Use of Network Meta-Analysis in Clinical Guidelines - Scientific Research

Meta-analysiscan be accomplished when severalscientificstudies that address the same issue, with each individual study record measurements assuming some degree oferror. META-ANALYSIS 01 03 02 Meta-analysis is a statistical analysisthat incorporates several results of scientific research. The goal is then to use statistical methods to extract a pooled approximation nearest to the unknown common truth based on the int erpretation of thiserror. Copyright © 2019 Pubrica. All rightsreserved

NETWORK META- ANALYSIS(NMA) Network meta-analysiscompares multiple approaches simultaneouslybyevaluatingexperimentsthat make01 different correlations in the sameanalysis. It is a difficult task to decide which one to choose when numerous treatment options areavailable. 02 The importance of network meta analysis lies in taking decisions explicitly instead of takingimplicitly. 03 Copyright © 2019 Pubrica. All rightsreserved

1 TYPES OF NETWORK META-ANALYSIS Direct Treatmentcomparison Traditional meta-analysis which is performed using research groups that explicitly (head-to head) evaluate the same twotreatments. 2 INDIRECT TREATMENTCOMPARISON Comparison of different approaches in health care using data from separateresearch. Often used due to the dearth of evidence from head- to-head comparative studies or insufficient evidence. Compared to direct comparison within the study, indirect comparison implies a comparison of different procedures between thestudies. Copyright © 2019 Pubrica. All rightsreserved

Using indirect treatment comparison, the advantage of A over B is obtained by means of comparing the trails of A vs C to that B vs C, even though this treatment fairly results in inaccurate estimates. Characterization of three or more comparison treatments as a structure of multiple comparison evidence are performed depending on the comparative studies conductedpair-wise. EXAMPLE OF INDIRECT TREATMENTCOMPARISON Copyright © 2019 Pubrica. All rightsreserved

Available therapies are constantly increasing for many medical indications. For example, for the treatment of depression and other mental disorders, a wide range of different–old and new–medications areavailable. COMPARISON OF CLINICAL TRIALS USINGNMA Physicians, clinicians and health policymakers often have to find out the most cost-effectivetreatment. Well performed randomized controlled trials provide the most accurate assessments of the comparative efficacy of competing for healthcare approaches. In randomized controlled trials, most methods were not measured directly. If there is zero or inadequate data from direct comparison trials, the outcomes of different studies may be used to assess the effects of differenttreatments. Standard meta-analysisacts as an effective tool for evidence base medicine in spite of its drawback of comparing only two alternative treatments at atime. If there are no studies that compare two strategies explicitly, it is impossible to measure their comparative effectiveness. Copyright © 2019 Pubrica. All rightsreserved

Multiple treatment meta-analysis therapies integrates both direct and indirect comparison data from a network of trials using multiple procedures to evaluate as widely and precisely as the possible findings of summarytreatment. 1 MIXED/MULTIPLE TREATMENTMETA-ANALYSES Mixed/Multiple treatment comparison (MTC) is nothing but the generalized form of generic pair meta- analysis for A Vs B to that of datasystems. 2 FOREXAMPLE Consider the study on A Vs B, B Vs C and A Vs C. MTC performs two roles where itstrengthens the relative effectiveness of two therapies using both direct and indirect comparisons and other one is to select the best treatment by simultaneously allowing all treatmentsinterferences. Copyright © 2019 Pubrica. All rightsreserved

NEED TO COMBINE DIRECT ANDINDIRECT TREATMENTCOMPARISON Combining direct and indirect may prove beneficial in some cases as givenbelow: Results are not reliable When study quality is low Supported by manufacturer Researchsizes A small number oftrials In addition to that, Network-wide levels of reliability/inconsistency can be helpful and provide continuity across the entire treatmentnetwork. Copyright © 2019 Pubrica. All rightsreserved

Even though the network meta-analysis has been recently used for development of WHO guidelines, its approach is well known within national agencies for health technology evaluation. 01 MEDICAL GUIDELINES WITHNMA In 2015, GRADE published guidance on how GRADE can be used in combination with networkmeta-analysis. 02 In addition, NICE (National Institute for Health and Clinical Excellence) in the UK and Northern Ireland has incorporated recommendations on network meta-analysis within its clinical guidelinesmanual. 03 “8% of 145 NICE clinical guidelines used network meta-analysis in 2012, but possibly the percentage has gone up today” Copyright © 2019 Pubrica. All rightsreserved

It is already mentioned that 8% out of 145 NICE clinical guideline use NMA. There are three typesof interventions as shown in belowfigure. HOW TO USENMA Type ofInterventions Copyright © 2019 Pubrica. All rightsreserved

NMA METHODOLOGIES FOLLOWED BYNICE CLINICALGUIDELINE Comparison of pointestimate Adjusted indirect comparison Bucher's adjusted indirectcomparison Bayesian Copyright © 2019 Pubrica. All rightsreserved

Make comparisons that donot properly account for potential biases in research designs, characteristics of intervention and populations ofstudy. Network meta-analyses forguideline development provides a parallel analysis of all possible treatment options and makes the use of the available evidence within a single review to the fullestextent. ADVANTAGES OFNMA 05 01 03 Opportunity to quantitatively evaluate the comparison of interventions which was not done directly in studies. This is essential to the development of guidelines as guideline design teams can rely more heavily on expertopinion in the absence ofhead-to-head. Examines both direct and indirect evidence together means stronger evidence base– often to a degree that signifies the difference between grading the strength of evidence as low versus fair orhigh. By doing so it offers a crispier evaluation of the clinical landscape that in effect isbetter suited fordecision-making. 02 04 Copyright © 2019 Pubrica. All rightsreserved

CHALLENGES OFNMA Network meta-analysis normally synthesizesevidence from only randomized controlled trials. But in thecase of randomized controlled trials, hefty cohort studies are notcaptured. 01 Network meta-analysis modelsdo not mean relative effects, rather they mean than absolute effects. 03 02 Although absolute effects can be derived from relative effects, alternative analytical methods may be preferred. This may be pivotalespecially for the evaluation of harmfuldrugs. Copyright © 2019 Pubrica. All rightsreserved

SUMMARY Clinical guidelines have growingly become evidence-based with theuse of meticulous evidence synthesizingmethods. High-quality, in pairs meta-analyses, have been extensively used overthe past decades, yet network meta-analysis approaches are gaining more importance to optimize the evaluation of competinginterventions. Copyright © 2019 Pubrica. All rightsreserved

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Use of Network Meta-Analysis in Clinical Guidelines - Scientific Research