Minimal important difference estimates for patient-reported outcomes: A systematic survey

A systematic review of minimum important changes for generic multi-attribute utility instruments and recommendations for their estimation

INTRODUCTION

Minimum important changes (MICs) represent thresholds for clinically meaningful change. Multi-attribute utility instruments (MAUIs) generate health state utilities (holistic measures of health-related quality of life). No systematic review of MICs specifically for MAUIs has been conducted. In addition, no guidelines for estimating MICs for MAUIs have been proposed. We aimed to correct these evidence gaps by producing guidelines contextualised by a systematic review.

METHODS

We searched ten databases for relevant records using various search terms. Extracted data were analysed narratively and descriptively. The presence of key reporting items (relating to precision, sensitivity, and concurrent validity) was also evaluated. Guidelines for MIC estimation were informed by the broader MIC literature and contextualised using study results.

RESULTS

The review identified 5035 non-duplicate records, with 68 entering the study. 282 unique, anchor-based MICs were extracted. Of these MICs, 119 (42.20%) pertained to the EQ-5D-3L, 82 (29.08%) to the EQ-5D-5L, and 50 (17.73%) to the SF-6D.v1. The most common anchor-based method used to estimate MICs (107, 37.94%) involved taking the mean change score for a group considered to have experienced a MIC. Distribution-based methods were also common, appearing in 31 (45.59%) of the included studies. The inclusion of key reporting items was generally deficient.

CONCLUSIONS

Deficiencies in reporting and diverse estimation methods raise concerns regarding the extant MAUI MIC literature. Researchers should exercise caution when using existing MAUI MICs. Recommendations presented in our study may assist researchers in effectively estimating MICs for use in health economics.

Patient-Reported Outcome Measures in Cardiovascular Research and Care: PRO(M)s and CONS

ABSTRACT

Patient-reported outcome measures (PROMs) are vital tools in cardiovascular disease research and care, providing insights that complement traditional clinical outcomes such as mortality and morbidity. PROMs capture patient experiences with cardiovascular disease, such as quality of life, functional capacity, and emotional well-being, allowing clinicians to assess how interventions affect daily life. PROMs are integral to cardiovascular investigations and management, especially in chronic conditions and rehabilitation, where they inform on the impact of personalized care plans by tracking symptom progression and patient adherence. Selecting and applying to cardiovascular research and practice effective PROMs involves evaluating their validity, reliability, and sensitivity to change, with instruments such as the Kansas City Cardiomyopathy Questionnaire and the Seattle Angina Questionnaire widely used for heart failure and coronary artery disease, respectively. Implementing PROMs in real-world practice requires addressing challenges related to workflow integration and patient adherence, emphasizing their value in patient-centered care. As digital health advances, remote PROM data collection through mobile applications and wearable devices will enhance access to and extent of PROMs, and artificial intelligence-driven analytical tools will provide real-time, automated and plausible more poignant insights for personalized treatment. Future efforts should focus on culturally adapting PROMs for diverse populations to ensure global applicability. PROMs should also be established as essential components of innovative research and responsive, patient-centered cardiovascular care.

Rehabilitation of patients with maxillary defects: A network meta-analysis

STATEMENT OF PROBLEM

Different treatments for maxillary defects have been described, but a meta-analysis of these treatments to provide clinical guidance is lacking.

PURPOSE

The purpose of this systematic review and network meta-analysis was to evaluate the effect of tissue-supported obturator prostheses and other rehabilitation treatments for patients with maxillary defects on patient-reported outcome measures (PROMs) assessed through quality of life (QoL) questionnaires.

MATERIAL AND METHODS

Inclusion criteria were parallel-arm randomized controlled trials (RCTs) and nonrandomized studies of intervention (NRSIs) with a tissue-supported obturator as one of the treatments. Nine databases and nonpeer-reviewed literature were searched. Independent reviewers selected studies, extracted data, and assessed the risk of bias. Seven outcomes were analyzed separately for RCTs and NRSIs: appearance, mastication, pain, social contact, speech, swallowing, and QoL. A Bayesian random-effect network meta-analysis (NMA) calculated mean differences (MD) and 95% credible interval (Crl) for each treatment comparison. Data interpretation followed the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach and the magnitude of the effect was calculated as the minimal important difference (MID) - the minimal clinical benefit for the patient - for each outcome.

RESULTS

The review included 4 RCTs and 9 NRSIs. Most studies had a high and critical risk of bias. There were 7 treatments: no reconstructive or rehabilitative treatment, surgical obturator, interim obturator, tissue-supported obturator, implant-supported obturator, magnet obturator, and flap, totaling 120 treatment comparisons (56 among RCTs and 64 among NRSIs). Some treatments reached the minimum clinical benefit (MID). However, the 95%Crl crossed the null effect line for all treatment comparisons, indicating that any treatment can be efficient. The certainty of the evidence was very low for all comparisons, mainly because of the risk of bias, indirectness, intransitivity, and imprecision.

CONCLUSIONS

No treatment was better than another for any outcome. More RCTs comparing treatments for the rehabilitation of maxillary defects are encouraged to improve the evidence.

Use of Minimal Important Difference for Patient-Reported Outcome Measures in Plastic Surgery: A Systematic Review

BACKGROUND

The minimal important difference (MID) is vital to consider when interpreting the clinical importance of observed changes from surgical interventions assessed by patient-reported outcome measures (PROMs). There is no accepted standard for how to calculate MIDs, and uptake in the plastic surgery literature is unknown, leading to methodologic and interpretation issues.

METHODS

Medline and Embase were searched to identify all plastic surgery randomized controlled trials (RCTs) using PROMs as outcomes and MID estimation studies for PROMs used by RCTs. Included studies were assessed for uptake and application of MIDs, and MID estimation methodology and values were categorized.

RESULTS

A total of 554 RCTs using PROMs as outcomes were identified. Of these, 419 RCTs had the possibility of incorporating a previously published MID. The uptake rate of MIDs was 11.5% ( n = 48 of 419). The most common ways MIDs were applied were to calculate sample size (37.5%) or to determine whether results were clinically important (35.4%). A total of 99 studies estimating MID values for the most common PROMs in plastic surgery, based on our review, were analyzed. The most common estimation methodologies were receiver operating characteristic curve analysis (49%), change difference (31%), and SD (25%).

CONCLUSIONS

This review highlights limited uptake and application of MIDs in plastic surgery. The authors propose 4 major barriers: (1) no repository of published MIDs for PROMs used in plastic surgery exists; (2) available MIDs are not specific to plastic surgery populations; (3) high heterogeneity in MID estimation methodology was present; and (4) there are wide ranges in MID values, with no superior choice identified.

Efficacy of Adjunctive Local Antimicrobials to Non-Surgical Periodontal Therapy in Pocket Reduction and Glycemic Control of Patients with Type 2 Diabetes: A Network Meta-Analysis

OBJECTIVE

This network meta-analysis [NMA] investigated the efficacy of adjunctive use of subgingivally delivered antimicrobials to non-surgical periodontal therapy [NSPT] in the glycemic control and periodontal pocket depth (PPD) reduction in patients with type 2 diabetes (T2D).

METHODS

Seven databases, grey literature, and registry platforms were searched up to February 2024 to identify randomized clinical trials (RCT) fulfilling the eligibility criteria. The risk of bias was assessed through Cochrane's tool (RoB 2). Two frequentist NMA were performed using a random-effects model to calculate mean differences (MD) as an effect measure and to quantitatively evaluate the glycated hemoglobin (HbA1c) and PPD. The certainty of evidence was assessed through the GRADE approach in a partially contextualized framework for interpreting results. Ten RCTs were included.

RESULTS

In total, 261 patients were treated with eight different local antimicrobials adjuvants to NSPT (azithromycin gel, clarithromycin gel, tetracycline fiber or ointment, chlorhexidine gel, doxycycline nanospheres, minocycline gel, and satranidazole gel), while 249 patients received NSPT alone or associated to placebo. Considering PPD reduction (8 included studies), the best results were found after six months for satranidazole gel (MD -2.64 mm; 95%CI -3.56, -1.72; moderate evidence certainty). For HbA1c control (7 included studies), doxycycline gel (MD - 0.80%; 95%CI -1.70, 0.10), chlorhexidine gel (MD -0.68%; 95%CI -1.34, -0.02), and tetracycline fiber (MD -0.62%; 95%CI -0.85, -0.39) showed promising results after three months (low evidence certainty).

CONCLUSION

The adjunctive use of satranidazole gel probably reduces PPD after a 6-month follow-up, while doxycycline gel, chlorhexidine gel, and tetracycline fiber may decrease HbA1c values in patients with T2D and periodontitis treated with NSPT after a 3-month follow up.

How to Conduct and Publish Systematic Reviews and Meta-Analyses in Dentistry

OBJECTIVE

To provide a guide for conducting systematic reviews and meta-analyses in dentistry, with emphasis on translating research findings into clinical practice.

OVERVIEW

Systematic reviews are essential tools for synthesizing research findings and translating evidence into clinical practice. These reviews help to identify the most effective treatment options and to determine areas requiring further research. A structured approach, including defining a concise research question, conducting comprehensive literature searches, and assessing the risk of bias, is critical for ensuring the review's trustworthiness. The GRADE approach facilitates the assessment of the certainty of evidence, which is crucial for formulating conclusions and making informed clinical decisions.

CONCLUSION

Systematic reviews provide invaluable insights into clinical decision-making by compiling, analyzing, and synthesizing multiple primary studies. Following a rigorous methodology ensures that systematic reviews are comprehensive, unbiased, and clinically relevant, ultimately contributing to better patient care and achieving better clinical outcomes.

CLINICAL SIGNIFICANCE

Methodologically sound systematic reviews and meta-analyses provide clinicians with high-quality, synthesized evidence, enabling informed clinical decisions and improved patient outcomes. They save time by consolidating research, informing treatment choices, and facilitating the translation of knowledge into clinical practice.

Effectiveness of a guided multicomponent internet and mobile gratitude training program - A pragmatic randomized controlled trial

Objective

To investigate the effectiveness of a guided, internet- and smartphone-based gratitude intervention on the transdiagnostic risk-factor 'repetitive negative thinking'. The multicomponent intervention integrates a variety of gratitude exercises, targeting the cognitive, emotional and behavioural facets of gratitude.

Method

Two hundred adults with pronounced repetitive negative thinking were recruited from the general population. Participants were randomly assigned to either a four-session guided gratitude intervention (n = 100) or waiting list (n = 100). The primary outcome was repetitive negative thinking three months after randomization, with exploratory assessments at six weeks and six months, the latter just for participants in the intervention group.

Results

Following the intention-to-treat principle, by analyses of covariance (ANCOVA), the gratitude intervention group exhibited significantly lower levels of repetitive negative thinking than controls at three months, with d = 0.66, 95 % CI [0.37, 0.94] maintained at six-month follow-up. Significant and meaningful beneficial effects were observed in symptoms of depression (d = 0.42) and generalized anxiety (d = 0.38). These effects were notably stronger in intervention completers who finished at least three sessions.

Conclusions

Results suggest that a multicomponent gratitude intervention is effective at reducing repetitive negative thinking. Multicomponent interventions may be a next step needed to fully realize the potential of gratitude interventions. Such interventions could expand the repertoire of transdiagnostic interventions, especially for repetitive negative thinking. Furthermore, due to its positive connotations, gratitude is a candidate for an indirect intervention aimed at reducing the burden of depression in the general population.

Trial registration

The study is registered in the German Clinical Trial Register (approved primary register of the WHO) as DRKS00006825. The trial protocol can be assessed at: https://www.drks.de/.

Exploring the fragility of meta-analyses in ophthalmology: a systematic review

OBJECTIVE

The fragility index (FI) of a meta-analysis evaluates the extent that the statistical significance can be changed by modifying the event status of individuals from included trials. Understanding the FI improves the interpretation of the results of meta-analyses and can help to inform changes to clinical practice. This review determined the fragility of ophthalmology-related meta-analyses.

METHODS

Meta-analyses of randomized controlled trials with binary outcomes published in a journal classified as 'Ophthalmology' according to the Journal Citation Report or an Ophthalmology-related Cochrane Review were included. An iterative process determined the FI of each meta-analysis. Multivariable linear regression modeling evaluated the relationship between the FI and potential predictive factors in statistically significant and non-significant meta-analyses.

RESULTS

175 meta-analyses were included. The median FI was 6 (Q1-Q3: 3-12). This meant that moving 6 outcomes from one group to another would reverse the study's findings. The FI was 1 for 18 (10.2%) of the included meta-analyses and was ≤5 for 75 (42.4%) of the included meta-analyses. The number of events (p < 0.001) and the p-value (p < 0.001) were the best predictors of the FI in both significant and non-significant meta-analyses.

CONCLUSION

The statistical significance of meta-analyses in ophthalmology often hinges on the outcome of a few patients. The number of events and the p-value are the most important factors in determining the fragility of the evidence. The FI is an easily interpretable measure that can supplement the reader's understanding of the strength of the evidence being presented.

PROSPERO REGISTRATION

CRD42022377589.

Systematic review reveals that EQ-5D minimally important differences vary with treatment type and may decrease with increasing baseline score

OBJECTIVES

To provide an updated summary of published anchor-based Minimally Important Difference (MID) estimates for the EQ-5D index and EQ visual analog scale (EQ VAS) scores and identify factors influencing those estimates.

STUDY DESIGN AND SETTING

We systematically searched eight electronic databases from January 1990 to March 2023. We examined the association of baseline score, type of score change (improvement/worsening), data source, value set, disease/condition, treatment type (surgical/non-surgical), and type of anchor (clinical vs. self-rated) with MID estimates for the EQ-5D-3L and EQ-5D-5L indices, and EQ VAS. Significant variables were used to develop prediction formulas for MID by testing both linear and nonlinear regression models.

RESULTS

Of 6786 records reviewed, 47 articles were included for analysis. MID ranges for improved scores were -0.13 to 0.68 (EQ-5D-3L), 0.01-0.41 (EQ-5D-5L), and 0.42-23.0 (EQ VAS). Surgical intervention and lower baseline scores were associated with higher MIDs for both the EQ indices but not for EQ VAS. The nonlinear polynomial model outperformed the linear model in predicting the MIDs. MIDs based on deteriorated scores were insufficient for quantitative synthesis (mean: -0.02 for EQ-5D-3L; -0.04 for EQ-5D-5L; and -6.5 for EQ VAS).

CONCLUSION

This review revealed that the MID of EQ-5D index scores varies with baseline score and treatment type, indicating that use of a uniform MID may not be appropriate. We recommend using baseline score-adjusted and treatment type-specific EQ-5D MIDs, and call for more MID research, particularly in the context of assessing deterioration in health using this widely used generic health-status instrument.

Major mistakes or errors in the use of trial sequential analysis in systematic reviews or meta-analyses - the METSA systematic review

BACKGROUND

Systematic reviews and data synthesis of randomised clinical trials play a crucial role in clinical practice, research, and health policy. Trial sequential analysis can be used in systematic reviews to control type I and type II errors, but methodological errors including lack of protocols and transparency are cause for concern. We assessed the reporting of trial sequential analysis.

METHODS

We searched Medline and the Cochrane Database of Systematic Reviews from 1 January 2018 to 31 December 2021 for systematic reviews and meta-analysis reports that include a trial sequential analysis. Only studies with at least two randomised clinical trials analysed in a forest plot and a trial sequential analysis were included. Two independent investigators assessed the studies. We evaluated protocolisation, reporting, and interpretation of the analyses, including their effect on any GRADE evaluation of imprecision.

RESULTS

We included 270 systematic reviews and 274 meta-analysis reports and extracted data from 624 trial sequential analyses. Only 134/270 (50%) systematic reviews planned the trial sequential analysis in the protocol. For analyses on dichotomous outcomes, the proportion of events in the control group was missing in 181/439 (41%), relative risk reduction in 105/439 (24%), alpha in 30/439 (7%), beta in 128/439 (29%), and heterogeneity in 232/439 (53%). For analyses on continuous outcomes, the minimally relevant difference was missing in 125/185 (68%), variance (or standard deviation) in 144/185 (78%), alpha in 23/185 (12%), beta in 63/185 (34%), and heterogeneity in 105/185 (57%). Graphical illustration of the trial sequential analysis was present in 93% of the analyses, however, the Z-curve was wrongly displayed in 135/624 (22%) and 227/624 (36%) did not include futility boundaries. The overall transparency of all 624 analyses was very poor in 236 (38%) and poor in 173 (28%).

CONCLUSIONS

The majority of trial sequential analyses are not transparent when preparing or presenting the required parameters, partly due to missing or poorly conducted protocols. This hampers interpretation, reproducibility, and validity.

STUDY REGISTRATION

PROSPERO CRD42021273811.

Nutrition Users' Guides: RCTs Part 2 - structured guide for interpreting and applying study results from randomised controlled trials on therapy or prevention questions

This article continues from a prior commentary on evaluating the risk of bias in randomised controlled trials addressing nutritional interventions. Having provided a synopsis of the risk of bias issues, we now address how to understand trial results, including the interpretation of best estimates of effect and the corresponding precision (eg, 95% CIs), as well as the applicability of the evidence to patients based on their unique circumstances (eg, patients' values and preferences when trading off potential desirable and undesirable health outcomes and indicators (eg, cholesterol), and the potential burden and cost of an intervention). Authors can express the estimates of effect for health outcomes and indicators in relative terms (relative risks, relative risk reductions, OR or HRs)-measures that are generally consistent across populations-and absolute terms (risk differences)-measures that are more intuitive to clinicians and patients. CIs, the range in which the true effect plausibly lies, capture the precision of estimates. To apply results to patients, clinicians should consider the extent to which the study participants were similar to their patients, the extent to which the interventions evaluated in the study are applicable to their patients and if all patient-important outcomes of potential benefit and harm were reported. Subsequently, clinicians should consider the values and preferences of their patients with respect to the balance of the benefits, harms and burdens (and possibly the costs) when making decisions about dietary interventions.

The gap between statistical and clinical significance: time to pay attention to clinical relevance in patient-reported outcome measures of insomnia

BACKGROUND

Appropriately defining and using the minimal important change (MIC) and the minimal clinically important difference (MCID) are crucial for determining whether the results are clinically significant. The aim of this study is to survey the status of randomized controlled trials (RCTs) for insomnia interventions to assess the inclusion and interpretation of MIC/MCID values.

METHODS

We conducted a cross-sectional study to survey the status of RCTs for insomnia interventions to assess the inclusion and appropriate interpretation of MIC/MCID values. A literature search was conducted by searching the main sleep medicine journals indexed in PubMed, the Excerpta Medica Database (EMBASE), and the Cochrane Central Register of Controlled Trials (CENTRAL) to identify a broad range of search terms. We included RCTs with no restriction on the intervention. The included studies used the Insomnia Severity Index (ISI) or the Pittsburgh Sleep Quality Index (PSQI) questionnaire as the outcome measures.

RESULTS

81 eligible studies were identified, and more than one-third of the included studies used MIC/MCID (n = 31, 38.3%). Among them, 21 studies with ISI as the outcome used MIC defined as a relative decrease ranging from 3 to 8 points. The most frequently used MIC value was a 6-point decrease (n = 7), followed by 8-point (n = 6) and 7-point decrease (n = 4), a 4 to 5-points decrease (n = 3), and a 30% reduction from baseline; 6 studies used MCID values, ranging from 2.8 to 4 points. The most frequently used MCID value was a 4-point decrease in the ISI (n = 4). 4 studies with PSQI as the outcome used a 3-point change as the MIC (n = 2) and a 2.5 to 2.7-point difference as MCID (n = 2). 4 non-inferiority design studies considered interval estimation when drawing clinically significant conclusions in their MCID usage.

CONCLUSIONS

The lack of consistent MIC/MCID interpretation and usage in outcome measures for insomnia highlights the urgent need for further efforts to address this issue and improve reporting practices.

Surgically-relevant quality of life thresholds for the Short Inflammatory Bowel Disease Questionnaire in Crohn's disease

BACKGROUND

Despite growing interest in patient-reported outcome measures to track the progression of Crohn's disease, frameworks to apply these questionnaires in the preoperative setting are lacking. Using the Short Inflammatory Bowel Disease Questionnaire (sIBDQ), this study aimed to describe the interpretable quality of life thresholds and examine potential associations with future bowel resection in Crohn's disease.

METHODS

Adult patients with Crohn's disease completing an sIBDQ at a clinic visit between 2020 and 2022 were eligible. A stoplight framework was adopted for sIBDQ scores, including a "Resection Red" zone suggesting poor quality of life that may benefit from discussions about surgery as well as a "Nonoperative Green" zone. Thresholds were identified with both anchor- and distribution-based methods using receiver operating characteristic curve analysis and subgroup percentile scores, respectively. To quantify associations between sIBDQ scores and subsequent bowel resection, multivariable logistic regression models were fit with covariates of age, sex assigned at birth, body mass index, medications, disease pattern and location, resection history, and the Harvey Bradshaw Index. The incremental discriminatory value of the sIBDQ beyond clinical factors was assessed through the area under the receiver operating characteristics curve (AUC) with an internal validation through bootstrap resampling.

RESULTS

Of the 2003 included patients, 102 underwent Crohn's-related bowel resection. The sIBDQ Nonoperative Green zone threshold ranged from 61 to 64 and the Resection Red zone from 36 to 38. When adjusting for clinical covariates, a worse sIBDQ score was associated with greater odds of subsequent 90-day bowel resection when considered as a 1-point (odds ratio [OR] [95% CI], 1.05 [1.03-1.07]) or 5-point change (OR [95% CI], 1.27 [1.14-1.41]). Inclusion of the sIBDQ modestly improved discriminative performance (AUC [95% CI], 0.85 [0.85-0.86]) relative to models that included only demographics (0.57 [0.57-0.58]) or demographics with clinical covariates (0.83 [0.83-0.84]).

CONCLUSION

In the decision-making process for bowel resection, disease-specific patient-reported outcome measures may be useful to identify patients with Crohn's disease with poor quality of life and promote a shared understanding of personalized burden.

The development of an archive of patient-reported outcome measures (PROMs) in oncology: The Italian PRO4All project

BACKGROUND

Choosing the most adequate measure of patient-reported outcomes (PROs) for a specific medical condition is not straightforward. This study aimed to develop a comprehensive archive of patient-reported outcome measures (PROMs), observer-reported outcome measures (ObsROMs) and caregiver-reported outcome measures (CROMs) in oncology and identify their main characteristics and target outcome domains.

MATERIALS AND METHODS

As part of the Italian PRO4All Project, we retrieved questionnaires through an extensive search of online databases. We developed a data extraction form to collect information on cancer type, questionnaire variant(s), recall period, and scoring system. We performed a content analysis of the questionnaires to assign each item a specific outcome domain according to a predefined 38-item taxonomy.

RESULTS

A total of 386 PROMs (n = 356), ObsROMs (n = 13) and CROMs (n = 17) were identified and described; of these, 358 were also analyzed in their content. 47.3 % of the instruments were cancer type-specific, 45.1 % were generic for cancer and 7.9 % were developed for the general population but also recommended in oncology. The great majority (92.2 %) were patient-reported. In 50.3 % the recall period was "last week". The mean number of items per questionnaire was 22.0 (range: 1-130). 7794 items were assigned an outcome domain, the most frequent being emotional functioning/wellbeing (22 %), physical functioning (15.7 %), general outcomes (10.1 %) and delivery of care (8.9 %).

CONCLUSIONS

There are a variety of patient and caregiver-reported measures in oncology. This archive can guide researchers and practitioners in selecting the most suitable measures and fostering a patient-centered approach in clinical trials, clinical practice, and regulatory activities.

Pediatric dentistry systematic reviews using the GRADE approach: methodological study

BACKGROUND

To assess the reporting of the certainty of the evidence using the GRADE approach in systematic reviews of interventions in pediatric dentistry.

METHODS

The inclusion criteria were systematic reviews of randomized clinical trials (RCTs) and non-randomized studies of interventions (NRSIs) in pediatric dentistry that reported the certainty of the evidence through the GRADE approach. Paired independent reviewers screened the studies, extracted data, and appraised the methodological quality using the Assessing the Methodological Quality of Systematic Reviews (AMSTAR 2) tool. The certainty of the evidence was extracted for each outcome. A descriptive analysis was conducted.

RESULTS

Around 28% of pediatric dentistry reviews of interventions used the GRADE approach (n = 24). Twenty reviews reported 112 evidence outcomes from RCTs and 13 from NRSIs using GRADE evidence profile tables. The methodological quality was high (16.7%), moderate (12.5%), low (37.5%), and critically low (33.3%), fulfilling the majority of the AMSTAR 2 criteria. The certainty of the evidence for outcomes generated from RCTs and NRSIs was very low (40.2% and 84.6%), low (33.1% and 7.7%), moderate (17.8% and 7.7%), and high (9.8% and 0.0%). The main reasons to downgrade the certainty were due to (for RCTs and NRSIs, respectively): risk of bias (68.8% and 84.6%), imprecision (67.8% and 100.0%), inconsistency (18.8% and 23.1%), indirectness (17.8% and 0.0%), and publication bias (7.1% and 0.0%).

CONCLUSION

The proportion of systematic reviews assessing the certainty of the evidence using the GRADE approach was considered small, considering the total initial number of published pediatric dentistry reviews of intervention. The certainty of the evidence was mainly very low and low, and the main problems for downgrading the certainty of evidence were due to risk of bias and imprecision.

REGISTRATION

PROSPERO database #CRD42022365443.

Calculation of the minimum clinically important difference (MCID) using different methodologies: case study and practical guide

INTRODUCTION

Establishing thresholds of change that are actually meaningful for the patient in an outcome measurement instrument is paramount. This concept is called the minimum clinically important difference (MCID). We summarize available MCID calculation methods relevant to spine surgery, and outline key considerations, followed by a step-by-step working example of how MCID can be calculated, using publicly available data, to enable the readers to follow the calculations themselves.

METHODS

Thirteen MCID calculations methods were summarized, including anchor-based methods, distribution-based methods, Reliable Change Index, 30% Reduction from Baseline, Social Comparison Approach and the Delphi method. All methods, except the latter two, were used to calculate MCID for improvement of Zurich Claudication Questionnaire (ZCQ) Symptom Severity of patients with lumbar spinal stenosis. Numeric Rating Scale for Leg Pain and Japanese Orthopaedic Association Back Pain Evaluation Questionnaire Walking Ability domain were used as anchors.

RESULTS

The MCID for improvement of ZCQ Symptom Severity ranged from 0.8 to 5.1. On average, distribution-based methods yielded lower MCID values, than anchor-based methods. The percentage of patients who achieved the calculated MCID threshold ranged from 9.5% to 61.9%.

CONCLUSIONS

MCID calculations are encouraged in spinal research to evaluate treatment success. Anchor-based methods, relying on scales assessing patient preferences, continue to be the "gold-standard" with receiver operating characteristic curve approach being optimal. In their absence, the minimum detectable change approach is acceptable. The provided explanation and step-by-step example of MCID calculations with statistical code and publicly available data can act as guidance in planning future MCID calculation studies.

The minimal important difference in orthodontic treatment duration: a survey across adult patients

BACKGROUND

The minimal important difference (MID) is defined as the smallest difference that the patient perceives as important. Furthermore, the smallest worthwhile effect (SWE) is the important change measured with the benefit-harm trade-off method. The aim of this study was to evaluate the MID in orthodontic treatment duration to inform the decision regarding seeking procedures to accelerate orthodontic tooth movement and reduce treatment duration.

METHODS

We constructed a survey eliciting views of the MID from adult participants from four countries undergoing orthodontic treatment. Ten questions addressed reduction in the treatment duration for both durations 12 and 24 months, and four questions were related to the reduction in treatment duration that the patients would require to undergo surgical or non-surgical adjunctive procedures. We applied a univariable random effects logistic regression model to examine the association between the participants' characteristics and the MID. Then, we fitted a multivariable logistic random effects regression including significant predictors.

RESULTS

Four hundred and fifty adults, with a median age of 21 (interquartile range: 19-24), undergoing orthodontic treatment participated in the survey. Of the respondents, 60% considered 15 days as a trivial reduction from 12 months duration of therapy and 70% considered 15 days a trivial reduction from 24 months. Of the respondents, 48% considered the period of 2 months a moderate reduction from 12 months, and 60% considered 2 months a moderate reduction from 24 months. From these results, we inferred that patients considered reductions of approximately 1 month as the MID in the treatment duration for both 12 and 24 months. However, SWE was considerably more than the MID for most of the participants to decide undergoing surgical adjunctive procedures to reduce the time of therapy. The participants required smaller SWE to undergo non-surgical procedures compared to surgical procedures.

CONCLUSION

The MID in the treatment duration is one month for both treatment durations 12 and 24 months. Patients require a greater SWE than the MID to undergo adjunctive procedures to shorten the duration, particularly for surgical procedures.

Anchor-based minimal important difference values are often sensitive to the distribution of the change score

PURPOSE

Anchor-based studies are today the most popular approach to determine a minimal important difference value for an outcome variable. However, a variety of construction methods for such values do exist. This constitutes a challenge to the field. In order to distinguish between more or less adequate construction methods, meaningful minimal requirements can be helpful. For example, minimal important difference values should not reflect the intervention(s) the patients are exposed to in the study used for construction, as they should later allow to compare interventions. This requires that they are not sensitive to the distribution of the change score observed. This study aims at investigating to which degree established construction methods fulfil this minimal requirement.

METHODS

Six constructions methods were considered, covering very popular and recently suggested methods. The sensitivity of MID values to the distribution of the change score was investigated in a simulation study for these six construction methods.

RESULTS

Five out of six construction methods turned out to yield MID values which are sensitive to the distribution of the change score to a degree that questions their usefulness. Insensitivity can be obtained by using construction methods based solely on an estimate of the conditional distribution of the anchor variable given the change score.

CONCLUSION

In future the computation of MID values should be based on construction methods avoiding sensitivity to the distribution of the change score.

The minimal important difference of patient-reported outcome measures related to female urinary incontinence: a systematic review

BACKGROUND

The minimal important difference is a valuable metric in ascertaining the clinical relevance of a treatment, offering valuable guidance in patient management. There is a lack of available evidence concerning this metric in the context of outcomes related to female urinary incontinence, which might negatively impact clinical decision-making.

OBJECTIVES

To summarize the minimal important difference of patient-reported outcome measures associated with urinary incontinence, calculated according to both distribution- and anchor-based methods.

METHODS

This is a systematic review conducted according to the PRISMA guidelines. The search strategy including the main terms for urinary incontinence and minimal important difference were used in five different databases (Medline, Embase, CINAHL, Web of Science, and Scopus) in 09 June 2021 and were updated in January 09, 2024 with no limits for date, language or publication status. Studies that provided minimal important difference (distribution- or anchor-based methods) for patient-reported outcome measures related to female urinary incontinence outcomes were included. The study selection and data extraction were performed independently by two different researchers. Only studies that reported the minimal important difference according to anchor-based methods were assessed by credibility and certainty of the evidence. When possible, absolute minimal important differences were calculated for each study separately according to the mean change of the group of participants that slightly improved.

RESULTS

Twelve studies were included. Thirteen questionnaires with their respective minimal important differences reported according to distribution (effect size, standard error of measurement, standardized response mean) and anchor-based methods were found. Most of the measures for anchor methods did not consider the smallest difference identified by the participants to calculate the minimal important difference. All reports related to anchor-based methods presented low credibility and very low certainty of the evidence. We pooled 20 different estimates of minimal important differences using data from primary studies, considering different anchors and questionnaires.

CONCLUSIONS

There is a high variability around the minimal important difference related to patient-reported outcome measures for urinary incontinence outcomes according to the method of analysis, questionnaires, and anchors used, however, the credibility and certainty of the evidence to support these is still limited.

Are web-based stress management interventions effective as an indirect treatment for depression? An individual participant data meta-analysis of six randomised trials

QUESTION

Depression is highly prevalent and associated with numerous adverse consequences for both individuals and society. Due to low uptake of direct treatment, interventions that target related, but less stigmatising problems, such as perceived stress, have emerged as a new research paradigm.This individual participant data (IPD) meta-analysis examines if a web-based stress management intervention can be used as an 'indirect' treatment of depression.

STUDY SELECTION AND ANALYSIS

Bayesian one-stage models were used to estimate pooled effects on depressive symptom severity, minimally important improvement and reliable deterioration. The dose-response relationship was examined using multilevel additive models, and IPD network meta-analysis was employed to estimate the effect of guidance.

FINDINGS

In total, N=1235 patients suffering from clinical-level depression from K=6 randomised trials were included. Moderate-to-large effects were found on depressive symptom severity at 7 weeks post-intervention (d=-0.65; 95% credibility interval (CrI): -0.84 to -0.48) as measured with the Center for Epidemiological Studies' Depression Scale. Effects were sustained at 3-month follow-up (d=-0.74; 95% CrI: -1.01 to -0.48). Post-intervention symptom severity was linearly related to the number of completed sessions. The incremental impact of guidance was estimated at d=-0.25 (95% CrI: -1.30 to 0.82), with a 35% posterior probability that guided and unguided formats produce equivalent effects.

CONCLUSIONS

Our results indicate that web-based stress management can serve as an indirect treatment, yielding effects comparable with direct interventions for depression. Further research is needed to determine if such formats can indeed increase the utilisation of evidence-based treatment, and to corroborate the favourable effects for human guidance.

STUDY REGISTRATION

Open material repository: osf.io/dbjc8, osf.io/3qtbe.

TRIAL REGISTRATION NUMBER

German Clinical Trial Registration (DRKS): DRKS00004749, DRKS00005112, DRKS00005384, DRKS00005687, DRKS00005699, DRKS00005990.

Estimating the smallest worthwhile difference of antidepressants: a cross-sectional survey

BACKGROUND

Approximately 30% of patients experience substantial improvement in depression after 2 months without treatment, and 45% with antidepressants. The smallest worthwhile difference (SWD) refers to an intervention's smallest beneficial effect over a comparison patients deem worthwhile given treatment burdens (harms, expenses and inconveniences), but is undetermined for antidepressants.

OBJECTIVE

Estimating the SWD of commonly prescribed antidepressants for depression compared to no treatment.

METHODS

The SWD was estimated as a patient-required difference in response rates between antidepressants and no treatment after 2 months. An online cross-sectional survey using Prolific, MQ Mental Health and Amazon Mechanical Turk crowdsourcing services in the UK and USA between October 2022 and January 2023 garnered participants (N=935) that were a mean age of 44.1 (SD=13.9) and 66% women (n=617).

FINDINGS

Of 935 participants, 124 reported moderate-to-severe depressive symptoms but were not in treatment, 390 were in treatment and 495 reported absent-to-mild symptoms with or without treatment experiences. The median SWD was a 20% (IQR=10-30%) difference in response rates for people with moderate-to-severe depressive symptoms, not in treatment, and willing to consider antidepressants, and 25% (IQR=10-35%) for the full sample.

CONCLUSIONS

Our observed SWDs mean that the current 15% antidepressant benefit over no treatment was sufficient for one in three people to accept antidepressants given the burdens, but two in three expected greater treatment benefits.

IMPLICATIONS

While a minority may be satisfied with the best currently available antidepressants, more effective and/or less burdensome medications are needed, with more attention given to patient perspectives.

Minimal important change and difference in health outcome: An overview of approaches, concepts, and methods

OBJECTIVE

To provide an overview of approaches, concepts, and methods used to define and assess minimal important change and difference in health outcome.

METHOD

A narrative review of the literature, guided by a conceptual framework.

RESULTS

We distinguish between (i) interpretation of health outcome in individuals versus groups, (ii) change within individuals or groups versus difference between change within individuals or groups; and (iii) the responder approach (based on the proportion of patients that obtain a defined response) versus the group average approach (based on the average amount of change in a group). We review approaches, concepts, and methods.

CONCLUSION

By bringing together and juxtaposing various approaches, concepts, and methods, we set a precursory step in the direction of consensus building in the field concerned with defining and assessing minimal important change and difference in health outcome. We emphasize the need for conceptual clarification and terminological standardization. We argue that assessing minimal importance of change and difference in health outcome is essentially a value judgment involving a range of considerations and perspectives.

Systematic Review Procedures for the World Health Organization (WHO) Evidence Syntheses on Benefits and Harms of Structured and Standardized Education/Advice, Structured Exercise Programs, Transcutaneous Electrical Nerve Stimulation (TENS), and Needling Therapies for the Management of Chronic Low Back Pain in Adults

As commissioned by the WHO, we updated and expanded the scope of four systematic reviews to inform its (in development) clinical practice guideline for the management of CPLBP in adults, including older adults. Methodological details and results of each review are described in the respective articles in this series. In the last article of this series, we discuss methodological considerations, clinical implications and recommendations for future research.

Intra-articular Hyaluronic Acid Treatments for Knee Osteoarthritis: A Systematic Review of Product Properties

INTRODUCTION

There are many intra-articular hyaluronic acid (IA-HA) products on the market that have known intrinsic differences in molecular size, source, and structure. The current review summarizes existing evidence describing and assessing these differences, while also identifying whether these differences have an impact on clinical outcomes.

METHODS

This systematic review summarized all literature that specifically addresses IA-HA product differences. Included studies summarized basic science and mechanism of action comparisons of IA-HA product differences, or systematic reviews that assess differences in clinical outcomes between IA-HA product differences.

RESULTS

A total of 20 investigations assessed basic science differences between IA-HA products, while 20 investigations provided assessments of the clinical outcome differences between IA-HA product characteristics. The published basic science literature provided a differentiation between low molecular weight (LMW) and high molecular weight (HMW) HA with regard to changes within the synovial fluid, driven by the interactions that these molecules have with receptors in the joint space. These differences in receptor interaction manifest within clinical outcomes, as meta-analyses comparing pain relief after IA-HA suggest that pain reduction is superior in patients who receive HMW HA as opposed to LMW HA.

CONCLUSION

This review highlights differences between IA-HA characteristics, and how important the molecular weight, derivation of the product, and structure are to variances in reported clinical outcomes to treat osteoarthritis (OA) of the knee. HMW IA-HAs have shown greater efficacy compared to the alternative of LMW products, while avian-derived and cross-linked products have potentially demonstrated an increase in inflammatory events over non-avian-derived, non-cross-linked HAs.

Patient-Reported Outcome Measure Use in Guidelines Published by the American Academy of Ophthalmology: A Review

TOPIC

We reviewed the use of patient-reported outcome measures (PROMs) in the treatment of ophthalmologic conditions as recommended by the Clinical Practice Guidelines (CPGs) published by the American Academy of Ophthalmology (AAO).

CLINICAL RELEVANCE

Patient-reported outcome measures are standardized instruments that provide information regarding a patient's health status or health-related quality of life. Patient-reported outcome measures are increasingly used to inform study end points in ophthalmology studies. However, the extent to which PROMs are ultimately informing patient management recommendations in ophthalmology as part of CPGs remains an area of evidence gap.

METHODS

We included all CPGs published by the AAO from inception to June 2022. We also included all primary studies and systematic reviews cited in the treatment sections of the CPGs evaluating treatment of an ophthalmic condition. The primary outcome was the frequency of PROMs discussed in CPGs and in cited studies evaluating treatment. Secondary outcomes included frequency of minimal important difference (MID) use to contextualize PROM results and percentage of strong and discretionary recommendations supported by PROMs. We published a study protocol a priori on PROSPERO (CRD42022307427). Reporting followed the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) guidelines. We assessed risk of bias using the Appraisal of Guidelines, Research and Evaluation II (AGREE II) instrument.

RESULTS

We identified 24 eligible CPGs, providing 2458 cited studies (2191 primary, 267 secondary) evaluating treatment of eye conditions. Ten CPGs (41.7%) reported consideration of PROMs. Of these, 31 of 94 (33%) recommendations were informed by studies evaluating a PROM as an outcome. Across all studies cited in the development of CPGs, 221 (9.0%) used PROMs as a primary or secondary outcome, of which 4 PROM results (1.8%) were interpreted using an empirically determined MID. Overall, the risk of bias was low for all CPGs.

CONCLUSIONS

Overall, outcomes of PROMs are seldom used in ophthalmology CPGs published by the AAO and in cited primary and secondary research on treatments. When PROMs were considered, their interpretation was seldom based on an MID. To improve patient care, guideline developers may consider incorporating PROMs and applicable MIDs to inform key outcomes when formulating treatment recommendations.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Microbiota signatures and mucosal healing in the use of enteral nutrition therapy v. corticosteroids for the treatment of children with Crohn's disease: a systematic review and meta-analysis

Corticosteroids (CS) and exclusive and partial enteral nutrition (EEN and PEN) are effective therapies in paediatric Crohn's disease (CD). This systematic review of randomised controlled trials (RCT) and cohort studies analyses the impact of EEN/PEN v. CS on intestinal microbiota, mucosal healing as well as other clinically important outcomes, including clinical remission, relapse, adherence, adverse events and health-related quality of life (HRQL) in paediatric CD. Three RCT (n 76) and sixteen cohort studies (n 1104) compared EEN v. CS. With limited available data (one RCT), the effect on intestinal microbiome indicated a trend towards EEN regarding Shannon diversity. Based on two RCT, EEN achieved higher mucosal healing than CS (risk ratio (RR) 2·36, 95 % CI (1·22, 4·57), low certainty). Compared with CS, patients on EEN were less likely to experience adverse events based on two RCT (RR 0·32, 95 % CI (0·13, 0·80), low certainty). For HRQL, there was a trend in favour of CS based on data from two published abstracts of cohort studies. Based on thirteen cohort studies, EEN achieved higher clinical remission than CS (RR 1·18, 95 % CI (1·02, 1·38), very low certainty). Studies also reported no important differences in relapse and adherence. Compared with CS, EEN may improve mucosal healing with fewer adverse events based on RCT data. While limited data indicate the need for further trials, this is the first systematic review to comprehensively summarise the data on intestinal microbiome, mucosal healing and HRQOL when comparing enteral nutrition and CS in paediatric CD.

The difference between statistical significance and clinical relevance. The case of minimal important change, non-inferiority trials, and smallest worthwhile effect

Clinical relevance and statistical significance are different concepts, linked via the sample size calculation. Threshold values for detecting a minimal important change over time are frequently (mis)interpreted as a threshold for the clinical relevance of a difference between groups. The magnitude of a difference between groups that is considered clinically relevant directly impacts the sample size calculation, and thereby the statistical significance in clinical study outcomes. Especially in non-inferiority trials the threshold for clinical relevance, i.e. the predefined margin for non-inferiority, is a crucial choice. A truly inferior treatment will be accepted as non-inferior when this margin is chosen too large. The magnitude of a clinically relevant difference between groups should be carefully considered, by determining the smallest effect for each specific study that is considered worthwhile. This means taking into account the (dis)advantages of both study interventions in terms of benefits, harms, costs, and potential side effects. This article clarifies common sources of confusion, illustrates the implications for clinical research with an example and provides specific suggestions to improve the design and interpretation of clinical research.

A lifecycle framework illustrates eight stages necessary for realizing the benefits of patient-centered clinical decision support

The design, development, implementation, use, and evaluation of high-quality, patient-centered clinical decision support (PC CDS) is necessary if we are to achieve the quintuple aim in healthcare. We developed a PC CDS lifecycle framework to promote a common understanding and language for communication among researchers, patients, clinicians, and policymakers. The framework puts the patient, and/or their caregiver at the center and illustrates how they are involved in all the following stages: Computable Clinical Knowledge, Patient-specific Inference, Information Delivery, Clinical Decision, Patient Behaviors, Health Outcomes, Aggregate Data, and patient-centered outcomes research (PCOR) Evidence. Using this idealized framework reminds key stakeholders that developing, deploying, and evaluating PC-CDS is a complex, sociotechnical challenge that requires consideration of all 8 stages. In addition, we need to ensure that patients, their caregivers, and the clinicians caring for them are explicitly involved at each stage to help us achieve the quintuple aim.

Minimal important change and difference for knee osteoarthritis outcome measurement tools after non-surgical interventions: a systematic review

OBJECTIVES

To systematically review and provide estimates of the minimal important change (MIC) and difference (MID) for outcome tools in people with knee osteoarthritis (OA) after non-surgical interventions. Design A systematic review.

DATA SOURCES

MEDLINE, CINAHL, Web of Science, Scopus and Cochrane databases were searched up to 21 September 2021.

ELIGIBILITY CRITERIA

We included studies that calculated MIC and MID using any calculation method including anchor, consensus and distribution methods, for any knee OA outcome tool after non-surgical interventions.

DATA EXTRACTION AND SYNTHESIS

We extracted reported MIC, MID and minimum detectable change (MDC) estimates. We used quality assessment tools appropriate to the studies' methods to screen out low-quality studies. Values were combined to produce a median and range, for each method.

RESULTS

Forty-eight studies were eligible (anchor-k=12, consensus-k=1 and distribution-k=35). MIC values for 13 outcome tools including Knee injury and Osteoarthritis Outcome Score (KOOS)-pain, activities of daily living (ADL), quality of life (QOL) and Western Ontario and McMaster Universities Arthritis Index (WOMAC)-function were estimated using 5 high-quality anchor studies. MID values for 23 tools including KOOS-pain, ADL, QOL and WOMAC-function, stiffness and total were estimated using 6 high-quality anchor studies. One moderate quality consensus study reported MIC for pain, function and global assessment. MDC values from distribution method estimates for 126 tools including KOOS-QOL and WOMAC-total were estimated using 38 good-to-fair-quality studies.

CONCLUSION

Median MIC, MID and MDC estimates were reported for outcome tools in people with knee OA after non-surgical interventions. The results of this review clarify the current understanding of MIC, MID and MDC in the knee OA population. However, some estimates suggest considerable heterogeneity and require careful interpretation.

PROSPERO REGISTRATION NUMBER

CRD42020215952.

Saturated fat and human health: a protocol for a methodologically innovative systematic review and meta-analysis to inform public health nutrition guidelines

BACKGROUND

The health effects of dietary fats are a controversial issue on which experts and authoritative organizations have often disagreed. Care providers, guideline developers, policy-makers, and researchers use systematic reviews to advise patients and members of the public on optimal dietary habits, and to formulate public health recommendations and policies. Existing reviews, however, have serious limitations that impede optimal dietary fat recommendations, such as a lack of focus on outcomes important to people, substantial risk of bias (RoB) issues, ignoring absolute estimates of effects together with comprehensive assessments of the certainty of the estimates for all outcomes.

OBJECTIVE

We therefore propose a methodologically innovative systematic review using direct and indirect evidence on diet and food-based fats (i.e., reduction or replacement of saturated fat with monounsaturated or polyunsaturated fat, or carbohydrates or protein) and the risk of important health outcomes.

METHODS

We will collaborate with an experienced research librarian to search MEDLINE, EMBASE, CINAHL, and the Cochrane Database of Systematic Reviews (CDSR) for randomized clinical trials (RCTs) addressing saturated fat and our health outcomes of interest. In duplicate, we will screen, extract results from primary studies, assess their RoB, conduct de novo meta-analyses and/or network meta-analysis, assess the impact of missing outcome data on meta-analyses, present absolute effect estimates, and assess the certainty of evidence for each outcome using the GRADE contextualized approach. Our work will inform recommendations on saturated fat based on international standards for reporting systematic reviews and guidelines.

CONCLUSION

Our systematic review and meta-analysis will provide the most comprehensive and rigorous summary of the evidence addressing the relationship between saturated fat modification for people-important health outcomes. The evidence from this review will be used to inform public health nutrition guidelines.

TRIAL REGISTRATION

PROSPERO Registration: CRD42023387377 .

Treatments for Burning Mouth Syndrome: A Network Meta-analysis

The aim of this systematic review and network meta-analysis (NMA) of randomized controlled trials was to evaluate the effectiveness of treatments for pain relief of burning mouth syndrome (BMS). Five databases and gray literature were searched. Independent reviewers selected studies, extracted data, and assessed the risk of bias. The primary outcome was pain relief or burning sensation, and the secondary outcomes were side effects, quality of life, salivary flow, and TNF-α and interleukin 6 levels. Four comparable interventions were grouped into different network geometries to ensure the transitivity assumption for pain: photobiomodulation therapy, alpha-lipoic acid, phytotherapics, and anxiolytics/antidepressants. Mean difference (MD) and 95% CI were calculated for continuous outcomes. The minimal important difference to consider a therapy beneficial against placebo was an MD of at least -1 for relief of pain. To interpret the results, the GRADE approach for NMA was used with a minimally contextualized framework and the magnitude of the effect. Forty-four trials were included (24 in the NMA). The anxiolytic (clonazepam) probably reduces the pain of BMS when compared with placebo (MD, -1.88; 95% CI, -2.61 to -1.16; moderate certainty). Photobiomodulation therapy (MD, -1.90; 95% CI, -3.58 to -0.21) and pregabalin (MD, -2.40; 95% CI, -3.49 to -1.32) achieved the minimal important difference of a beneficial effect with low or very low certainty. Among all tested treatments, only clonazepam is likely to reduce the pain of BMS when compared with placebo. The majority of the other treatments had low and very low certainty, mainly due to imprecision, indirectness, and intransitivity. More randomized controlled trials comparing treatments against placebo are encouraged to confirm the evidence and test possible alternative treatments (PROSPERO CRD42021255039).

Impacts of the preceding cancer-specific health-related quality of life instruments on the responses to the subsequent EQ-5D-5L

BACKGROUND

In clinical studies, the EQ-5D-5L is often employed with disease-specific health-related quality of life instruments. The questions in the former are more general than the latter; however, it is known that responses to general questions can be influenced by preceding specific questions. Thus, the responses to the EQ-5D-5L have the possibility of being influenced by the preceding disease-specific health-related quality of life instruments. This may lead to bias in the cost-effectiveness analysis results. Therefore, this study aimed to evaluate the impact of the preceding cancer-specific health-related quality of life instruments on the EQ-5D-5L responses.

METHODS

We prepared questionnaire booklets containing the EQ-5D-5L, the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 30, and the Functional Assessment of Cancer Therapy General with different orders. Using a quasi-randomized design, they were distributed to the patients undergoing drug therapy for advanced cancer, who were classified into three groups: Groups 1, 2, and 3 (the EQ-5D-5L placed first, second, and last, respectively). We compared the EQ-5D-5L index and the missingness of EQ-5D-5L among the groups.

RESULTS

The mean EQ-5D-5L index was 0.796, 0.760, and 0.789 for groups 1 (n = 300), 2 (n = 306), and 3 (n = 331), respectively. The difference between Groups 2 and 1 was - 0.036 (95% CI - 0.065 to - 0.007; p = 0.015). The proportion of patients with an incomplete EQ-5D-5L was 0.11, 0.11, and 0.05 for Groups 1, 2, and 3, respectively. The difference of the proportions between group 3 and 1 and between 3 and 2 was - 0.06 (95% CI - 0.10 to - 0.02; p = 0.003) and - 0.06 (95% CI - 0.10 to - 0.02; p = 0.003), respectively.

CONCLUSIONS

Although the EQ-5D-5L index differed according to the instrument orders, the difference size would not be considerably larger than the minimally important difference. The patients tended to complete the EQ-5D-5L when they were placed at the end of the questionnaire.

Guidelines for Reporting Outcomes in Trial Protocols: The SPIRIT-Outcomes 2022 Extension

IMPORTANCE

Complete information in a trial protocol regarding study outcomes is crucial for obtaining regulatory approvals, ensuring standardized trial conduct, reducing research waste, and providing transparency of methods to facilitate trial replication, critical appraisal, accurate reporting and interpretation of trial results, and knowledge synthesis. However, recommendations on what outcome-specific information should be included are diverse and inconsistent. To improve reporting practices promoting transparent and reproducible outcome selection, assessment, and analysis, a need for specific and harmonized guidance as to what outcome-specific information should be addressed in clinical trial protocols exists.

OBJECTIVE

To develop harmonized, evidence- and consensus-based standards for describing outcomes in clinical trial protocols through integration with the Standard Protocol Items: Recommendations for Interventional Trials (SPIRIT) 2013 statement.

EVIDENCE REVIEW

Using the Enhancing the Quality and Transparency of Health Research (EQUATOR) methodological framework, the SPIRIT-Outcomes 2022 extension of the SPIRIT 2013 statement was developed by (1) generation and evaluation of candidate outcome reporting items via consultation with experts and a scoping review of existing guidance for reporting trial outcomes (published within the 10 years prior to March 19, 2018) identified through expert solicitation, electronic database searches of MEDLINE and the Cochrane Methodology Register, gray literature searches, and reference list searches; (2) a 3-round international Delphi voting process (November 2018-February 2019) completed by 124 panelists from 22 countries to rate and identify additional items; and (3) an in-person consensus meeting (April 9-10, 2019) attended by 25 panelists to identify essential items for outcome-specific reporting to be addressed in clinical trial protocols.

FINDINGS

The scoping review and consultation with experts identified 108 recommendations relevant to outcome-specific reporting to be addressed in trial protocols, the majority (72%) of which were not included in the SPIRIT 2013 statement. All recommendations were consolidated into 56 items for Delphi voting; after the Delphi survey process, 19 items met criteria for further evaluation at the consensus meeting and possible inclusion in the SPIRIT-Outcomes 2022 extension. The discussions during and after the consensus meeting yielded 9 items that elaborate on the SPIRIT 2013 statement checklist items and are related to completely defining and justifying the choice of primary, secondary, and other outcomes (SPIRIT 2013 statement checklist item 12) prospectively in the trial protocol, defining and justifying the target difference between treatment groups for the primary outcome used in the sample size calculations (SPIRIT 2013 statement checklist item 14), describing the responsiveness of the study instruments used to assess the outcome and providing details on the outcome assessors (SPIRIT 2013 statement checklist item 18a), and describing any planned methods to account for multiplicity relating to the analyses or interpretation of the results (SPIRIT 2013 statement checklist item 20a).

CONCLUSIONS AND RELEVANCE

This SPIRIT-Outcomes 2022 extension of the SPIRIT 2013 statement provides 9 outcome-specific items that should be addressed in all trial protocols and may help increase trial utility, replicability, and transparency and may minimize the risk of selective nonreporting of trial results.

Guidelines for Reporting Outcomes in Trial Reports: The CONSORT-Outcomes 2022 Extension

IMPORTANCE

Clinicians, patients, and policy makers rely on published results from clinical trials to help make evidence-informed decisions. To critically evaluate and use trial results, readers require complete and transparent information regarding what was planned, done, and found. Specific and harmonized guidance as to what outcome-specific information should be reported in publications of clinical trials is needed to reduce deficient reporting practices that obscure issues with outcome selection, assessment, and analysis.

OBJECTIVE

To develop harmonized, evidence- and consensus-based standards for reporting outcomes in clinical trial reports through integration with the Consolidated Standards of Reporting Trials (CONSORT) 2010 statement.

EVIDENCE REVIEW

Using the Enhancing the Quality and Transparency of Health Research (EQUATOR) methodological framework, the CONSORT-Outcomes 2022 extension of the CONSORT 2010 statement was developed by (1) generation and evaluation of candidate outcome reporting items via consultation with experts and a scoping review of existing guidance for reporting trial outcomes (published within the 10 years prior to March 19, 2018) identified through expert solicitation, electronic database searches of MEDLINE and the Cochrane Methodology Register, gray literature searches, and reference list searches; (2) a 3-round international Delphi voting process (November 2018-February 2019) completed by 124 panelists from 22 countries to rate and identify additional items; and (3) an in-person consensus meeting (April 9-10, 2019) attended by 25 panelists to identify essential items for the reporting of outcomes in clinical trial reports.

FINDINGS

The scoping review and consultation with experts identified 128 recommendations relevant to reporting outcomes in trial reports, the majority (83%) of which were not included in the CONSORT 2010 statement. All recommendations were consolidated into 64 items for Delphi voting; after the Delphi survey process, 30 items met criteria for further evaluation at the consensus meeting and possible inclusion in the CONSORT-Outcomes 2022 extension. The discussions during and after the consensus meeting yielded 17 items that elaborate on the CONSORT 2010 statement checklist items and are related to completely defining and justifying the trial outcomes, including how and when they were assessed (CONSORT 2010 statement checklist item 6a), defining and justifying the target difference between treatment groups during sample size calculations (CONSORT 2010 statement checklist item 7a), describing the statistical methods used to compare groups for the primary and secondary outcomes (CONSORT 2010 statement checklist item 12a), and describing the prespecified analyses and any outcome analyses not prespecified (CONSORT 2010 statement checklist item 18).

CONCLUSIONS AND RELEVANCE

This CONSORT-Outcomes 2022 extension of the CONSORT 2010 statement provides 17 outcome-specific items that should be addressed in all published clinical trial reports and may help increase trial utility, replicability, and transparency and may minimize the risk of selective nonreporting of trial results.

How much is enough? Considering minimally important change in youth mental health outcomes

To make decisions in mental health care, service users, clinicians, and administrators need to make sense of research findings. Unfortunately, study results are often presented as raw questionnaire scores at different time points and regression coefficients, which are difficult to interpret with regards to their clinical meaning. Other commonly reported treatment outcome indicators in clinical trials or meta-analyses do not convey whether a given change score would make a noticeable difference to service users. There is an urgent need to improve the interpretability and relevance of outcome indicators in youth mental health (aged 12-24 years), in which shared decision making and person-centred care are cornerstones of an ongoing global transformation of care. In this Personal View, we make a case for considering minimally important change (MIC) as a meaningful, accessible, and user-centred outcome indicator. We discuss what the MIC represents, how it is calculated, and how it can be implemented in dialogues between clinician and researcher, and between youth and clinician. We outline how use of the MIC could enhance reporting in clinical trials, meta-analyses, clinical practice guidelines, and measurement-based care. Finally, we identify current methodological challenges around estimating the MIC and areas for future research. Efforts to select outcome domains and valid measurement instruments that resonate with youth, families, and clinicians have increased in the past 5 years. In this context, now is the time to define demarcations of changes in outcome scores that are clinically relevant, and meaningful to youth and families. Through the use of MIC, youth-centred outcome measurement, analysis, and reporting would support youth-centred therapeutic decision making.

Protocol for a systematic review and meta-analysis of minimal important differences for generic multiattribute utility instruments

INTRODUCTION

Generic multiattribute utility instruments (MAUIs) are efficient tools for determining and enumerating health-related quality of life. MAUIs accomplish this by generating health state utilities (HSUs) via algorithms. Minimal important differences (MIDs) assist with the interpretation of HSUs by estimating minimum changes that are clinically significant. The overall goal of the proposed systematic review and meta-analysis is the development of comprehensive guidelines for MID estimation.

METHODS AND ANALYSIS

This protocol defines a systematic review and meta-analysis of MIDs for generic MAUIs. The proposed research will involve a comprehensive investigation of 10 databases (EconLit, IDEAs database, INAHTA database, Medline, PsycINFO, Embase, Emcare, JBIEBP and CINAHL) from 1 June 2022 to 7 June 2022, and will be performed and reported in accordance with several validated guidelines, principally the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The quality of papers, considered for inclusion in the review, will be appraised using the COnsensus-based Standards for the selection of health Measurement INstruments, inter alia.Narrative analysis will involve identifying the characteristics of MIDs including methods of calculation, sources of heterogeneity, and validation. Meta-analysis will also be conducted. The descriptive element of meta-analysis will involve the generation of I² statistics and Galbraith plots of MID heterogeneity. Together with narrative analysis, this will allow sources of MID heterogeniety to be identified. A multilevel mixed model, estimated via restricted maximum likelihood estimation, will be constructed for the purposes of meta-regression. Meta-regression will attempt to enumerate the effects of sources of heterogeneity on MID estimates. Meta-analysis will be concluded with pooling of MIDs via a linear random-effects model.

ETHICS AND DISSEMINATION

Ethics approval is not required for this review, as it will aggregate data from published literature. Methods of dissemination will include publication in a peer-reviewed journal, as well as presentation at conferences and seminars.

PROSPERO REGISTRATION NUMBER

CRD42021261821.

Meaningful thresholds for patient-reported outcomes following interventions for anterior cruciate ligament tear or traumatic meniscus injury: a systematic review for the OPTIKNEE consensus

OBJECTIVE

We synthesised and assessed credibility (ie, trustworthiness) of thresholds that define meaningful scores for patient-reported outcome measures (PROMs) following interventions for anterior cruciate ligament (ACL) tear or traumatic meniscus injury.

DESIGN

Systematic review, narrative synthesis.

DATA SOURCES

We searched five databases, handsearched references of included studies and tracked citations.

ELIGIBILITY

Included studies investigated: individuals with ACL tear or meniscus injury; mean age <35 years; and PROM thresholds calculated using any method to define a minimal important change (MIC) or a meaningful post-treatment score (Patient Acceptable Symptom State (PASS) or Treatment Failure).

RESULTS

We included 18 studies (15 ACL, 3 meniscus). Three different methods were used to calculate anchor-based MICs across 9 PROMs, PASS thresholds across 4 PROMs and treatment failure for 1 PROM. Credibility was rated 'high' for only one study-an MIC of 18 for the Knee injury and Osteoarthritis Outcome Score Quality-of-life (KOOS-QOL) subscale (using the MID Credibility Assessment Tool). Where multiple thresholds were calculated among 'low' credibility thresholds in ACL studies, MICs converged to within a 10-point range for KOOS-Symptoms (-1.2 to 5.4) and function in daily living (activities of daily living, ADL 0.5-8.1) subscales, and the International Knee Documentation Committee Subjective Knee Form (7.1-16.2). Other PROM thresholds differed up to 30 points. PASS thresholds converged to within a 10-point range in KOOS-ADL for ACL tears (92.3-100), and KOOS-Symptoms (73-78) and KOOS-QOL (53-57) in meniscus injuries.

CONCLUSION

Meaningful PROM thresholds were highly susceptible to study heterogeneity. While PROM thresholds can aid interpretability in research and clinical practice, they should be cautiously interpreted.

Designing clinically useful psychopharmacological trials: challenges and ways forward

The clinical guidelines that underpin the use of drugs for mental disorders are informed by evidence from randomised controlled trials (RCTs). RCTs are performed to obtain marketing authorisation from regulators. The methods used in these RCTs could be appropriate for early phases of drug development because they identify drugs with important harms and drugs that are efficacious for specific health problems and populations. RCTs done before marketing authorisation do not tend to address clinical questions that concern the effectiveness of a drug in heterogeneous and comorbid populations, the optimisation of drug sequencing and discontinuation, or the comparative benefits and harms of different drugs that could be used for the same health problem. This Review proposes an overview of some shortcomings of RCTs, at an individual level and at the whole portfolio level, and identifies some methods in planning, conducting, and carrying out analyses in RCTs that could enhance their ability to support therapeutic decisions. These suggestions include: identifying patient-important questions to be investigated by psychopharmacological RCTs; embedding pragmatic RCTs within clinical practice to improve generalisability to target populations; collecting evidence about drugs in overlooked populations; developing methods to facilitate the recruitment of patients with mental disorders and to reduce the number of patients who drop out, using specific methods; using core outcome sets to standardise the assessment of benefits and harms; and recording systematically serious objective outcomes, such as suicide or hospitalisation, to be evaluated in meta-analyses. This work is a call to address questions relevant to patients using diverse design of RCTs, thus contributing to the development of a patient-centred, evidence-based psychiatry.

Important questions for the malignant hematologist to consider when designing or evaluating a study with patient-reported outcome measures (PROMs)

Patient-reported outcome measures (PROMs), which are measures of symptom burden, health-related quality of life (HRQoL), and therapy effectiveness have become increasingly important in clinical research. They are unique in that they are reported directly from the patient, without clinician interpretation, thereby avoiding clinician bias. With an increased focus on the patient at the center of health care, PROMs have been increasingly incorporated into clinical research, systematic reviews, and clinical guidelines. Despite the recognition of the importance of including PROMs into clinical haematologic cancer research, barriers have prevented their integration into cancer research. This review highlights the value of including PROMs into clinical haematologic cancer research and addresses the methodological challenges in using and evaluating PROMs. We propose important questions for the malignant haematologist to consider when designing or evaluating a study that includes PROMs.

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.

Toward a rigorous assessment of the statistical performances of methods to estimate the Minimal Important Difference of Patient-Reported Outcomes: a protocol for a large-scale simulation study

Interpreting observed changes over time in Patient-Reported Outcomes (PRO) measures is still considered a challenge. Indeed, concluding an observed change at group level is statistically significant does not necessarily equate this change is meaningful from the perspective of the patient. To help interpret within and/or between group changes in the measure over time, the estimation of the Minimal Important Difference (MID) of the instrument - the smallest value that patients consider as a perceived change - is useful. In the last 30 years, a plethora of methods and estimators have been proposed to derive this MID value using clinical data from sample of patients. MIDs for hundreds of PROs have been estimated, with frequently a substantial variability in the results depending on the method used. Nonetheless, a rigorous assessment of the statistical performances of numerous proposed methods for estimating MIDs by experimental design such as Monte-Carlo study has never been performed. The purpose of this paper is to thoroughly depict a protocol for a large-scale simulation study designed to investigate the statistical performances, especially bias against a true populational value, of the common proposed estimators for MID. This paper depicts how investigated methods and estimators were retained after the conduct of a systematic review, the design of a conceptual model that formally defines what is the true populational MID value and the translation of the conceptual model into a model allowing the simulation of responses of items to a hypothetical PRO at two times of measurement along with the response to a Patient Global Rating of Change at the second time under the constraint of a known true MID value. A statistical analysis plan is depicted in order to conclude if working hypotheses on what could be appropriate MID estimators will be verified. Strengths, assumptions, and limits of the simulation model are exposed. Finally, we show how this protocol could be the basis for fostering future methodological research on the issue of interpreting changes in PRO measures.

A systematic survey identified methodological issues in studies estimating anchor-based minimal important differences in patient-reported outcomes

OBJECTIVE

To systematically survey the literature addressing the reporting of studies estimating anchor-based minimal important differences (MIDs) and choice of optimal MIDs.

STUDY DESIGN AND SETTING

We searched Medline, Embase and PsycINFO from 1987 to March 2020. Teams of two reviewers independently identified eligible publications and extracted quotations addressing relevant issues for reporting and/or selecting anchor-based MIDs. Using a coding list, we assigned the same code to quotations capturing similar or related issues. For each code, we generated an 'item', i.e., a specific phrase or sentence capturing the underlying concept. When multiple concepts existed under a single code, the team created multiple items for that code. We clustered codes addressing a broader methodological issue into a 'category' and classified items as relevant for reporting, relevant for selecting an anchor-based MID, or both.

RESULTS

We identified 136 eligible publications that provided 6 categories (MID definition, anchors, patient-reported outcome measures, generalizability and statistics) and 24 codes. These codes contained 34 items related to reporting MID studies, of which 29 were also related to selecting MIDs.

CONCLUSION

The systematic survey identified items related to reporting of anchor-based MID studies and selecting optimal MIDs. These provide a conceptual framework to inform the design of studies related to MIDs, and a basis for developing a reporting standard and a selection approach for MIDs.

Self-management interventions for issues identified in a geriatric assessment: A systematic review

BACKGROUND

With the development of electronic geriatric assessment (GA), recommendations for self-management can be provided to patients without the presence of health care providers. Our research question was to identify what self-management interventions can be used by patients to address issues identified in GA and to determine their effect on patient-centered outcomes such as quality of life, health, mood, cognition, and functional status.

METHODS

Searches were conducted on July 13, 2021, by a health sciences librarian in Medline, Embase, CINAHL, PsycInfo, and the Cochrane Library. A combination of database-specific subject headings and text word searches was used such as self-management, a key word for each of the geriatric assessment domains and older adults. Two independent reviewers reviewed abstracts and full texts for inclusion and abstracted data. Narrative synthesis was used to summarize findings.

RESULTS

Among 28,520 abstracts reviewed, 34 randomized controlled trials were included. The most frequently studied geriatric domains were mood (n = 13 studies), mobility/falls (n = 12), quality of life (n = 11), and functional status (n = 7). The majority of studies demonstrated positive effects on mobility/falls (9 of 12), pain (3 of 5), comorbidity (4 of 4), and medication management (4 of 4). Most studies were of low to moderate quality. All geriatric domains were targeted in at least one study.

CONCLUSIONS

Low- to moderate-quality studies show a variety of effective self-efficacy-targeted interventions exist for older adults to improve several important geriatric domains and related outcomes. However, long-term effects, validation, and scalability of these interventions remain largely unknown.

Modifying the quality-adjusted life year calculation to account for meaningful change in health-related quality of life: insights from a pragmatic clinical trial

BACKGROUND

We propose a modified quality-adjusted life year (QALY) calculation that aims to be consistent with guidance for interpreting change in patient-reported outcomes. This calculation incorporates the minimally important difference (MID) in generic preference-based health-related quality of life (HRQL) change scores to reflect what might be considered meaningful HRQL improvement/deterioration. In doing so, we review common issues in QALY calculations such as adjustment for baseline scores and standardizing for between-group differences.

METHODS

Using EQ-5D-5L outcome data from the Alberta TEAMCare-Primary Care Network trial in the management of depression for patients with type 2 diabetes (n = 98), this study compared results from different QALY calculation methods to investigate the impact of (i) adjusting for baseline HRQL score, (ii) standardizing between-group differences at baseline, and (iii) adjusting for 'meaningful' HRQL changes. The following QALY calculation methods are examined: area under curve (QALY-AUC), change from baseline (QALY-CFB), regression modelling (QALY-R), and incorporating an MID for HRQL changes from baseline (QALY-MID).

RESULTS

The incremental QALY-AUC estimate favoured the Collaborative Care group (0.031) while the incremental QALY-CFB (-0.028) estimate favoured Enhanced Care. Adjusting for meaningful HRQL changes resulted in a crude incremental QALY-MID of -0.023; however, after adjusting for between-group differences at baseline, QALY-R and adjusted incremental QALY-MID estimates were -0.007 and -0.001, respectively. In addition, recursive regression analyses showed that very low baseline HRQL scores impact incremental QALY estimates.

CONCLUSIONS

Uncertainty in incremental QALY estimates reflects uncertainty in the value of small within-individual change as well as the impact of small differences between groups at baseline. Applying a responder-definition approach yielded crude and adjusted QALY-MID estimates that were more in favour of Collaborative Care than QALY-CFB and QALY-R estimates, respectively, suggesting that ambiguous small changes in HRQL scores have the potential to influence QALY outcomes used in economic or non-economic applications.