A systematic review pools 8 trials on antihypertensive therapy. Funnel plot asymmetry is detected with small studies showing larger treatment effects. The I² statistic is 72%. Which combination of findings BEST describes the state of the evidence?
- A Significant publication bias; moderate heterogeneity
- B No publication bias; low heterogeneity
- C Possible publication bias; substantial heterogeneity ✓
- D Possible publication bias; low heterogeneity
Correct answer: C. Possible publication bias; substantial heterogeneity
Explanation
Funnel plot asymmetry with small-study effects suggests possible publication bias (or small-study effect), though other causes such as true heterogeneity can produce the same pattern. An I² of 72% indicates substantial heterogeneity (>50%). 'Significant' publication bias cannot be definitively concluded from visual asymmetry alone, making B the most accurate interpretation.
Reference: Park's Textbook of Preventive and Social Medicine, 27th ed.
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