1. Epidemiology and Global Health
  2. Human Biology and Medicine
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Standardized mean differences cause funnel plot distortion in publication bias assessments

  1. Peter-Paul Zwetsloot Is a corresponding author
  2. Mira Van Der Naald
  3. Emily S Sena
  4. David W Howells
  5. Joanna IntHout
  6. Joris AH De Groot
  7. Steven AJ Chamuleau
  8. Malcolm R MacLeod
  9. Kimberley E Wever Is a corresponding author
  1. University Medical Center Utrecht, Netherlands
  2. University of Edinburgh, United Kingdom
  3. University of Tasmania, Australia
  4. Radboud Institute for Health Sciences, Radboud University Medical Center, Netherlands
  5. The University of Edinburgh, United Kingdom
  6. Radboud University Medical Center, Netherlands
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Cite as: eLife 2017;6:e24260 doi: 10.7554/eLife.24260

Abstract

Meta-analyses are increasingly used for synthesis of evidence, and often include an assessment of publication bias based on detection of asymmetry in funnel plots. We studied the influence of different normalisation approaches, sample size and intervention effects on funnel plot asymmetry, using empirical datasets and illustrative simulations. We found that funnel plots of the Standardized Mean Difference (SMD) plotted against the standard error (SE) are susceptible to distortion, leading to overestimation of the existence and extent of publication bias. Distortion was more severe when the primary studies had a small sample size and when an intervention effect was present. We show that using the Normalised Mean Difference (when possible), or plotting the SMD against a sample size-based precision estimate, are more reliable alternatives. We conclude that funnel plots using the SMD in combination with the SE are unsuitable for publication bias assessments and can lead to false-positive results.

Article and author information

Author details

  1. Peter-Paul Zwetsloot

    Department of Cardiology, Experimental Cardiology Laboratory, University Medical Center Utrecht, Utrecht, Netherlands
    For correspondence
    P.P.M.Zwetsloot@umcutrecht.nl
    Competing interests
    The authors declare that no competing interests exist.
  2. Mira Van Der Naald

    Department of Cardiology, Experimental Cardiology Laboratory, University Medical Center Utrecht, Utrecht, Netherlands
    Competing interests
    The authors declare that no competing interests exist.
  3. Emily S Sena

    Center for Clinical Brain Sciences, University of Edinburgh, Edinburgh, United Kingdom
    Competing interests
    The authors declare that no competing interests exist.
  4. David W Howells

    School of Medicine, University of Tasmania, Hobart, Australia
    Competing interests
    The authors declare that no competing interests exist.
  5. Joanna IntHout

    Department for Health Evidence, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, Netherlands
    Competing interests
    The authors declare that no competing interests exist.
  6. Joris AH De Groot

    Department for Health Evidence, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, Netherlands
    Competing interests
    The authors declare that no competing interests exist.
  7. Steven AJ Chamuleau

    Department of Cardiology, Experimental Cardiology Laboratory, University Medical Center Utrecht, Utrecht, Netherlands
    Competing interests
    The authors declare that no competing interests exist.
  8. Malcolm R MacLeod

    Centre for Clinical Brain Sciences, The University of Edinburgh, Edinburgh, United Kingdom
    Competing interests
    The authors declare that no competing interests exist.
  9. Kimberley E Wever

    Systematic Review Centre for Laboratory Animal Experimentation, Radboud University Medical Center, Nijmegen, Netherlands
    For correspondence
    kim.wever@radboudumc.nl
    Competing interests
    The authors declare that no competing interests exist.
    ORCID icon 0000-0003-3635-3660

Funding

National Institute of Environmental Health Sciences (National Toxicology Program research funding)

  • Kimberley E Wever

Netherlands Cardiovascular Research Initiative (CVON-HUSTCARE)

  • Steven AJ Chamuleau

National Centre for the Replacement, Refinement and Reduction of Animals in Research (Infrastructure Award)

  • Emily S Sena
  • Malcolm R MacLeod

Alexander Suerman program (PhD student Scholarship)

  • Peter-Paul Zwetsloot

The funders had no role in study design, data collection and interpretation, or the decision to submit the work for publication.

Reviewing Editor

  1. M Dawn Teare, Reviewing Editor, University of Sheffield, United Kingdom

Publication history

  1. Received: December 14, 2016
  2. Accepted: August 21, 2017
  3. Accepted Manuscript published: September 8, 2017 (version 1)

Copyright

© 2017, Zwetsloot et al.

This article is distributed under the terms of the Creative Commons Attribution License permitting unrestricted use and redistribution provided that the original author and source are credited.

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