Anchors Away: Navigating Unanchored Indirect Comparisons with Multilevel Unanchored Meta-Regression (ML-UMR)
Unanchored indirect treatment comparisons using single-arm studies or disconnected evidence are increasingly used in health technology assessment (HTA) when randomized evidence is unavailable. Existing methods, including matching-adjusted indirect comparison (MAIC) and simulated treatment comparison (STC), are generally limited to pairwise settings and typically estimate marginal effects in the comparator study population, which may differ from the decision-relevant population. We propose multilevel unanchored meta-regression (ML-UMR), a Bayesian regression framework for synthesizing individual patient data and aggregate data from fully disconnected evidence. ML-UMR extends multilevel network meta-regression (ML-NMR) to unanchored settings by jointly modeling individual- and aggregate-level data within a unified likelihood, enabling estimation of treatment-specific outcomes and both marginal and conditional effects across multiple treatments, studies, and target populations. ML-UMR distinguishes assumptions required to identify treatment effects from those required to transport results to target populations. As with all unanchored comparisons, valid inference relies on strong and often unverifiable assumptions, including conditional exchangeability, correct specification of the outcome model, and cross-treatment assumptions (e.g., shared prognostic factor assumption (SPFA)). ML-UMR does not lessen these requirements but makes them explicit within a unified framework and facilitates sensitivity analyses. In simulation studies, ML-UMR produced low bias and nominal coverage for comparator-population effects. Transportability to alternative populations depended critically on identifying assumptions: violations of SPFA led to bias under strong effect modification, whereas incorporating subgroup information restored near-unbiased estimation and nominal coverage.