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Sengul A, Escobar E, Flores JR, Kwok M, Kono S, Guyatt G, Jackevicius CA. Non-Inferiority Trials: A Systematic Review on Methodological Quality and Reporting Standards. J Gen Intern Med 2024:10.1007/s11606-024-08890-9. [PMID: 38954320 DOI: 10.1007/s11606-024-08890-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Accepted: 06/12/2024] [Indexed: 07/04/2024]
Abstract
BACKGROUND Non-inferiority (NI) trials require unique trial design and methods, which pose challenges in their interpretation and applicability, risking introduction of inferior therapies in clinical practice. With the abundance of novel therapies, NI trials are increasing in publication. Prior studies found inadequate quality of reporting of NI studies, but were limited to certain specialties/journals, lacked NI margin evaluation, and did not examine temporal changes in quality. We conducted a systematic review without restriction to journal type, journal impact factor, disease state or intervention to evaluate the quality of NI trials, including a comprehensive risk of bias assessment and comparison of quality over time. METHODOLOGY We searched PubMed and Cochrane Library databases for NI trials published in English in 2014 and 2019. They were assessed for: study design and NI margin characteristics, primary results, and risk of bias for blinding, concealment, analysis method and missing outcome data. RESULTS We included 823 studies. Between 2014 and 2019, a shift from publication in specialty to general journals (15% vs 28%, p < 0.001) and from pharmacological to non-pharmacological interventions (25% vs 38%, p = 0.025) was observed. The NI margin was specified in most trials for both years (94% vs 95%). Rationale for the NI margin increased (36% vs 57%, p < 0.001), but remained low, with clinical judgement the most common rationale (30% vs 23%), but more 2019 articles incorporating patient values (0.3% vs 21%, p < 0.001). Over 50% of studies were open-label for both years. Gold standard method of analyses (both per protocol + (modified) intention to treat) declined over time (43% vs 36%, p < 0.001). DISCUSSION The methodological quality and reporting of NI trials remains inadequate although improving in some areas. Improved methods for NI margin justification, blinding, and analysis method are warranted to facilitate clinical decision-making.
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Affiliation(s)
- Anthony Sengul
- Department of Pharmacy Practice and Administration, Western University of Health Sciences, Pomona, CA, USA
| | | | - John R Flores
- Kaiser Permanente San Bernardino County, Fontana, CA, USA
| | | | - Shogo Kono
- VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | - Gordon Guyatt
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Cynthia A Jackevicius
- Department of Pharmacy Practice and Administration, Western University of Health Sciences, Pomona, CA, USA.
- VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA.
- Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada.
- ICES, Toronto, Canada.
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Komorowski AS, Lo CKL, Kapoor AK, Smieja M, Loeb M, Mertz D, Bai AD. More Than a Decade Since the Latest CONSORT Non-inferiority Trials Extension: Do Infectious Diseases Trials Do Enough? Clin Infect Dis 2024; 78:324-329. [PMID: 37739456 DOI: 10.1093/cid/ciad574] [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: 08/03/2023] [Revised: 09/05/2023] [Accepted: 09/20/2023] [Indexed: 09/24/2023] Open
Abstract
More than a decade after the Consolidated Standards of Reporting Trials group released a reporting items checklist for non-inferiority randomized controlled trials, the infectious diseases literature continues to underreport these items. Trialists, journals, and peer reviewers should redouble their efforts to ensure infectious diseases studies meet these minimum reporting standards.
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Affiliation(s)
- Adam S Komorowski
- Medical Microbiology, Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Ontario, Canada
- Department of Health Research Methodology, Evidence, and Impact, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Carson K L Lo
- Transplant Infectious Diseases and Ajmera Transplant Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Andrew K Kapoor
- Division of Infectious Diseases, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Marek Smieja
- Medical Microbiology, Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Ontario, Canada
- Department of Health Research Methodology, Evidence, and Impact, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
- Division of Infectious Diseases, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Mark Loeb
- Medical Microbiology, Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Ontario, Canada
- Department of Health Research Methodology, Evidence, and Impact, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
- Division of Infectious Diseases, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Dominik Mertz
- Department of Health Research Methodology, Evidence, and Impact, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
- Division of Infectious Diseases, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Anthony D Bai
- Division of Infectious Diseases, Department of Medicine, Queen's University, Kingston, Ontario, Canada
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Lo CKL, Komorowski AS, Hall CW, Sandstrom TS, Alamer AAM, Mourad O, Li XX, Al Ohaly R, Benoit MÈ, Duncan DB, Fuller CA, Shaw S, Suresh M, Smaill F, Kapoor AK, Smieja M, Mertz D, Bai AD. Methodological and Reporting Quality of Noninferiority Randomized Controlled Trials Comparing Antiretroviral Therapies: A Systematic Review. Clin Infect Dis 2023; 77:1023-1031. [PMID: 37243351 DOI: 10.1093/cid/ciad308] [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: 03/08/2023] [Revised: 05/15/2023] [Accepted: 05/19/2023] [Indexed: 05/28/2023] Open
Abstract
BACKGROUND It is unclear whether the reporting quality of antiretroviral (ARV) noninferiority (NI) randomized controlled trials (RCTs) has improved since the CONSORT guideline release in 2006. The primary objective of this systematic review was assessing the methodological and reporting quality of ARV NI-RCTs. We also assessed reporting quality by funding source and publication year. METHODS We searched Medline, Embase, and Cochrane Central from inception to 14 November 2022. We included NI-RCTs comparing ≥2 ARV regimens used for human immunodeficiency virus treatment or prophylaxis. We used the Cochrane Risk of Bias 2.0 tool to assess risk of bias. Screening and data extraction were performed blinded and in duplicate. Descriptive statistics were used to summarize data; statistical tests were 2 sided, with significance defined as P < .05. The systematic review was prospectively registered (PROSPERO CRD42022328586), and not funded. RESULTS We included 160 articles reporting 171 trials. Of these articles, 101 (63.1%) did not justify the NI margin used, and 28 (17.5%) did not provide sufficient information for sample size calculation. Eighty-nine of 160 (55.6%) reported both intention-to-treat and per-protocol analyses, while 118 (73.8%) described missing data handling. Ten of 171 trials (5.9%) reported potentially misleading results. Pharmaceutical industry-funded trials were more likely to be double-blinded (28.1% vs 10.3%; P = .03) and to describe missing data handling (78.5% vs 59.0%; P = .02). The overall risk of bias was low in 96 of 160 studies (60.0%). CONCLUSIONS ARV NI-RCTs should improve NI margin justification, reporting of intention-to-treat and per-protocol analyses, and missing data handling to increase CONSORT adherence.
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Affiliation(s)
- Carson K L Lo
- Division of Infectious Diseases, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Transplant Infectious Diseases and Ajmera Transplant Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Adam S Komorowski
- Division of Medical Microbiology, Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Ontario, Canada
- Department of Health Research Methodology, Evidence, and Impact, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Clayton W Hall
- Division of Medical Microbiology, Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Teslin S Sandstrom
- Division of Medical Microbiology, Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
| | - Amnah A M Alamer
- Division of Infectious Diseases, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Department of Internal Medicine, King Faisal University, Hofuf, Saudi Arabia
| | - Omar Mourad
- Division of Infectious Diseases, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Xena X Li
- Division of Medical Microbiology, Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Ontario, Canada
- Shared Hospital Laboratory, Toronto, Ontario, Canada
| | - Rand Al Ohaly
- Division of Infectious Diseases, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Marie-Ève Benoit
- Division of Infectious Diseases, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Division of Medical Microbiology, Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Ontario, Canada
| | - D Brody Duncan
- Division of Medical Microbiology, Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Charlotte A Fuller
- Division of Medical Microbiology, Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Shazeema Shaw
- Division of Infectious Diseases, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Division of Infectious Diseases, Georgetown Public Hospital Corporation, Georgetown, Guyana
| | - Mallika Suresh
- Michael G. DeGroote School of Medicine, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Fiona Smaill
- Division of Medical Microbiology, Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Andrew K Kapoor
- Division of Infectious Diseases, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Marek Smieja
- Division of Infectious Diseases, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Division of Medical Microbiology, Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Ontario, Canada
- Department of Health Research Methodology, Evidence, and Impact, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Dominik Mertz
- Division of Infectious Diseases, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Department of Health Research Methodology, Evidence, and Impact, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Anthony D Bai
- Department of Health Research Methodology, Evidence, and Impact, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
- Division of Infectious Diseases, Department of Medicine, Queen's University, Kingston, Ontario, Canada
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