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Meta-analyses involving cross-over trials: methodological issues
Abstract
BACKGROUND: Meta-analysis of randomized controlled trials (RCTs) is usually based on trials where patients are randomized individually into two different, parallel, treatment groups. This paper concentrates on RCTs of a different design-two-period, two-treatment cross-over trials. METHODS: The characteristics of these trials are outlined, with detailed examples of methods for analysis for both continuous and binary data. These case studies are then extended into the context of a meta-analysis. The Cochrane Library was surveyed to assess current practice for synthesis. RESULTS: Methods are described for continuous and binary data for use both when the necessary paired data are given and also when they need to be calculated or imputed, and some suggestions are provided to help people wishing to synthesize data from cross-over trials into meta-analyses. The survey suggested that about 8% of the trials in the Cochrane library were cross-over trials and 18% of the reviews referred to such trials, although there was no consistent approach to their inclusion into the reviews. CONCLUSIONS: Methods do exist for including valuable information from two-period, two-treatment cross-over trials into quantitative reviews. However, poor reporting of cross-over trials will often impede attempts to perform a meta-analysis using the available methods.
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“In such cases, a conservative correlation value of 0.5 is commonly used (80).”
From Carbohydrate ingestion during prolonged exercise and net skeletal muscle glycogen utilization: A meta-analysis. (2026) · cites this paper as [80]
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“Since all included studies utilised a cross-over design, dependency was accounted for when computing sampling variance using previously described methods [49].”
From The effect of caffeine on subsequent sleep: A systematic review and meta-analysis (2023) · cites this paper as [49]
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“cross-over trials are not appropriate if the condition of interest is unstable (Elbourne 2002).”
From Compulsory community and involuntary outpatient treatment for people with severe mental disorders. (2017) · cites this paper as Elbourne 2002
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“For the implementation of cross-over trials in the meta-analysis, we used the method according to Becker/Balagtas [34]. This method ensures that no participants were counted double in the meta-analysis.”
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“In order to include cross-over trials in our trials using the method by Becker/Balagtas, OR was used to provide a stable effects measure [34].”
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“Non-daily vs. daily statin dosing resulted in an OR of 0.58 (95% CI 0.23–1.43). [34,51,52].”
From Safety outcomes of statin vs non-statin lipid-lowering interventions in patients with prior statin-associated muscle symptoms: A systematic review and meta-analysis (2025) · cites this paper as [34]
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Physical exercise training for cystic fibrosis
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Carbamazepine for acute and chronic pain in adults
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Oral paliperidone for schizophrenia
Nussbaum, A. M., & Stroup, T. S. (2008) · Cochrane Database of Systematic Reviews · doi:10.1002/14651858.cd006369.pub2 · Cited by 195
Topical tacrolimus for atopic dermatitis
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Nebulised hypertonic saline for cystic fibrosis
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Soy Protein Reduces Serum Cholesterol by Both Intrinsic and Food Displacement Mechanisms
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Preformed crowns for decayed primary molar teeth
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Semen preparation techniques for intrauterine insemination
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Metadata
- Authors
- Elbourne, D. R., Altman, D. G., Higgins, J. P., Curtin, F., Worthington, H. V., & Vail, A.
- Affiliations
- London School of Hygiene & Tropical Medicine (GB)
- Merck KGaA, Darmstadt (Germany) (DE)
- University Dental Hospital of Manchester (GB)
- Salford Royal Hospital (GB)
- Corresponding author
- Elbourne, Diana R
- Venue
- International Journal of Epidemiology
- Publisher
- Oxford University Press (OUP)
- Published
- 2002-02
- Volume
- 31
- Issue
- 1
- Pages
- 140-149
- ISSN
- 0300-5771 (ISSN-L)
- 1464-3685
- OpenAlex
- W2130235475
- Cited by
- 2,305
- References
- 37
- Citations by year
- 2026: 58 · 2025: 58 · 2024: 72 · 2023: 87 · 2022: 116 · 2021: 129 · 2020: 107 · 2019: 111 · 2018: 128 · 2017: 131 · 2016: 145 · 2015: 147 · 2014: 174 · 2013: 135 · 2012: 144
- FWCI
- 47.29
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- International Journal of Epidemiology (publishedVersion)
- PubMed (publishedVersion)
- Research Explorer (The University of Manchester) (submittedVersion)
- Funders
- Medical Research Council
- Topics
- Social Sciences › Decision Sciences › Statistics, Probability and Uncertainty › Meta-analysis and systematic reviews
- Physical Sciences › Mathematics › Statistics and Probability › Statistical Methods in Clinical Trials
- Physical Sciences › Mathematics › Statistics and Probability › Statistical Methods in Epidemiology
- Keywords
- crossover trial, meta-analysis, randomized controlled trials, continuous data, binary data, missing data imputation, trial reporting quality, Cochrane Library
- MeSH terms
- Humans, Review Literature as Topic, Meta-Analysis as Topic, Randomized Controlled Trials as Topic, Cross-Over Studies
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