CINeMA: An approach for assessing confidence in the results of a network meta-analysis

Nikolakopoulou, Adriani; Higgins, Julian P T; Papakonstantinou, Theodoros; Chaimani, Anna; Giovane, Cinzia Del; Egger, Matthias; Salanti, Georgia

doi:10.1371/journal.pmed.1003082

Cited by 758 publications

(625 citation statements)

References 57 publications

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“…The evaluation of the credibility of results from a metaanalysis; for that, we evaluated the confidence in the results from network meta-analyses. It was done using the Confidence in Network Meta-Analysis (CINeMA) tool, which is based on the Grading of Recommendations Assessment (GRADE) approach of the ordinary meta-analysis [12,13] (Supplementary material).…”

Section: Assessing Confidence In the Resultsmentioning

confidence: 99%

Pharmacological Interventions for Post-operative Sore Throat (POST): A Network Meta-analysis

2020

Signa Vitae

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Background: To study the efficacy of current post-extubation pharmacologic treatments for postoperative sore throat (POST) prevention. Method: We searched nine databases for randomized controlled trials (RCTs) assessing the efficacy of post-extubation treatments in POST prevention. A network meta-analysis was used to pool the results. Results: Of the 124 records screened, we included 13 studies with 1820 patients. Ketorolac tromethamine was found to be the most effective with the lowest POST rates (P-score = 0.99), followed by ketamine (P-score = 0.68), amyl-m-cresol (P-score = 0.67), flurbiprofen (P-score = 0.66), benzydamine hydrochloride (P-score = 0.62), magnesium (P-score = 0.33), dexamethasone (P-score = 0.30), and lidocaine (P-score = 0.07). Moreover, the following treatments were found to be significantly effective in reducing POST in comparison to control/placebo treatment: ketorolac tromethamine (OR = 0.11; [95% CI=0.05 – 0.21]) followed by ketamine (OR = 0.32; [95% CI = 0.17 – 0.62]), amyl-m-cresol (OR = 0.32; [95% CI = 0.14 – 0.73]), flurbiprofen (OR = 0.33;[95% CI = 0.13 – 0.81]), and benzydamine hydrochloride (OR = 0.36; [95% CI = 0.24 –0.54]). Conclusion: Ketorolac tromethamine, ketamine, amyl-m-cresol, flurbiprofen, and benzydamine hydrochloride were found to be significantly effective in reducing POST. Moreover, ketorolac tromethamine was the most effective and significantly better than all other treatments in reducing POST rates.

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Section: Assessing Confidence In the Resultsmentioning

confidence: 99%

Pharmacological Interventions for Post-operative Sore Throat (POST): A Network Meta-analysis

2020

Signa Vitae

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“…The decision maker must grasp how the biased trials affect the network estimates, and this depends on the geometry of the networks and size of the trials. Sensitivity analyses which remove the trials at high risk of bias, threshold analyses, or CINeMA may provide some insight into this [39][40][41][42][43]. Methods for integrating such assessments into the spie chart should be explored in future work.…”

Section: Discussionmentioning

confidence: 99%

“…if CINeMA is used to evaluate the confidence in the NMA results [41][42][43], then an overall confidence rating for each outcome may be represented through colours or symbols on the spie chart for a given treatment.…”

Section: Discussionmentioning

confidence: 99%

Spie charts for quantifying treatment effectiveness and safety in multiple outcome network meta-analysis: A proof-of-concept study

Daly

Mbuagbaw

Thabane

et al. 2020

Preprint

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Background: Network meta-analysis (NMA) simultaneously synthesises direct and indirect evidence on the relative efficacy and safety of at least three treatments. A decision maker may use the coherent results of an NMA to determine which treatment is best for a given outcome. However, this evidence must be balanced across multiple outcomes. This study aims to provide a framework that permits the objective integration of the comparative effectiveness and safety of treatments across multiple outcomes.Methods: In the proposed framework, measures of each treatment’s performance are plotted on its own pie chart, superimposed on another pie chart representing the performance of a hypothetical treatment that is the best across all outcomes. This creates a spie chart for each treatment, where the coverage area represents the probability a treatment ranks best overall. The angles of each sector may be adjusted to reflect the importance of each outcome to a decision maker. The framework is illustrated using two published NMA datasets comparing dietary oils and fats and psoriasis treatments. Outcome measures are plotted in terms of the surface under the cumulative ranking curve. The use of the spie chart was contrasted with that of the radar plot.Results: In the NMA comparing the effects of dietary oils and fats on four lipid biomarkers, the ease of incorporating the lipids’ relative importance on spie charts was demonstrated using coefficients from a published risk prediction model on coronary heart disease. Radar plots produced two sets of areas based on the ordering of the lipids on the axes, while the spie chart only produced one set. In the NMA comparing psoriasis treatments, the areas inside spie charts containing both efficacy and safety outcomes masked critical information on the treatments’ comparative safety. Plotting the areas inside spie charts of the efficacy outcomes against measures of the safety outcome facilitated simultaneous comparisons of the treatments’ benefits and harms.Conclusions: The spie chart is more optimal than a radar plot for integrating the comparative effectiveness or safety of a treatment across multiple outcomes. Formal validation in the decision-making context, along with statistical comparisons with other recent approaches are required.

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“…We will assess con dence in network meta-analysis results using CINeMA (Con dence in Net-work Meta-Analysis) (60)(61)(62).…”

Section: Overall Assessment Of Risk Of Biasmentioning

confidence: 99%

Vaccines to prevent COVID-19: a protocol for a living systematic review with network meta-analysis including individual patient data (The LIVING VACCINE Project)

Korang

Juul

Feinberg

et al. 2020

Preprint

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Background: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) causes corona virus disease 2019 (COVID-19) which has rapidly spread worldwide. Several human randomized clinical trials assessing potential vaccines are currently underway. There is an urgent need for a living systematic review that continuously assesses the beneficial and harmful effects of all available vaccines for COVID-19.Methods/design: We will conduct a living systematic review based on searches of major medical databases (e.g. MEDLINE, EMBASE, CENTRAL) and clinical trial registries from their inception onwards to identify relevant randomized clinical trials. We will update the literature search once a week to continuously assess if new evidence is available. Two review authors will independently extract data and conduct risk of bias assessments. We will include randomized clinical trials comparing any vaccine aiming to prevent COVID-19 (including but not limited to messenger RNA; DNA; non-replicating viral vector; replicating viral vector; inactivated virus; protein subunit; dendritic cell; other vaccines) with any comparator (placebo; ‘active placebo’; no intervention; standard care; an ‘active’ intervention; another vaccine for COVID-19) for participants in all age groups.Primary outcomes will be all-cause mortality; a diagnosis of COVID-19; and serious adverse events. Secondary outcomes will be quality of life, and non-serious adverse events. The living systematic review will include aggregate data meta-analyses, Trial Sequential Analyses, network meta-analyses, and individual patient data meta-analyses. Within-study bias will be assessed using Cochrane risk of bias tool. The Grading of Recommendations, Assessment, Development and Evaluations (GRADE) and Confidence in Network Meta-Analysis (CINeMA) approaches will be used to assess certainty of evidence. Observational studies describing harms identified during the search for trials will also be included and described and analyzed separately.Discussion: COVID-19 has become a pandemic with substantial mortality. A living systematic review assessing the beneficial and harmful effects of different vaccines is urgently needed. This living systematic review will regularly inform best practice in vaccine prevention and clinical research of this highly prevalent disease.Systematic review registration: PROSPERO CRD42020196492

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CINeMA: An approach for assessing confidence in the results of a network meta-analysis

Cited by 758 publications

References 57 publications

Pharmacological Interventions for Post-operative Sore Throat (POST): A Network Meta-analysis

Pharmacological Interventions for Post-operative Sore Throat (POST): A Network Meta-analysis

Spie charts for quantifying treatment effectiveness and safety in multiple outcome network meta-analysis: A proof-of-concept study

Vaccines to prevent COVID-19: a protocol for a living systematic review with network meta-analysis including individual patient data (The LIVING VACCINE Project)

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