PA, Phelps K, Bosse M, Karunakar M, Kempton L, Sims S, Hsu J, Seymour R, Churchill C, Mayfield A, Sweeney J, Jaeblon T, Beer R, Bauer B, Meredith S, Talwar S, Domes CM, Gage MJ, Reilly RM, Paniagua A, Dupree J, Weaver MJ, von Keudell AG, Sagona AE, Mehta S, Donegan D, Horan A, Dooley M, Heng M, Harris MB, Lhowe DW, Esposito JG, Alnasser A, Shannon SF, Scott AN, Clinch B, Weber B, Beltran MJ, Archdeacon MT, Sagi HC, Wyrick JD, Le TT, Laughlin RT, Thomson CG, Hasselfeld K, Lin CA, Vrahas MS, Moon CN, Little MT, Marecek GS, Dubuclet DM, Scolaro JA, Learned JR, Lim PK, Demas S, Amirhekmat A, Dela Cruz YM. Aqueous skin antisepsis before surgical fixation of open fractures (Aqueous-PREP): a multiple-period, cluster-randomised, crossover trial

BACKGROUND

Chlorhexidine skin antisepsis is frequently recommended for most surgical procedures; however, it is unclear if these recommendations should apply to surgery involving traumatic contaminated wounds where povidone-iodine has previously been preferred. We aimed to compare the effect of aqueous 10% povidone-iodine versus aqueous 4% chlorhexidine gluconate on the risk of surgical site infection in patients who required surgery for an open fracture.

METHODS

We conducted a multiple-period, cluster-randomised, crossover trial (Aqueous-PREP) at 14 hospitals in Canada, Spain, and the USA. Eligible patients were adults aged 18 years or older with an open extremity fracture treated with a surgical fixation implant. For inclusion, the open fracture required formal surgical debridement within 72 h of the injury. Participating sites were randomly assigned (1:1) to use either aqueous 10% povidone-iodine or aqueous 4% chlorhexidine gluconate immediately before surgical incision; sites then alternated between the study interventions every 2 months. Participants, health-care providers, and study personnel were aware of the treatment assignment due to the colour of the solutions. The outcome adjudicators and data analysts were masked to treatment allocation. The primary outcome was surgical site infection, guided by the 2017 US Centers for Disease Control and Prevention National Healthcare Safety Network reporting criteria, which included superficial incisional infection within 30 days or deep incisional or organ space infection within 90 days of surgery. The primary analyses followed the intention-to-treat principle and included all participants in the groups to which they were randomly assigned. This study is registered with ClinicalTrials.gov, NCT03385304.

FINDINGS

Between April 8, 2018, and June 8, 2021, 3619 patients were assessed for eligibility and 1683 were enrolled and randomly assigned to povidone-iodine (n=847) or chlorhexidine gluconate (n=836). The trial's adjudication committee determined that 45 participants were ineligible, leaving 1638 participants in the primary analysis, with 828 in the povidone-iodine group and 810 in the chlorhexidine gluconate group (mean age 44·9 years [SD 18·0]; 629 [38%] were female and 1009 [62%] were male). Among 1571 participants in whom the primary outcome was known, a surgical site infection occurred in 59 (7%) of 787 participants in the povidone-iodine group and 58 (7%) of 784 in the chlorhexidine gluconate group (odds ratio 1·11, 95% CI 0·74 to 1·65; p=0·61; risk difference 0·6%, 95% CI -1·4 to 3·4).

INTERPRETATION

For patients who require surgical fixation of an open fracture, either aqueous 10% povidone-iodine or aqueous 4% chlorhexidine gluconate can be selected for skin antisepsis on the basis of solution availability, patient contraindications, or product cost. These findings might also have implications for antisepsis of other traumatic wounds.

FUNDING

US Department of Defense, Canadian Institutes of Health Research, McMaster University Surgical Associates, PSI Foundation.

The impact of COVID-19 restrictions on participant enrollment in the PREPARE trial

Background

At the initiation of the COVID-19 pandemic, restrictions forced researchers to decide whether to continue their ongoing clinical trials. The PREPARE (Pragmatic Randomized Trial Evaluating Pre-Operative Alcohol Skin Solutions in Fractured Extremities) trial is a pragmatic cluster-randomized crossover trial in patients with open and closed fractures. PREPARE was enrolling over 200 participants per month at the initiation of the pandemic. We aim to describe how the COVID-19 research restrictions affected participant enrollment.

Methods

The PREPARE protocol permitted telephone consent, however, sites were obtaining consent in-person. To continue enrollment after the initiation of the restrictions participating sites obtained ethics approval for telephone consent scripts and the waiver of a signature on the consent form. We recorded the number of sites that switched to telephone consent, paused enrollment, and the length of the pause. We used t-tests to compare the differences in monthly enrollment between July 2019 and November 2020.

Results

All 19 sites quickly implement telephone consent. Fourteen out of nineteen (73.6%) sites paused enrollment due to COVID-19 restrictions. The median length of enrollment pause was 46.5 days (range, 7–121 days; interquartile range, 61 days). The months immediately following the implementation of restrictions had significantly lower enrollment.

Conclusion

A pragmatic design allowed sites to quickly adapt their procedures for obtaining informed consent via telephone and allowed for minimal interruptions to enrollment during the pandemic.

Short-term outcomes vary by surgical approach in total hip arthroplasty: a network meta-analysis

BACKGROUND

The direct anterior approach (DAA) has increased in popularity in recent years. Proponents cite its muscle-sparing approach and purported reduction in pain and improvement in function when compared to the traditional surgical approaches. There remains controversy surrounding the validity of these claims. The objective of this study was to compare the common total hip surgical approaches in terms of pain scores, functional outcomes, opioid use and complications within the first 12 weeks postoperatively.

METHODS

A network meta-analysis of randomized controlled trials (RCT) comparing postoperative outcomes of different surgical approaches in primary THA up to 12 weeks was performed. PubMed, MEDLINE, Embase, Web of Science and SCOPUS were systematically searched from inception to May 2020. Outcomes included pain scores, functional outcome scores, length of stay (LOS), complications and opioid consumption.

RESULTS

Twenty-five RCTs (n = 2339) were included. The DAA demonstrated statistically significant improvement in Harris Hip Scores at 6 weeks when compared to the posterior and direct lateral approaches. The DAA reduced pain scores on postoperative day 2 and at 2 weeks compared to the direct lateral approach. The anterolateral approach was found to have a significantly shorter LOS compared to the other major surgical approaches. The differences in functional outcomes or pain scores did not surpass conventional cutoffs for a minimal clinically important difference.

CONCLUSION

The DAA led to functional improvements at 6 weeks compared to the posterior and direct lateral approaches and reduced postoperative pain compared to the direct lateral approach. However, these improvements failed to reach clinical significance. All major surgical approaches led to large improvements in function by 12 weeks with relatively low complication rates. Whether a short-term statistically significant improvement in function is sufficiently patient important to recommend DAA as a standard remains uncertain.

Defining Minimally Important Differences in Functional Outcomes in Musculoskeletal Oncology

BACKGROUND

Functional outcomes are commonly reported in studies of patients undergoing limb-salvage surgery for the treatment of musculoskeletal tumors; however, interpretation requires knowledge of the smallest amount of improvement that is important to patients: the minimally important difference (MID). We established the MIDs for the Musculoskeletal Tumor Society Rating Scale-93 (MSTS-93) and Toronto Extremity Salvage Score (TESS) for patients with bone tumors undergoing lower-extremity endoprosthetic reconstruction.

METHODS

This study was a secondary analysis of the recently completed PARITY (Prophylactic Antibiotic Regimens in Tumor Surgery) study. We used MSTS-93 and TESS data from this trial to calculate (1) the anchor-based MIDs with use of an overall function scale and a receiver operating characteristic curve analysis and (2) the distribution-based MIDs based on one-half of the standard deviation of the change scores from baseline to the 12-month follow-up and one-half the standard deviation of baseline scores.

RESULTS

Five hundred and ninety-one patients were available for analysis. The Pearson correlation coefficients for the association between changes in MSTS-93 and TESS scores and changes in the external anchor scores were 0.71 and 0.57, indicating high and moderate correlations. The anchor-based MID was 12 points for the MSTS-93 and 11 points for the TESS. Distribution-based MIDs were larger: 16 to 17 points for the MSTS-93 and 14 points for the TESS.

CONCLUSIONS

Two methods for determining MIDs for the MSTS-93 and TESS for patients undergoing lower-extremity endoprosthetic reconstruction for musculoskeletal tumors yielded quantitatively different results. We suggest the use of anchor-based MIDs, which are grounded in changes in functional status that are meaningful to patients. These thresholds can facilitate responder analyses and indicate whether significant differences following interventions are clinically important to patients.

LEVEL OF EVIDENCE

Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.

The Senhance Surgical System in Colorectal Surgery: A Systematic Review

The Senhance Surgical System allows for infrared eye tracking, haptic feedback, and an adjustable upright seat allowing for improved ergonomics. This systematic review was designed with the aim of reviewing the current literature pertaining to the use of the Senhance Surgical System in colorectal surgery. Medline, EMBASE, and CENTRAL were searched. Articles were eligible for inclusion if they evaluated adults undergoing colorectal surgery with the Senhance Surgical System. The primary outcome was intraoperative efficacy; as defined by operative time, estimated blood loss (EBL), and conversion. A DerSimonian and Laird inverse variance random-effects meta-analysis was used to generate overall effect size estimates and narrative review was provided for each outcome. Six observational studies with 223 patients (mean age: 63.7, 41.2% female, mean BMI: 24.4 kg/m²) were included. The most common indication for surgery was colorectal cancer (n = 180, 80.7%) and the most common operation was anterior resection (n = 72, 32.3%). Meta-analyses demonstrated a pooled total operative time of 229.8 min (95% CI 189.3-270.4, I² = 0%), console time of 141.3 min (95% CI 106.5-176.1, I² = 0%), and docking time of 10.8 min (95% CI 6.4-15.2, I² = 0%). The pooled EBL was 37.0 mL (95% CI 24.7-49.2, I² = 20%). Overall, there were nine (4.0%) conversions to laparoscopy/laparotomy. The Senhance Surgical System has an acceptable safety profile, reasonable docking and console times, low conversion rates, and an affordable case cost across a variety of colorectal surgeries. Further prospective, comparative trials with other robotic surgical platforms are warranted.

A pragmatic randomized trial evaluating pre-operative aqueous antiseptic skin solutions in open fractures (Aqueous-PREP): statistical analysis plan

Background

Approximately 1 in 10 patients with a surgically treated open fracture will develop a surgical site infection. The Aqueous-PREP trial will investigate the effect of 10% povidone-iodine versus 4% chlorhexidine in aqueous antiseptic solutions in reducing infections after open fracture surgery. The study protocol was published in April 2020.

Methods and design

The Aqueous-PREP trial is a pragmatic, multicenter, open-label, randomized multiple period cluster crossover trial. Each participating cluster is randomly assigned in a 1:1 ratio to provide 1 of the 2 study interventions on all eligible patients during a study period. The intervention periods are 2 months in length. After completing a 2-month period, the participating cluster crosses over to the alternative intervention. We plan to enroll a minimum of 1540 patients at 14 sites.

Results

The primary outcome is surgical site infection guided by the Centers for Disease Control and Prevention’s National Healthcare Safety Network reporting criteria (2017). All participants’ surgical site infection surveillance period will end 30 days after definitive fracture management surgery for superficial infections and 90 days after definitive fracture management surgery for deep incisional or organ/space infections [1]. The secondary outcome is an unplanned fracture-related reoperation within 12 months of the fracture.

Conclusion

This manuscript serves as the formal statistical analysis plan (version 1.0) for the Aqueous-PREP trial. The statistical analysis plan was completed on February 28, 2022.

High social media attention scores are not reflective of study quality: an altmetrics-based content analysis

Recent literature has demonstrated the associations between social media attention, as measured by altmetric attention score (AAS), and higher citation rates across medical disciplines. Despite increasing use of AAS, an understanding of factors associated with higher AAS and social media attention remains lacking. Furthermore, if this increased attention correlates with a higher methodological quality and lower biases has not been determined. Therefore, the purpose of the current study was to determine the relationship between methodological quality, study biases and the AAS in randomized controlled trials (RCTs). All RCTs from 2016 in the New England Journal of Medicine (NEJM), Journal of the American Medical Society (JAMA), and Lancet were extracted and the (1) AAS; (2) Methodological Bias (JADAD Scale); Study Bias (Cochrane Risk-of-Bias tool for RCTs) recorded. A total of 296 RCTs with a median (range) AAS and citation rate per article of 234.0(7-4079) and 165.0(4-3257), respectively, were included. The AAS was positively associated with citation rate (β 0.19, 95% CI 0.10-0.29; P < 0.001). Methodological bias was not associated with the AAS (β - 36.3, 95% CI - 83.5-10.9; P = 0.131), but was negatively associated with higher citation rates (β - 66.4, 95% CI - 106.0 to - 26.9; P = 0.001). The number of study biases was not associated with the AAS (β 43.7, 95% CI - 6.3-93.7;P = 0.086), but was positively associated with a higher citation rate (β 64.5, 95% CI 22.4-106.6; P = 0.003). The online attention of RCTs in medical journals was not necessarily reflective of high methodological quality and minimal study biases, but was associated with higher citation rates. Researchers and clinicians should critically examine each article despite the amount of online attention an article receives as the AAS does not necessarily reflect article quality.

Who, if anyone, may benefit from a total hip arthroplasty after a displaced femoral neck fracture?

Aims

The aim of this study was to explore the functional results in a fitter subgroup of participants in the Hip Fracture Evaluation with Alternatives of Total Hip Arthroplasty versus Hemiarthroplasty (HEALTH) trial to determine whether there was an advantage of total hip arthroplasty (THA) versus hemiarthroplasty (HA) in this population.

Methods

We performed a post hoc exploratory analysis of a fitter cohort of patients from the HEALTH trial. Participants were aged over 50 years and had sustained a low-energy displaced femoral neck fracture (FNF). The fittest participant cohort was defined as participants aged 70 years or younger, classified as American Society of Anesthesiologists grade I or II, independent walkers prior to fracture, and living at home prior to fracture. Multilevel models were used to estimate the effect of THA versus HA on functional outcomes. In addition, a sensitivity analysis of the definition of the fittest participant cohort was performed.

Results

There were 143 patients included in the fittest cohort. Mean age was 66 years (SD 4.5) and 103 were female (72%). No clinically relevant differences were found between the treatment groups in the primary and sensitivity analyses.

Conclusion

This analysis found no differences in functional outcomes between HA and THA within two years of displaced low-energy FNF in a subgroup analysis of the fittest HEALTH patients. These findings suggest that very few patients above 50 years of age benefit in a clinically meaningful way from a THA versus a HA early after injury.

Cite this article: Bone Jt Open 2022;3(8):611–617.

Effects of Bariatric Surgery on People with Obesity and Polycystic Ovary Syndrome: a Large Single Center Study from India

PURPOSE

Bariatric surgery has been proven to be a successful management strategy for morbid obesity, but limited studies exist on its effect on polycystic ovary syndrome (PCOS) in terms of clinical, hormonal, and comorbidities.

MATERIALS AND METHODS

This is a prospective observational study of 1013 PCOS patients who underwent bariatric surgery from a single high-volume center. Assessment of demographic data and menstrual irregularity as well as hirsutism and comorbidities was done preoperatively 6-month and yearly follow-up, whereas data regarding %TWL and %EWL was taken at follow-up visits conducted at regular intervals of 6 months, and 1, 2, 3, 4, and 5 years following surgery.

RESULTS

Out of 1013 PCOS patients, 993 patients had hirsutism before surgery, and 741 (74.6%; p < 0.001) had complete resolution of hirsutism at end of 6 months' follow-up. A total of 202 (20.3%) had moderate resolution at follow-up of 1 year, 5 patients had minimal resolution at end of 2 years, and 45 (4.5%) patients reported no change in their hirsutism at 4 and 5 years of follow-up. Among 1007 women with PCOS who had menstrual dysfunction, 936 (93% p < 0.0001) women restored their normal menstrual cycle at 6 months post-surgery with 55.4% EWL while remaining other 71 (7%) women reported regular menses at 2 years post-surgery at 74.2% EWL and continued to have normal menstrual pattern during the entire follow-up period. Similarly, all the associated comorbidities T2DM (79.7%), HTN (78.7%), DLP (93.2%), and OSA (98.5%) and symptoms of PCOS were statistically (p < 0.0001) and completely resolved at end years of follow-up.

CONCLUSION

Bariatric surgery is a good option for women with obesity and PCOS. It is effectively reducing weight along with PCOS and its disorder including hirsutism and menstrual irregularity in women with obesity and PCOS.

Serious reporting deficiencies exist in minimal important difference studies: Current state and suggestions for improvement

OBJECTIVE

To evaluate reporting of minimal important difference (MID) estimates using anchor-based methods for patient-reported outcome measures (PROMs), and the association with reporting deficiencies on their credibility.

STUDY DESIGN AND SETTING

Systematic survey of primary studies empirically estimating MIDs. We searched Medline, EMBASE, PsycINFO, and the Patient-Reported Outcome and Quality of Life Instruments Database until October 2018. We evaluated study reporting, focusing on participants' demographics, intervention(s), characteristics of PROMs and anchors, and MID estimation method(s). We assessed the impact of reporting issues on credibility of MID estimates.

RESULTS

In 585 studies reporting on 5,324 MID estimates for 526 distinct PROMs, authors frequently failed to adequately report key characteristics of PROMs and MIDs, including minimum and maximum values of PROM scale, measure of variability accompanying the MID estimate and number of participants included in the MID calculation. Across MID estimates (n=5,324), the most serious reporting issues impacting credibility included infrequent reporting of the correlation between the anchor and PROM (66%), inadequate details to judge precision of MID point estimate (13%), and insufficient information about the threshold used to ascertain MIDs (16%).

CONCLUSION

Serious issues of incomplete reporting in the MID literature threaten the optimal use of MID estimates to inform the magnitude of effects of interventions on PROMs.

Patient Selection in One Anastomosis/Mini Gastric Bypass-an Expert Modified Delphi Consensus

PURPOSE

One anastomosis/mini gastric bypass (OAGB/MGB) is up to date the third most performed obesity and metabolic procedure worldwide, which recently has been endorsed by ASMBS. The main criticisms are the risk of bile reflux, esophageal cancer, and malnutrition. Although IFSO has recognized this procedure, guidance is needed regarding selection criteria. To give clinicians a daily support in performing the right patient selection in OAGB/MGB, the aim of this paper is to generate clinical guidelines based on an expert modified Delphi consensus.

METHODS

A committee of 57 recognized bariatric surgeons from 24 countries created 69 statements. Modified Delphi consensus voting was performed in two rounds. An agreement/disagreement among ≥ 70.0% of the experts was considered to indicate a consensus.

RESULTS

Consensus was achieved for 56 statements. Remarkably, ≥ 90.0% of the experts felt that OAGB/MGB is an acceptable and suitable option "in patients with Body mass index (BMI) > 70, BMI > 60, BMI > 50 kg/m² as a one-stage procedure," "as the second stage of a two-stage bariatric surgery after Sleeve Gastrectomy for BMI > 50 kg/m² (instead of BPD/DS)," and "in patients with weight regain after restrictive procedures. No consensus was reached on the statement that OAGB/MGB is a suitable option in case of resistant Helicobacter pylori. This is likely as there is a concern that this procedure is associated with reflux and its related long-term complications including risk of cancer in the esophagus or stomach. Also no consensus reached on OAGB/MGB as conversional surgery in patients with GERD after restrictive procedures. Consensus for disagreement was predominantly achieved "in case of intestinal metaplasia of the stomach" (74.55%), "in patients with severe Gastro Esophageal Reflux Disease (GERD)(C,D)" (75.44%), "in patients with Barrett's metaplasia" (89.29%), and "in documented insulinoma" (89.47%).

CONCLUSION

Patient selection in OAGB/MGB is still a point of discussion among experts. There was consensus that OAGB/MGB is a suitable option in elderly patients, patients with low BMI (30-35 kg/m²) with associated metabolic problems, and patients with BMIs more than 50 kg/m² as one-stage procedure. OAGB/MGB can also be a safe procedure in vegetarian and vegan patients. Although OAGB/MGB can be a suitable procedure in patients with large hiatal hernia with concurrent hiatal hernia, it should not be offered to patients with grade C or D esophagitis or Barrett's metaplasia.

Abstract CT158: Use of 4-demethyl-4-cholesteryloxycarbonyl-penclomedine (DM-CHOC-PEN) as therapy for advanced non-small cell lung cancer (NSCLC) involving the CNS

Background: 4-Demethyl-4-cholesteryloxycarbonylpenclomedine (DM-CHOC-PEN) is a poly-chlorinated pyridine cholesteryl carbonate that was designed to penetrate the blood brain barrier and be useful as therapy for brain tumors (IND 68,876). A 3-stage mechanism is proposed for drug entry into the CNS and into cancer cells via reversible binding with sialic acid on the surface of RBC’s; and transported into cancer cells with L-glutamine. DM-CHOC-PEN has a MOA via bis-alkylation of DNA @ N7-guanine and N4-cytosine. DM-CHOC-PEN has completed clinical trials involving sixty-four (64) adults and nineteen (19) adolescent/young adult subjects with advanced cancers. Long term survival, good qualities of life and minimal toxicities [AACR #1185, 2013; AACR #CT 129, 2019; AACR #CT152, 2021] have been reported. This update provides affirmation that the drug, previously described as a treatment for non-small cell lung cancer (NSCLC) involving the CNS, is well tolerated with continued durations of responses, no new toxicities, good survival and good quality of life. Primary aims of the previously reported DM-CHOC-PEN clinical trials were to assess clinical response and monitor toxicities/safety and verify the maximum tolerated doses (MTD) for the drug administered IV to subjects with cancer. Here is an update on the long term responses, tolerance and quality of survival in subjects with NSCLC involving the CNS.

Subjects & Methods: DM-CHOC-PEN was administered to adults (&gt; 18 y/o) with NSCLC involving the CNS that lacked genetic rearrangements or tumor targets and/or had failed standard therapies as a 3-hr IV infusion once every 21 days employing a verified 2-tiered MTD schedule: 85.8 mg/m2 for subjects with liver involvement and 98.7 mg/m2 for subjects with normal livers.

Results: Sixteen (16) adult subjects with NSCLC have been treated to date, which 11 had NSCLC (adeno/large cell carcinomas) involving the CNS that lacked genetic rearrangements, had no tumor targets, and/or had failed standard therapies. Seven of the 11 subjects with NSCLC involving the CNS also possessed cerebellar metastases. The drug was well tolerated with no Gr-3 toxicities. The most common Gr-2 adverse effects were reversible fatigue (17%), reversible vasogenic edema (9%) and nausea (9%). No drug associated neuro/psychological, hematological, cardiac or renal toxicities have been observed, nor have there been any drug associated deaths reported. The pK modelling and properties for the drug have been previously reported [AACR #1185, 2013] and continue to be confirmed. Eight (8) subjects with NSCLC involving the CNS responded to DM-CHOC-PEN with documented CR/PR (RECIST 1.1) and improved OS/QOL/PFS (Kaplan-Meier) lasting 8 - 82+ mos. with survivals of 25% at 34 mos., 50% at 10 mos. and 8% at 84+ mos.

Conclusion: DM-CHOC-PEN is a bis-alkylator of DNA that is safe at the dose levels described and has produced long term objective responses with manageable toxicities and improved quality of life in subjects with NSCLC involving the CNS lacking genetic rearrangements or tumor targets and/or had failed standard therapies. Complete data on subject responses and observed toxicities will be presented. Supported by NCI/SBIR grants - R43/44CA132257 and NIH NIGMS 1 U54 GM104940 - the latter supports the Louisiana Clinical and Translational Science Center, New Orleans, LA

Citation Format: Lee Roy Morgan, Roy S. Weiner, T. Mahmood, C. Gordon, M. Bhandari, AH Rodgers, ML Ware, Marc Matrana, Thomas M. Cosgriff, Philip Friedlander, J-J Zou. Use of 4-demethyl-4-cholesteryloxycarbonyl-penclomedine (DM-CHOC-PEN) as therapy for advanced non-small cell lung cancer (NSCLC) involving the CNS [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr CT158.

Development and design validation of a novel network meta-analysis presentation tool for multiple outcomes: a qualitative descriptive study

OBJECTIVE

The Grades of Recommendations, Assessment, Development and Evaluation working group recently developed an innovative approach to interpreting results from network meta-analyses (NMA) through minimally and partially contextualised methods; however, the optimal method for presenting results for multiple outcomes using this approach remains uncertain. We; therefore, developed and iteratively modified a presentation method that effectively summarises NMA results of multiple outcomes for clinicians using this new interpretation approach.

DESIGN

Qualitative descriptive study.

SETTING

A steering group of seven individuals with experience in NMA and design validation studies developed two colour-coded presentation formats for evaluation. Through an iterative process, we assessed the validity of both formats to maximise their clarity and ease of interpretation.

PARTICIPANTS

26 participants including 20 clinicians who routinely provide patient care, 3 research staff/research methodologists and 3 residents.

MAIN OUTCOME MEASURES

Two team members used qualitative content analysis to independently analyse transcripts of all interviews. The steering group reviewed the analyses and responded with serial modifications of the presentation format.

RESULTS

To ensure that readers could easily discern the benefits and safety of each included treatment across all assessed outcomes, participants primarily focused on simple information presentations, with intuitive organisational decisions and colour coding. Feedback ultimately resulted in two presentation versions, each preferred by a substantial group of participants, and development of a legend to facilitate interpretation.

CONCLUSION

Iterative design validation facilitated the development of two novel formats for presenting minimally or partially contextualised NMA results for multiple outcomes. These presentation approaches appeal to audiences that include clinicians with limited familiarity with NMAs.