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A GRADE Working Group approach for rating the quality of treatment effect estimates from network meta-analysis

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Puhan, M. A., Schunemann, H. J., Murad, M. H., Li, T., Brignardello-Petersen, R., Singh, J. A., Kessels, A. G., Guyatt, G. H., for the GRADE Working Group·2014·BMJ

DOI 10.1136/bmj.g5630

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Abstract

Network meta-analysis (NMA), combining direct and indirect comparisons, is increasingly being used to examine the comparative effectiveness of medical interventions. Minimal guidance exists on how to rate the quality of evidence supporting treatment effect estimates obtained from NMA. We present a four-step approach to rate the quality of evidence in each of the direct, indirect, and NMA estimates based on methods developed by the GRADE working group. Using an example of a published NMA, we show that the quality of evidence supporting NMA estimates varies from high to very low across comparisons, and that quality ratings given to a whole network are uninformative and likely to mislead.

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GRADE guidelines: 3. Rating the quality of evidence
Balshem, H., Helfand, M., Schünemann, H. J., Oxman, A. D., Kunz, R., Brozek, J., Vist, G. E., Falck-Ytter, Y., Meerpohl, J., & Norris, S. (2011) · Journal of Clinical Epidemiology · doi:10.1016/j.jclinepi.2010.07.015 · Cited by 8,285
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GRADE guidelines: 4. Rating the quality of evidence—study limitations (risk of bias)
Guyatt, G. H., Oxman, A. D., Vist, G., Kunz, R., Brozek, J., Alonso-Coello, P., Montori, V., Akl, E. A., Djulbegovic, B., & Falck-Ytter, Y. (2011) · Journal of Clinical Epidemiology · doi:10.1016/j.jclinepi.2010.07.017 · Cited by 2,798
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GRADE guidelines 6. Rating the quality of evidence—imprecision
Guyatt, G. H., Oxman, A. D., Kunz, R., Brozek, J., Alonso-Coello, P., Rind, D., Devereaux, P. J., Montori, V. M., Freyschuss, B., Vist, G., et al. (2011) · Journal of Clinical Epidemiology · doi:10.1016/j.jclinepi.2011.01.012 · Cited by 2,693
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Checking consistency in mixed treatment comparison meta-analysis
Dias, S., Welton, N. J., Caldwell, D. M., & Ades, A. E. (2010) · Statistics in Medicine · doi:10.1002/sim.3767 · Cited by 2,521
Graphical tools for network meta-analysis in STATA
Chaimani, A., Higgins, J. P. T., Mavridis, D., Spyridonos, P., & Salanti, G. (2013) · PLoS ONE · doi:10.1371/journal.pone.0076654 · Cited by 2,473
GRADE guidelines: 7. Rating the quality of evidence—inconsistency
Guyatt, G. H., Oxman, A. D., Kunz, R., Woodcock, J., Brozek, J., Helfand, M., Alonso-Coello, P., Glasziou, P., Jaeschke, R., Akl, E. A., et al. (2011) · Journal of Clinical Epidemiology · doi:10.1016/j.jclinepi.2011.03.017 · Cited by 2,320
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Lu, G., & Ades, A. E. (2004) · Statistics in Medicine · doi:10.1002/sim.1875 · Cited by 2,172
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Higgins, J. P. T., Jackson, D., Barrett, J. K., Lu, G., Ades, A. E., & White, I. R. (2012) · Research Synthesis Methods · doi:10.1002/jrsm.1044 · Cited by 2,098
GRADE guidelines: 8. Rating the quality of evidence—indirectness
Guyatt, G. H., Oxman, A. D., Kunz, R., Woodcock, J., Brozek, J., Helfand, M., Alonso-Coello, P., Falck-Ytter, Y., Jaeschke, R., Vist, G., et al. (2011) · Journal of Clinical Epidemiology · doi:10.1016/j.jclinepi.2011.04.014 · Cited by 1,843
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“For direct evidence, we evaluate the quality from five aspects (risk of bias, inconsistency, inaccuracy, indirectness, imprecision and publication bias) [24].”
Method
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“29 30 Since we undertook this process, further detailed guidance has been published providing practical strategies for GRADE-assessing NMA effect estimates, that seeks to reduce the significant workload involved.”
Method
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“The Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) criteria was applied to evaluate the quality of evidence [30].”
Method
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“The GRADE approach can be used to assess the quality of evidence estimates in network meta-analysis (NMA) [26].”
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“placebo 273 49 (10) 67/33 22 (7) — 62 (26) 17.”
Influential
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“19 This approach will assess the quality of evidence for each outcome for direct and indirect estimates as well as rating the overall quality of evidence from the NMA effect estimates.”
Background
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BackgroundMethod
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“In terms of indirect evidence, we assessed certainty according to imprecision, intransitivity, and the lowermost-certainty ratings for the direct comparisons, forming the first-order loop with the most influencing to an indirect estimate.(20) To assess the certainty of the overall NMAs, direct and indirect evidence we…”
Background
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“27 The quality of evidence depends on study design, risk of bias, consistency, directness, and precision of the findings.”
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“85,86 This study has limitations, including a lack of consideration of the scope of the systematic reviews.”
Background
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“0,([37]) which includes random sequence generation (selection bias), allocation concealment (selection bias), blinding of participants and personnel (performance bias), blinding of outcome assessment (detection bias), incomplete outcome data (attrition bias), selective reporting (reporting bias) and other bias.”
BackgroundMethod
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“Puhan MA, Schunemann HJ, Murad MH, Li T, Brignardello-Petersen R, Singh JA, Kessels AG, Guyatt GH: A GRADE Working Group approach for rating the quality of treatment effect estimates from network meta-analysis.”
Influential
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Background
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Self-citation
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Authors: Puhan, M. A., Schunemann, H. J., Murad, M. H., Li, T., Brignardello-Petersen, R., Singh, J. A., Kessels, A. G., Guyatt, G. H., & for the GRADE Working Group
Affiliations: University of Zurich (CH)
Mayo Clinic (US)
Johns Hopkins University (US)
University of Alabama (US)
Maastricht University (NL)
McMaster University (CA)
Corresponding author: Puhan, M. A.
ORCID: Puhan, M. A.
Murad, M. H.
Li, T.
Singh, J. A.
Guyatt, G. H.
Venue: BMJ
Publisher: BMJ
Published: 2014-09-24
Volume: 349
Issue: sep24 5
Pages: g5630-g5630
ISSN: 1756-1833 (ISSN-L)
DOI: 10.1136/bmj.g5630
OpenAlex: W2155798268
Cited by: 1,812
References: 39
Citations by year: 2026: 160 · 2025: 177 · 2024: 216 · 2023: 175 · 2022: 205 · 2021: 276 · 2020: 201 · 2019: 128 · 2018: 96 · 2017: 72 · 2016: 63 · 2015: 36 · 2014: 4
FWCI: 57.15
Type: journal article
Language: en
Update notices: correction (2015-06-17)
Open access: bronze
doi.org
Locations: BMJ (publishedVersion)
PubMed (publishedVersion)
Research Publications (Maastricht University) (publishedVersion, other-oa)
Zurich Open Repository and Archive (University of Zurich) (acceptedVersion, other-oa)
HighWire Press Open Archive (submittedVersion)
Zurich Open Repository and Archive (University of Zurich) (submittedVersion, other-oa)
Research Publications (Maastricht University) (submittedVersion, other-oa)
Zurich Open Repository and Archive (University of Zurich)
Topics: Social Sciences › Decision Sciences › Statistics, Probability and Uncertainty › Meta-analysis and systematic reviews
Social Sciences › Sociology and Political Science › Delphi Technique in Research
Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Clinical practice guidelines implementation
Keywords: network meta-analysis, quality of evidence, GRADE, treatment effect estimates, comparative effectiveness
MeSH terms: Humans, Quality Assurance, Health Care, Meta-Analysis as Topic, Practice Guidelines as Topic, Evidence-Based Medicine, Guideline Adherence

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A GRADE Working Group approach for rating the quality of treatment effect estimates from network meta-analysis

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