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Making forest and funnel plots

Graeme Hickey
October 03, 2016

Making forest and funnel plots

Presented at the 30th Annual EACTS Meeting, Barcelona, Spain (1-5 October 2016)

Graeme Hickey

October 03, 2016
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  1. Meta-analysis from start to finish
    Graeme L. Hickey*
    Department of Biostatistics, University of Liverpool
    * No conflicts of interest

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  3. Early all-cause mortality
    Five randomized trials

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  4. TAVI SAVR
    Trial
    Year of
    publication
    Events, n Total, n Events, n Total, n
    NOTION 2015 3 139 5 135
    PARTNER 2011 12 348 22 351
    PARTNER 2A 2016 39 1011 41 1021
    STACCATO 2012 2 34 0 36
    US CoreValve 2014 13 390 16 357
    Outcome: early all-cause mortality

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  5. Jones et al (39)
    Kobrin et al (40)
    Latib et al (12)
    Minutello et al (41)
    Muneretto et al (42)
    Onorati et al (43)
    Osnabrugge et al (13)
    Papadopoulos et al (44)
    Piazza et al (14)
    Santarpino et al (45)
    Schymik et al (15)
    Stöhr et al (46)
    Tamburino et al (16)
    Thakkar et al (47)
    Thongprayoon et al (48)
    Thourani et al (17)
    Walther et al (49)
    Wendt et al (50)
    Zweng et al (51)
    Random-effects model
    Heterogeneity: l2 = 39.3%; tau-squared = 0.1507; P = 0.017
    Random-effects model
    Heterogeneity: l2 = 37%; tau-squared = 0.1253; P = 0.0172
    Test for overall effect: P = 0.9041
    Test for subgroup differences: Q = 2.2; P = 0.1415
    0
    20
    2
    20
    20
    1
    2
    3
    33
    3
    3
    21
    20
    2
    3
    12
    10
    9
    2
    287
    356
    1.37 (0.68–2.77)
    1.00 (0.14–7.23)
    1.34 (0.79–2.30)
    2.23 (1.16–4.27)
    3.11 (0.12–79.64)
    0.65 (0.10–4.10)
    0.46 (0.11–1.98)
    1.35 (0.79–2.31)
    0.59 (0.14–2.53)
    0.32 (0.09–1.21)
    1.70 (0.82–3.51)
    0.83 (0.45–1.51)
    1.00 (0.13–7.60)
    1.51 (0.25–9.12)
    0.27 (0.14–0.52)
    0.63 (0.27–1.48)
    2.72 (0.69–10.63)
    1.00 (0.13–7.43)
    1.08 (0.84–1.38)
    1.01 (0.81–1.26)
    0.0
    4.8
    1.1
    6.1
    5.2
    0.4
    1.2
    1.8
    6.1
    1.8
    2.1
    4.6
    5.5
    1.0
    1.3
    5.1
    3.9
    2.0
    1.0
    81.7
    100
    0
    15
    2
    45
    19
    0
    3
    6
    25
    5
    9
    13
    24
    2
    2
    38
    15
    3
    2
    309
    393
    20
    194
    111
    595
    204
    28
    42
    40
    405
    102
    216
    175
    650
    30
    195
    1077
    100
    62
    44
    5657
    7579
    20
    194
    111
    1785
    408
    28
    42
    40
    405
    102
    216
    175
    650
    30
    195
    944
    100
    51
    44
    6907
    8807
    0.01 0.1 1 10 100
    Favors TAVI Favors SAVR
    Knapp–Hartung random-effects OR and 95% CI for 30-day all-cause mortality stratified by study design. NOTION = Nordic Aortic Valve Intervention;
    OR = odds ratio; PARTNER = Placement of Aortic Transcatheter Valves; SAVR = surgical aortic valve replacement; STACCATO = A Prospective,
    Randomised Trial of Transapical Transcatheter Aortic Valve Implantation Versus Surgical Aortic Valve Replacement in Operable Elderly Patients With
    Aortic Stenosis; TAVI = transcatheter aortic valve implantation.
    * Percentages do not sum to 18.3% and 81.7% for randomized and matched studies, respectively, because of rounding.
    www.annals.org Annals of Internal Medicine • Vol. 165 No. 5 • 6 September 2016 337
    Downloaded From: http://annals.org/ by a University of Liverpool User on 09/21/2016
    Figure 1. Forest plot for early all-cause mortality in the overall population.
    Study (Reference)
    Randomized studies
    NOTION (9, 10)
    PARTNER (3–5)
    PARTNER 2A (11)
    STACCATO (26)
    U.S. CoreValve (6–8)
    Random-effects model
    Heterogeneity: l2 = 0%; tau-squared = 0; P = 0.4571
    Matched studies
    Ailawadi et al (27)
    Appel et al (28)
    Biancari et al (29)
    Conradi et al (30)
    D'Onofrio et al (31)
    Fusari et al (33)
    Guarracino et al (34)
    Hannan et al (35)
    Higgins et al (36)
    Holzhey et al (37)
    Johansson et al (38)
    Jones et al (39)
    Kobrin et al (40)
    Latib et al (12)
    Minutello et al (41)
    Muneretto et al (42)
    Onorati et al (43)
    Events, n
    3
    12
    39
    2
    13
    69
    34
    3
    10
    6
    2
    0
    3
    19
    6
    14
    4
    0
    20
    2
    20
    20
    1
    OR (95% CI)
    0.57 (0.13–2.45)
    0.53 (0.26–1.10)
    0.96 (0.61–1.50)
    5.62 (0.26–121.32)
    0.73 (0.35–1.55)
    0.80 (0.51–1.25)
    1.61 (0.92–2.81)
    1.54 (0.24–9.66)
    5.30 (1.14–24.63)
    0.85 (0.27–2.63)
    5.27 (0.24–113.60)
    0.19 (0.01–4.06)
    3.22 (0.32–32.89)
    1.00 (0.52–1.92)
    1.57 (0.41–6.00)
    0.76 (0.36–1.58)
    1.00 (0.23–4.31)
    1.37 (0.68–2.77)
    1.00 (0.14–7.23)
    1.34 (0.79–2.30)
    2.23 (1.16–4.27)
    3.11 (0.12–79.64)
    Weight (Random), %*
    1.8
    4.7
    6.9
    0.5
    4.5
    18.3
    5.9
    1.2
    1.6
    2.6
    0.5
    0.5
    0.8
    5.2
    2.1
    4.6
    1.8
    0.0
    4.8
    1.1
    6.1
    5.2
    0.4
    Events, n
    5
    22
    41
    0
    16
    84
    22
    2
    2
    7
    0
    2
    1
    19
    4
    18
    4
    0
    15
    2
    45
    19
    0
    Total, n
    139
    348
    1011
    34
    390
    1922
    340
    45
    144
    82
    38
    30
    30
    405
    46
    167
    40
    20
    194
    111
    595
    204
    28
    Total, n
    135
    351
    1021
    36
    357
    1900
    340
    45
    144
    82
    38
    30
    30
    405
    46
    167
    40
    20
    194
    111
    1785
    408
    28
    TAVI SAVR
    Systematic Review and Meta-analysis of TAVI Versus SAVR
    REVIEW
    NB. 31 observational studies have been deleted from the reported forest plot
    Heterogeneity statistics
    Labelled table of raw data
    Effect sizes &
    confidence intervals
    Weights
    Pooled
    estimate
    Direction labels
    Nicely formatted axes
    Forest plot with
    null line

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  6. Systematic review
    Data extraction
    Software
    51 packages available
    for meta-analysis
    71 packages available
    for meta-analysis
    RevMan
    $$$

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  7. + other software
    packages & online
    web calculators

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  8. * Only for preparation of Cochrane Reviews or for purely academic use.

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  13. 1 2 3
    5
    4
    > Finish
    6

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