SynthesisBMC medical education2025
Less is more? A systematic review and network meta-analysis on MCQ option numbers.
Synthesis in BMC medical education, 2025. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 2 papers.
What it found
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The abstract states no effect estimate the extractor could read, or names no intervention and outcome on the map, so this paper lights no cell and moves no belief. It is still indexed, cited and linked below.
The trial behind it
Trials whose registry record cites this paper, or whose number appears in the abstract. A trial that started after this paper was published is citing it as background, not reporting it.
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Who cites it
2 citing papers in PubMed.
- Reducing the Number of Distractors in Multiple-Choice Questions: A Randomized Study in Undergraduate Medical Education.Perspectives on medical education · 2026Trial
- Item analysis and performance of EMQ, MCQ, and SAQ in dental education and students' perception of extended-matching questions.BMC medical education · 2026Article
Corrections and comments
PubMed lists nothing against this paper. Absence here is not a guarantee, only a check that was made.
Authors and funding
2 authors.
Funding
No grant is acknowledged in the PubMed record.
Abstract
backgroundMultiple-choice questions (MCQs) are widely used in health sciences education due to their scalability and objectivity. While traditionally constructed with four or five options, emerging evidence suggests that using fewer options may enhance test efficiency without compromising psychometric quality. This study systematically compared the performance of 3-, 4-, and 5-option MCQs.
methodsA systematic review and network meta-analysis (NMA) was conducted using studies from electronic databases. Included studies compared psychometric outcomes of MCQs with 3-, 4-, or 5-option formats. Outcomes included student scores, difficulty (a measure of how easy an item was, with a higher index indicating greater ease of answering) and discrimination indices, response time, reliability coefficients, and risk of non-functioning distractors (NFDs). A random-effects NMA was performed using Hedges' g and odds ratios (OR), with 95% confidence intervals. The certainty of evidence was assessed using the GRADE approach.
resultsForty-six studies (33,437 students and 7,535 test items) were included. Compared to 5-option MCQs, 3-option MCQs had significantly higher student scores (g = 0.42; 95% CI: 0.28, 0.56), higher difficulty index (g: 0.27; 95% CI: 0.03, 0.51), shorter test completion time (g = -1.78; 95% CI: -2.1, -1.5), and lower risk of NFDs (OR = 0.6; 95% CI: 0.4, 0.8). Discrimination indices and reliability coefficients did not differ significantly across option formats. Bootstrap and sensitivity analyses corroborate these findings. Amongst studies in health sciences, 3-option (g: 0.38; 95% CI: 0.09, 0.67) and 4-option MCQs (g: 0.29; 95% CI: 0.01, 0.57) had higher difficulty index compared to 5-option MCQs; no differences were observed in the discrimination index between the options; and 3-option MCQ had significantly lower risk of an NFD compared to 4-option (OR: 0.49; 95% CI: 0.32, 0.75) and 5-option MCQs (OR: 0.56; 95% CI: 0.37, 0.84). The evidence certainty was rated very low.
conclusionMCQs with 3-options demonstrate comparable validity and psychometric quality to those with 4- or 5-options, while offering efficiency benefits such as shorter response time and reduced risk of NFD. Given the very low certainty of evidence, these findings should be interpreted with caution. While the direction of effect appears consistent, the magnitude and generalizability remain uncertain, and educators are advised to consider local validation before widespread adoption.
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