Misleading funnel plot for detection of bias in meta-analysis.

Publication and other forms of selection biases pose a threat to the validity of meta-analysis. Funnel plots are usually used to detect such biases; asymmetrical plots are interpreted to suggest that biases are present. Using 198 published meta-analyses, we demonstrate that the shape of a funnel plot is largely determined by the arbitrary choice of the method to construct the plot. When a different definition of precision and/or effect measure were used, the conclusion about the shape of the plot was altered in 37 (86%) of the 43 meta-analyses with an asymmetrical plot suggesting selection bias. In the absence of a consensus on how the plot should be constructed, asymmetrical funnel plots should be interpreted cautiously. These findings also suggest that the discrepancies between large trials and corresponding meta-analyses and heterogeneity in meta-analyses may also be determined by how they are evaluated.