Wasmann KA, Wijsman P, van Dieren S, Bemelman W, Buskens C. Partially randomised patient preference trials as an alternative design to randomised controlled trials: systematic review and meta-analyses.
BMJ Open 2019;
9:e031151. [PMID:
31619428 PMCID:
PMC6797441 DOI:
10.1136/bmjopen-2019-031151]
[Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Revised: 07/12/2019] [Accepted: 09/16/2019] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVE
Randomised controlled trials (RCT) are the gold standard to provide unbiased data. However, when patients have a treatment preference, randomisation may influence participation and outcomes (eg, external and internal validity). The aim of this study was to assess the influence of patients' preference in RCTs by analysing partially randomised patient preference trials (RPPT); an RCT and preference cohort combined.
DESIGN
Systematic review and meta-analyses.
DATA SOURCES
MEDLINE, Embase, PsycINFO and the Cochrane Library.
ELIGIBILITY CRITERIA FOR SELECTING STUDIES
RPPTs published between January 2005 and October 2018 reporting on allocation of patients to randomised and preference cohorts were included.
DATA EXTRACTION AND SYNTHESIS
Two independent reviewers extracted data. The main outcomes were the difference in external validity (participation and baseline characteristics) and internal validity (lost to follow-up, crossover and the primary outcome) between the randomised and the preference cohort within each RPPT, compared in a meta-regression using a Wald test. Risk of bias was not assessed, as no quality assessment for RPPTs has yet been developed.
RESULTS
In total, 117 of 3734 identified articles met screening criteria and 44 were eligible (24 873 patients). The participation rate in RPPTs was >95% in 14 trials (range: 48%-100%) and the randomisation refusal rate was >50% in 26 trials (range: 19%-99%). Higher education, female, older age, race and prior experience with one treatment arm were characteristics of patients declining randomisation. The lost to follow-up and cross-over rate were significantly higher in the randomised cohort compared with the preference cohort. Following the meta-analysis, the reported primary outcomes were comparable between both cohorts of the RPPTs, mean difference 0.093 (95% CI -0.178 to 0.364, p=0.502).
CONCLUSIONS
Patients' preference led to a substantial proportion of a specific patient group refusing randomisation, while it did not influence the primary outcome within an RPPT. Therefore, RPPTs could increase external validity without compromising the internal validity compared with RCTs.
PROSPERO REGISTRATION NUMBER
CRD42019094438.
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