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Goldkuhle M, Guyatt GH, Kreuzberger N, Akl EA, Dahm P, van Dalen EC, Hemkens LG, Klugar M, Mustafa RA, Nonino F, Schünemann HJ, Trivella M, Skoetz N. GRADE concept 4: rating the certainty of evidence when study interventions or comparators differ from PICO targets. J Clin Epidemiol 2023; 159:40-48. [PMID: 37146659 DOI: 10.1016/j.jclinepi.2023.04.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 04/13/2023] [Accepted: 04/26/2023] [Indexed: 05/07/2023]
Abstract
OBJECTIVES This Grading of Recommendations Assessment, Development and Evaluation (GRADE) concept article offers systematic reviewers, guideline authors, and other users of evidence assistance in addressing randomized trial situations in which interventions or comparators differ from those in the target people, interventions, comparators, and outcomes. To clarify what GRADE considers under indirectness of interventions and comparators, we focus on a particular example: when comparator arm participants receive some or all aspects of the intervention management strategy (treatment switching). STUDY DESIGN AND SETTING An interdisciplinary panel of the GRADE working group members developed this concept article through an iterative review of examples in multiple teleconferences, small group sessions, and e-mail correspondence. After presentation at a GRADE working group meeting in November 2022, attendees approved the final concept paper, which we support with examples from systematic reviews and individual trials. RESULTS In the presence of safeguards against risk of bias, trials provide unbiased estimates of the effect of an intervention on the people as enrolled, the interventions as implemented, the comparators as implemented, and the outcomes as measured. Within the GRADE framework, differences in the people, interventions, comparators, and outcomes elements between the review or guideline recommendation targets and the trials as implemented constitute issues of indirectness. The intervention or comparator group management strategy as implemented, when it differs from the target comparator, constitutes one potential source of indirectness: Indirectness of interventions and comparators-comparator group receipt of the intervention constitutes a specific subcategory of said indirectness. The proportion of comparator arm participants that received the intervention and the apparent magnitude of effect bear on whether one should rate down, and if one does, to what extent. CONCLUSION Treatment switching and other differences between review or guideline recommendation target interventions and comparators vs. interventions and comparators as implemented in otherwise relevant trials are best considered issues of indirectness.
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Affiliation(s)
- Marius Goldkuhle
- Evidence-based Medicine, Department I of Internal Medicine, Faculty of Medicine and University Hospital Cologne, University of Cologne, Kerpener Str. 62, 50937 Cologne, Germany.
| | - Gordon H Guyatt
- Department of Health Research Methods, Evidence, and Impact, Michael G DeGroote Cochrane Canada Centre, Cochrane Canada, McMaster GRADE Centre and Department of Medicine, McMaster University, 1280 Main St. W., Hamilton, ON L8S 4K1, Canada
| | - Nina Kreuzberger
- Evidence-based Medicine, Department I of Internal Medicine, Faculty of Medicine and University Hospital Cologne, University of Cologne, Kerpener Str. 62, 50937 Cologne, Germany
| | - Elie A Akl
- Department of Internal Medicine, American University of Beirut, Lebanon, P.O.Box 11-0236 and Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main St. W., Hamilton, ON L8S 4K1, Canada
| | - Philipp Dahm
- Minneapolis VA Health Care System, Urology Section 112D, One Veterans Drive, Minneapolis, Minnesota 55417
| | - Elvira C van Dalen
- Princess Máxima Center for Pediatric Oncology, Heidelberglaan 25, 3584CS Utrecht, the Netherlands
| | - Lars G Hemkens
- Department of Clinical Research, University Hospital Basel, University of Basel, Basel, Switzerland; Research Center for Clinical Neuroimmunology and Neuroscience Basel (RC2NB), University Hospital Basel and University of Basel, Basel, Switzerland; Meta-Research Innovation Center at Stanford (METRICS), Stanford University, Stanford, CA, USA; Meta-Research Innovation Center Berlin (METRIC-B), Berlin Institute of Health, Berlin, Germany
| | - Miloslav Klugar
- Czech National Centre for Evidence-Based Healthcare and Knowledge Translation (Cochrane Czech Republic, Czech EBHC: JBI Centre of Excellence, Masaryk University GRADE Centre), Faculty of Medicine, Masaryk University, 625 00 Brno, Czech Republic; Institute of Health Information and Statistics of the Czech Republic, 100 00 Prague, Czech Republic
| | - Reem A Mustafa
- Department of Medicine and Population Health, University of Kansas Health System, 3901 Rainbow Blvd, MS3002, Kansas City, KS 66160, USA; Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main St. W., Hamilton, Ontario L8S 4K1, Canada
| | - Francesco Nonino
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Unit of Epidemiology and Statistics, Cochrane Review Group Multiple Sclerosis and Rare Diseases of the CNS, Via Altura 3, 40139 Bologna, Italy
| | - Holger J Schünemann
- Department of Health Research Methods, Evidence, and Impact, Michael G DeGroote Cochrane Canada Centre, Cochrane Canada and McMaster GRADE Centre, McMaster University, Hamilton, Ontario, Canada; Department of Medicine, McMaster University, Hamilton, Ontario, Canada; Department of Biomedical Sciences, Humanitas University, Milan, Italy; Cochrane Canada, Hamilton, Ontario, Canada
| | - Marialene Trivella
- Department of Cardiovascular Medicine, John Radcliffe Hospital, University of Oxford, UK; Department of Population Health, London School of Hygiene and Tropical Medicine, London
| | - Nicole Skoetz
- Evidence-based Medicine, Department I of Internal Medicine, Faculty of Medicine and University Hospital Cologne, University of Cologne, Kerpener Str. 62, 50937 Cologne, Germany
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Pohl M, Baumann L, Behnisch R, Kirchner M, Krisam J, Sander A. Estimands-a Basic Element for Clinical Trials. Part 29 of a Series on Evaluation of Scientific Publications. DEUTSCHES ARZTEBLATT INTERNATIONAL 2021; 118:883-888. [PMID: 34857075 DOI: 10.3238/arztebl.m2021.0373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Revised: 06/18/2021] [Accepted: 11/03/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Clinical trials are of central importance for the evaluation and comparison of treatments. The transparency and intelligibility of the treatment effect under investigation is an essential matter for physicians, patients, and health-care authorities. The estimand framework has been introduced because many trials are deficient in this respect. METHODS Introduction, definition, and application of the estimand framework on the basis of an example and a selective review of the literature. RESULTS The estimand framework provides a systematic approach to the definition of the treatment effect under investigation in a clinical trial. An estimand consists of five attributes: treatment, population, variable, population-level summary, and handling of intercurrent events. Each of these attributes is defined in an interdisciplinary discussion during the trial planning phase, based on the clinical question being asked. Special attention is given to the handling of intercurrent events (ICEs): these are events-e.g., discontinuation or modification of treatment or the use of emergency medication-that can occur once the treatment has begun and might affect the possibility of observing the endpoints or their interpretability. There are various strategies for the handling of ICEs; these can, for example, also reflect the existing intentionto- treat (ITT) principle. Per-protocol analyses, in contrast, are prone to bias and cannot be represented in a sensible manner by an estimand, although they may be performed as a supplementary analysis. The discussion of potential intercurrent events and how they should appropriately be handled in view of the aim of the trial must already take place in the planning phase. CONCLUSION Use of the estimand framework should make it easier for both physicians and patients to understand what trials reveal about the efficacy of treatment, and to compare the results of different trials.
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Rastmanesh R. Metformin and Malignant Tumors: Not Over the Hill: A Short Comment [Letter]. Diabetes Metab Syndr Obes 2021; 14:3839-3840. [PMID: 34522110 PMCID: PMC8434858 DOI: 10.2147/dmso.s335574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Accepted: 08/26/2021] [Indexed: 11/23/2022] Open
Affiliation(s)
- Reza Rastmanesh
- The Nutrition Society, London, UK
- The American Physical Society, College Park, MD, USA
- Correspondence: Reza Rastmanesh Private Clinic, #6, Physicians Building, Sarshar Alley, Vali Asr Street, Tajrish, Tehran, 1961835555, Iran Email
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