Using network meta-analysis to evaluate the existence of small-study effects in a network of interventions.

Suggested methods for exploring the presence of small-study effects in a meta-analysis and the possibility of publication bias are associated with important limitations. When a meta-analysis comprises only a few studies, funnel plots are difficult to interpret, and regression-based approaches to test and account for small-study effects have low power. Assuming that the cause of funnel plot asymmetry is likely to affect an entire research field rather than only a particular comparison of interventions, we suggest that network meta-regression is employed to account for small-study effects in a set of related meta-analyses. We present several possible models for the direction and distribution of small-study effects and we describe the methods by re-analysing two published networks.