Why carry out this study?
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Clinicians and healthcare payers have a multitude of options for treating moderate-to-severe plaque psoriasis, and network meta-analysis (NMA), a method by which multiple interventions can be compared simultaneously in a single analysis, has been used widely to support decision making based on the best available evidence of efficacy and safety. |
Despite the widespread application of NMA to synthesize randomized evidence in psoriasis, skepticism around its use and mistrust of its results persist. |
To address these concerns, we performed a systematic review of published NMAs assessing biologic therapies for moderate-to-severe psoriasis, aiming to assess the methodological quality of these analyses and explore differences in their results. |
What was learned from the study?
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Twenty-five NMAs have been published since 2006 and most have come to broadly similar results and conclusions, considering the available data when they were performed. |
The most useful NMAs for clinical decision making are those that: include all relevant trials of comparator treatments, assessed in a way that reflects their marketing authorization and expected use in clinical practice; provide a thorough assessment of heterogeneity and inconsistency; and report comparative effects and associated uncertainty in a comprehensive manner. |
Digital Features
Introduction
Methods
Study Identification
Data Extraction and Quality Assessment
Data Analysis
Results
Search Results
Included NMAs
Study Identification and Selection in the NMAs
NMA | Interventions | Population | Outcome | Time point (weeks) | Study design and phase | ||||||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
ETN | IFX | ADA | UST | SEC | IXE | BRO | GUS | TIL | RIS | CZP | Other bio | Other non-bio | |||||
Woolacott 2006 [35] | L | L, U3 | ✓ | ✓ | Adults, M-to-S PsO | PASI 50, 75, 90 | 10–12 | RCT, phase NR | |||||||||
Reich 2008 [32] | L | L | ✓ | Active chronic stable plaque PsO | PASI 50, 75, 90 | 10–12 and 24 | RCT, phase 2 and 3 | ||||||||||
Bansback 2009 [31] | HD | L | L | ✓ | ✓ | M-to-S PsO | PASI 50, 75, 90 | Not defined; primary endpoint | RCT, phase NR | ||||||||
Reich 2012 [39] | LD | L | L | WB, U45 U90 | ✓ | Adults, plaque type PsO | PASI 50, 75, 90 | 10–16 | RCT, phase NR | ||||||||
Lin 2012 [43] | HD | L | L | U45, U90 | ✓ | M-to-S plaque PsO | PASI 50, 75, 90 | 10–16 | RCT, phase 3 | ||||||||
Gupta 2014 [19] | L | L | L | U45 | ✓ | ✓ | Adults (18+), chronic plaque PsO | PASI 75 | 10–16 | RCT, phase 3 and above | |||||||
Messori 2015 [18] | L | L | U45, U90 | M-to-S PsO | Safety: AEs, Infectious AEs | 12–24 | RCT, phase NR | ||||||||||
Signorovitch 2015 [42] | L | L | L | U45, U90 | ✓ | M-to-S PsO | PASI 50, 75, 90 | 10–16 | RCT, phase 2 and 3 | ||||||||
Gomez Garcia 2016 [23] | L | L | L | WB, U45 U90 | L | Adults, M-to-S PsO | PASI 75, 90; Safety: any AE | 10–16 | RCT, phase NR | ||||||||
Jabbar-Lopez 2017 [17] | A | A | A | A | A | A | Adults and children, any severity PsO; ≤ 50% PsA | PASI 75; withdrawal due to AE; DLQI; Clear/almost clear | > 12 (but include 10-week IFX) | RCT, phase 2 and 3, ≥ 50 patients | |||||||
Sbidian 2017 [34] | A | A | A | A | A | A | A | A | A | A | ✓ | ✓ | Adults, M-to-S plaque PsO OR PsA with M-to-S PsO | PASI 75, 90; SAE, AE; PGA 0/1; DLQI | 12–16 | RCT, phase 2 and above | |
Geng 2018 [22] | L, U25 | L, U3 | L | U45, U90 | ✓ | ✓ | Adults, M-to-S PsO | PASI 50, 75, 90 | NR | RCT, phase NR | |||||||
Loos 2018 [24] | HD | L | L | WB, U45 U90 | L | L | L | ✓ | Adults, M-to-S chronic plaque PsO | PASI 50, 75, 90 | 10–16 | RCT, phase 3 | |||||
Sawyer 2018 (i) [36] | LD, HD | L | L | WB, U45, U90 | L | L | L, U140 | ✓ | Adults, M-to-S chronic plaque PsO | PASI 50, 75, 90, 100 | 10–16 | RCT, phase NR | |||||
Sawyer 2018 (m) [40] | HD | L | L | WB, U45, U90 | L | L | L | ✓ | Adults, M-to-S chronic plaque PsO | PASI 75, 90, 100 | 40–64 | RCT, phase 2 and 3, OLE | |||||
Cameron 2018 [38] | L | L | L | WB, U45, U90 | L | L | L, U140 | L | L | La | ✓ | Adults, M-to-S chronic plaque PsO | PASI 50, 75, 90, 100; PGA 0/1; safety | End of induction | RCT, phase 3 and 4 | ||
Sawyer 2019 [37] | LD, HD | L | L | WB, U45, U90 | L | L | L | L | L100 | L | L200, 2400 | ✓ | Adults, M-to-S chronic plaque PsO | PASI 50, 75, 90, 100 | 10–16 | RCT, phase NR | |
Bai 2019 [21] | U45, WB + U90 | L | L | L | L | L | L | ✓ | Adults, M-to-S chronic plaque PsO | PASI 75, 100; PGA 0/1; AE; SAE; discontinuation due to AE | 12–16 | RCT, phase NR | |||||
Xu 2019a b[25] | HD | L | L | A | A | A | L | L | ✓ | Adults, M-to-S chronic plaque PsO | PASI 50, 75, 90, 100; PGA 0/1; DLQI; headache; infection; discontinuation; | 12–16 | RCT or quasi RCT, phase NR | ||||
Xu 2019b [26] | L | WB | A | A | A | A | Adults, M-to-S chronic plaque PsO | PASI 75; AE | 12–24 | RCT, phase NR | |||||||
Warren 2019 [41] | LD, HD | L | L | WB, U45, U90 | L | L | L | L | L100, L200 | M-to-S chronic plaque PsO | PAIS 75, 90, 100 | 12–16 | RCT, phase 2 and above | ||||
Wu 2020 [44] | A | A | A | A | A | Aa | Aa | Aa | Aa | ✓ | Patients with PsO | Change in body weight or BMI | Up to 24 | RCT or non-RCT | |||
Sbidian 2020 [33] | A | A | A | A | A | A | A | A | A | A | A | ✓ | ✓ | Adults, M-to-S chronic plaque PsO | PASI 75, 90; SAE, AE; PGA 0/1; DLQI | 8–24 | RCT, phase 2 and above |
Warren 2020 [20] | HD | L | L | WB | L | L | L | L | L100 | L | L400 | Adults, M-to-S chronic plaque PsO | PASI 75, 90, 100; DLQI 0/1; | 4, 8 and 12 | RCT, phase 3 | ||
Armstrong 2020 [30] | L | L | L | WB, U45, U90 | L | L | L | L | L100, L200 | L | L200, L400 | ✓ | Adults, M-to-S chronic plaque PsO | PASI 75, 90, 100 | 10–16; 44–60 | RCT, phase 2 and above |
Source of Funding and Conflicts of Interest
NMA Analytical Methods and Assessment of Quality using ISPOR Criteria
NMA | Analysis and base-case model type | PASI outcome type (cut-offs); summary statistic | Timepoints | Treatment of doses | How was heterogeneity considered | How was inconsistency considered | Number of studies | |
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Woolacott 2006 [35] | Bayesian, ordered probit, RE | Ordered categorical (50, 75, 90); RR | 4–16 weeks | ETN doses analyzed separately, IFX combined 5 mg and 3 mg/ kga | Qualitative assessment of clinical characteristics and quantitative assessment based on χ2 for pair-wise analyses; RE model used | N/A; no loops of evidence in the network | 16 | |
Reich 2008 [32] | Bayesian, ordered probit, RE | Ordered categorical (50, 75, 90); RR | 10–12 and 24 weeks | Analyzed separately | Assessed based on clinical characteristics and χ2 for pair-wise analysis; only considered significant for infliximab; explored by removing the smallest study from pairwise analyses; RE model used | N/A; no loops of evidence in the network | 15 | |
Bansback 2009 [31] | Bayesian, ordered probit, RE | Ordered categorical (50, 75, 90); RR | 8–16 weeks | One dose per drug with lower or higher doses tested in sensitivity analysis | Qualitative assessment of baseline characteristics; meta-regression on baseline characteristics considered, but deemed unnecessary; sensitivity analyses performed using different trials and high or low evaluated dosages were run and compared with base case results; RE model used | NR | 22 | |
Reich 2012 [39] | Bayesian, ordered probit, RE | Ordered categorical (50, 75, 90); RR | 10–16 weeks | Analyzed separately | Assessment NR; RE model used | NR | 20 | |
Lin 2012 [43] | Bayesian, binomial logit (assumed), RE | Dichotomous (50, 75, 90); OR | 10–16 weeks | Analyzed separately | Three models assessed for best fit: FE, RE and RE with meta-regression on disease duration and BSA involvement; sensitivity analyses performed using high or low evaluated dosages and excluding studies with only treatment-naïve patients; RE model used | Compared results including and excluding head-to-head trials, but results inconclusive | 17 | |
Gupta 2014 [19] | Bayesian, binomial logit (assumed), RE | Dichotomous (75); OR | 10–16 weeks | For ETN both licensed doses combined; for other one dose per drug | Qualitative assessment of study and patient characteristics, quantitative assessment based on Q and I2 statistics for pairwise analyses; RE model used | Node-splitting analysis for each loop of evidence in network; no inconsistency detected | 21 | |
Messori 2015 [18] | Bayesian; binomial logit (assumed), FE | N/A | 12–24 weeks | Analyzed separately | Accounted for in a meta-regression (not described); RE and FE models compared for goodness of fit and FE model used | NR | Any SAE 10, any infectious AE 11 | |
Signorovitch 2015 [42] | Bayesian, ordered probit, RE, included regression adjustment for placebo arm responses | Ordered categorical (50, 75, 90); RR | 8–16 weeks | Analyzed separately | RE models with and without adjustment for placebo arm responses compared for goodness of fit and RE model with adjustment used; sensitivity analyses performed using WB dosing for ustekinumab and using binomial logit model at PASI 75 alone | NR | 15 | |
Gomez Garcia 2016 [23] | Frequentist multivariate, RE | Dichotomous (75, 90); OR | 10–16 weeks | Analyzed separately | Quantitative assessment based on I2 in pairwise meta-analysis | Assessed using the ratio of ORs where a value ≥ 2 indicated potential inconsistency; some evidence of inconsistency identified | 27 | |
Jabbar-Lopez 2017 [17] | Frequentist multivariate, RE | Dichotomous (75, 90b); OR | > 12 weeks reported, but 10-week IFX trials included | All doses combined | Assessed by visual inspection of forest plots; RE model used; subgroup analysis included data on licensed biologic doses only | Assessed by visual inspection of forest plots, loop-specific inconsistency plots and calculation of an inconsistency factorb; some evidence of inconsistency identified | PASI 75: 40, Withdrawals due to AEs: 36 | |
Sbidian 2017 [34] | Frequentist multivariate, choice of FE or RE NR | Dichotomous (75, 90); RR | 12–16 weeks | All doses combined | Assessed by inspection of patient and study characteristics and estimation of between-study standard deviation followed by comparison with empirical distributions; subgroup analyses and meta-regression on key patient characteristics planned, but data insufficient to perform; sensitivity analyses at dose-level considering each drug dose a different intervention, excluding trials at high risk of bias or with total sample size of < 50 patients and analyzing outcomes on observed cases only | Assessed using loop-specific and side-splitting approaches (Bucher 1997 and Dias 2010) and by fitting a design by treatment interaction model; some evidence of inconsistency identified | PASI 90: 58; SAE: 60; PASI 75: 64; Any AE: 54 | |
Geng 2018 [22] | Bayesian, binomial logit (assumed), RE | Dichotomous assumed (50, 75, 90); OR | NR | Analyzed separately | Assessment NR; RE model used | Assessed by node-splitting; because p > 0.05, the inconsistency model was used | 33 | |
Loos 2018 [24] | Bayesian, ordered probit, RE, included regression adjustment for placebo arm responses | Ordered categorical (50, 75, 90); RR | 10–16 weeks | Only one dose per drug except UST, where doses were combined | Assessment NR; RE model with adjustment for placebo arm responses used | NR | 34 | |
Sawyer 2018 (i) [36] | Bayesian, ordered probit, RE, included regression adjustment for placebo arm responses | Ordered categorical (50, 75, 90, 100); RR | 10–16 weeks | Analyzed separately | Qualitative assessment of study and patient characteristics; RE and FE models with and without adjustment for placebo arm responses compared for goodness of fit and RE model with adjustment used; sensitivity analyses performed including data from trial arms of unlicensed doses of systemic therapies | Assessed using RE unrelated mean effects model; no evidence of inconsistency detected | 41 | |
Sawyer 2018(m) [40] | Bayesian, ordered probit, FE | Ordered categorical (75, 90, 100); RR | 40–64 weeks | Analyzed separately | Qualitative assessment of study design, patient characteristics and endpoints; FE and RE models assessed for goodness of fit and FE model used; sensitivity analysis performed excluding studies with < 5% of patients report prior biologic exposure | Assessed using loop-specific approach (Bucher 1997); no evidence of inconsistency detected | 17 | |
Cameron 2018c [38] | Base-case analysis | Bayesian, binomial logit, RE, included regression adjustment for placebo arm responses | Dichotomous (50, 75, 90, 100); RR | 10–16 weeks | Analyzed separately | Qualitative assessment of study and patient characteristics; quantitative assessment based I2 statistics for pairwise analyses; FE and RE models combined with several meta-regressions to account for variation in placebo response, prior biologic use, body weight, disease duration, age, race, and baseline outcome scores were compared for goodness of fit; RE model with placebo adjustment used for PASI 50, 90 and 100 and RE model with disease duration adjustment used for PASI 75 | Assessed by comparing the mean of the posterior residual deviance and DIC statistics in fitted consistency and inconsistency models; no evidence of inconsistency detected | 45 |
Supplementary analysisc | Bayesian, ordered probit, RE, included regression adjustment for placebo arm responses | Ordered categorical (50, 75, 90, 100); RR | RE model combined with meta-regression to account for variation in placebo response using covariate at each PASI cut-off; RE model with placebo adjustment used | |||||
Sawyer 2019 [37] | Bayesian, ordered probit, RE, included regression adjustment for placebo arm responses | Ordered categorical (50, 75, 90, 100); RR | 10–16 weeks | Analyzed separately | Qualitative assessment of study and patient characteristics; RE models with and without adjustment for placebo arm responses compared for goodness of fit; sensitivity analyses performed to test impact of excluding trials reporting < 5% biologic exposed patients, using a different timepoint (12 weeks rather than 16 weeks) for secukinumab, and excluding studies with fewer than 50 patients per arm | Assessed using RE unrelated mean effects model; no evidence of inconsistency detected | 77 | |
Bai 2019 [21] | Frequentist, model type NR, choice of FE or RE NR | Dichotomous (75, 100); RR | 12–16 weeks | Only one dose per drug except UST, where high dose and WB dose combined | NR | Assessed using loop-specific approach; some inconsistency detected | 28 | |
Xu 2019a [25] | Bayesian, binomial logit (assumed), RE | Dichotomous (50, 75, 90, 100); OR | 12–16 weeks | Only one dose per drug except IXE, SEC, UST, where doses were combinedd | Assessment NR; RE model used | Node-splitting and net heat plots conducted; node-splitting showed some inconsistency; net heat plots showed no statistical inconsistency | 54 | |
Xu 2019b [26] | Bayesian, binomial logit (assumed), choice of FE or RE NR | Dichotomous (75); RR | 12–24 weeks | All doses combined | Assessment NR; subgroup analyses stratified by drugs and time of follow-up. Meta-regression analysis was performed by publication year, drugs, number of patients, male ratio, white ratio, time of follow-up, biologic agents and PsA. Sensitivity analysis was conducted to find whether one or more studies deviated from the overall results | Method NR, but no significant inconsistency found | 13 | |
Warren 2019 [41] | Bayesian, model type NR, FE | Unclear; proportion of AUC (75, 90, 100) | 12–16 weeks | Analyzed separately | Authors comment on similarity of inclusion/exclusion criteria of trials and similarity of baseline characteristics; FE and RE models assessed for goodness of fit and FE model used; estimated percentages of maximum AUC from NMA were placebo-adjusted, but no rationale provided for why | NR | 28 | |
Wu 2020 [44] | Frequentist, model type NR, RE | N/A | Up to 24 weeks | All doses combined | NR | Assessed using design-by-treatment model, loop inconsistency model and node-splitting model | BW change: 6 BMI change: 5 | |
Sbidian 2020 [34] | Frequentist multivariate, choice of FE or RE NR | Dichotomous (75, 90); RR | 8–24 weeks | All doses combined | Assessed by inspection of patient and study characteristics and estimation of between-study standard deviation followed by comparison with empirical distributions; subgroup analyses and meta-regression on key patient characteristics planned, but data insufficient to perform; sensitivity analyses at dose-level considering each drug dose a different intervention, excluding trials at high risk of bias or with total sample size of < 50 patients and analyzing outcomes on observed cases only | Assessed using loop-specific and side-splitting approaches (Bucher 1997and Dias 2010) and by fitting a design by treatment interaction model; some evidence of inconsistency identified | PASI 75: 107 PASI 90: 95 | |
Warren 2020 [20] | Bayesian and frequentist, model type NR, FE | Dichotomous (75, 90); unclear | 4, 8 and 12 weeks | Analyzed separately | Assessment NR; authors assumed studies to be generally similar and consistent | NR | 33 | |
Armstrong 2020 [30] | Bayesian, ordered probit, RE, included regression adjustment for placebo arm responses | Ordered categorical (50, 75, 90, 100); Response rates | 10–16 weeks | Analyzed separately | Assessment NR; to account for heterogeneity across trials, a model that adjusted for reference-arm response was implemented | NR | 60 |
Question | Woolacott 2006 [35] | Reich 2008 [32] | Bansback 2009 [31] | Reich 2012 [39] | Lin 2012 [43] | Gupta 2014 [19] | Messori 2015 [18] | Signorovitch 2015 [42] | Gomez Garcia 2016 [23] | Jabbar-Lopez 2017 [17] | Sbidian 2017 [34] | Geng 2018 [22] | Loos 2018 [24] |
---|---|---|---|---|---|---|---|---|---|---|---|---|---|
Did the researchers attempt to identify and include all relevant randomized controlled trials? (RCTs) | ✓ | ✓ | ✓ | ✓ | ✓ | ✗ | ✗ | ✓ | ✗ | ✓ | ✓ | ✗ | ✗ |
Do trials for interventions of interest form one connected network of RCTs? | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ |
Is it apparent that poor quality studies were included, thereby leading to bias? | ✗ | ✗ | ✗ | ✗ | ✗ | ✗ | ✗ | ✗ | ✗ | ✗ | ✗ | ✓ | ✗ |
Is it likely that bias was induced by selective reporting of outcomes in the studies? | ✗ | ✗ | ✗ | ✗ | ✗ | ✗ | ✗ | ✗ | ✗ | ✗ | ✗ | ✗ | ✗ |
Are there systematic differences in treatment effect modifiers across the different treatment comparisons in the network? | ✗ | ✗ | ✗ | ✗ | ✗ | ✗ | ? | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ |
Were imbalances in effect modifiers across the different treatment comparisons identified before reviewing individual study results? | ✗ | ✗ | ✗ | ✗ | ✓ | ✓ | ✗ | ✓ | ✗ | ✗ | ✓ | ✗ | ✓ |
Were statistical methods used that preserve within-study randomization? | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ |
If both direct and indirect comparisons are available for pairwise contrasts was agreement evaluated or discussed? | N/A | N/A | ✗ | ✗ | ✓ | ✓ | ✗ | ✗ | ✓ | ✓ | ✓ | ✓ | ✗ |
In the presence of consistency, were both direct and indirect evidence included in the network meta-analysis? | NI | ✓ | NI | NI | ✓ | ✓ | NI | NI | ✓ | ✓ | ✓ | ✓ | NI |
With an imbalance in the distribution of treatment effect modifiers across the different types of comparisons in the network of trials, did researchers attempt to minimize this bias with the analysis? | N/A | N/A | N/A | N/A | ✓ | N/A | NI | ✓ | NI | NI | ✓ | NI | ✓ |
Was a valid rationale provided for the use of RE or FE models? | ✓ | ✓ | ✗ | ✗ | ✓ | ✗ | ✓ | ✗ | ✗ | ✗ | ✓ | ✗ | ✓ |
If a RE model was used, were assumptions about heterogeneity explored or discussed? | ✗ | ✗ | ✗ | ✗ | ✓ | ✓ | N/A | ✓ | ✗ | ✗ | ✓ | ✗ | ✓ |
Is a graphical or tabular representation of the evidence network provided with information on the number of RCTs per direct comparison? | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ |
Are the individual study results reported? | ✓ | ✓ | ✓ | ✓ | P | ✗ | ✓ | ✓ | ✗ | ✓ | ✓ | ✓ | ✓ |
Are direct results reported separately from results of indirect comparisons or network meta-analyses? | P | ✓ | ✗ | ✗ | P | P | ✗ | ✗ | ✓ | ✓ | ✓ | P | ✗ |
Are all pairwise contrasts between interventions as obtained with NMA reported along with measure of uncertainty? | ✗ | ✗ | ✗ | ✗ | P | ✓ | ✓ | P | ✓ | ✓ | ✓ | ✓ | ✓ |
Is a ranking of interventions provided given the reported treatment effects and its uncertainty outcome? | ✗ | ✗ | ✗ | ✓ | P* | P* | ✓ | ✗ | ✓ | ✓ | ✓ | P* | ✗ |
Is the impact of important patient characteristics on treatment effects reported? | ✗ | ✗ | ✗ | ✓ | ✓ | ✗ | ✗ | ✓ | ✗ | ✗ | ✓ | ✗ | ✗ |
Question | Sawyer 2018 (i) [36] | Sawyer 2018 (m) [40] | Cameron 2018 [38] | Sawyer 2019 [37] | Bai 2019 [21] | Xu 2019a [25] | Xu 2019b [26] | Warren 2019 [41] | Wu 2020 [44] | Sbidian 2020 [33] | Warren 2020 [20] | Armstrong 2020 [30] |
---|---|---|---|---|---|---|---|---|---|---|---|---|
Did the researchers attempt to identify and include all relevant randomized controlled trials? (RCTs) | ✓ | ✓ | ✓ | ✓ | ✗ | ✗ | ✗ | ✓ | ✓ | ✓ | ? | ✓ |
Do trials for interventions of interest form one connected network of RCTs? | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | P | ✓ | ✓ | ✓ |
Is it apparent that poor quality studies were included, thereby leading to bias? | ✗ | ✗ | ✗ | ✗ | ✗ | ✗ | ✗ | ✗ | ✓ | ✗ | ✗ | ✗ |
Is it likely that bias was induced by selective reporting of outcomes in the studies? | ✗ | ✗ | ✗ | ✗ | ✗ | ✗ | ✗ | ✗ | ✗ | ✗ | ✗ | ✗ |
Are there systematic differences in treatment effect modifiers across the different treatment comparisons in the network? | ✓ | ✓ | ✓ | ✓ | ✗ | ✓ | ✗ | ✓ | ? | ✓ | ? | ✓ |
Were imbalances in effect modifiers across the different treatment comparisons identified before reviewing individual study results? | ✓ | ✓ | ✓ | ✓ | ✗ | ✗ | ✗ | ✗ | ✗ | ✓ | ✗ | ✓ |
Were statistical methods used that preserve within-study randomization? | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | N/A | ✓ | ✓ | ✓ |
If both direct and indirect comparisons are available for pairwise contrasts was agreement evaluated or discussed? | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | ✗ | ✓ | ✓ | ✗ | ✗ |
In the presence of consistency, were both direct and indirect evidence included in the network meta-analysis? | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | NI | ✓ | ✓ | NI | NI |
With an imbalance in the distribution of treatment effect modifiers across the different types of comparisons in the network of trials, did researchers attempt to minimize this bias with the analysis? | ✓ | ✓ | ✓ | ✓ | NI | NI | NI | NI | NI | ✓ | NI | ✓ |
Was a valid rationale provided for the use of RE or FE models? | ✓ | ✓ | ✓ | ✗ | ✗ | ✗ | ✗ | ✗ | ✗ | ✗ | ✗ | ✗ |
If a RE model was used, were assumptions about heterogeneity explored or discussed? | ✓ | ✓ | ✓ | ✓ | ✗ | ✗ | NR | N/A | ✗ | ✓ | NR | ✓ |
Is a graphical or tabular representation of the evidence network provided with information on the number of RCTs per direct comparison? | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | ✗ | ✓ | ✓ | ✓ |
Are the individual study results reported? | ✓ | ✓ | ✗ | ✓ | ✓ | ✗ | ✓ | ✓ | ✓ | ✓ | ✗ | ✓ |
Are direct results reported separately from results of indirect comparisons or network meta-analyses? | ✗ | ✗ | ✗ | ✗ | ✗ | ✗ | ✓ | ✗ | ✓ | ✓ | ✗ | ✗ |
Are all pairwise contrasts between interventions as obtained with NMA reported along with measure of uncertainty? | ✗ | ✓ | ✓ | ✓ | ✓ | ✓ | P | ✗ | ✓ | ✓ | ✗ | ✗ |
Is a ranking of interventions provided given the reported treatment effects and its uncertainty outcome? | ✗ | ✓ | ✓ | ✗ | ✓ | ✓ | ✓ | ✗ | ✓ | ✓ | P* | ✗ |
Is the impact of important patient characteristics on treatment effects reported? | ✓ | ✓ | ✓ | ✓ | ✗ | ✗ | ✓ | ✗ | ✗ | ✓ | ✗ | ✓ |