heor-agent-mcp 1.0.1 → 1.0.3

package/README.md

@@ -6,7 +6,7 @@
 
 **AI-powered Health Economics and Outcomes Research (HEOR) agent as a Model Context Protocol server.**
 
-Automates literature review across 42 data sources, risk of bias assessment (RoB 2 / ROBINS-I / AMSTAR-2), state-of-the-art cost-effectiveness modelling, HTA dossier preparation for NICE / EMA / FDA / IQWiG / HAS / EU JCA, and a persistent project knowledge base — all callable as MCP tools from Claude.ai, Claude Code, and any MCP-compatible host.
+Automates literature review across 44 data sources, risk of bias assessment (RoB 2 / ROBINS-I / AMSTAR-2), EQ-5D value set impact estimation, state-of-the-art cost-effectiveness modelling, HTA dossier preparation for NICE / EMA / FDA / IQWiG / HAS / EU JCA, and a persistent project knowledge base — all callable as MCP tools from Claude.ai, Claude Code, and any MCP-compatible host.
 
 Built for pharmaceutical, biotech, CRO, and medical affairs teams who need rigorous, auditable HEOR workflows without building infrastructure from scratch.
 

package/dist/formatters/comparisonMarkdown.d.ts.map

@@ -1 +1 @@
-{"version":3,"file":"comparisonMarkdown.d.ts","sourceRoot":"","sources":["../../src/formatters/comparisonMarkdown.ts"],"names":[],"mappings":"AAAA,OAAO,KAAK,EAAE,wBAAwB,EAAE,MAAM,qBAAqB,CAAC;AAYpE,wBAAgB,oBAAoB,CAAC,MAAM,EAAE,wBAAwB,GAAG,MAAM,CAqG7E"}
+{"version":3,"file":"comparisonMarkdown.d.ts","sourceRoot":"","sources":["../../src/formatters/comparisonMarkdown.ts"],"names":[],"mappings":"AAAA,OAAO,KAAK,EAAE,wBAAwB,EAAE,MAAM,qBAAqB,CAAC;AAYpE,wBAAgB,oBAAoB,CAAC,MAAM,EAAE,wBAAwB,GAAG,MAAM,CA2H7E"}

package/dist/formatters/comparisonMarkdown.js

@@ -47,6 +47,22 @@ export function comparisonToMarkdown(result) {
             lines.push(`| ${e.intervention} vs ${e.comparator} | ${est} | ${ci} | ${p} | ${via} | ${method} |`);
         }
         lines.push("");
+        // Bucher consistency check (when direct h2h evidence available)
+        const conflicts = estimates.filter((e) => e.consistency_check && e.consistency_check.severity !== "none");
+        if (conflicts.length > 0) {
+            lines.push("**Bucher consistency check (direct vs indirect):**");
+            lines.push("");
+            for (const e of conflicts) {
+                const c = e.consistency_check;
+                const icon = c.severity === "substantial"
+                    ? "🚨"
+                    : c.severity === "moderate"
+                        ? "⚠️"
+                        : "ℹ️";
+                lines.push(`${icon} **${e.intervention} vs ${e.comparator}** (severity: ${c.severity}): ${c.rationale}`);
+            }
+            lines.push("");
+        }
     }
     // Heterogeneity statistics (I², Cochran Q)
     if (result.heterogeneity && result.heterogeneity.length > 0) {

package/dist/formatters/comparisonMarkdown.js.map

@@ -1 +1 @@
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package/dist/grade/eq5dImpact.d.ts

@@ -0,0 +1,43 @@
+/**
+ * Baseline-utility-aware EQ-5D 3L→5L impact estimator.
+ *
+ * Biz, Hernández Alava, Wailoo (2026) report category-level medians for the
+ * UK 3L→5L value-set transition. The new 5L value set has compressed utilities
+ * in mild–moderate health states relative to 3L (DSU mapping), which means
+ * the ICER impact of the transition depends strongly on the patient cohort's
+ * baseline utility:
+ *
+ *   - non_cancer_qol_only: utility loss is concentrated in the 0.6–0.9 zone.
+ *     Drugs treating MILD chronic conditions (baseline ~0.85, e.g., mild
+ *     plaque psoriasis) see the biggest ICER increase. SEVERE versions of
+ *     these conditions (baseline ~0.45, e.g., severe HS Hurley III) see
+ *     less impact because patients spend more time in low-utility states
+ *     where 5L compression is less severe.
+ *
+ *   - cancer_life_extending: improvement is concentrated in severe states
+ *     (5L assigns higher utility to the worst states than DSU mapping does),
+ *     so a drug treating advanced/metastatic disease (baseline ~0.4) sees
+ *     a bigger ICER decrease than one treating early-stage disease.
+ *
+ *   - non_cancer_life_extending: Biz report mixed direction (7/11 decreased,
+ *     4/11 increased). Modulation is not defensible without the underlying
+ *     state-by-state utility differences, so we return median + warning.
+ *
+ * The modulation factor is deliberately conservative — labelled as an
+ * extrapolation, not a finding from the paper. Users are advised to re-run
+ * their economic model with both value sets for an exact estimate.
+ */
+import type { IndicationType } from "../data/eq5dValueSets.js";
+export interface BaselineAdjustedImpact {
+    indication_type: IndicationType;
+    icer_change_pct: {
+        point: number;
+        lower: number;
+        upper: number;
+    };
+    is_baseline_adjusted: boolean;
+    baseline_utility?: number;
+    rationale: string;
+}
+export declare function estimateBaselineAdjustedImpact(indication: IndicationType, baseline_utility: number | undefined): BaselineAdjustedImpact;
+//# sourceMappingURL=eq5dImpact.d.ts.map

package/dist/grade/eq5dImpact.d.ts.map

@@ -0,0 +1 @@
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package/dist/grade/eq5dImpact.js

@@ -0,0 +1,119 @@
+/**
+ * Baseline-utility-aware EQ-5D 3L→5L impact estimator.
+ *
+ * Biz, Hernández Alava, Wailoo (2026) report category-level medians for the
+ * UK 3L→5L value-set transition. The new 5L value set has compressed utilities
+ * in mild–moderate health states relative to 3L (DSU mapping), which means
+ * the ICER impact of the transition depends strongly on the patient cohort's
+ * baseline utility:
+ *
+ *   - non_cancer_qol_only: utility loss is concentrated in the 0.6–0.9 zone.
+ *     Drugs treating MILD chronic conditions (baseline ~0.85, e.g., mild
+ *     plaque psoriasis) see the biggest ICER increase. SEVERE versions of
+ *     these conditions (baseline ~0.45, e.g., severe HS Hurley III) see
+ *     less impact because patients spend more time in low-utility states
+ *     where 5L compression is less severe.
+ *
+ *   - cancer_life_extending: improvement is concentrated in severe states
+ *     (5L assigns higher utility to the worst states than DSU mapping does),
+ *     so a drug treating advanced/metastatic disease (baseline ~0.4) sees
+ *     a bigger ICER decrease than one treating early-stage disease.
+ *
+ *   - non_cancer_life_extending: Biz report mixed direction (7/11 decreased,
+ *     4/11 increased). Modulation is not defensible without the underlying
+ *     state-by-state utility differences, so we return median + warning.
+ *
+ * The modulation factor is deliberately conservative — labelled as an
+ * extrapolation, not a finding from the paper. Users are advised to re-run
+ * their economic model with both value sets for an exact estimate.
+ */
+import { getImpactEstimate } from "../data/eq5dValueSets.js";
+/**
+ * Modulate the published median by baseline utility.
+ *
+ * Reference baselines (calibrated so multiplier=1.0 ≈ published median):
+ *   - non_cancer_qol_only:    ref_baseline = 0.65 (typical of NICE TA dataset)
+ *   - cancer_life_extending:  ref_baseline = 0.55
+ *
+ * Linear scaling within plausible bounds (×0.4 to ×1.7) — wider than the
+ * IQR of the published distribution to acknowledge extrapolation uncertainty.
+ */
+function multiplierForQolOnly(baseline) {
+    const ref = 0.65;
+    const slope = 1.5; // each +0.1 baseline → +15% multiplier
+    const raw = 1 + slope * (baseline - ref);
+    return Math.min(1.7, Math.max(0.4, raw));
+}
+function multiplierForCancer(baseline) {
+    // For cancer life-extending, a LOWER baseline means BIGGER impact (more negative %).
+    // ref=0.55 → multiplier=1.0
+    const ref = 0.55;
+    const slope = -2.0; // each +0.1 baseline → -20% multiplier (less impact)
+    const raw = 1 + slope * (baseline - ref);
+    return Math.min(1.7, Math.max(0.4, raw));
+}
+export function estimateBaselineAdjustedImpact(indication, baseline_utility) {
+    if (baseline_utility !== undefined) {
+        if (baseline_utility < 0 || baseline_utility > 1) {
+            throw new Error(`baseline_utility must be in [0, 1]; got ${baseline_utility}`);
+        }
+    }
+    const published = getImpactEstimate(indication);
+    const median = published?.median_icer_change_pct ?? 0;
+    // Range for unmodulated estimate (±25% of median to reflect inter-study spread)
+    const baseRange = {
+        point: median,
+        lower: median - Math.abs(median) * 0.25,
+        upper: median + Math.abs(median) * 0.25,
+    };
+    if (baseline_utility === undefined) {
+        return {
+            indication_type: indication,
+            icer_change_pct: baseRange,
+            is_baseline_adjusted: false,
+            rationale: `Published median for ${indication} (Biz et al. 2026, n=${published?.examples?.length ?? 0} indication examples).`,
+        };
+    }
+    if (indication === "non_cancer_life_extending") {
+        return {
+            indication_type: indication,
+            icer_change_pct: baseRange,
+            is_baseline_adjusted: false,
+            baseline_utility,
+            rationale: "Mixed/heterogeneous direction in Biz 2026 (7/11 decreased, 4/11 increased) — cannot reliably modulate by baseline utility. Re-run the model with both value sets for an exact estimate.",
+        };
+    }
+    let multiplier;
+    let directionalNote;
+    if (indication === "non_cancer_qol_only") {
+        multiplier = multiplierForQolOnly(baseline_utility);
+        directionalNote =
+            baseline_utility > 0.75
+                ? `MILD baseline utility (${baseline_utility.toFixed(2)}) → 5L compression in mild-moderate states hits this cohort harder; expect larger ICER increase than category median.`
+                : baseline_utility < 0.55
+                    ? `SEVERE baseline utility (${baseline_utility.toFixed(2)}) → patients spend more time in low-utility states where 5L compression is less severe; expect smaller ICER increase than category median.`
+                    : `Baseline utility (${baseline_utility.toFixed(2)}) near typical NICE TA dataset average — expect impact close to published median.`;
+    }
+    else {
+        multiplier = multiplierForCancer(baseline_utility);
+        directionalNote =
+            baseline_utility < 0.45
+                ? `Advanced/metastatic disease (baseline=${baseline_utility.toFixed(2)}) — 5L assigns higher utility to severe states than DSU mapping; expect larger ICER decrease than median.`
+                : baseline_utility > 0.65
+                    ? `Earlier-stage disease (baseline=${baseline_utility.toFixed(2)}) — patients spend less time in severe states; expect smaller ICER decrease than median.`
+                    : `Baseline utility (${baseline_utility.toFixed(2)}) near typical advanced-cancer dataset average — expect impact close to published median.`;
+    }
+    const adjustedPoint = median * multiplier;
+    return {
+        indication_type: indication,
+        icer_change_pct: {
+            point: adjustedPoint,
+            lower: adjustedPoint - Math.abs(adjustedPoint) * 0.30,
+            upper: adjustedPoint + Math.abs(adjustedPoint) * 0.30,
+        },
+        is_baseline_adjusted: true,
+        baseline_utility,
+        rationale: `${directionalNote} This is an EXTRAPOLATION beyond Biz 2026 (which reports only category-level medians) — not a direct finding. Approximation: multiplier ${multiplier.toFixed(2)}× applied to published median ${median}%. Validate by re-running your model under both value sets.`,
+    };
+}
+//# sourceMappingURL=eq5dImpact.js.map

package/dist/grade/eq5dImpact.js.map

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package/dist/grade/inconsistency.d.ts

@@ -0,0 +1,29 @@
+/**
+ * GRADE Inconsistency assessment.
+ *
+ * Per Cochrane Handbook Ch. 10.10 / GRADE Handbook 5.1, inconsistency reflects
+ * heterogeneity of effect estimates across studies — NOT the number of studies.
+ *
+ * Single-study comparisons cannot be assessed for inconsistency; they are
+ * downgraded for imprecision instead. This function returns "not_assessable"
+ * for k=1, mapping I² bands to GRADE inconsistency levels otherwise.
+ *
+ * I² interpretation bands (Cochrane):
+ *   0–40%   might not be important
+ *   30–60%  moderate heterogeneity
+ *   50–90%  substantial heterogeneity
+ *   75–100% considerable heterogeneity
+ *
+ * GRADE downgrade mapping:
+ *   <50%   Low (no downgrade)
+ *   50–75% Moderate (consider 1-step downgrade — "Serious")
+ *   >75%   Serious (1-step downgrade — "Very Serious" if ≥90%)
+ */
+export type GradeInconsistency = "not_assessable" | "Low" | "Moderate" | "Serious" | "Very Serious";
+export interface InconsistencyAssessment {
+    level: GradeInconsistency;
+    downgrade_steps: 0 | 1 | 2;
+    rationale: string;
+}
+export declare function assessInconsistency(n_studies: number, i_squared_pct: number | null): InconsistencyAssessment;
+//# sourceMappingURL=inconsistency.d.ts.map

package/dist/grade/inconsistency.d.ts.map

@@ -0,0 +1 @@
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package/dist/grade/inconsistency.js

@@ -0,0 +1,71 @@
+/**
+ * GRADE Inconsistency assessment.
+ *
+ * Per Cochrane Handbook Ch. 10.10 / GRADE Handbook 5.1, inconsistency reflects
+ * heterogeneity of effect estimates across studies — NOT the number of studies.
+ *
+ * Single-study comparisons cannot be assessed for inconsistency; they are
+ * downgraded for imprecision instead. This function returns "not_assessable"
+ * for k=1, mapping I² bands to GRADE inconsistency levels otherwise.
+ *
+ * I² interpretation bands (Cochrane):
+ *   0–40%   might not be important
+ *   30–60%  moderate heterogeneity
+ *   50–90%  substantial heterogeneity
+ *   75–100% considerable heterogeneity
+ *
+ * GRADE downgrade mapping:
+ *   <50%   Low (no downgrade)
+ *   50–75% Moderate (consider 1-step downgrade — "Serious")
+ *   >75%   Serious (1-step downgrade — "Very Serious" if ≥90%)
+ */
+export function assessInconsistency(n_studies, i_squared_pct) {
+    if (n_studies <= 0) {
+        return {
+            level: "not_assessable",
+            downgrade_steps: 0,
+            rationale: "No studies — domain not assessable",
+        };
+    }
+    if (n_studies === 1) {
+        return {
+            level: "not_assessable",
+            downgrade_steps: 0,
+            rationale: "Single study — inconsistency not assessable (consider imprecision instead)",
+        };
+    }
+    if (i_squared_pct == null) {
+        return {
+            level: "Moderate",
+            downgrade_steps: 0,
+            rationale: "Multiple studies but I² not computed — manual heterogeneity review recommended",
+        };
+    }
+    if (i_squared_pct >= 90) {
+        return {
+            level: "Very Serious",
+            downgrade_steps: 2,
+            rationale: `I²=${i_squared_pct.toFixed(0)}% (considerable heterogeneity, ≥90%)`,
+        };
+    }
+    if (i_squared_pct >= 75) {
+        return {
+            level: "Serious",
+            downgrade_steps: 1,
+            rationale: `I²=${i_squared_pct.toFixed(0)}% (considerable heterogeneity, 75–89%)`,
+        };
+    }
+    if (i_squared_pct >= 50) {
+        return {
+            level: "Moderate",
+            downgrade_steps: 1,
+            rationale: `I²=${i_squared_pct.toFixed(0)}% (substantial heterogeneity, 50–74%)`,
+        };
+    }
+    return {
+        level: "Low",
+        downgrade_steps: 0,
+        rationale: `I²=${i_squared_pct.toFixed(0)}% (low heterogeneity, <50%)`,
+    };
+}
+//# sourceMappingURL=inconsistency.js.map

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package/dist/grade/upgrading.d.ts

@@ -0,0 +1,32 @@
+/**
+ * GRADE Upgrading assessment for observational evidence (Guyatt 2011).
+ *
+ * GRADE allows upgrading observational studies that start at "Low" certainty
+ * for three specific reasons:
+ *   1. Large magnitude of effect (RR < 0.5 or > 2.0 → +1; RR < 0.2 or > 5.0 → +2)
+ *   2. Dose-response gradient
+ *   3. Plausible confounding/bias would reduce the observed effect (i.e.,
+ *      bias is biasing toward null, so the true effect is likely larger)
+ *
+ * Total upgrade is capped at +2 steps. Upgrading does NOT apply when the
+ * starting certainty is High (RCTs) — RCTs cannot be upgraded above High.
+ *
+ * Reference: Guyatt GH et al. GRADE guidelines: 9. Rating up the quality
+ * of evidence. J Clin Epidemiol. 2011;64(12):1311-1316.
+ */
+export interface UpgradingInput {
+    /** Starting certainty before downgrades — "High" for RCTs, "Low" for observational. */
+    start_certainty: "High" | "Low";
+    /** Magnitude of effect (effect size relative to control). */
+    large_effect?: "none" | "large" | "very_large";
+    /** Documented dose-response gradient. */
+    dose_response?: boolean;
+    /** Plausible residual confounding would bias the effect toward null. */
+    plausible_confounding_toward_null?: boolean;
+}
+export interface UpgradingAssessment {
+    upgrade_steps: 0 | 1 | 2;
+    rationale: string;
+}
+export declare function assessUpgrading(input: UpgradingInput): UpgradingAssessment;
+//# sourceMappingURL=upgrading.d.ts.map

package/dist/grade/upgrading.d.ts.map

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package/dist/grade/upgrading.js

@@ -0,0 +1,54 @@
+/**
+ * GRADE Upgrading assessment for observational evidence (Guyatt 2011).
+ *
+ * GRADE allows upgrading observational studies that start at "Low" certainty
+ * for three specific reasons:
+ *   1. Large magnitude of effect (RR < 0.5 or > 2.0 → +1; RR < 0.2 or > 5.0 → +2)
+ *   2. Dose-response gradient
+ *   3. Plausible confounding/bias would reduce the observed effect (i.e.,
+ *      bias is biasing toward null, so the true effect is likely larger)
+ *
+ * Total upgrade is capped at +2 steps. Upgrading does NOT apply when the
+ * starting certainty is High (RCTs) — RCTs cannot be upgraded above High.
+ *
+ * Reference: Guyatt GH et al. GRADE guidelines: 9. Rating up the quality
+ * of evidence. J Clin Epidemiol. 2011;64(12):1311-1316.
+ */
+export function assessUpgrading(input) {
+    if (input.start_certainty === "High") {
+        return {
+            upgrade_steps: 0,
+            rationale: "Upgrading not applicable — RCT evidence already starts High",
+        };
+    }
+    const reasons = [];
+    let raw = 0;
+    if (input.large_effect === "very_large") {
+        raw += 2;
+        reasons.push("very large effect (RR < 0.2 or > 5.0)");
+    }
+    else if (input.large_effect === "large") {
+        raw += 1;
+        reasons.push("large effect (RR < 0.5 or > 2.0)");
+    }
+    if (input.dose_response) {
+        raw += 1;
+        reasons.push("dose-response gradient");
+    }
+    if (input.plausible_confounding_toward_null) {
+        raw += 1;
+        reasons.push("plausible confounding biases toward null");
+    }
+    const capped = Math.min(raw, 2);
+    if (raw === 0) {
+        return {
+            upgrade_steps: 0,
+            rationale: "No upgrading criteria met (Guyatt 2011)",
+        };
+    }
+    return {
+        upgrade_steps: capped,
+        rationale: reasons.join("; ") + (raw > capped ? " (capped at +2 per GRADE)" : ""),
+    };
+}
+//# sourceMappingURL=upgrading.js.map

package/dist/grade/upgrading.js.map

@@ -0,0 +1 @@
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package/dist/network/bucher.d.ts

@@ -25,5 +25,5 @@ export declare function bucherIndirect(ab: PooledEstimate, cb: PooledEstimate):
  *
  * Returns the indirect estimate of A vs C.
  */
-export declare function computeIndirectComparison(intervention: string, comparator: string, bridge: string, directAB: DirectComparison[], directCB: DirectComparison[], outcome: string, measure: EffectMeasure): IndirectEstimate;
+export declare function computeIndirectComparison(intervention: string, comparator: string, bridge: string, directAB: DirectComparison[], directCB: DirectComparison[], outcome: string, measure: EffectMeasure, directAC?: DirectComparison[]): IndirectEstimate;
 //# sourceMappingURL=bucher.d.ts.map

package/dist/network/bucher.d.ts.map

@@ -1 +1 @@
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+{"version":3,"file":"bucher.d.ts","sourceRoot":"","sources":["../../src/network/bucher.ts"],"names":[],"mappings":"AAAA,OAAO,KAAK,EACV,aAAa,EACb,cAAc,EACd,gBAAgB,EAChB,gBAAgB,EACjB,MAAM,YAAY,CAAC;AAGpB,iCAAiC;AACjC,wBAAgB,QAAQ,CAAC,KAAK,EAAE,MAAM,EAAE,KAAK,EAAE,MAAM,GAAG,MAAM,CAE7D;AAED,6DAA6D;AAC7D,wBAAgB,SAAS,CAAC,CAAC,EAAE,MAAM,GAAG,MAAM,CAc3C;AAED,sCAAsC;AACtC,wBAAgB,WAAW,CAAC,CAAC,EAAE,MAAM,GAAG,MAAM,CAE7C;AAiDD,4CAA4C;AAC5C,wBAAgB,eAAe,CAC7B,OAAO,EAAE,KAAK,CAAC;IAAE,KAAK,EAAE,MAAM,CAAC;IAAC,EAAE,EAAE,MAAM,CAAA;CAAE,CAAC,GAC5C,cAAc,CAqBhB;AAED,2DAA2D;AAC3D,wBAAgB,cAAc,CAC5B,EAAE,EAAE,cAAc,EAClB,EAAE,EAAE,cAAc,GACjB;IAAE,KAAK,EAAE,MAAM,CAAC;IAAC,EAAE,EAAE,MAAM,CAAC;IAAC,CAAC,EAAE,MAAM,CAAC;IAAC,OAAO,EAAE,MAAM,CAAA;CAAE,CAM3D;AAED;;;;;;;GAOG;AACH,wBAAgB,yBAAyB,CACvC,YAAY,EAAE,MAAM,EACpB,UAAU,EAAE,MAAM,EAClB,MAAM,EAAE,MAAM,EACd,QAAQ,EAAE,gBAAgB,EAAE,EAC5B,QAAQ,EAAE,gBAAgB,EAAE,EAC5B,OAAO,EAAE,MAAM,EACf,OAAO,EAAE,aAAa,EACtB,QAAQ,CAAC,EAAE,gBAAgB,EAAE,GAC5B,gBAAgB,CA+ElB"}

package/dist/network/bucher.js

@@ -1,3 +1,4 @@
+import { assessConsistencyConflict } from "./consistency.js";
 /** Standard error from 95% CI */
 export function seFromCI(lower, upper) {
     return (upper - lower) / 3.92;
@@ -11,7 +12,7 @@ export function normalCDF(x) {
     const p = d *
         Math.exp((-z * z) / 2.0) *
         (t *
-            (0.319381530 +
+            (0.31938153 +
                 t *
                     (-0.356563782 +
                         t * (1.781477937 + t * (-1.821255978 + t * 1.330274429)))));
@@ -87,7 +88,7 @@ export function bucherIndirect(ab, cb) {
  *
  * Returns the indirect estimate of A vs C.
  */
-export function computeIndirectComparison(intervention, comparator, bridge, directAB, directCB, outcome, measure) {
+export function computeIndirectComparison(intervention, comparator, bridge, directAB, directCB, outcome, measure, directAC) {
     // Convert to working scale and pool
     const abStudies = directAB.map((d) => ({
         value: toWorkingScale(d.estimate, seOnWorkingScale(d.estimate, d.ci_lower, d.ci_upper, measure), measure).value,
@@ -105,6 +106,27 @@ export function computeIndirectComparison(intervention, comparator, bridge, dire
     const ciLowerWorking = indirect.value - 1.96 * indirect.se;
     const ciUpperWorking = indirect.value + 1.96 * indirect.se;
     const result = fromWorkingScale(indirect.value, ciLowerWorking, ciUpperWorking, measure);
+    // Optional Bucher consistency check vs direct h2h evidence
+    let consistency_check;
+    if (directAC && directAC.length > 0) {
+        const acStudies = directAC.map((d) => ({
+            value: toWorkingScale(d.estimate, seOnWorkingScale(d.estimate, d.ci_lower, d.ci_upper, measure), measure).value,
+            se: seOnWorkingScale(d.estimate, d.ci_lower, d.ci_upper, measure),
+        }));
+        const pooledAC = poolFixedEffect(acStudies);
+        const assessment = assessConsistencyConflict({
+            indirect: { value: indirect.value, se: indirect.se },
+            direct: { value: pooledAC.value, se: pooledAC.se },
+        });
+        consistency_check = {
+            has_conflict: assessment.has_conflict,
+            severity: assessment.severity,
+            direct_estimate: pooledAC.value,
+            direct_n_studies: pooledAC.n_studies,
+            z_difference: assessment.z_difference,
+            rationale: assessment.rationale,
+        };
+    }
     return {
         intervention,
         comparator,
@@ -120,6 +142,7 @@ export function computeIndirectComparison(intervention, comparator, bridge, dire
         p_value: indirect.p_value,
         pooled_ab: pooledAB,
         pooled_bc: pooledCB,
+        consistency_check,
     };
 }
 //# sourceMappingURL=bucher.js.map

package/dist/network/bucher.js.map

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package/dist/network/consistency.d.ts

@@ -0,0 +1,44 @@
+/**
+ * Bucher consistency assumption check.
+ *
+ * Bucher's 1997 indirect comparison method requires that the bridge-comparator
+ * effect is the same in trials of A-vs-B and C-vs-B. When direct head-to-head
+ * (A-vs-C) evidence ALSO exists, we can test this assumption empirically by
+ * comparing the direct and indirect estimates — if they disagree, the
+ * consistency assumption is suspect and the indirect estimate may be biased.
+ *
+ * Test statistic: z = (direct - indirect) / sqrt(SE_direct² + SE_indirect²)
+ *
+ * Severity bands (Cochrane Handbook Ch. 11.4.3 / NICE DSU TSD 18):
+ *   |z| < 1.5    → no conflict
+ *   1.5–1.96     → moderate inconsistency (warrants discussion)
+ *   ≥1.96        → substantial inconsistency (consistency assumption violated)
+ *   any opposite-direction with both estimates significant → substantial
+ *
+ * Note: the working scale matters. For OR/HR/RR, both estimates must be on the
+ * log scale before differencing. This function assumes the caller has already
+ * converted to the working scale.
+ */
+export interface ConsistencyInput {
+    /** Indirect (Bucher) estimate on the working scale (log for ratio measures). */
+    indirect: {
+        value: number;
+        se: number;
+    };
+    /** Direct (head-to-head) estimate on the working scale, or null if no h2h. */
+    direct: {
+        value: number;
+        se: number;
+    } | null;
+}
+export type ConsistencySeverity = "untestable" | "none" | "moderate" | "substantial";
+export interface ConsistencyAssessment {
+    has_conflict: boolean;
+    severity: ConsistencySeverity;
+    difference: number;
+    se_difference: number;
+    z_difference: number;
+    rationale: string;
+}
+export declare function assessConsistencyConflict(input: ConsistencyInput): ConsistencyAssessment;
+//# sourceMappingURL=consistency.d.ts.map

package/dist/network/consistency.d.ts.map

@@ -0,0 +1 @@
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