Cited by 1,812Meta-analysis and systematic reviewsDelphi Technique in ResearchClinical practice guidelines implementation

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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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Graphical tools for network meta-analysis in STATA
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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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Combination of direct and indirect evidence in mixed treatment comparisons
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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
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MethodInfluential
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Method
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Jhou, H., Chen, P., Ou‐Yang, L., Lin, C. S., Tang, S.-E., & Lee, C. (2021) · Frontiers in Medicine · doi:10.3389/fmed.2021.752984 · Cited by 28
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Guaiana, G., Meader, N., Barbui, C., Davies, S., Furukawa, T. A., Imai, H., Dias, S., Caldwell, D. M., Koesters, M., Tajika, A., et al. (2023) · Cochrane Database of Systematic Reviews · doi:10.1002/14651858.cd012729.pub3 · Cited by 35
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Chaudhry, H., Foote, C. J., Guyatt, G. H., Thabane, L., Furukawa, T. A., Petrisor, B. A., & Bhandari, M. (2015) · Clinical Orthopaedics and Related Research · doi:10.1007/s11999-015-4287-9 · Cited by 28
Self-citation
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Pike, E., Hamidi, V., Sæterdal, I., Odgaard‐Jensen, J., & Klemp, M. (2017) · BMJ Open · doi:10.1136/bmjopen-2016-014880 · Cited by 28
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Method
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MethodInfluential
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Method
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Background
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Method
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Nagasaka, K., Harigai, M., Hagino, N., Hara, A., Horita, T., Hayashi, T., Itabashi, M., Ito, S., Katsumata, Y., Kawashima, S., et al. (2018) · Modern Rheumatology · doi:10.1080/14397595.2018.1500111 · Cited by 27
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Method
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Method
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Filippini, G., Clerico, M., Beiki, O., Mattoscio, M., Piazza, F., Giovane, C. D., Fredrikson, S., Tramacere, I., & Scalfari, A. (2016) · Cochrane Database of Systematic Reviews · doi:10.1002/14651858.cd012200 · Cited by 27
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Method
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BackgroundMethod
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Cao, C.-F., Ma, K., Qian-lu, L., Luan, F.-J., Wang, Q., Zhang, M., Viswanath, O., Myrcik, D., Varrassi, G., & Wang, H. (2021) · Journal of Clinical Medicine · doi:10.3390/jcm10071493 · Cited by 27
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Method
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Method
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“Adapted from [8].”
InfluentialSelf-citation
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Siemieniuk, R. A. C., Foroutan, F., Mirza, R. D., Ming, J. M., Alexander, P. E., Agarwal, A., Lesi, O. A., Merglen, A., Chang, Y., Zhang, Y., et al. (2017) · BMJ Open · doi:10.1136/bmjopen-2017-019022 · Cited by 26
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BackgroundMethodSelf-citation
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Method
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Luo, M., Zhao, X., Deng, M., Hu, Y., Yang, X., Mei, Z., Meng, L., & Wang, Y. (2022) · Journal of Neurosurgical Anesthesiology · doi:10.1097/ana.0000000000000868 · Cited by 25
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“The quality rating of RCTs started with high quality, which was then downgraded based on risk of bias, inconsistency (heterogeneity), indirectness, imprecision, and publication bias for direct estimates.(24,25)”
Background
Chinese herbal medicine for functional dyspepsia: a network meta-analysis of prokinetic-controlled randomised trials
Ho, L. T. F., Zhong, C. C., Wong, C. H. L., Wu, J. C., Chan, K. K., Wu, X., Leung, T. H., & Chung, V. C. (2021) · Chinese Medicine · doi:10.1186/s13020-021-00556-6 · Cited by 26
“Quality of evidence was assessed for pairwise meta-analyses and NMAs using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach [23, 24].”
Method

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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