantiles are taken from empirical studies and are specific to the type of outcome and comparison.

    “The reference quantiles are taken from empirical studies and are specific to the type of outcome and comparison (Rhodes, Turner, & Higgins, 2015; Turner, Davey, Clarke, Thompson, & Higgins, 2012).”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites Rhodes, Turner, & Higgins, 2015

      Not checked in the free run.

    • cites Turner, Davey, Clarke, Thompson, & Higgins, 2012

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    The contribution matrix is calculated using the flow decomposition method described in Papakonstantinou et al. (2018) and is used later in the evaluation of within-study bias and indirectness.

    “It is calculated using the flow decomposition method described in (Papakonstantinou et al., 2018) and is used later in the evaluation of within‐study bias and indirectness.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Papakonstantinou et al., 2018

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    CINeMA is largely based on the methodological framework described previously.

    “It is largely based on the methodological framework described previously (Nikolakopoulou et al., 2019; Salanti et al., 2014).”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites Nikolakopoulou et al., 2019

      Not checked in the free run.

    • cites Salanti et al., 2014

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Interpretationnone given

    Indirectness and Incoherence domains are closely related, as they both refer to considerations of similarity across included studies which could or could not manifest statistically in the data.

    “For example, “Indirectness” and “Incoherence” domains are closely related, as they both refer to considerations of similarity across included studies which could or could not manifest statistically in the data.”
    Quote in the paperNot a substantial claim
  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    SIDE is a method to separate indirect from direct evidence.

    “the results of the second method, Separating Indirect from Direct Evidence (SIDE; Dias et al., 2010), are shown”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Dias et al., 2010

      Not checked in the free run.

  • Classified as probably not a substantial claim.

    Interpretationreasoning

    CINeMA is a transparent framework to evaluate evidence from systematic reviews with multiple interventions.

    “CINeMA is a transparent framework to evaluate evidence from systematic reviews with multiple interventions”
    Quote in the paperSubstantial claim
28 of 28
  • The paper relies on this without support.

    A user-friendly system to evaluate the confidence that can be placed in the results of NMA is currently lacking.

    “a user‐friendly system to evaluate the confidence that can be placed in the results of NMA is currently lacking.”
  • The paper relies on this without support.

    High risk of bias should be associated with “Major concerns,” moderate risk of bias with “Some concerns,” and low risk of bias with “No concerns.”

    “High RoB should be associated with “Major concerns,” moderate RoB with “Some concerns,” and low RoB with “No concerns.””
  • The authors state this as an assumption.

    A core assumption in NMA is that of transitivity; that there is an underlying true relative treatment effect which applies to all studies regardless of the treatments being compared.

    “A core assumption in NMA is that of transitivity; that there is an underlying true relative treatment effect which applies to all studies regardless of the treatments being compared.”
  • The authors state this as an assumption.

    Treatment effects approximately follow the normal distribution.

    “assumes that treatment effects approximately follow the normal distribution.”
4 of 4

Claims other papers make about this one

Each is checked against this paper’s own text: does it say what the citing paper says it does?

Self-check

Percentages, sums and reported differences re-computed from the paper’s own numbers.

Each contradiction between two passages listed here was confirmed by an independent check.

  • Heterogeneity rules point to the imprecision panel

    Minor

    The heterogeneity section says its rules are illustrated in Figure 4a, but the figure caption assigns heterogeneity to panel 4b and imprecision to panel 4a.

  • Contribution-matrix bars are described as columns rather than rows

    Minor

    The paper says each bar represents a relative-effect estimate, while its description of the contribution matrix places relative effects in rows and studies in columns. A bar for one relative effect therefore corresponds to a row, not a column.

2 of 2

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Authors
Papakonstantinou, T., Nikolakopoulou, A., Higgins, J. P. T., Egger, M., & Salanti, G.
Affiliations
  • University of Bern (CH)
  • University of Bristol (GB)
Corresponding author
Papakonstantinou, Theodoros
Venue
Campbell Systematic Reviews
Published
2020-03
Volume
16
Issue
1
Pages
e1080-e1080
ISSN
1891-1803 (ISSN-L)
OpenAlex
W3011743134
Cited by
596
References
27
Citations by year
2026: 126 · 2025: 168 · 2024: 115 · 2023: 67 · 2022: 66 · 2021: 40 · 2020: 14
FWCI
28.51
Type
journal article
Language
en
Open access
Locations
  • Campbell Systematic Reviews (publishedVersion, cc-by)
  • PubMed Central (publishedVersion, cc-by)
  • PubMed (publishedVersion)
  • Bern Open Repository and Information System (University of Bern) (submittedVersion, cc-by)
  • DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
  • Explore Bristol Research (submittedVersion, cc-by)
  • Open Access CRIS of the University of Bern
Funders
  • National Science Foundation
  • National Institute for Health and Care Research (NF-SI-0617-10145)
  • Schweizerischer Nationalfonds zur Förderung der Wissenschaftlichen Forschung (179158, 174281)
Topics
  • Social Sciences › Decision Sciences › Statistics, Probability and Uncertainty › Meta-analysis and systematic reviews
  • Social Sciences › Sociology and Political Science › Delphi Technique in Research
  • Physical Sciences › Mathematics › Statistics and Probability › Statistical Methods in Clinical Trials
Keywords
network meta-analysis, cinema, confidence estimation, risk of bias, indirectness, heterogeneity, reporting bias, imprecision, incoherence, web application

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