Forest plot

A forest plot, also known as a blobbogram, is a

graphical display of estimated results from a number of
scientific studies addressing the same question, along
with the overall results.[1] It was developed for use in
medical research as a means of graphically
representing a meta-analysis of the results of
randomized controlled trials. In the last twenty years,
similar meta-analytical techniques have been applied in
observational studies (e.g. environmental
epidemiology) and forest plots are often used in
presenting the results of such studies also.
An example forest plot of five odds ratios
Although forest plots can take several forms, they are (squares, proportional to weights used in meta-
commonly presented with two columns. The left-hand analysis), with the summary measure (centre line
column lists the names of the studies (frequently of diamond) and associated confidence intervals
randomized controlled trials or epidemiological (lateral tips of diamond), and solid vertical line of
studies), commonly in chronological order from the top no effect. Names of (fictional) studies are shown
on the left, odds ratios and confidence intervals on
downwards. The right-hand column is a plot of the
the right.
measure of effect (e.g. an odds ratio) for each of these
studies (often represented by a square) incorporating
confidence intervals represented by horizontal lines.
The graph may be plotted on a natural logarithmic scale when using odds ratios or other ratio-based effect
measures, so that the confidence intervals are symmetrical about the means from each study and to ensure
undue emphasis is not given to odds ratios greater than 1 when compared to those less than 1. The area of
each square is proportional to the study's weight in the meta-analysis. The overall meta-analysed measure of
effect is often represented on the plot as a dashed vertical line. This meta-analysed measure of effect is
commonly plotted as a diamond, the lateral points of which indicate confidence intervals for this estimate.

A vertical line representing no effect is also plotted. If the confidence intervals for individual studies overlap
with this line, it demonstrates that at the given level of confidence their effect sizes do not differ from no
effect for the individual study. The same applies for the meta-analysed measure of effect: if the points of the
diamond overlap the line of no effect the overall meta-analysed result cannot be said to differ from no effect
at the given level of confidence.

Forest plots date back to at least the 1970s. One plot is shown in a 1985 book about meta-analysis.[2]: 2 52 
The first use in print of the expression "forest plot" may be in an abstract for a poster at the Pittsburgh (US)
meeting of the Society for Clinical Trials in May 1996.[3] An informative investigation on the origin of the
notion "forest plot" was published in 2001.[4] The name refers to the forest of lines produced. In September
1990, Richard Peto joked that the plot was named after a breast cancer researcher called Pat Forrest and as
a result the name has sometimes been spelled "forrest plot".[4]

Example
This blobbogram is from an iconic medical review; it shows clinical trials of the use of corticosteroids to
hasten lung development in pregnancies where a baby is likely to be born prematurely. Long after there
was enough evidence to show that this treatment saved babies' lives, the evidence was not widely known
and the treatment was
not widely used. After
a systematic review
made the evidence
better-known, the
treatment was used
more, preventing
thousands of pre-term
babies from dying of
infant respiratory
distress syndrome.
However, when the
treatment was rolled
This blobbogram uses seven studies to show that corticosteroids can hasten lung
out in lower- and
development in pregnancies where a baby is likely to be born prematurely. An odds
middle-income ratio (OR) of one indicates no effect; studies with confidence intervals (horizontal
countries, it was found lines) crossing one (vertical line) are inconclusive. Powerful studies (here, those with
that more pre-term more participants) have narrower (shorter) confidence intervals. A study with an odds
babies died. It is ratio of one and a very narrow confidence interval would indicate no significant effect.
thought that this may Here the summary and the Auckland study have narrow confidence intervals that do
be because of the not cross one, indicating that these studies would be judged statistically significant.
higher risk of infection,
which is more likely to
kill a baby in places with lower-quality medical care.[5] The current version of the medical review (http://on
linelibrary.wiley.com/doi/10.1002/14651858.CD004454.pub3/) states that there is "little need" for further
research into the usefulness of the treatment in higher-income countries, but further research is needed on
how best to treat lower-income and higher-risk mothers, and optimal dosage.

Reading a forest plot

Study identities

Studies included in the meta-analysis and incorporated into the forest plot will generally be identified in
chronological order on the left hand side by author and date. There is no significance given to the vertical
position assumed by a particular study.

Standardized mean difference

The chart portion of the forest plot will be on the right hand side and will indicate the mean difference in
effect between the test and control groups in the studies. A more precise rendering of the data shows up in
number form in the text of each line, while a somewhat less precise graphic representation shows up in
chart form on the right. The vertical line (y-axis) indicates no effect. The horizontal distance of a box from
the y-axis demonstrates the difference between the test and control (the experimental data with control data
subtracted out) in relation to no observable effect, otherwise known as the magnitude of the experimental
effect.

Confidence interval whiskers

The thin horizontal lines—sometimes referred to as whiskers—emerging from the box indicate the
magnitude of the confidence interval. The longer the lines, the wider the confidence interval, and the less
reliable the data. The shorter the lines, the narrower the confidence interval and the more reliable the data.

If either the box or the confidence interval whiskers pass through the y-axis of no effect, the study data is
said to be statistically insignificant.

Weight

The meaningfulness of the study data, or power, is indicated by the weight (size) of the box. More
meaningful data, such as those from studies with greater sample sizes and smaller confidence intervals, is
indicated by a larger sized box than data from less meaningful studies, and they contribute to the pooled
result to a greater degree.

Heterogeneity

The forest plot is able to demonstrate the degree to which data from multiple studies observing the same
effect overlap with one another. Results that fail to overlap well are termed heterogeneous and is referred to
as the heterogeneity of the data—such data is less conclusive. If the results are similar between various
studies, the data is said to be homogeneous, and the tendency is for these data to be more conclusive.

The heterogeneity is indicated by the I2 . A heterogeneity of less than 50% is termed low, and indicates a
greater degree of similarity between study data than an I2 value above 50%, which indicates more
dissimilarity.

See also
Galbraith plot
Funnel plot
The Cochrane (organisation) logo is a forest plot
A forest plot helps determine whether further research is needed

References
1. Lalkhen, AG (2008). "Statistics V: Introduction to clinical trials and systematic reviews" (http
s://doi.org/10.1093%2Fbjaceaccp%2Fmkn023). Continuing Education in Anaesthesia,
Critical Care & Pain. 8 (4): 143–146. doi:10.1093/bjaceaccp/mkn023 (https://doi.org/10.109
3%2Fbjaceaccp%2Fmkn023).
2. Larry V. Hedges and Ingram Olkin (1985). Statistical Methods for Meta-Analysis. Orlando:
Academic Press. ISBN 978-0-12-336380-0.
3. Bijnens L, Collette L, Ivanov A, Hoctin Boes G, Sylvester R (1996). Can the forest plot be
simplified without losing relevant information in meta-analyses? Communication at the
meeting of the SCT, Pittsburgh, Pennsylvania, 5–8 May 1996. Controlled Clinical Trials
17(2S): 124.
4. Steff Lewis & Mike Clarke (June 2001). "Forest plots: trying to see the wood and the trees" (h
ttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC1120528). BMJ. 322 (7300): 1479–1480.
doi:10.1136/bmj.322.7300.1479 (https://doi.org/10.1136%2Fbmj.322.7300.1479).
PMC 1120528 (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1120528). PMID 11408310
(https://pubmed.ncbi.nlm.nih.gov/11408310).
 5. Iain Chalmers (October 4, 2016). "Should the Cochrane logo be accompanied by a health
warning?" (http://www.evidentlycochrane.net/cochrane-logo-health-warning/).

External links
MIX 2.0 (http://www.meta-analysis-made-easy.com) – software to perform meta-analysis and
create forest plots in Excel.
MetaXL (http://www.epigear.com) – Software that can create forest plots and run bias
adjusted meta-analyses

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