Network meta-analysis of rare events using penalized likelihood regression

TL;DR

This paper introduces a penalized likelihood approach for network meta-analysis of rare events, effectively handling zero-event data without study exclusion or arbitrary imputations, and demonstrating superior bias reduction in simulations.

Contribution

The authors propose a novel penalized likelihood NMA method that addresses rare event challenges without excluding studies or using arbitrary data imputations.

Findings

Performs well across various scenarios in simulations

Results often show smaller bias than existing methods

Effective for networks with very few studies per comparison

Abstract

Network meta-analysis (NMA) of rare events has attracted little attention in the literature. Until recently, networks of interventions with rare events were analyzed using the inverse-variance NMA approach. However, when events are rare the normal approximation made by this model can be poor and effect estimates are potentially biased. Other methods for the synthesis of such data are the recent extension of the Mantel-Haenszel approach to NMA or the use of the non-central hypergeometric distribution. In this article, we suggest a new common-effect NMA approach that can be applied even in networks of interventions with extremely low or even zero number of events without requiring study exclusion or arbitrary imputations. Our method is based on the implementation of the penalized likelihood function proposed by Firth for bias reduction of the maximum likelihood estimate to the logistic expression of the NMA model. A limitation of our method is that heterogeneity cannot be taken into account as an additive parameter as in most meta-analytical models. However, we account for heterogeneity by incorporating a multiplicative overdispersion term using a two-stage approach. We show through simulations that our method performs consistently well across all tested scenarios and most often results in smaller bias than other available methods. We also illustrate the use of our method through two clinical examples. We conclude that our "penalized likelihood NMA" approach is promising for the analysis of binary outcomes with rare events especially for networks with very few studies per comparison and very low control group risks.