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Chakraborty I, Shreya A, Mendiratta J, Bhan A, Saberwal G. An analysis of deficiencies in the ethics committee data of certain interventional trials registered with the Clinical Trials Registry-India. PLOS GLOBAL PUBLIC HEALTH 2022; 2:e0000617. [PMID: 36962581 PMCID: PMC10021301 DOI: 10.1371/journal.pgph.0000617] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Accepted: 09/27/2022] [Indexed: 03/26/2023]
Abstract
There is widespread agreement that clinical trials should be registered in a public registry, preferably before the trial commences. It is also important that details of each trial in the public record are complete and accurate. In this study, we examined the trial sites and ethics committee (EC) data for 1359 recent Phase 2 or Phase 3 interventional trials registered with Clinical Trials Registry-India (CTRI), to identify categories of problems that prevent the clear identification of which EC approved a given site. We created an SQLite database that hosted the relevant CTRI records, and queried this database, as needed. We identified two broad categories of problems: those pertaining to the understanding of an individual trial and those to adopting a data analytics approach for a large number of trials. Overall, about 30 problems were identified, such as an EC not being listed; an uninformative name of the EC that precluded its clear identification; ambiguity in which EC supervised a particular site; repetition of a site or an EC; the use of a given acronym for different organizations; site name not clearly listed, etc. The large number of problems with the data in the EC or site field creates a challenge to link particular sites with particular ECs, especially if a programme is used to find the matches. We make a few suggestions on how the situation could be improved. Most importantly, list the EC registration number for each EC, merge the site and EC tables so that it is clear which EC is linked to which site; and implement logic rules that would prevent a trial from being registered unless certain conditions were met. This will raise user confidence in CTRI EC data, and enable data based public policy and inferences. This will also contribute to increased transparency, and trust, in clinical trials, and their oversight, in India.
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Affiliation(s)
| | - Adya Shreya
- Institute of Bioinformatics and Applied Biotechnology, Bengaluru, India
| | | | - Anant Bhan
- Centre for Ethics, Yenepoya (deemed to be University), Mangaluru, India
| | - Gayatri Saberwal
- Institute of Bioinformatics and Applied Biotechnology, Bengaluru, India
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Østengaard L, Lundh A, Tjørnhøj-Thomsen T, Abdi S, Gelle MHA, Stewart LA, Boutron I, Hróbjartsson A. Influence and management of conflicts of interest in randomised clinical trials: qualitative interview study. BMJ 2020; 371:m3764. [PMID: 33109515 PMCID: PMC7590918 DOI: 10.1136/bmj.m3764] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To characterise and analyse the experiences of trial researchers of if and how conflicts of interest had unduly influenced clinical trials they had worked on, what management strategies they had used to minimise any potential influence, and their experiences and views on conflicts of interest more generally. DESIGN Qualitative interview study. PARTICIPANTS Trial researchers who had participated in at least 10 clinical trials with methodological or statistical expertise. Researchers differed by geographical location, educational background, and experience with different types of funders. Interviewees were identified by searches on Web of Science and snowball sampling. 52 trial researchers were approached by email; 20 agreed to be interviewed. SETTING Interviews conducted by telephone, recorded, transcribed verbatim, imported to NVivo 12, and analysed by systematic text condensation. Semistructured interviews focused on financial and non-financial conflicts of interest. RESULTS The interviewees had participated in a median of 37.5 trials and were mainly male physicians who had experience with commercial and non-commercial trial funders. Two predefined themes (influence of conflicts of interest and management strategies) and two additional themes (definition and reporting of conflicts of interest) emerged. Examples of perceived influence of conflicts of interest were: choice of inferior comparator, manipulation of the randomisation process, prematurely stopping the trials, fabrication of data, blocking access to data, and spin (eg, overly favourable interpretation of the results). Examples of strategies to manage conflicts of interest were: disclosure procedures, exclusion of the funder from design and analysis, independent committees, contracts ensuring complete access to the data, and no restriction by the funder on analysis and reporting. Interviewees used different definitions or thresholds for what they considered to be conflicts of interest, and they described different criteria for when to report them. Some interviewees considered non-commercial financial conflicts of interest (eg, funding of trials by governmental health agencies with a political agenda) to be equally or more important than commercial financial conflicts of interest (eg, funding by drug and device companies), but more challenging to report and manage. CONCLUSION This study described how trial researchers perceive conflicts of interest unduly influencing clinical trials they had worked on, and the management strategies they used to prevent these influences. The results indicated considerable variability in researchers' understanding of what conflicts of interest are and when they should be reported.
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Affiliation(s)
- Lasse Østengaard
- Centre for Evidence-Based Medicine Odense (CEBMO), Odense University Hospital, Kløvervænget 10, 13th floor, 5000 Odense C, Denmark
- Open Patient data Exploratory Network (OPEN), Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- University Library of Southern Denmark, Odense, Denmark
| | - Andreas Lundh
- Centre for Evidence-Based Medicine Odense (CEBMO), Odense University Hospital, Kløvervænget 10, 13th floor, 5000 Odense C, Denmark
- Open Patient data Exploratory Network (OPEN), Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- Department of Infectious Diseases, Hvidovre Hospital, Hvidovre, Denmark
| | - Tine Tjørnhøj-Thomsen
- National Institute of Public Health, University of Southern Denmark, Copenhagen, Denmark
| | - Suhayb Abdi
- Centre for Evidence-Based Medicine Odense (CEBMO), Odense University Hospital, Kløvervænget 10, 13th floor, 5000 Odense C, Denmark
| | - Mustafe H A Gelle
- Centre for Evidence-Based Medicine Odense (CEBMO), Odense University Hospital, Kløvervænget 10, 13th floor, 5000 Odense C, Denmark
| | - Lesley A Stewart
- Centre for Reviews and Dissemination, University of York, York, UK
| | - Isabelle Boutron
- Université de Paris, CRESS, Inserm, INRA, F-75004, Paris, France
| | - Asbjørn Hróbjartsson
- Centre for Evidence-Based Medicine Odense (CEBMO), Odense University Hospital, Kløvervænget 10, 13th floor, 5000 Odense C, Denmark
- Open Patient data Exploratory Network (OPEN), Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
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Huiskens J, Kool BR, Bakker J, Bruns ER, de Jonge SW, Olthof PB, van Rosmalen BV, van Gulik TM, Hooft L, Punt CJ. From registration to publication: A study on Dutch academic randomized controlled trials. Res Synth Methods 2020; 11:218-226. [PMID: 31614063 PMCID: PMC7078864 DOI: 10.1002/jrsm.1379] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Revised: 07/28/2019] [Accepted: 09/04/2019] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Registration of clinical trials has been initiated in order to assess adherence of the reported results to the original trial protocol. This study aimed to investigate the publication rates, timely dissemination of results, and the prevalence of consistency in hypothesis, sample size, and primary endpoint of Dutch investigator-initiated randomized controlled clinical trials (RCTs). METHODS All Dutch investigator-initiated RCTs with a completion date between December 31, 2010, and January 1, 2012, and registered in the Trial Register of The Netherlands database were included. PubMed was searched for the publication of these RCT results until September 2016, and the time to the publication date was calculated. Consistency in hypothesis, sample size, and primary endpoint compared with the registry data were assessed. RESULTS The search resulted in a total of 168 Dutch investigator-initiated RCTs. In September 2016, the results of 129 (77%) trials had been published, of which 50 (39%) within 2 years after completion of accrual. Consistency in hypothesis with the original protocol was observed in 108 (84%) RCTs; in 71 trials (55%), the planned sample size was reached; and 103 trials (80%) presented the original primary endpoint. Consistency in all three parameters was observed in 50 studies (39%). CONCLUSION This study shows that approximately one out of four Dutch investigator-initiated RCTs remains unpublished 5 years after initiation. The observed low overall consistency with the initial study outline is a matter of concern and warrants improvements in trial design and assessment of trial feasibility.
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Affiliation(s)
- Joost Huiskens
- Department of Surgery, Amsterdam UMC, Location AMCUniversity of AmsterdamAmsterdamThe Netherlands
- Department of Medical Oncology, Amsterdam UMC, Location AMCUniversity of AmsterdamAmsterdamThe Netherlands
| | - Boudewijn R.J. Kool
- Department of Surgery, Amsterdam UMC, Location AMCUniversity of AmsterdamAmsterdamThe Netherlands
| | - Jean‐Michel Bakker
- Department of Medical Oncology, Amsterdam UMC, Location AMCUniversity of AmsterdamAmsterdamThe Netherlands
| | - Emma R.J. Bruns
- Department of Surgery, Amsterdam UMC, Location AMCUniversity of AmsterdamAmsterdamThe Netherlands
| | - Stijn W. de Jonge
- Department of Surgery, Amsterdam UMC, Location AMCUniversity of AmsterdamAmsterdamThe Netherlands
- Department of EpidemiologyHarvard T.H. Chan School of Public HealthBostonMassachusetts
| | - Pim B. Olthof
- Department of Surgery, Amsterdam UMC, Location AMCUniversity of AmsterdamAmsterdamThe Netherlands
- Department of SurgeryErasmus Medical CenterRotterdamThe Netherlands
| | - Belle V. van Rosmalen
- Department of Surgery, Amsterdam UMC, Location AMCUniversity of AmsterdamAmsterdamThe Netherlands
| | - Thomas M. van Gulik
- Department of Surgery, Amsterdam UMC, Location AMCUniversity of AmsterdamAmsterdamThe Netherlands
| | - Lotty Hooft
- Cochrane Netherlands, Julius Center for Health Sciences and Primary CareUniversity Medical Center UtrechtUtrechtThe Netherlands
| | - Cornelis J.A. Punt
- Department of Medical Oncology, Amsterdam UMC, Location AMCUniversity of AmsterdamAmsterdamThe Netherlands
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Knowledge dissemination in clinical trials: Exploring influences of institutional support and type of innovation on selective reporting. RESEARCH POLICY 2018. [DOI: 10.1016/j.respol.2018.04.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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The Conduct and Reporting of Child Health Research: An Analysis of Randomized Controlled Trials Published in 2012 and Evaluation of Change over 5 Years. J Pediatr 2018; 193:237-244.e37. [PMID: 29169611 DOI: 10.1016/j.jpeds.2017.09.014] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2017] [Revised: 08/10/2017] [Accepted: 09/07/2017] [Indexed: 12/11/2022]
Abstract
OBJECTIVES For child health randomized controlled trials (RCTs) published in 2012, we aimed to describe design and reporting characteristics and evaluate changes since 2007; assess the association between trial design and registration and risk of bias (RoB); and assess the association between RoB and effect size. STUDY DESIGN For 300 RCTs, we extracted design and reporting characteristics and assessed RoB. We assessed 5-year changes in design and reporting (based on 300 RCTs we had previously analyzed) using the Fisher exact test. We tested for associations between design and reporting characteristics and overall RoB and registration using the Fisher exact, Cochran-Armitage, Kruskal-Wallis, and Jonckheere-Terpstra tests. We pooled effect sizes and tested for differences by RoB using the χ2 test for subgroups in meta-analysis. RESULTS The 2012 and 2007 RCTs differed with respect to many design and reporting characteristics. From 2007 to 2012, RoB did not change for random sequence generation and improved for allocation concealment (P < .001). Fewer 2012 RCTs were rated high overall RoB and more were rated unclear (P = .03). Only 7.3% of 2012 RCTs were rated low overall RoB. Trial registration doubled from 2007 to 2012 (23% to 46%) (P < .001) and was associated with lower RoB (P = .009). Effect size did not differ by RoB (P = .43) CONCLUSIONS: Random sequence generation and allocation concealment were not often reported, and selective reporting was prevalent. Measures to increase trialists' awareness and application of existing reporting guidance, and the prospective registration of RCTs is needed to improve the trustworthiness of findings from this field.
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Ayaz-Shah AA, Hussain S, Knight SR. Do clinical trials reflect reality? A systematic review of inclusion/exclusion criteria in trials of renal transplant immunosuppression. Transpl Int 2018; 31:353-360. [PMID: 29274240 DOI: 10.1111/tri.13109] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2017] [Revised: 10/24/2017] [Accepted: 12/15/2017] [Indexed: 02/01/2023]
Abstract
Renal transplant recipients and donors are becoming increasingly more marginal, with more expanded criteria (ECD) and donation after circulatory death (DCD) donors and older recipients. Despite this, high-risk donors and recipients are often excluded from clinical trials, leading to uncertainty about the generalizability of findings. We extracted data regarding inclusion/exclusion criteria from 174 trials of immunosuppression in renal transplant recipients published over a 5-year period and compared criteria with those specified in published trial registries. Frequently reported donor exclusion criteria were age (16.1%), donor type and cold ischaemic time (22.4%). Common recipient exclusion criteria included upper age limit (38.5%), high panel reactive antibody (PRA) (42.5%) and previous transplantation (39.7%). Inclusion/exclusion criteria recorded in trial registries matched those reported in the manuscript in only 6 (7.8%) trials. Of registered trials, 51 (66.2%) trials included additional criteria in the manuscript, 51 (66.2%) were missing criteria in the manuscript specified in the protocol, and in 19 (24.7%) key criteria changed from the protocol to the manuscript. Our findings suggest many recent immunosuppression trials have restrictive inclusion criteria which may not be reflective of current renal transplant populations. Discrepancies between trial protocols and published reports raise the possibility of selection bias.
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Affiliation(s)
- Anam A Ayaz-Shah
- Centre for Evidence in Transplantation, Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK
| | - Samia Hussain
- Centre for Evidence in Transplantation, Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK.,Nuffield Department of Surgical Sciences, Oxford Transplant Centre, University of Oxford Churchill Hospital, Oxford, UK
| | - Simon R Knight
- Centre for Evidence in Transplantation, Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK.,Nuffield Department of Surgical Sciences, Oxford Transplant Centre, University of Oxford Churchill Hospital, Oxford, UK
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Abstract
INTRODUCTION Growing evidence points for the need to publish study protocols in the health field. The aim of this paper was to observe whether the growing interest in publishing study protocols in the broader health field has been translated into increased publications of rehabilitation study protocols. EVIDENCE ACQUISITION PubMed was searched with appropriate combinations of Medical Subject Headings up to December 2014. The effective presence of study protocols was manually screened. Regression models analyzed the yearly growth of publications. Two-sample Z-tests analyzed whether the proportion of systematic reviews (SRs) and randomized controlled trials (RCTs) among study protocols differed from that of the same designs for the broader rehabilitation research. EVIDENCE SYNTHESIS Up to December 2014, 746 publications of rehabilitation study protocols were identified, with an exponential growth since 2005 (r2=0.981; P<0.001). RCT protocols were the most common among rehabilitation study protocols (83%), while RCTs were significantly more prevalent among study protocols than among the broader rehabilitation research (83% vs. 35.8%; P<0.001). For SRs, the picture was reversed: significantly less common among study protocols (2.8% vs. 9.3%; P<0.001). Funding was more often reported by rehabilitation study protocols than the broader rehabilitation research (90% vs. 53.1%; P<0.001). Rehabilitation journals published a significantly lower share of rehabilitation study protocols than they did for the broader rehabilitation research (1.8% vs.16.7%; P<0.001). CONCLUSIONS Identifying the reasons for these discrepancies and reverting unwarranted disparities (e.g. low rate of publication for rehabilitation SR protocols) are likely new avenues for rehabilitation research and its publication. SRs, particularly those aggregating RCT results, are considered the best standard of evidence to guide rehabilitation clinical practice; however, that standard can be improved in rigor and/or transparency if the publications of rehabilitation SRs protocols become more common.
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Affiliation(s)
- Tiago S Jesus
- Global Health and Tropical Medicine (GHTM) & WHO Collaborating Centre for Health Workforce Policy and Planning, Institute of Hygiene and Tropical Medicine, NOVA University of Lisbon, Lisbon, Portugal -
| | - Heather L Colquhoun
- Department of Occupational Science and Occupational Therapy, University of Toronto, Toronto, ON, Canada.,Rehabilitation Sciences Institute (RSI), University of Toronto, Toronto, ON, Canada
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Muir WW, Ueyama Y, Noel-Morgan J, Kilborne A, Page J. A Systematic Review of the Quality of IV Fluid Therapy in Veterinary Medicine. Front Vet Sci 2017; 4:127. [PMID: 28856137 PMCID: PMC5557817 DOI: 10.3389/fvets.2017.00127] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Accepted: 07/25/2017] [Indexed: 01/10/2023] Open
Abstract
Objective To evaluate the quality of the veterinary literature investigating IV fluid therapy in dogs, cats, horses, and cattle. Design Systematic review. Procedures The preferred reporting of items for systematic review and meta-analysis protocols (PRISMA-P) was employed for systematic review of all relevant IV fluid therapy manuscripts published from January 1969 through December 2016 in the Commonwealth Agricultural Bureaux International (CABI) database. Independent grading systems used to evaluate manuscripts included the updated CONsolidated Standards of Reporting Trials 2012 checklist, risk of bias for animal intervention studies, criteria for levels of evidence, and methodological quality (Jadad scale). The quality of articles published before and after 2010 was compared. Results One hundred and thirty-nine articles (63 dogs, 7 cats, 39 horses, 30 cattle) from 7,258 met the inclusion criteria. More than 50% of the manuscripts did not comply with minimal requirements for reporting randomized controlled trials. The most non-compliant items included identification of specific predefined objectives or a hypothesis, identification of trial design, how sample size was determined, randomization, and blinding procedures. Most studies were underpowered and at risk for selection, performance, and detection bias. The overall quality of the articles improved for articles published after 2010. Conclusion and clinical relevance Most of the veterinary literature investigating the administration of IV fluid therapy in dogs, cats, horses, and cattle is descriptive, does not comply with standards for evidence, or provide adequate translation to clinical practice. Authors should employ and journal editors should enforce international consensus recommendations and guidelines for publication of data from animal experiments investigating IV fluid therapy.
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Affiliation(s)
- William W Muir
- QTest Labs, Columbus, OH, United States.,College of Veterinary Medicine, Lincoln Memorial University, Harrogate, TN, United States
| | | | - Jessica Noel-Morgan
- Center for Cardiovascular and Pulmonary Research, The Research Institute at Nationwide Children's Hospital, Columbus, OH, United States
| | - Allison Kilborne
- Department of Veterinary Clinical Sciences, College of Veterinary Medicine, Columbus, OH, United States
| | - Jessica Page
- Department of Veterinary Clinical Sciences, College of Veterinary Medicine, Columbus, OH, United States
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Primary endpoint discrepancies were found in one in ten clinical drug trials. Results of an inception cohort study. J Clin Epidemiol 2017; 89:199-208. [PMID: 28535887 DOI: 10.1016/j.jclinepi.2017.05.012] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2016] [Revised: 04/26/2017] [Accepted: 05/15/2017] [Indexed: 01/02/2023]
Abstract
OBJECTIVE To identify the occurrence and determinants of protocol-publication discrepancies in clinical drug trials. STUDY DESIGN AND SETTING All published clinical drug trials reviewed by the Dutch institutional review boards in 2007 were analyzed. Discrepancies between trial protocols and publications were measured among key reporting aspects. We evaluated the association of trial characteristics with discrepancies in primary endpoints by calculating the risk ratio (RR) and 95% confidence interval (CI). RESULTS Of the 334 published trials, 32 (9.6%) had a protocol/publication discrepancy in the primary endpoints. Among the subgroup of randomized controlled trials (RCTs; N = 204), 12 (5.9%) had a discrepancy in the primary endpoint. Investigator-initiated trials with and without industry (co-) funding were associated with having discrepancies in the primary endpoints compared with industry-sponsored trials (RR 3.7; 95% CI 1.4-9.9 and RR 4.4; 95% CI 2.0-9.5, respectively). Furthermore, other than phase 1-4 trials (vs. phase 1; RR 4.6; 95% CI 1.1-19.3), multicenter trials were also conducted outside the European Union (vs. single center; RR 0.2; 95% CI 0.1-0.6), not prospectively registered trials (RR 3.3; 95% CI 1.5-7.5), non-RCTs (vs. superiority RCT; RR 2.4; 95% CI 1.2-4.8) and, among the RCTs, crossover compared with a parallel group design (RR 3.7; 95% CI 1.1-12.3) were significantly associated with having discrepancies in the primary endpoints. CONCLUSIONS Improvement in completeness of reporting is still needed, especially among investigator-initiated trials and non-RCTs. To eliminate undisclosed discrepancies, trial protocols should be available in the public domain at the same time when the trial is published.
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Li T, Boutron I, Salman RAS, Cobo E, Flemyng E, Grimshaw JM, Altman DG. Review and publication of protocol submissions to Trials - what have we learned in 10 years? Trials 2016; 18:34. [PMID: 28114958 PMCID: PMC5256548 DOI: 10.1186/s13063-016-1743-0] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2016] [Accepted: 12/05/2016] [Indexed: 11/17/2022] Open
Abstract
Trials has 10 years of experience in providing open access publication of protocols for randomised controlled trials. In this editorial, the senior editors and editors-in-chief of Trials discuss editorial issues regarding managing trial protocol submissions, including the content and format of the protocol, timing of submission, approaches to tracking protocol amendments, and the purpose of peer reviewing a protocol submission. With the clarification and guidance provided, we hope we can make the process of publishing trial protocols more efficient and useful to trial investigators and readers.
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Affiliation(s)
- Tianjing Li
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 North Wolfe Street, Room E6011, Baltimore, MD 21205 USA
| | - Isabelle Boutron
- University Paris Descartes, Inserm Methods Team, CRESS-UMR 1153, Paris, France
- Centre d’épidémiologie Clinique, Hôpital Hôtel-Dieu, 1 place du Parvis Notre-Dame, Paris, 75004 France
| | - Rustam Al-Shahi Salman
- Centre for Clinical Brain Sciences, University of Edinburgh, Chancellor’s Building, 49 Little France Crescent, Edinburgh, EH16 4SB UK
| | - Erik Cobo
- Statistics and Operations Research Department, Barcelona Tech, Carrer de Jordi Girona 1, C5-213, 08034 Barcelona, Spain
| | - Ella Flemyng
- BioMed Central, 236 Gray’s Inn Road, London, WC1X 8HB UK
| | - Jeremy M. Grimshaw
- Ottawa Hospital Research Institute, The Ottawa Hospital - General Campus, 501 Smyth Road, Box 711, Ottawa, ON K1H 8L6 Canada
| | - Douglas G. Altman
- Centre for Statistics in Medicine, University of Oxford, Botnar Research Centre, Windmill Road, Oxford, OX3 7LD UK
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