The 5 min meta-analysis: understanding how to read and interpret a forest plot

‘Classic’ forest plots show the effect sizes from individual studies and the aggregate effect from a meta-analysis. However, in ecology and evolution meta-analyses routinely contain over 100 effect sizes, making the classic forest plot of limited use. We surveyed 102 meta-analyses in ecology and evolution, finding that only 11% use the classic forest plot. Instead, most used a ‘forest-like plot’, showing point estimates (with 95% confidence intervals; CIs) from a series of subgroups or categories in a meta-regression. We propose a modification of the forest-like plot, which we name the ‘orchard plot’. Orchard plots, in addition to showing overall mean effects and CIs from meta-analyses/regressions, also includes 95% prediction intervals (PIs), and the individual effect sizes scaled by their precision. The PI allows the user and reader to see the range in which an effect size from a future study may be expected to fall. The PI, therefore, provides an intuitive interpretation of any heterogeneity in the data. Supplementing the PI, the inclusion of underlying effect sizes also allows the user to see any influential or outlying effect sizes. We showcase the orchard plot with example datasets from ecology and evolution, using the R package, orchard, including several functions for visualizing meta-analytic data using forest-plot derivatives. We consider the orchard plot as a variant on the classic forest plot, cultivated to the needs of meta-analysts in ecology and evolution. Hopefully, the orchard plot will prove fruitful for visualizing large collections of heterogeneous effect sizes regardless of the field of study.

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671 Update of a systematic review and meta-analysis studying the association between antibiotic use and clinical outcomes of non-small-cell lung cancer patients treated with immune checkpoint inhibitors

Journal for ImmunoTherapy of Cancer ◽

10.1136/jitc-2020-sitc2020.0671 ◽

2020 ◽

Vol 8 (Suppl 3) ◽

pp. A708-A708

Author(s):

Pierre-Alain Bandinelli ◽

Julie Cervesi ◽

Clément Le Bescop ◽

Renaud Buffet ◽

Jean De Gunzburg ◽

...

Keyword(s):

Systematic Review ◽

Clinical Outcomes ◽

Time Window ◽

Checkpoint Inhibitors ◽

Meta Analysis ◽

Progression Free Survival ◽

Antibiotic Use ◽

Forest Plot ◽

Antibiotic Exposure ◽

Hazard Ratios

BackgroundImmune checkpoint inhibitors (ICIs) have been shown to improve patients‘ clinical outcomes in a variety of cancers, but with variable efficacy. Prior research has also suggested that systemic antibiotic (ABX) exposure may impact the intestinal microbiota and result in suboptimal ICI treatment outcomes. Our team published a systematic review and meta-analysis showing that ABX use could indeed decrease the survival of patients diagnosed with non-small-cell lung cancer (NSCLC) and treated with ICIs.1 The present abstract aims at updating this meta-analysis by incorporating new studies that have been published in the period ranging from September 2019 to August 2020.MethodsMedline (through PubMed), the Cochrane Library and major oncology conferences proceedings were systematically searched to identify studies assessing the impact of ABX use on the clinical outcomes of NSCLC patients treated with ICIs. Studies were found eligible for inclusion when they mentioned a hazard ratio (HR) or Kaplan–Meier curves for overall survival (OS) or progression-free survival (PFS) based on antibiotic exposure. Pooled HRs for OS and PFS and HRs for OS and PFS according to different time windows for ABX exposure were calculated.Results6 eligible new studies were identified between September 2019 and August 2020 while 3 other studies were updated with new information. Altogether, 27 studies reported data for OS (6,436 patients, 826 of whom coming from new studies) and 24 for PFS (3,751 patients, 786 of whom coming from new studies). The pooled HR was 1.75 (95% confidence interval [CI]: 1.38–2.23) for OS and 1.57 (95% CI: 1.28–1.92) for PFS, confirming a significantly reduced survival in patients with NSCLC exposed to ABX. The detailed analysis in subgroups based on the time window of exposure (figure 1, figure 2) suggests that the deleterious effect of ABX is stronger when the exposition happens shortly before and after the initiation of the ICI treatment.Abstract 671 Figure 1Forest plot of hazard ratios for overall survival of patients diagnosed with NSCLC and exposed to antibiotics versus not exposed to antibiotics, according to the time window of antibiotic exposureAbstract 671 Figure 2Forest plot of hazard ratios for progression-free survival of patients diagnosed with NSCLC and exposed to antibiotics versus not exposed to antibiotics, according to the time window of antibiotic exposureConclusionsThe update of the meta-analysis confirms the previously reported deleterious effect of ABX on ICI treatment outcomes, taking into account the latest publications in the field. The topic deserves further research to uncover if the effect will stand with 1st line use of ICI together with chemotherapies and/or other approved combinations, elucidate the mechanisms at stake and improve care of patients.ReferencesLurienne L, Cervesi J, Duhalde L, de Gunzburg J, Andremont A, Zalcman G, et al. NSCLC immunotherapy efficacy and antibiotic use: a systematic review and meta-analysis. J Thorac Oncol 2020;15:1147–1159.

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Abstract P127: Posttraumatic Stress Disorder and Risk for Coronary Heart Disease: A Meta-analytic Review

Circulation ◽

10.1161/circ.127.suppl_12.ap127 ◽

2013 ◽

Vol 127 (suppl_12) ◽

Author(s):

Donald Edmondson ◽

Ian M Kronish ◽

Jonathan A Shaffer ◽

Louise Falzon ◽

Matthew M Burg

Keyword(s):

Posttraumatic Stress Disorder ◽

Coronary Heart Disease ◽

Heart Disease ◽

Posttraumatic Stress ◽

Stress Disorder ◽

Meta Analysis ◽

Cochrane Library ◽

Forest Plot ◽

Increased Risk ◽

Analytic Review

Context: Recent evidence suggests that posttraumatic stress disorder (PTSD) may be associated with increased risk for coronary heart disease (CHD). Objective: To determine the association of PTSD to incident CHD using systematic review and meta-analysis. Data Sources: Articles were identified by searching Ovid MEDLINE, PsycINFO, Scopus, Cochrane Library, PILOTS database, and through manual search of reference lists. Study Selection: Prospective cohort studies that assessed PTSD in participants free of CHD and assessed subsequent CHD or cardiac-specific mortality. Data Extraction: We extracted estimates of the association of PTSD to incident CHD, as well as study characteristics. Odds ratios were converted to hazard ratios (HR), and a random-effects model was used to pool results. Data Synthesis: Five studies met our inclusion criteria (N= 401,712); 4 of these included depression as a covariate. The pooled HR for the magnitude of the relationship between PTSD and CHD was 1.53 (95% CI, 1.27-1.84) before adjustment for depression. The pooled HR estimate for the 4 depression-adjusted estimates (N= 362,388) was 1.22 (95% CI, 1.05-1.42). Conclusion: PTSD is independently associated with increased risk for incident CHD, even after adjusting for depression and other covariates. Figure 1. Forest plot of association of PTSD to incident MI or cardiac mortality Note: The area of each square is proportional to the study’s weight in the meta-analysis, and each line represents the confidence interval around the estimate. The diamond represents the aggregate estimate, and its lateral points indicate confidence intervals for this estimate.

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Systematic review and meta-analysis of the prevalence of coronavirus in the world: One health approach is urgent

10.1101/2021.06.09.21258651 ◽

2021 ◽

Author(s):

Ricardo Faustino ◽

Miguel Faria ◽

Monica Teixeira ◽

Filipe Palavra ◽

Maria Do Ceu Costa ◽

...

Keyword(s):

Systematic Review ◽

Fixed Effects ◽

One Health ◽

Animal Species ◽

Meta Analysis ◽

Epidemiological Surveillance ◽

Forest Plot ◽

Atypical Pneumonia ◽

Systematic Analysis ◽

Different Strains

Coronaviruses have been responsible for major epidemic crises in 2003 with SARS-CoV-1, in 2012 with MERS-CoV and in 2019 with SARS-CoV-2 (COVID-19), causing serious atypical pneumonia in humans. We intend, with this systematic analysis and meta-analysis, to clarify the prevalence of the various strains of coronavirus in different animal species. For this purpose, we carried out an electronic survey using Pubmed's Veterinary Science search tool to conduct a systematic assessment of published studies reporting the prevalence of different strains of coronavirus in different animal species between 2015 and 2020. We conducted different analysis to assess sensitivity, publication bias, and heterogeneity, using random and fixed effects. The final meta-analysis included 42 studies for systematic review and 29 in the meta-analysis. For the geographic regions with a prevalence greater than or equal to 0.20 (Forest plot overall; prevalence = 0.20, p < 0.01, Q = 10476.22 and I2 = 100%), the most commonly detected viruses were: enteric coronavirus (ECoV), pigeon-dominant coronavirus, (PdCoV), Avian coronavirus M41, Avian coronavirus C46, Avian coronavirus A99, Avian coronavirus JMK, MERS-CoV, Bovine coronavirus, Ro-BatCoV GCCDC1, Alphacoronavirus, Betacoronavirus, Deltacoronavirus, Gamacoronavirus and human coronaviruses (HCoVs). The wide presence of different strains of coronavirus in different animal species on all continents demonstrates the great biodiversity and ubiquity of these viruses. The most recent epidemiological crises caused by coronavirus demonstrates our unpreparedness to anticipate and mitigate emerging risks, as well as the need to implement new epidemiological surveillance programs for viruses. Combined with the need to create advanced training courses in One Health, this is paramount in order to ensure greater effectiveness in fighting the next pandemics.

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Effectiveness of the Internet-based Versus Face-to-Face Interaction on Reduction of Tobacco use among Adults: A Systematic Review and Meta-Analysis

10.21203/rs.3.rs-318627/v1 ◽

2021 ◽

Author(s):

Rajesh Kumar ◽

Ravi Kant ◽

Poonam Yadav ◽

Tamar Rodney ◽

Mukesh Bairwa

Keyword(s):

Developing Countries ◽

Tobacco Use ◽

Meta Analysis ◽

Intervention Group ◽

The Internet ◽

Control Group ◽

Forest Plot ◽

Cochrane Central Register ◽

Face To Face

Abstract BackgroundThe burden of tobacco-associated disorders is prevalent worldwide. Over the years, many innovative internet-based approaches have been utilized with variable success to quit tobacco. Though the effectiveness of internet-based and face-to-face interventions on quitting smoking are very well reported in the literature, due to limitation in methodology and limited sample size, it is required to integrate and analyze these studies' findings to reach a single conclusion. The study evaluated the effectiveness of the internet as an intervention approach versus face-to-face interaction on reducing tobacco use as control among adults.MethodsA systematic search was performed through various electronic databases such as Medline, PsychInfo, PubMed, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), ResearchGate, Google Scholar, and Academia. Reference lists of the eligible articles were also screened. Full-text articles were included as per eligibility criteria (PICO framework). No ethnicity restriction was applied.ResultsA total of 13 studies were selected for meta-analysis, with 3852 and 3908 participants in intervention and control groups respectively. Forest plot favours the intervention group at one month follow up for tobacco quitting (OR: 2.37, CI: 1.86-3.02, P-0.00001, I2 =0%), at three months (OR: 1.88, CI: 1.48-2.40, P-0.00001, I2 =42%) at six months (OR: 2.02, CI: 1.64-2.50, P-0.00001, I2 =38%) and at 1 year of follow-up (OR: 1.43, CI: 1.18-1.74, P-0.00001, I2 = 36%) comparing to control group. ConclusionInternet and web-based interventions are highly useful in tobacco quitting at one month, three months, six months, and one year of follow-up compared to face-to-face interaction or no intervention, although the level of evidence was moderate. Additionally, limited availability of trials in developing countries, arising need for research of internet use in developing countries to quit tobacco. Prospero Registration number- PROSPERO 2020 CRD42020214306

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Evaluation of Nimotuzumab for the treatment of head and neck cancer: Meta-analysis of controlled trials

Bionatura ◽

10.21931/rb/2020.05.01.8 ◽

2020 ◽

Vol 5 (1) ◽

pp. 1056-1062

Author(s):

Carmen Viada ◽

Aliz M. Vega ◽

Mayte Robaina ◽

Aliuska Frías ◽

Mabel Álvarez ◽

...

Keyword(s):

Monoclonal Antibody ◽

Sensitivity Analysis ◽

Head And Neck Cancer ◽

Head And Neck ◽

Phase Ii ◽

Neck Cancer ◽

Meta Analysis ◽

Sufficient Evidence ◽

Forest Plot ◽

Controlled Trials

Nimotuzumab, humanized monoclonal antibody, directed against the epidermal growth factor receptor: highly expressed protein in malignant tumors of epithelial origin. It has been registered for head and neck tumors since 2002. To determine the effectiveness of Nimotuzumab in head and neck cancer through the combined meta-analysis technique. A search was conducted in PubMed, in an indexed magazine with the words “Nimotuzumab”, “head and neck,” 48 articles published by Cuban and foreign authors were detected between April 1, 2005, and July 31, 2019, in which the results of clinical studies conducted with the monoclonal antibody Nimotuzumab are described. Seven clinical trials conducted in Cuba from 2005-2019 with Nimotuzumab are described; three Phase I / II (with 14, 10 and 10 patients respectively), a Phase II / III with 106 patients, a Phase II with 37 patients, two Phase IV (with 386 and 225 patients each) and a study promoted by the Researcher with 17 patients. From these studies, the three controlled trials were selected by the PRISMA flow chart. The meta-analysis consisted of the construction of the Forest Plot graph, the sensitivity analysis and the cumulative analysis. The meta-analysis shows favorable results for Nimotuzumab, without heterogeneity (I2 = 0%). The sensitivity analysis reveals that the test that differs most from the others is Phase II / III. The cumulative analysis indicates that after the second trial, there is already sufficient evidence.

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Predictive value of pregnancy-associated plasma protein-A in relation to fetal loss: A systematic review and meta-analysis

International Journal of Reproductive BioMedicine ◽

10.18502/ijrm.v13i6.7281 ◽

2020 ◽

Author(s):

Zahra Hadizadeh-Talasaz ◽

Ali Taghipour ◽

Seyede Houra Mousavi-Vahed ◽

Robab Latifnejad Roudsari

Keyword(s):

Systematic Review ◽

Likelihood Ratio ◽

Plasma Protein ◽

Predictive Value ◽

Meta Analysis ◽

Protein A ◽

Fetal Loss ◽

Positive Likelihood Ratio ◽

Negative Likelihood Ratio ◽

Forest Plot

Background: For a woman with bleeding and threatened abortion, ultrasound scan is done to confirm the viability of the fetus; however, 10-15% of the embryos are eventually aborted. Distinguishing between women with good and poor prognosis can be a helpful approach. Objective: This study aimed to review the predictive value of Pregnancy-associated Plasma Protein A (PAPP-A) in relation to the diagnosis of fetal loss. Materials and Methods: The articles published in multiple databases including Web of Science, PubMed, MEDLINE, Scopus, and Persian databases such as ISC, Magiran, and IranMedx were searched for articles published until May 2019. MeSH terms was used for searching the databases including fetal loss OR pregnancy loss OR abortion OR miscarriage with the following word using AND; Pregnancy-Associated Plasma Protein- A OR PAPP-A. Two reviewers extracted data and recorded them in a pre-defined form and assessed the quality of articles using the Newcastle-Ottawa tool. Meta-analysis was done using the Comprehensive Meta-Analysis/2.0 software and MetaDisc. Results: A total number of 16 studies were eligible for the qualitative data synthesis, out of which 8 studies were included in the meta-analysis. All studies had high and medium quality. The forest plot analysis showed a sensitivity of 57% (95% CI: 53-63%), a specificity of 83% (95% CI: 80-85%), a positive likelihood ratio of 3.52 (95% CI: 2.44- 5.07), a negative likelihood ratio of 0.54 (95% CI: 0.37-0.79), and a diagnostic odds ratio of 6.95 (95% CI: 3.58-13.50). Conclusion: PAPP-A cannot be recommended on a routine basis for predicting fetal loss and still further research with a combination of other biomarkers is required. Key words: Pregnancy-associated plasma protein-A, Fetal loss, Pregnancy, Systematic review.

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AB0820 COMPARATIVE EFFICACY OF GUSELKUMAB IN PATIENTS WITH PSORIATIC ARTHRITIS: RESULTS FROM SYSTEMATIC LITERATURE REVIEW AND NETWORK META-ANALYSIS

Annals of the Rheumatic Diseases ◽

10.1136/annrheumdis-2020-eular.6013 ◽

2020 ◽

Vol 79 (Suppl 1) ◽

pp. 1713-1714

Author(s):

I. Mcinnes ◽

P. J. Mease ◽

K. Eaton ◽

A. Schubert ◽

S. Peterson ◽

...

Keyword(s):

Psoriatic Arthritis ◽

Literature Review ◽

Adverse Events ◽

Systematic Literature Review ◽

Targeted Therapies ◽

Meta Analysis ◽

Tumor Necrosis Factor Inhibitor ◽

Forest Plot ◽

Research Support ◽

Phase 3

Background:The efficacy of the interleukin (IL)-23 subunit p19 inhibitor guselkumab (GUS) for psoriatic arthritis (PsA) has recently been demonstrated in two Phase 3 trials (DISCOVER-1 & -2) but has not been evaluated versus existing targeted therapies for PsA.Objectives:To compare GUS to targeted therapies for PsA through network meta-analysis (NMA).Methods:A systematic literature review was performed to identify PsA randomized controlled trials from 2000 to 2018. Bayesian NMAs were performed to compare treatments on American College of Rheumatology (ACR) 20/50/70 response, Psoriasis Area Severity Index (PASI) 75/90/100 response, Health Assessment Questionnaire Disability Index (HAQ-DI) score, resolution of enthesitis (RoE), resolution of dactylitis (RoD), adverse events (AEs) and serious adverse events (SAEs). Analyses used random effects models that adjusted for placebo response via meta-regression on baseline risk when feasible. Results are summarized by ranking treatments according to median absolute probabilities of response derived from NMAs.Results:Twenty-six Phase 3 studies were included in the quantitative synthesis. Studies were placebo-controlled up to 24 weeks and evaluated 13 targeted therapies for PsA. Absolute probabilities are reported for PASI 90 & ACR 20 responses according toFigure 1,and a forest plot of relative risks versus placebo for AEs is reported according toFigure 2. For ACR 20 response, GUS 100 mg every 4 weeks (Q4W) and every 8 weeks (Q8W) ranked 5th and 8th out of 20 interventions and were comparable to IL-17A inhibitor (IL-17Ai) and most tumor necrosis factor inhibitor (TNFi) agents. Similar findings were observed for ACR 50 and 70 responses. For PASI 90 response, GUS Q4W and Q8W ranked 1st and 2nd out of 15 interventions and were highly likely to provide a greater benefit than most other agents. Similar findings were observed for PASI 75 and 100 responses. For HAQ-DI score, GUS Q4W and Q8W ranked 6th and 10th out of 20 interventions and were comparable to IL-17Ai and most TNFi agents. For RoE, GUS Q4W and Q8W ranked 8th and 6th out of 13 interventions and were comparable to IL-17Ai and TNFi agents. For RoD, GUS Q4W and Q8W ranked 8th and 9th out of 13 interventions and were comparable to most IL-17Ai and TNFi agents. For AEs, GUS Q4W and Q8W ranked 3rd and 2nd out of 19 interventions and were comparable to IL-17Ai and TNFi agents. Likewise, for SAEs, GUS Q4W and Q8W ranked 4th and 5th out of 20 interventions and were comparable to IL-17Ai and TNFi agents. Analyses that controlled for previous exposure to biologics or assessed outcomes at alternative timepoints were broadly consistent with primary analysis results.Conclusion:NMA results indicate that GUS is comparable to most targeted PsA treatments for improvement in arthritis, soft tissue damage, physical function, and safety outcomes. For PASI outcomes, GUS is highly likely to provide a greater benefit than other targeted PsA treatments.Disclosure of Interests:Iain McInnes Grant/research support from: Bristol-Myers Squibb, Celgene, Eli Lilly and Company, Janssen, and UCB, Consultant of: AbbVie, Bristol-Myers Squibb, Celgene, Eli Lilly and Company, Gilead, Janssen, Novartis, Pfizer, and UCB, Philip J Mease Grant/research support from: Abbott, Amgen, Biogen Idec, BMS, Celgene Corporation, Eli Lilly, Novartis, Pfizer, Sun Pharmaceutical, UCB – grant/research support, Consultant of: Abbott, Amgen, Biogen Idec, BMS, Celgene Corporation, Eli Lilly, Novartis, Pfizer, Sun Pharmaceutical, UCB – consultant, Speakers bureau: Abbott, Amgen, Biogen Idec, BMS, Eli Lilly, Genentech, Janssen, Pfizer, UCB – speakers bureau, Kiefer Eaton Shareholder of: Test Pharma, Consultant of: Janssen, Agata Schubert Employee of: Janssen-Cilag, Steve Peterson Employee of: Janssen Research & Development, LLC, Tim Disher Consultant of: Janssen, Wim Noel Employee of: Janssen Pharmaceuticals NV, Hassan Fareen Employee of: Janssen, Chetan Karyekar Shareholder of: Johnson & Johnson, Consultant of: Janssen, Employee of: Janssen Global Services, LLC. Previously, Novartis, Bristol-Myers Squibb, and Abbott Labs., Suzy Van Sanden Employee of: Janssen, Christopher T. Ritchlin Grant/research support from: UCB Pharma, AbbVie, Amgen, Consultant of: UCB Pharma, Amgen, AbbVie, Lilly, Pfizer, Novartis, Gilead, Janssen, Wolf-Henning Boehncke Grant/research support from: Janssen Research & Development, LLC, Consultant of: Janssen

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Abstract 309: Is Right Bundle Branch Block Associated with Poor Outcomes in the Setting of an Acute Coronary Syndrome? A Systematic Review and Meta-analysis

Circulation Cardiovascular Quality and Outcomes ◽

10.1161/circoutcomes.7.suppl_1.309 ◽

2014 ◽

Vol 7 (suppl_1) ◽

Author(s):

Ahmad Hazem ◽

Sunita Sharma ◽

Amit Sharma ◽

Cameron Leitch ◽

Roopalakshmi Sharadanant ◽

...

Keyword(s):

Systematic Review ◽

Acute Coronary Syndrome ◽

Right Bundle Branch Block ◽

Risk Ratio ◽

Meta Analysis ◽

Forest Plot ◽

Bundle Branch Block ◽

Coronary Syndrome ◽

All Cause Mortality

Importance: Up to 10% of patients with acute myocardial infarction (AMI) have right bundle branch block (RBBB), and RBBB has been associated with a higher risk of mortality. We performed a systematic review and meta-analysis to determine the prognostic significance of RBBB for patients with AMI. Acute coronary syndrome (ACS) Data Sources: We have systematically searched Ovid, Scopus and Web of Science through January 2014. Study Selection: Reviewers working independently and in duplicate screened all eligible abstracts, selecting studies that described all-cause mortality or cardiovascular death in patients with RBBB and suspected ACS. We excluded studies that reported unadjusted outcomes. Knowledge synthesis: We pooled risk ratio with hazard ratio in studies reporting those outcomes. When reported, odds ratio was converted into risk ratio using reported event rate in each study’s unexposed -read: non RBBB- group. Main Outcomes: All-cause mortality and cardiovascular mortality (death). Results: Eighteen studies were found that reported eligible data. All were observational studies, involving over 89,000 patients. In short-term follow up (up to 30 days), RBBB on presentation was associated with higher all-cause mortality rate, compared to patients without RBBB (RR 2.23, 95% CI 1.76-2.82). There was a trend for higher mortality at long-term follow up (range: 6 months-16 years) that did not reach statistical significance (RR 1.45, 95% CI 0.93-2.25). Figure-1 demonstrates the forest plot. Risk of bias was assessed with the Newcastle-Ottawa scale and majority of included studied were deemed moderate to high quality. Conclusion and Relevance: RBBB is associated with a more than 2-fold higher risk of all-cause mortality in patients with AMI at 30 days follow up. Patients with AMI and RBBB represent a high risk group for adverse outcomes. A sentence on the differential findings for new vs. old RBBB and association with outcomes could follow here.

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Application of Network Meta-Analysis to Assess the Comparative Effectiveness of Oral Care Interventions in Preventing Ventilator Associated Pneumonia in Critically Ill Patients.

10.21203/rs.3.rs-23653/v1 ◽

2020 ◽

Author(s):

Satheeshkumar PS ◽

Stephen Sonis

Keyword(s):

Usual Care ◽

Critically Ill ◽

Critically Ill Patients ◽

Povidone Iodine ◽

Meta Analysis ◽

Oral Care ◽

Forest Plot ◽

Care Groups ◽

Ranking Order ◽

Hierarchical Assessment

Abstract Background In this research, we assessed the efficacy of a novel analytic, network metanalysis (NMA), in creating a hierarchy to define the most effective oral care intervention (OCI) for the prevention and management of ventilation-associated pneumonia (VAP). Methods We applied NMA to a previously published robust pairwise meta-analysis (PMA). Statistical analyses were based on comparing rates of total VAP events between intervention groups and placebo-usual care groups. We synthesized a netgraph, reported ranking order of the treatment and summarized our output by a forest plot with a reference treatment placebo/usual care. Results With our inclusion and exclusion critiera for the NMA we extracted 25 studies (4473 subjects). The NMA included 16 treatments, 29 pairwise comparisons and 15 designs. Based on the results of multiple comparisons with frequentist ranking probability P scores, tooth brushing (P score fixed of 0.9353, P score random of 0.8892), toothbrushing with povidone iodine (P score fixed of 0.9091, P score random 0.8801), and furacillin (P score fixed of 0.8798, P score random 0.8358) were the best three interventions for preventing VAP. Conclusion NMA appeared to be an effective platform from which multiple interventions reported in disparate clinical trials could be compared to derive a hierarchical assessment of efficacy in the intervention of VAP. According to the NMA outcome, toothbrushing alone or toothbrushing along with a potent antiseptic mouthwash povidone iodine was related to the highest response rate in preventing VAP in critically ill patients followed by furacillin and chlorhexidine 0.2%, respectively.

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