Simultaneous comparison of multiple treatments: combining direct and indirect evidence

doi:10.1136/bmj.331.7521.897

BMJ 2005;331:897-900 (15 October), doi:10.1136/bmj.331.7521.897

Education and debate

Simultaneous comparison of multiple treatments: combining direct and indirect evidence

Deborah M Caldwell, research associate¹, A E Ades, professor of public health science¹, J P T Higgins, senior research associate²

¹ Medical Research Council Health Services Research Collaboration, Department of Social Medicine, University of Bristol, Bristol BS8 2PR, ² Medical Research Council Biostatistics Unit, Institute of Public Health, Cambridge CB2 2SR

Correspondence to: D M Caldwell d.m.caldwell@bristol.ac.uk

How can policy makers decide which of five treatments is thebest? Standard meta-analysis provides little help but evidencebased decisions are possible

The first 150 words of the full text of this article appear below.

Introduction

Several possible treatments are often available to treat patientswith the same condition. Decisions about optimal care, and theclinical practice guidelines that inform these decisions, relyon evidence based evaluation of the different treatment options.^1
2Systematic reviews and meta-analyses of randomised controlledtrials are the main sources of evidence. However, most systematicreviews focus on pair-wise, direct comparisons of treatments(often with the comparator being a placebo or control group),which can make it difficult to determine the best treatment.In the absence of a collection of large, high quality, randomisedtrials comparing all eligible treatments (which is invariablythe situation), we have to rely on indirect comparisons of multipletreatments. For example, an indirect estimate of the benefitof A over B can be obtained by comparing trials of A v C withtrials of B v C,^3-5 even though indirect comparisons producerelatively imprecise estimates.⁶ We describe . . . [Full text of this article]

The need to combine direct and indirect evidence

Thrombolysis and angioplasty after myocardial infarction

Multiple comparisons versus pair-wise meta-analysis

Bias, randomisation, and generalisability

Can these methods be used routinely?

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