#### 9.6.3.1 Is the effect different in different subgroups?

Valid investigations of whether an intervention works differently in different subgroups involve comparing the subgroups with each other. When there are only two subgroups the overlap of the confidence intervals of the summary estimates in the two groups can be considered. Non-overlap of the confidence intervals indicates statistical significance, but note that the confidence intervals can overlap to a small degree and the difference still be statistically significant.

A simple approach for a significance test that can be used to investigate differences between two or more subgroups is described by Borenstein et al. (Borenstein 2008). This method is implemented from RevMan version 5.1 for all types of meta-analysis. The procedure is to undertake a standard test for heterogeneity across subgroup results rather than across individual study results. When the meta-analysis uses a fixed-effect inverse-variance weighted average approach, the method is exactly equivalent to the test described by Deeks (Deeks 2001). An I-squared statistic is also computed for subgroup differences. This describes the percentage of the variability in effect estimates from the different subgroups that is due to genuine subgroup differences rather than sampling error (chance). Note that these methods for examining subgroup differences should only be used when the data in the subgroups are independent (i.e. they should not be used if the same study participants contribute to more than one of the subgroups in the forest plot).

If fixed-effect models are used for the analysis within each subgroup, then these statistics relate to differences in typical effects across different subgroups. If random-effects models are used for the analysis within each subgroup, then the statistics relate to variation in the mean effects in the different subgroups. An alternative method for testing for differences between subgroups is to use meta-regression techniques, in which case a random-effects model is generally preferred (see Section 9.6.4). Tests for subgroup differences based on random-effects models may be regarded as preferable to those based on fixed-effect models, due to the high risk of false-positive results when comparing subgroups in a fixed-effect model (Higgins 2004).