The Quality of Randomized Controlled Trials in High-impact Rheumatology Journals, 1998-2018

A practical guide to estimating treatment effects in patients with rheumatic diseases using real-world data

OBJECTIVE

Randomized controlled trials are considered the gold standard in study methodology. However, due to their study design and inclusion criteria, these studies may not capture the heterogeneity of real-world patient populations. In contrast, the lack of randomization and the presence of both measured and unmeasured confounding factors could bias the estimated treatment effect when using observational data. While causal inference methods allow for the estimation of treatment effects, their mathematical complexity may hinder their application in clinical research.

METHODS

We present a practical, nontechnical guide using a common statistical package (Stata) and a motivational simulated dataset that mirrors real-world observational data from patients with rheumatic diseases. We demonstrate regression analysis, regression adjustment, inverse-probability weighting, propensity score (PS) matching and two robust estimation methods.

RESULTS

Although the methods applied to control for confounding factors produced similar results, the commonly used one-to-one PS matching method could yield biased results if not thoroughly assessed.

CONCLUSION

The guide we propose aims to facilitate the use of readily available methods in a common statistical package. It may contribute to robust and transparent epidemiological and statistical methods, thereby enhancing effectiveness research using observational data in rheumatology.

Evaluating the completeness of the reporting of abstracts since the publication of the CONSORT extension for abstracts: an evaluation of randomized controlled trial in ten nursing journals

BACKGROUND

As a practice-oriented discipline, strict adherence to reporting guidelines is particularly important in randomized controlled trial (RCT) abstracts of the nursing area. However, whether abstract reports after 2010 have complied with the Consolidated Standards of Reporting Trials for Abstracts (CONSORT-A) guideline is unclear. This study aimed to evaluate whether the publication of CONSORT-A has improved abstract reporting in nursing and explores the factors associated with better adherence to the guidelines.

METHODS

We searched the Web of Science for 200 RCTs randomly selected from ten nursing journals. We used a data extraction form based on CONSORT-A, including 16 items, to analyze the reporting adherence to the guidelines, and the reporting rate of each item and the total score for each abstract were used to indicate adherence and overall quality score (OQS, range 0-16). A comparison of the total mean score between the two periods was made, and affecting factors were analyzed.

RESULTS

In the studies we included, 48 abstracts were published pre-CONSORT-A whereas 152 post-CONSORT-A. The overall mean score for reporting adherence to 16 items was 7.41 ± 2.78 and 9.16 ± 2.76 for pre- and post-CONSORT-A, respectively (total score: 16). The most poorly reported items are "harms (0%)," "outcomes in method (8.5%)," "randomization (25%)," and "blinding (6.5%)." Items including the year of publication, impact factor, multiple center trial, word count, and structured abstract are significantly associated with higher adherence.

CONCLUSIONS

The adherence to abstract reporting in nursing literature has improved since the CONSORT-A era, but the overall completeness of RCT abstracts remained low. A joint effort by authors, editors, and journals is necessary to improve reporting quality of RCT abstracts.

Comparative Efficacy Randomized Controlled Trials in Rheumatology Guidelines

BACKGROUND

Comparative efficacy randomized controlled trials (RCTs) compare two active interventions in a head-to-head design. They are useful for informing clinical practice guidelines, but the degree to which such trials inform clinical practice guidelines in rheumatology is unknown.

METHODS

The American College of Rheumatology (ACR) and European Alliance of Associations for Rheumatology (EULAR) websites were searched from January 1, 2017, to June 12, 2021, for clinical practice guidelines. RCTs referenced by each guideline were identified, and information regarding design and outcomes were extracted. Clinical practice recommendations from each guideline were also analyzed.

RESULTS

Fifteen ACR- and nine EULAR-endorsed guidelines were included, which cited 609 RCTs and provided 481 recommendations. Referenced RCTs enrolled an average of 418 patients (SD 985), most commonly evaluated biologic/targeted synthetic disease-modifying antirheumatic drugs (70.1%), and infrequently used a head-to-head design (28%). A minority of recommendations received a high level of evidence (LOE) by the Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) methodology (2.9%) or an "A" grade by the Oxford Centre for Evidence based Medicine Standards (OCEBM) methodology (28.9%). LOE was higher for recommendations informed by RCTs (P < 0.001) or head-to-head RCTs (P = 0.008). Many recommendations received a strong recommendation despite low (8 [2.6%]) or very low (25 [8.3%]) LOE.

CONCLUSION

Less than one in six rheumatology guideline recommendations are informed by head-to-head RCTs. Recommendations that were informed by head-to-head RCTs were more likely to have a high LOE by both GRADE and OCEBM. Efforts to introduce more comparative efficacy RCTs should be undertaken.

Industry Payments to Practicing US Rheumatologists, 2014-2019

BACKGROUND

Payments from the pharmaceutical industry to practicing physicians may influence prescribing behavior. The objective of this study was to investigate the nature, quantity, and geographical distribution of payments to US rheumatologists.

METHODS

General payments from industry sponsors to US rheumatologists from 2014-2019 were extracted from the Centers for Medicare & Medicaid Services (CMS) Open Payments database. Gender was identified by linking physicians to the National Plan and Provider Enumeration System (NPPES) registry. Data were reported in aggregate, trends over time were assessed using linear regression models, and differences by gender were analyzed using the Wilcoxon rank-sum test.

RESULTS

Over the six-year time period from 2014-2019, a total of $221,254,966 from 1,610,668 payments were made to 5,723 rheumatologists. The median payment was $15 (interquartile range (IQR) $10 - $22) and the median amount of payments received by individual rheumatologists was $2,818 (IQR $464 to $11,560). The majority of rheumatologists (3,416/5,723, 59%) received under $5,000, but 368/5,723 (6%) received over $100,000 each and accounted for 78% of the total. The yearly value of payments increased over time ($3,703,264 per year, p < 0.001) and the median payment to male rheumatologists was significantly higher than the median payment to female rheumatologists ($3,732, IQR $542-$15,841 vs. $2,084, IQR $394-$8,186, p < 0.001).

CONCLUSIONS

The value of industry payments have increased over time and are concentrated among a small number of rheumatologists. Future studies should investigate the degree to which industry payments have influenced prescribing in the field of rheumatology.