Use of core outcome sets was low in clinical trials published in major medical journals

How do we measure dysarthria after stroke? A systematic review to guide the core outcome set for dysarthria

OBJECTIVES

A consensus study to establish a Core Outcome Set for dysarthria after stroke identified four key outcome domains that should be measured in research and clinical practice: (1) intelligibility of speech, (2) ability to participate in conversations, (3) living well with dysarthria and (4) communication partners skills and knowledge (where relevant). This review aimed to systematically identify corresponding measurement instruments and to examine their clinical utility and psychometric properties.

DESIGN

Systematic review conducted in alignment with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

DATA SOURCES

CINAHL, EMBASE, MEDLINE, PsycInfo and Cochrane Stroke Group Trials Register, CENTRAL, Linguistics and Language Behavioral Abstracts (LLBA). Major trials registers: WHO ICTRP, ISRCTN registry and ClinicalTrials.gov searched March 2024.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

We included trials that developed or used measurement instruments for poststroke dysarthria. We identified studies that could be included in an update of the Cochrane systematic review of interventions for non-progressive dysarthria to identify what measurement instruments were used in therapy trials for poststroke dysarthria.

DATA EXTRACTION AND SYNTHESIS

Records were screened independently by three authors. Psychometric data were extracted, by two authors, from included studies and methodological quality was evaluated using Consensus-based Standards for the selection of health Measurement Instruments (COSMIN) and Core Outcome Measures in Effectiveness Trials (COMET) guidance. Assessment of clinical utility followed Outcome Measures in Rheumatology (OMERACT) guidance.

RESULTS

Following screening, 19 publications reporting 12 measurement instruments were identified. According to COSMIN standards, all 19 publications were rated as having low, very low or unknown quality of evidence. Three measurement instruments were identified as having the most relevant clinical utility to the population, the highest quality of evidence and had the potential to measure some specific aspects from three of the four agreed domains, intelligibility, conversations and living well with dysarthria from the patient and clinician perspective. These were the Frenchay Dysarthria Assessment II, the Communication Outcomes After Stroke Scale and the Therapy Outcome Measures for Dysarthria.

CONCLUSIONS

This review provides a comprehensive overview and appraisal of dysarthria measurement instruments to align with a Core Outcome Set. We only included English language-based measurement instruments. Many dysarthria measurement instruments were developed for non-stroke populations, including progressive dysarthria, with limited psychometric data for stroke. Measurement instruments with uncertain quality of evidence can still be considered for inclusion with a Core Outcome Set and three have been suggested. There is a need for further psychometric testing of these and the development of new measurement instruments to cover all aspects of intelligibility, conversations, living well with dysarthria and communication partner skills.

PROSPERO REGISTRATION NUMBER

CRD42022302998.

Empty pelvis syndrome as a cause of major morbidity after pelvic exenteration: validation of a core data set

BACKGROUND

Pelvic exenteration (PE) is a potentially curative treatment for advanced pelvic cancers. However, PE procedures are associated with empty pelvis syndrome (EPS), a spectrum of complications including pelvic sepsis, sinus formation, fistulae, and bowel obstruction. Inconsistent reporting has impeded progress in understanding EPS. The PelvEx Collaborative introduced a core data set of descriptors and outcomes to address these issues and the aim of this study was to validate this data set.

METHODS

An observational cohort study applied the EPS core data set to a prospectively maintained PE database. Patterns of major and minor manifestations were evaluated; logistic regression was used to explore relationships between descriptors and outcomes, and inter-descriptor correlation was assessed using Cramer's V.

RESULTS

EPS occurred in 32.1% of patients (105 of 327) and was the leading cause of major morbidity. Infected pelvic collections (occurring in 23.5%) were associated with subsequent chronic sinus formation (OR 3.08, P = 0.01) and fistulae (P = 0.05). The risk of EPS increased with external beam radiotherapy (OR 1.01 per 1 Gy, P = 0.01), sacrectomy (OR 3.78, P < 0.001), total cystectomy (OR 2.46, P = 0.001), internal iliac vessel ligation (unilateral OR 1.94, P = 0.045; bilateral OR 3.65, P < 0.001), and infralevator exenteration (OR 3.69, P < 0.001). Omentoplasty reduced pelvic bowel obstruction (OR 0.27, P = 0.004) and perineal flaps were linked to a higher rate of reconstruction-related major morbidity compared with biological mesh alone (20.8% versus 1.2% respectively, P = 0.002).

CONCLUSION

The PelvEx Collaborative core data set standardizes reporting of EPS, with this study detailing the acute and chronic complications arising as a consequence. Biological mesh was associated with reduced reconstruction-related morbidity compared with perineal flaps. Further validation in additional cohorts is required to address potential confounding factors.

Patient Engagement and Patient Experience Data in Regulatory Review and Health Technology Assessment: Where Are We Today?

BACKGROUND

As healthcare stakeholders aim to support patient-centered care, patients play an increasingly important role in pharmaceutical and medical technology development and healthcare decision-making. Patient engagement (PE), patient experience data (PED), and meaningful integration of PE to enrich PED have been evolving rapidly. This landscape review focuses on emerging PE/PED practices and guidelines in 2023.

METHODS

References published between January-December 2023 on the use of PE and PED from health technology assessment (HTA) and regulatory bodies in different countries, three peer-reviewed journals, and referred resources from collaborators were analyzed. These references were compared with those in our previous publication (August 2021-January 2023, 17-month period).

RESULTS

Overall, 28 references from HTA/regulatory bodies, 26 from peer-reviewed articles, and 17 referred resources were identified. Eight references on PE and PED integration (PE + PED) were identified in 2023 from HTA/regulatory bodies, compared with none in the previous 17-month analysis. Emerging trends on the role of PE, PED, and real-world evidence in HTA/regulatory deliberations, transparency and geographic variations in the use of such evidence and practices, and gaps thereof have been highlighted.

CONCLUSIONS

The increase in PE, PED, and PE + PED references worldwide in 2023 versus the prior 17-month analysis suggests accelerated adoption of PE + PED practices. However, a need remains for comprehensive, actionable guidance on best practices for use of PE and PED for harmonization and incorporation into HTA/regulatory processes. Patient input-essential for evidence-based decision-making-provides valuable insights that enhance care quality, treatment relevance and effectiveness, and builds trust and sustainability.

Core outcome sets in cancer clinical trials: current status and future opportunities-an EORTC perspective

BACKGROUND

Inconsistent, varied and selective outcome reporting is problematic in clinical trials. Core outcome sets (COS) standardise the outcomes that should be measured and reported in all trials in a specific area of health or health care. We reviewed available cancer COS and assessed their uptake in cancer clinical trials through surveying members of the European Organisation for Research and Treatment of Cancer (EORTC).

METHODS

This study employs an exploratory cross-sectional design across two phases. The Core Outcome Measures in Effectiveness Trials (COMET) Initiative database was searched for cancer-specific COS on June 1st, 2023. Awareness and use of COS amongst EORTC trialists was assessed in November 2023 via an online survey.

RESULTS

We identified a total of 85 cancer-related COS on the COMET database. Of these, 69 related to the tumour types as categorised by the EORTC and their disease orientated groups. A total of 710 EORTC members responded, of whom half (50%) stated they were unfamiliar with COS. Relevant COS were available to over a quarter of respondents, with a tenth utilising available COS. Those who chose not to use an available COS cited volume of outcomes, lack of time and infrastructure for implementation as key barriers.

CONCLUSIONS

While COS are becoming increasingly available to, and acknowledged by, cancer clinical trialists, their implementation is currently still limited. Our findings indicate that further development of COS to fill gaps for missing tumour types, greater involvement of trialists in the COS development process, and increased awareness and understanding of COS amongst trialists are all required to ensure widespread implementation of COS in cancer clinical trials.

Uptake of core outcome sets in paediatric clinical trials: a protocol

INTRODUCTION

A growing number of paediatric core outcome sets (COS) have been developed in the past 20 years. Previous studies have provided many useful insights into the uptake of COS. In addition to the awareness of COS among clinical trialists, the COS development process (especially patient participation) and the actions of the developers can promote COS uptake. However, the uptake of COS in paediatric clinical trials needs to be further explored. The aim of this study is to provide information on the rationale and use of paediatric COS in clinical trials, and to analyse in depth the awareness and views of COS developers and clinical trialists about the development and use of COS.

METHODS AND ANALYSIS

We will include all paediatric COS identified in our previous systematic review and those subsequently included in the Core Outcome Measures in Effectiveness Trials (COMET) database. We will extract the target condition, population, intervention, list of core outcomes and the details of patient involvement. Next, we will search the Clinicaltrials.gov and WHO International Clinical Trials Registry Platform for trials on health conditions addressed by the identified COS. We will assess the comparability of the scopes in each COS-trial pair and determine for the outcomes in each clinical trial if they match exactly or generally, or if they do not match, with the outcomes of their respective COS. Finally, we will conduct a survey and semistructured interviews among COS developers and clinical trialists to examine their views.

ETHICS AND DISSEMINATION

Ethical approval for the study has been granted by the ethics committee of the Institute of Health Data Science, Lanzhou University (No. HDS-202405-01). This study was registered on COMET (https://www.comet-initiative.org/Studies/Details/3122).

HOW TO REPORT OUTCOMES IN CLINICAL DENTAL RESEARCH

Outcomes, also known as endpoints, are a critical component in clinical research evaluating the effects of healthcare interventions. The validity of a clinical study depends on the appropriate selection and usage of outcomes. Therefore, complete, accurate, and transparent reporting of outcomes is essential for the critical appraisal of a study's methods and findings. However, empirical research has shown that the reporting of outcomes is often incomplete and selective in clinical dental research, hindering evidence synthesis and evidence-based dental practice. To improve and standardize outcome reporting, reporting guidelines that provide specific guidance for all types of outcomes, namely the SPIRIT-Outcomes 2022 and CONSORT-Outcomes 2022, have been developed and released recently. In addition, reporting guidelines for certain types of outcomes have also been published, including harms, patient-reported outcomes (PROs), and surrogate outcomes. The present article describes common classifications of outcomes, current issues in outcome reporting, and using reporting guidelines to standardize and improve outcome reporting in clinical dental research. The role of core outcome sets in outcome reporting is also discussed. This article aims to provide guidance and suggestions to help improve the completeness and transparency of outcome reporting and reduce relevant research waste in clinical dental research.

Assessment of the methodological quality of studies on core outcome sets for respiratory diseases: A systematic review and meta-research study

BACKGROUND

With increasing attention to core outcome sets (COS), the number of studies on COS for respiratory diseases (COS-RD) is on the rise. However, the methodological quality is still unclear. Therefore, we conducted a study to assess the methodological quality of studies on COS-RD.

METHODS

PubMed, Embase, Cochrane Library, and Web of Science were searched for study protocols or original studies on COS-RD about adults, from their inception to February 23, 2024. The COMET database and Chinese databases (including China National Knowledge Infrastructure, Wanfang Data, Chongqing VIP database, and China Biology Medicine) were also searched as a supplement. Two researchers independently screened the literature, extracted the data, and assessed the methodological quality of included studies using the Core Outcome Set-STAndardised Protocol (COS-STAP) statement, the Core Outcome Set-STAndards for Development (COS-STAD) recommendations, and the Core Outcome Set-STAndards for Reporting (COS-STAR) statement.

RESULTS

A total of 27 articles (five study protocols and 22 original studies, 26 studies) were included in this study. For the assessment of study protocols using the COS-STAP statement, the item with the lowest complete reporting rate was "missing data" (Item 9, 40.0%), while "description how outcomes may be dropped/combined, with reasons" (Item 5b, 60.0%) and "dissemination" (Item 11, 60.0%) had relatively low complete reporting rates. For the assessment of original studies using the COS-STAD recommendations, the item with the highest non-reporting rate was "care was taken to avoid ambiguity of language used in the list of outcomes" (Item 11, 45.5%), while "the population(s) covered by COS" (Item 3, 31.8%) and "the intervention(s) covered by COS" (Item 4, 31.8%) had relatively high non-reporting rate. When using the COS-STAR statement to assess the original studies, the item with the lowest complete reporting rate was "protocol deviations" (Item 11, 13.6%), while "describe how outcomes were dropped/combined, with reasons (if applicable)" (Item 6b, 36.4%), "participants" (Item 5, 40.9%), "ethics and consent" (Item 10, 54.5%), "protocol/registry entry" (Item 14, 63.6%), and "outcome scoring" (Item 8, 63.6%) had relatively low complete reporting rates.

CONCLUSION

The methodological quality of studies on COS-RD needs to be further improved. The appropriate use of aforementioned international reporting standards can advance the methodological quality and reporting transparency of studies on COS-RD.

Assessing the uptake of infertility core outcome set in IVF randomized controlled trials

STUDY QUESTION

Do the infertility core outcome set and standardized definitions affect the outcome selection for randomized controlled trials, and what aspects should be further improved in the future?

SUMMARY ANSWER

Intrauterine pregnancy demonstrated the highest uptake level, whereas others were low, especially in neonatal outcomes; as time progresses, the target sample size increases, and with prospective registration, the consistency between outcomes reported in registrations and infertility core outcome set improves significantly.

WHAT IS KNOWN ALREADY

The infertility core outcome set, published on 30 November 2020, aims to standardize outcome reporting and prevent selective reporting bias; however, there is a paucity of research evaluating its actual adoption, which is crucial for the timely promotion of transparency, standardization, adjustment of development strategies, and efficient resource utilization.

STUDY DESIGN, SIZE, DURATION

This cross-sectional study included 1673 eligible randomized controlled trial registrations for infertility in 18 registries from March 2004 to July 2024 based on registry entries.

PARTICIPANTS/MATERIALS, SETTING, METHODS

A total of 4625 infertility-related studies from 1 November 1999 to 26 July 2024 were retrieved in the World Health Organization International Clinical Trials Registry Platform. Finally, 1673 randomized controlled trial registrations were selected and divided into four period groups. Period, target sample size, prospective registration, blinding, support, and countries/regions were potential influencing factors. The consistency of outcomes, definitions, and standardized denominators of randomized controlled trial registry entries with the recommendations of the infertility core outcome set were the main outcomes. Independent retrieval, screening, data extraction, and consistency evaluations by two assessors and expert consultations were conducted to assess the uptake and potential influencing factors of the infertility core outcome set in randomized controlled trials involving infertile patients undergoing in vitro fertilization.

MAIN RESULTS AND THE ROLE OF CHANCE

Results reveal that the reporting level in the pregnancy domain was significantly higher than that in the neonatal domain (13.6% vs 5.7%). Intrauterine pregnancy (66.9%), live birth (27.6%), and miscarriage (26.5%) had relatively high uptake levels. The uptake of most core outcomes and domains, as well as the total number of reported core outcomes, showed statistically significant differences based on period, target sample size, and prospective registration. Multivariable analyses supported the above finding. Reasons responsible for the results may be attributed to the lack of effective promotional measures, as well as the limited researcher awareness regarding this core outcome set.

LIMITATIONS, REASONS FOR CAUTION

Some results in this study may have been influenced by the subjective judgment of the evaluators due to the complexity of the information in registries.

WIDER IMPLICATIONS OF THE FINDINGS

Uptake of most core outcomes or domains is increasing but is not yet ideal. Moreover, the upward trend cannot be solely attributed to the publication of the infertility core outcome set. The key to promoting uptake is to thoroughly explore and recognize the factors that both facilitate and hinder the uptake of the infertility core outcome set, further expand and publicize the core outcome set, and foster multidisciplinary or multiple stakeholder cooperation.

STUDY FUNDING/COMPETING INTEREST(S)

This study was supported by the Capital's Funds for Health Improvement and Research (CFH 2024-2G-4097), as well as the special fund of Beijing Key Clinical Specialty Construction Project. The authors have no conflicts of interest to declare.

TRIAL REGISTRATION NUMBER

http://www.comet-initiative.org/Studies/Details/3184.

Use, knowledge, & attitudes on core outcome sets among trialists & systematic reviewers in India: A survey

Background & objectives Core Outcome Sets (COS) are consensus-derived standardized outcomes that improve the transparency, consistency, homogeneity, and usefulness of outcomes. While COS are being increasingly developed, not much is known about their awareness, use, knowledge, and attitudes among trialists and systematic reviewers. This study aimed to examine the use, knowledge, and attitudes about COS among clinical trialists and systematic reviewers in India. Methods We conducted an anonymous online survey between August 2023 to November 2023, using a questionnaire hosted on REDCap including trialists and/or systematic reviewers as participants. The survey tool evaluated awareness, use and attitudes on COS, including through a couple of open-ended questions. Results A total of 523 trialists/ systematic reviewers participated in this survey. Of these, only 51.4 per cent indicated that they were aware of COS. Only 13.9 per cent trialists and 10.5 per cent systematic reviewers were using them, while mere 6 per cent had been involved in COS development. Lack of available COS for conditions of interest in an Indian context was identified as one of the barriers in its uptake. Even among participants who were aware, many were not clear about COS concepts, and although they expressed positive attitudes about the benefits of COS usage, they also indicated that they perceived COS as restrictive, costly, blocking innovation, and increasing patient burden. We identified health conditions relevant to India, where there is no COS available or where COS is present but were mentioned to be not relevant or valid for the Indian context. Interpretation & conclusions As per our knowledge, this study is the largest survey on this domain globally. Through this study several barriers for enhancing COS awareness and uptake were identified indicating the need for resources and systematic efforts to address these barriers in India and globally. We also identify COS which need to be developed or updated to be relevant to Indian context.

Assessing the Uptake of the Lung Cancer Core Outcome Set: A Cross-Sectional Analysis

Introduction

A core outcome set (COS) helps standardize outcome measurements across clinical trials. Although lung cancer is the leading cause of cancer-related deaths, research exploring COS implementation across lung cancer trials remains limited. We aim to analyze the uptake of the lung cancer COS and identify potential gaps in COS adherence.

Methods

On June 26, 2023, we conducted a cross-sectional analysis of clinical trials that evaluated lung cancer interventions. Our sample consisted of studies registered on ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform between September 2011 and June 2023. In a masked and duplicate fashion, investigators extracted data regarding trial characteristics and COS adoption. An interrupted time series analysis was conducted to evaluate the adherence of lung cancer COS before and after its publication.

Results

Of the 626 observed trials, we found no overall significant difference in lung cancer COS uptake pre- and post-publication (0.01%, 95% confidence interval: -0.16% to 0.19%, p=0.85). The most frequently measured outcomes were "overall survival" (91.69%%) and "treatment-related mortalities" (54.69%). Health-related quality of life questionnaires were typically used to evaluate outcomes in the "Degree of health" domain (49.20%). Outcomes related to "time from diagnosis to treatment" (0%), "place of death" (0.16%), and "duration of time spent in the hospital at the end of life" (1.60%) were rarely measured.

Conclusions

Despite the advantages of COS implementation, adherence across lung cancer clinical trials remains alarmingly low-which could compromise data reliability and patient care. Our findings showcase these inconsistencies and emphasize the need for proactive approaches to improve uptake.

Development of a core outcome set for psychological therapy trials on acute psychiatric inpatient wards

BACKGROUND

Consensus on what outcomes should be included in trials of psychological therapies on acute psychiatric inpatient wards is currently lacking. Inclusion of different viewpoints, including service user perspectives, is crucial in ensuring that future trials measure outcomes which are meaningful and important. Development of a Core Outcome Set (COS), a minimum standardised set of outcomes to be measured and reported, would help improve synthesis and interpretation of clinical trial data in this area.

METHODS

Stage 1 of the COS development involved compiling a comprehensive long-list of outcomes from key sources including i) a systematic review of outcomes from published trials, ii) online survey of key stakeholders (service users, carers, healthcare professionals, researchers, and end users of research), iii) qualitative interviews with service users and carers. Stage 2 involved stakeholder groups short-listing the outcomes using consensus methods (e-Delphi survey). The final outcome set was derived from the short-list at a consensus meeting of stakeholders, facilitated by an Independent Chair.

RESULTS

A long-list of 68 outcomes was compiled from the systematic review (n = 30 trials), online stakeholder survey (n = 100 participants) and qualitative interviews (n = 15 participants). Fifty stakeholders took part in the e-Delphi study, where the long-list was cut down to a short-list of 12 outcomes over 2 rounds. Nine stakeholders took part in the final consensus meeting, and after some outcomes were removed and/or amalgamated, a final set of 6 outcomes was recommended for inclusion in the COS. These were Ability to Cope, Hopefulness, Quality of Life, Psychosis Symptoms, Mood, and Self-Harm Behaviours.

CONCLUSIONS

Widespread future adoption of the COS will reduce research waste by ensuring that outcomes are more easily comparable across trials, and that the full range of stakeholder priorities are represented in trial outcomes. This makes it more likely that effective therapies will be identified in a timely fashion and successfully implemented in routine clinical practice. The final 6-outcome COS should be feasible to implement given the need keep participant burden to a minimum in inpatient trials. Further work is needed to make recommendations for the best outcome measurement instruments to use, including the use of patient-reported outcomes alongside clinician-rated measures.

TRIAL REGISTRATION

Not applicable.

Uptake of core outcome sets by clinical trialists in China: a protocol

Background

The concept of core outcome sets (COS) has been introduced in China for about 10 years. In recent years, some Chinese researchers also committed to developing COS, though the majority of COS are ongoing. However, there were more than 500 published COS for research in the COMET database by 2020. The extent of availability of COS for the top 25 diseases with the highest burden in China is unknown. In addition, the uptake of COS in clinical trials for these diseases is unknown, along with the knowledge, perceptions, and views of the clinical trialist community in China on the use of COS in relation to choosing outcomes for their research.

Methods

The main burden of disease in China will be identified. Then we will search the COMET database to identify if there are ongoing or completed relevant COS research A COS published since 2012 would be preferred to one published before 2012 for the analysis of COS uptake if one meets the eligibility criteria. We will extract scopes of published eligible COS, including condition, population, interventions, and core outcomes. Then we will search the Chinese Clinical Trial Registry using disease names for each disease that has a published COS. We will assess the overlap in scope between clinical trials and COS. Then we will conduct an online survey and semi-structured interviews to identify the knowledge and perceptions of COS among primary investigators of included clinical trials.

Discussion

This research will fill in gaps between COS and the burden of disease in China. Understanding clinical trialists'knowledge and perceptions of COS may help dissemination and application of COS in the future.

Trial registration

This research is registered in Core Outcome Measures in Effectiveness: https://www.comet-initiative.org/Studies/Details/2563.

Towards a core outcome set for dysarthria after stroke: What should we measure?

OBJECTIVE

To identify and agree on what outcome domains should be measured in research and clinical practice when working with stroke survivors who have dysarthria.

DESIGN

Delphi process, two rounds of an online survey followed by two online consensus meetings.

SETTING

UK and Australia.

PARTICIPANTS

Stroke survivors with experience of dysarthria, speech and language therapists/pathologists working in stroke and communication researchers.

METHODS

Initial list of outcome domains generated from existing literature and with our patient and public involvement group to develop the survey. Participants completed two rounds of this survey to rate importance. Outcomes were identified as 'in', 'unclear' or 'out' from the second survey. All participants were invited to two consensus meetings to discuss these results followed by voting to identify critically important outcome domains for a future Core Outcome Set. All outcomes were voted on in the consensus meetings and included if 70% of meeting participants voted 'yes' for critically important.

RESULTS

In total, 148 surveys were fully completed, and 28 participants attended the consensus meetings. A core outcome set for dysarthria after stroke should include four outcome domains: (a) intelligibility of speech, (b) ability to participate in conversations, (c) living well with dysarthria, (d) skills and knowledge of communication partners (where relevant).

CONCLUSIONS

We describe the consensus of 'what' speech outcomes after stroke are valued by all stakeholders including those with lived experience. We share these findings to encourage the measurement of these domains in clinical practice and research and for future research to identify 'how' best to measure these outcomes.

Frequency of Prenatal Care Visits: A Core Outcome Set for Prenatal Care Schedules

Objective: The aim of this study is to develop a core outcome set for the frequency and modality of prenatal care visits. Material and Methods: A consensus development study was conducted in the United States with participants, including 31 health care professionals, 12 public policy members or public health payers, and 18 public members, representing 24 states. A modified Delphi method and modified nominal group technique were utilized. Results: Twenty-one potential core outcomes were developed by combining the outcomes reported in three systematic reviews that evaluated the frequency of prenatal care visits or modality of prenatal visit type (e.g., in person, telemedicine, or hybrids of both). Eighteen consensus outcomes were identified from the Delphi process, following which 10 maternal and 4 neonatal outcomes were agreed at the consensus development meeting. Maternal core outcomes include maternal quality of life; maternal mental health outcomes; the experience of maternity care; lost time; attendance of recommended visits; unplanned care utilization; completion of the American College of Obstetricians and Gynecologists-recommended services; diagnosis of obstetric complications-proportion and timing; disparities in care outcomes; and severe maternal morbidity or mortality. Neonatal core outcomes include gestational age at birth, birth weight, stillbirth or perinatal death, and neonatal intensive care unit admissions. Conclusions: The core outcome set for the frequency and modality of prenatal visits should be utilized in forthcoming randomized controlled trials and systematic reviews. Such application will warrant that in future research, consistent reporting will enrich care and improve outcomes. Clinical Trial Registration number: 2021.

Core Patient-Reported Outcomes for Trials in Nephrology

The outcomes reported in trials across all stages of chronic kidney disease (CKD) are highly variable and often do not include outcomes that are directly relevant to patients and caregivers. Frequently, the outcomes reported in trials are often unvalidated surrogate biochemical end points. The omission of outcomes that are meaningful and important to patients can diminish the value of trials in supporting treatment decisions. In response, there have been increasing efforts across many health and medical disciplines to develop core outcome sets, defined as the minimum set of outcomes to be reported in all trials in a specific health area to improve the relevance and consistency of reporting trial outcomes. The international Standardized Outcomes in Nephrology (SONG) initiative was established in 2014 and has since developed seven core outcome sets for different diagnosis and treatment stages of CKD. The core outcomes were based on consensus among patients, caregivers, and health professionals. Each core outcome set includes at least one patient-reported outcome, including fatigue (hemodialysis), life participation (kidney transplantation, peritoneal dialysis, early CKD not yet requiring kidney replacement therapy, children and adolescents, and glomerular disease), and pain (polycystic kidney disease). This article outlines how patient-reported outcomes are currently reported in trials, discusses core patient-reported outcomes that have been established for trials in kidney disease, and outlines strategies for implementing core patient-reported outcomes in trials.

Study found increasing use of core outcome sets in Cochrane systematic reviews and identified facilitators and barriers

OBJECTIVES

In 2019, only 7% of Cochrane systematic reviews (SRs) cited a core outcome set (COS) in relation to choosing outcomes, even though a relevant COS existed but was not mentioned (or cited) for a further 29% of SRs. Our objectives for the current work were to (1) examine the extent to which authors are currently considering COS to inform outcome choice in Cochrane protocols and completed SRs, and (2) understand author facilitators and barriers to using COS.

STUDY DESIGN AND SETTING

We examined all completed Cochrane SRs published in the last 3 months of 2022 and all Cochrane protocols published in 2022 for the extent to which they: (a) cited a COS, (b) searched for COS, (c) used outcomes from existing COS, and (d) reported outcome inconsistency among included studies and/or noted the need for COS. One investigator extracted information; a second extractor verified all information, discussing discrepancies to achieve consensus. We then conducted an online survey of authors of the included SRs to assess awareness of COS and identify facilitators and barriers to using COS to inform outcome choice.

RESULTS

Objective 1: We included 294 SRs of interventions (84 completed SRs and 210 published SR protocols), of which 13% cited specific COS and 5% did not cite but mentioned searching for COS. A median of 83% of core outcomes from cited COS (interquartile range [IQR] 57%-100%) were included in the corresponding SR. We identified a relevant COS for 39% of SRs that did not cite a COS. A median of 50% of core outcomes from noncited COS (IQR 35%-72%) were included in the corresponding SR. Objective 2: Authors of 236 (80%) of the 294 eligible SRs completed our survey. Seventy-seven percent of authors noted being aware of COS before the survey. Fifty-five percent of authors who did not cite COS but were aware of them reported searching for a COS. The most reported facilitators of using COS were author awareness of the existence of COS (59%), author positive perceptions of COS (52%), and recommendation in the Cochrane Handbook regarding COS use (48%). The most reported barriers related to matching of the scope of the COS and the SR: the COS target population was too narrow/broad relative to the SR population (29%) or the COS target intervention was too narrow/broad relative to the SR intervention (21%). Most authors (87%) mentioned that they would consider incorporating missing core outcomes in the SR/update.

CONCLUSION

Since 2019, there is increasing consideration and awareness of COS when choosing outcomes for Cochrane SRs of interventions, but uptake remains low and can be improved further. Use of COS in SRs is important to improve outcome standardization, reduce research waste, and improve evidence syntheses of the relevant effects of interventions across health research.

Taking a chance on outcome standardisation: A cross-sectional analysis assessing the uptake of the prevention of preterm birth core outcome set in randomised controlled trials

OBJECTIVE

Analyse uptake of the core outcome set (COS) within preterm birth (PTB) clinical trials.

DESIGN

On 26 June 2023, we conducted a systematic search of phase III/IV trial registry entries regarding PTB interventions via ClinicalTrials.gov and the International Clinical Trial Registry Platform. These trials were analysed for the outcomes measured.

SETTING

N/A.

SAMPLE

After searching the two databases, 5257 randomised controlled trials (RCTs) were screened, resulting in 92 RCTs for analysis.

METHODS

Inclusion criteria were the following: subjects were patients receiving an intervention for PTB, study enrolment began within 5 years prior to publication of PTB COS to 26 June 2023, and evaluated the efficacy of interventions. Authors screened and extracted data in masked, duplicate fashion, then performed an interrupted time series analysis, analysis of variance and correlation analysis.

MAIN OUTCOME MEASURES

We extracted outcomes measured by each clinical trial in our sample. Trials were analysed for the percentage of adopted outcomes from PTB COS.

RESULTS

After COS publication, there was no significant change in percentage of COS outcomes measured. The most measured outcome was 'offspring mortality' (54.34%, 50/92) and the least measured outcome was 'late neonatal neurodevelopment morbidity' (3.26%, 3/92). Additionally, 22.83% (21/92) of trials measured zero outcomes related to the PTB COS.

CONCLUSION

Our results demonstrated no significant change in outcome measurement before or after PTB COS publication. We recommend focusing on both the measurement of outcomes and the assessments that are used.

Representation of published core outcome sets in practice guidelines

OBJECTIVES

A core outcome set (COS) is an agreed standardized set of outcomes that should be measured and reported, as a minimum, in specific areas of health or health care. A COS is developed through a consensus process to ensure health care outcomes to be measured are relevant to decision-makers, including patients and health-care professionals. Use of COS in guideline development is likely to increase the relevance of the guideline to those decision-makers. Previous work has looked at the uptake of COS in trials, systematic reviews, health technology assessments and regulatory guidance but to date there has been no evaluation of the use of COS in practice guideline development. The objective of this study was to investigate the representation of core outcomes in a set of international practice guidelines.

STUDY DESIGN AND SETTING

We searched for clinical guidelines relevant to ten high-quality COS (with focus on the United Kingdom, Germany, China, India, Canada, Denmark, United States and World Health Organisation). We matched scope between COS and guideline in terms of condition, population and outcome. We calculated the proportion of guidelines mentioning or referencing COS and the proportion of COS domains specifically, or generally, matching to outcomes specified in each guideline populations, interventions, comparators and outcome (PICO) statement.

RESULTS

We found 38 guidelines that contained 170 PICO statements matching the scope of the ten COS and of sufficient quality to allow data extraction. None of the guidelines reviewed explicitly mentioned or referenced the relevant COS. The median (range) of the proportion of core outcomes covered either specifically or generally by the guideline PICO was 30% (0%-100%).

CONCLUSION

There is no evidence that COS are being used routinely to inform the guideline development process, and concordance between outcomes in published guidelines and those in COS is limited. Further work is warranted to explore barriers and facilitators in the use of COS when developing clinical guidelines.

Analysis of core outcome set reporting in coronary intervention trials

BACKGROUND

This paper will focus on outcome reporting within percutaneous coronary intervention (PCI) trials. A core outcome set (COS) is a standardised set of outcomes that are recommended to be reported in every clinical trial. Using a COS can help to ensure that all relevant outcomes are consistently reported across clinical trials. In 2018, the European Society of Cardiology outlined the only COS published for PCI trials.

METHODS

We searched the literature for all randomised controlled trials published between 2014 and 2022. PCI trials included were late-phase trials and must investigate coronary intervention. The primary outcome was the proportion of trials that reported all of the COS-defined outcomes within their publication as either a primary, secondary or safety endpoint. The secondary outcomes included; the number of primary outcomes reported per study, the proportion of studies which use patient and public involvement (PPI) during trial design, outcome variability and outcome consistency.

RESULTS

9580 trials were screened and 115 studies met inclusion/exclusion criteria. Our study demonstrated that 55% (34/62) of PCI trials used a COS when it was available, compared with 40% (21/53) before the availability of a PCI COS set, p=0.121. Fewer primary outcomes were reported after the implementation of the COS, 2 compared with 2.3, p=0.014. There was no difference in the use of PPI between either group. There was a higher level of variability in outcomes reported before the availability of the COS, while the consistency of outcome reporting remained similar.

CONCLUSION

The use of a COS in PCI trials is low. This study provides evidence that there still is a lack of awareness of the COS among those who design clinical trials. We also presented the inconsistency and heterogenicity in reporting clinical trial outcomes. Finally, there was a clear lack of PPI utilisation in PCI trials.

Using behavioral science to increase core outcome set use in trials

OBJECTIVES

Core outcome sets (COS) are agreed sets of outcomes for use in clinical trials, which can increase standardization and reduce heterogeneity of outcomes in research. Using a COS, or not, is a behavior that can potentially be increased using behavioral strategies. The aim of this study was to identify behavioral intervention components to potentially increase use of COS in trials.

METHODS

This project was informed by the Behavior Change Wheel framework. Two reviewers extracted barriers and facilitators to COS use from four recently published studies examining COS use in trials. Barriers and facilitators were coded to the Capability, Opportunity, Motivation-Behavior (COM-B) model, which forms part of the Behavior Change Wheel. COM-B findings were mapped to intervention functions by two reviewers, and then mapped to behavior change techniques (BCTs). Full-team Affordability, Practicability, Effectiveness/Cost-effectiveness, Acceptability, Side effects/Safety, Equity ratings were used to reach consensus on intervention functions and BCTs. BCTs were operationalized using examples of tangible potential applications and were categorized based on similarity.

RESULTS

Barriers and facilitators were identified for all capability, opportunity and motivation aspects of the COM-B model. Five intervention functions (education, training, enablement, persuasion, and modeling) and 15 BCTs were identified. Thirty-six BCT examples were developed, including providing information on benefits of COS for health research, and information choosing COS. BCT examples are categorized by approaches related to "workshops," "guidance," "audio/visual resources," and "other resources."

CONCLUSION

Study findings represent diverse ways to potentially increase COS use in trials. Future work is needed to examine effects of these behavioral intervention components on COS use. If effective, increased use of COS can improve outcome reporting and minimize outcome heterogeneity and research waste.

OMERACT Core outcome measurement set for shared decision making in rheumatic and musculoskeletal conditions: a scoping review to identify candidate instruments

OBJECTIVES

Shared decision making (SDM) is a central tenet in rheumatic and musculoskeletal care. The lack of standardization regarding SDM instruments and outcomes in clinical trials threatens the comparative effectiveness of interventions. The Outcome Measures in Rheumatology (OMERACT) SDM Working Group is developing a Core Outcome Set for trials of SDM interventions in rheumatology and musculoskeletal health. The working group reached consensus on a Core Outcome Domain Set in 2020. The next step is to develop a Core Outcome Measurement Set through the OMERACT Filter 2.2.

METHODS

We conducted a scoping review (PRISMA-ScR) to identify candidate instruments for the OMERACT Filter 2.2 We systematically reviewed five databases (Ovid MEDLINE®, Embase, Cochrane Library, CINAHL and Web of Science). An information specialist designed search strategies to identify all measurement instruments used in SDM studies in adults or children living with rheumatic or musculoskeletal diseases or their important others. Paired reviewers independently screened titles, abstracts, and full text articles. We extracted characteristics of all candidate instruments (e.g., measured construct, measurement properties). We classified candidate instruments and summarized evidence gaps with an adapted version of the Summary of Measurement Properties (SOMP) table.

RESULTS

We found 14,464 citations, read 239 full text articles, and included 99 eligible studies. We identified 220 potential candidate instruments. The five most used measurement instruments were the Decisional Conflict Scale (traditional and low literacy versions) (n=38), the Hip/Knee-Decision Quality Instrument (n=20), the Decision Regret Scale (n=9), the Preparation for Decision Making Scale (n=8), and the CollaboRATE (n=8). Only 44 candidate instruments (20%) had any measurement properties reported by the included studies. Of these instruments, only 57% matched with at least one of the 7-criteria adapted SOMP table.

CONCLUSION

We identified 220 candidate instruments used in the SDM literature amongst people with rheumatic and musculoskeletal diseases. Our classification of instruments showed evidence gaps and inconsistent reporting of measurement properties. The next steps for the OMERACT SDM Working Group are to match candidate instruments with Core Domains, assess feasibility and review validation studies of measurement instruments in rheumatic diseases or other conditions. Development and validation of new instruments may be required for some Core Domains.

An international consensus study to identify "what" outcomes should be included in a core outcome set for endodontic treatments (COSET) for utilization in clinical practice and research

BACKGROUND

Development of a standardized set of topic-specific outcomes known as a Core Outcome Set (COS) is important to address issues of heterogeneity in reporting research findings in order to streamline evidence synthesis and clinical decision making.

AIM

The aim of the current international consensus study is to identify "what" outcomes to include in the Core Outcome Set for Endodontic Treatments (COSET). Outcomes of various endodontic treatments (non-surgical root canal treatment, surgical endodontics, vital pulp treatment and revitalization procedures) performed on permanent teeth were considered.

METHODS

A standard validated methodology for COS development and reporting was adopted. The process involved identification of existing outcomes through four published scoping reviews. This enabled creation of a list of outcomes to be prioritized via semi-structured patient interviews, e-Delphi process and a consensus meeting with a range of relevant global stakeholders. Outcomes were prioritized using a 1-9 Likert scale, with outcomes rated 7-9 considered critical, 4-6 are important and 1-3 are less important. Outcomes rated 7-9 by ≥70% and 1-3 by <15% of participants were considered to achieve consensus for inclusion in the COS. The outcomes that did not achieve consensus in the first round were considered for further prioritization in the second Delphi round and consensus meeting. Final decisions about the outcomes to include in COSET were made by voting during the consensus panel meeting using the Zoom Poll function.

RESULTS

A total of 95 participants including patients contributed to the COS development process. The consensus panel recommended, with strong consensus, eight outcomes shared across all treatment modalities for inclusion in COSET: pain; signs of infection (swelling, sinus tract); further intervention/exacerbation; tenderness to percussion/palpation; radiographic evidence of disease progression/healing; function; tooth survival; and patient satisfaction. Additional treatment specific outcomes were also recommended.

DISCUSSION

Many of the outcomes included in COSET are patient reported. All should be included in future outcomes studies.

CONCLUSION

COSET identified outcomes that are important for patients and clinicians and validated these using a rigorous methodology. Further work is ongoing to determine "how" and "when" these outcomes should be measured.

The Uptake of the Core Outcome Set for Non-Specific Low Back Pain Clinical Trials is Poor: A Meta-Epidemiological Study of Trial Registrations

We conducted a meta-epidemiological study on all non-specific low back pain (NSLBP) trial registrations on the World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov. We aimed to 1) assess the uptake of the core outcome set (COS) for NSLBP in clinical trials; 2) assess the uptake of the core outcome measurement set for NSLBP in clinical trials; and 3) determine whether specific study characteristics are associated with the COS uptake. After applying the relevant filters for the condition, study type, and phase of the trial, 240 registry entries were included in this study. Only 50 (20.8%) entries showed a full COS uptake, and this rate did not increase over time. Most registry entries that planned to measure physical functioning (n = 152) used the Roland-Morris Disability Questionnaire (n = 74; 48.7%); a small percentage used the numeric rating scale (n = 60; 27.3%) or Short Form-12 (n = 5; 8.3%) if they planned to measure pain intensity (n = 220) or health-related quality of life (n = 60), respectively. Only the planned sample size (OR = 1.02; 95% CI = 1.01, 1.03) showed a significant but small association with COS uptake. The uptake of the COS for NSLBP is poor. Only 21% of the randomized controlled trials aimed to measure all COS domains in their study registration and COS uptake is not increased over time. Great heterogeneity in measurement instruments was also observed, revealing poor core outcome measurement set uptake. PERSPECTIVE: The Core Outcome Set (COS) for non-specific low back pain was published more than 20 years ago. We evaluated whether trial registrations are using this set of outcomes when testing interventions for low back pain. Full uptake was found only in 21% of the sample, and this is not increasing over time. Researchers should use the COS to ensure that trials measure relevant outcomes consistently.

European Glaucoma Society - A guide on surgical innovation for glaucoma

PROLOGUE: Glaucoma surgery has been, for many decades now, dominated by the universal gold standard which is trabeculectomy augmented with antimetabolites. Tubes also came into the scene to complement what we use to call conventional or traditional glaucoma surgery. More recently we experienced a changing glaucoma surgery environment with the "advent" of what we have become used to calling Minimally Invasive Glaucoma Surgery (MIGS). What is the unmet need, what is the gap that these newcomers aim to fill? Hippocrates taught us "bring benefit, not harm" and new glaucoma techniques and devices aim to provide safer surgery compared to conventional surgery. For the patient, but also for the clinician, safety is important. Is more safety achieved with new glaucoma surgery and, if so, is it associated with better, equivalent, or worse efficacy? Is new glaucoma surgery intended to replace conventional surgery or to complement it as an 'add-on' to what clinicians already have in their hands to manage glaucoma? Which surgery should be chosen for which patient? What are the options? Are they equivalent? These are too many questions for the clinician! What are the answers to the questions? What is the evidence to support answers? Do we need more evidence and how can we produce high-quality evidence? This EGS Guide explores the changing and challenging glaucoma surgery environment aiming to provide answers to these questions. The EGS uses four words to highlight a continuum: Innovation, Education, Communication, and Implementation. Translating innovation to successful implementation is crucially important and requires high-quality evidence to ensure steps forward to a positive impact on health care when it comes to implementation. The vision of EGS is to provide the best possible well-being and minimal glaucomainduced visual disability in individuals with glaucoma within an affordable healthcare system. In this regard, assessing the changes in glaucoma surgery is a pivotal contribution to better care. As mentioned, this Guide aims to provide answers to the crucial questions above. However, every clinician is aware that answers may differ for every person: an individualised approach is needed. Therefore, there will be no uniform answer for all situations and all patients. Clinicians would need, through the clinical method and possibly some algorithm, to reach answers and decisions at the individual level. In this regard, evidence is needed to support clinicians to make decisions. Of key importance in this Guide is to provide an overview of existing evidence on glaucoma surgery and specifically on recent innovations and novel devices, but also to set standards in surgical design and reporting for future studies on glaucoma surgical innovation. Designing studies in surgery is particularly challenging because of many subtle variations inherent to surgery and hence multiple factors involved in the outcome, but even more because one needs to define carefully outcomes relevant to the research question but also to the future translation into clinical practice. In addition this Guide aims to provide clinical recommendations on novel procedures already in use when insufficient evidence exists. EGS has a long tradition to provide guidance to the ophthalmic community in Europe and worldwide through the EGS Guidelines (now in their 5th Edition). The EGS leadership recognized that the changing environment in glaucoma surgery currently represents a major challenge for the clinician, needing specific guidance. Therefore, the decision was made to issue this Guide on Glaucoma Surgery in order to help clinicians to make appropriate decisions for their patients and also to provide the framework and guidance for researchers to improve the quality of evidence in future studies. Ultimately this Guide will support better Glaucoma Care in accordance with EGS's Vision and Mission. Fotis Topouzis EGS President

Developing consensus on core outcome sets of domains for acute, the transition from acute to chronic, recurrent/episodic, and chronic pain: results of the INTEGRATE-pain Delphi process

BACKGROUND

Pain is the leading cause of disability worldwide among adults and effective treatment options remain elusive. Data harmonization efforts, such as through core outcome sets (COS), could improve care by highlighting cross-cutting pain mechanisms and treatments. Existing pain-related COS often focus on specific conditions, which can hamper data harmonization across various pain states.

METHODS

Our objective was to develop four overarching COS of domains/subdomains (i.e., what to measure) that transcend pain conditions within different pain categories. We hosted a meeting to assess the need for these four COS in pain research and clinical practice. Potential COS domains/subdomains were identified via a systematic literature review (SLR), meeting attendees, and Delphi participants. We conducted an online, three step Delphi process to reach a consensus on domains to be included in the four final COS. Survey respondents were identified from the SLR and pain-related social networks, including multidisciplinary health care professionals, researchers, and people with lived experience (PWLE) of pain. Advisory boards consisting of COS experts and PWLE provided advice throughout the process.

FINDINGS

Domains in final COS were generally related to aspects of pain, quality of life, and physical function/activity limitations, with some differences among pain categories. This effort was the first to generate four separate, overarching COS to encourage international data harmonization within and across different pain categories.

INTERPRETATION

The adoption of the COS in research and clinical practice will facilitate comparisons and data integration around the world and across pain studies to optimize resources, expedite therapeutic discovery, and improve pain care.

FUNDING

Innovative Medicines Initiative 2 Join Undertaking; European Union Horizon 2020 research innovation program, European Federation of Pharmaceutical Industries and Associations (EFPIA) provided funding for IMI-PainCare. RDT acknowledges grants from Esteve and TEVA.

Saldanha I, Smith V, Toomey E, Williamson P. Using behavioural science to enhance use of core outcome sets in trials: protocol

Background

Core outcome sets (COS) represent agreed-upon sets of outcomes, which are the minimum that should be measured and reported in all trials in specific health areas. Use of COS can reduce outcome heterogeneity, selective outcome reporting, and research waste, and can facilitate evidence syntheses. Despite benefits of using COS, current use of COS in trials is low. COS use can be understood as a behaviour, in that it is something trialists do, or not do, adequately. The aim of this study is to identify strategies, informed by behaviour change theory, to increase COS use in trials.

Methods

The project will be conducted in two stages, informed by the behaviour change wheel (BCW). The BCW is a theoretically based framework that can be used to classify, identify, and develop behaviour change strategies. In Stage 1, barriers and enablers to COS use will be extracted from published studies that examined trialist's use of COS. Barriers and facilitators will be mapped to the components of COM-B model (capability, opportunity, and motivation), which forms part of the BCW framework. Stage 2 will build on Stage 1 findings to identify and select intervention functions and behaviour change techniques to enhance COS use in trials.

Discussion

The findings of this study will provide an understanding of the behavioural factors that influence COS use in trials and what strategies might be used to target these factors to increase COS use in trials.

Saldanha I, Smith V, Toomey E, Williamson P. Using behavioural science to enhance use of core outcome sets in trials: protocol

BACKGROUND

Core outcome sets (COS) represent agreed-upon sets of outcomes, which are the minimum that should be measured and reported in all trials in specific health areas. Use of COS can reduce outcome heterogeneity, selective outcome reporting, and research waste, and can facilitate evidence syntheses. Despite benefits of using COS, current use of COS in trials is low. COS use can be understood as a behaviour, in that it is something trialists do, or not do, adequately. The aim of this study is to identify strategies, informed by behaviour change theory, to increase COS use in trials.

METHODS

The project will be conducted in two stages, informed by the behaviour change wheel (BCW). The BCW is a theoretically based framework that can be used to classify, identify, and develop behaviour change strategies. In Stage 1, barriers and enablers to COS use will be extracted from published studies that examined trialist's use of COS. Barriers and facilitators will be mapped to the components of COM-B model (capability, opportunity, and motivation), which forms part of the BCW framework. Stage 2 will build on Stage 1 findings to identify and select intervention functions and behaviour change techniques to enhance COS use in trials.

DISCUSSION

The findings of this study will provide an understanding of the behavioural factors that influence COS use in trials and what strategies might be used to target these factors to increase COS use in trials.

The Harmonising Outcome Measures for Eczema (HOME) implementation roadmap

BACKGROUND

Core outcome sets (COS) are consensus-driven sets of minimum outcomes that should be measured and reported in all clinical trials. COS aim to reduce heterogeneity in outcome measurement and reporting, and selective outcome reporting. Implementing COS into clinical trials is challenging. Guidance to improve COS uptake in dermatology is lacking.

OBJECTIVES

To develop a structured practical guide to COS implementation.

METHODS

Members of the Harmonising Outcome Measurement for Eczema (HOME) executive committee developed an expert opinion-based roadmap founded on a combination of a review of the COS implementation literature, the Core Outcome Measures in Effectiveness Trials (COMET) initiative resources, input from HOME members and experience in COS development and clinical trials.

RESULTS

The data review and input from HOME members was synthesized into themes, which guided roadmap development: (a) barriers and facilitators to COS uptake based on stakeholder awareness/engagement and COS features; and (b) key implementation science principles (assessment-driven, data-centred, priority-based and context-sensitive). The HOME implementation roadmap follows three stages. Firstly, the COS uptake scope and goals need to be defined. Secondly, during COS development, preparation for future implementation is supported by establishing the COS as a credible evidence-informed consensus by applying robust COS development methodology, engaging multiple stakeholders, fostering sustained and global engagement, emphasizing COS ease of use and universal applicability, and providing recommendations on COS use. Thirdly, incorporating completed COS into primary (trials) and secondary (reviews) research is an iterative process starting with mapping COS uptake and stakeholders' attitudes, followed by designing and carrying out targeted implementation projects. Main themes for implementation projects identified at HOME are stakeholder awareness/engagement; universal applicability for different populations; and improving ease-of-use by reducing administrative and study burden. Formal implementation frameworks can be used to identify implementation barriers/facilitators and to design implementation strategies. The effect of these strategies on uptake should be evaluated and implementation plans adjusted accordingly.

CONCLUSIONS

COS can improve the quality and applicability of research and, so, clinical practice but can only succeed if used and reported consistently. The HOME implementation roadmap is an extension of the original HOME roadmap for COS development and provides a pragmatic framework to develop COS implementation strategies.

Implementation of the HOME core outcome set for clinical trials of atopic eczema-barriers and opportunities: the HOME IX meeting report

The Harmonising Outcome Measures for Eczema (HOME) initiative established a core outcome set (COS) for atopic eczema (AE) clinical trials in 2019. This set encompasses four core outcome domains and corresponding measurement instruments: clinical signs (EASI), patient-reported symptoms (POEM and NRS 11 point for worst itch over the last 24 h), quality of life (DLQI/CDLQI/IDQoLI), and long-term control (Recap or ADCT). Following its roadmap, the HOME initiative is now focused on supporting implementation of the COS. To identify barriers and facilitators to implementation of the COS, and to guide the effort to promote COS uptake, a virtual consensus meeting was held over 2 days (September 25-26, 2021) attended by 55 participants (26 healthcare professionals, 16 methodologists, 5 patients, 4 industry representatives, and 4 students). Implementation themes were identified by a pre-meeting survey distributed to HOME members, presentations, and whole-group discussion. Participants were divided into five multi-professional small groups which ranked their top 3 most important themes, followed by whole-group discussion and anonymous consensus voting (consensus criteria: < 30% disagreement). Three most important implementation themes were identified and agreed upon: (1) awareness and stakeholder engagement, (2) universal applicability of the COS, and (3) ensuring minimum administrative burden. Working groups to address these issues are now a priority for the HOME initiative. The results from this meeting will inform the development of a HOME Implementation Roadmap in an effort to support other COS groups planning for effective implementation of their core sets.

Current trends, barriers, and facilitators of use of core outcome sets in Cochrane systematic reviews: Protocol

Background: Core outcome sets (COS) represent agreed-upon minimum outcomes that should be reported in all studies in a given topic area. Cochrane reviews are considered among the most rigorously conducted systematic reviews (SRs). In 2019, seven of the first 100 published Cochrane SRs (7%) cited a COS in relation to choosing outcomes. A relevant COS existed but was not mentioned (or cited) for 27 of the remaining 93 SRs (29%). Among Cochrane Review Group editors surveyed in 2019, 86% felt that COS should definitely/possibly be used in Cochrane SRs. As of September 2019, the Cochrane Handbook recommends that SR teams consult resources that host relevant COS when choosing outcomes for the SR. Objectives: (1) Examine the extent to which authors are currently considering COS to inform outcome choice in Cochrane protocols and completed SRs. (2) Understand author barriers and facilitators of using COS in Cochrane protocols and completed SRs. Methods: We will examine the extent to which all Cochrane SRs published in the last 3 months of 2022 and all Cochrane protocols published in 2022: (a) cited a COS, (b) searched for COS, and (c) reported outcome inconsistency among included studies and/or noted the need for COS. One investigator will extract information from SRs and protocols; a second extractor will verify all information, discussing discrepancies to achieve consensus. Using Jisc Online Surveys ®, we will conduct an online anonymous survey of authors of all the included completed SRs and protocols to assess author awareness of COS and identify barriers and facilitators of using COS to inform outcome choice. Discussion: This study will provide key information regarding uptake of COS by Cochrane SR authors and the barriers and facilitators that they experience. Our findings will inform approaches to increasing awareness and uptake of COS in future SRs, both with and beyond Cochrane.

Current trends, barriers, and facilitators of use of core outcome sets in Cochrane systematic reviews: Protocol

Background: Core outcome sets (COS) represent agreed-upon minimum outcomes that should be reported in all studies in a given topic area. Cochrane reviews are considered among the most rigorously conducted systematic reviews (SRs). In 2019, seven of the first 100 published Cochrane SRs (7%) cited a COS in relation to choosing outcomes. A relevant COS existed but was not mentioned (or cited) for 27 of the remaining 93 SRs (29%). Among Cochrane Review Group editors surveyed in 2019, 86% felt that COS should definitely/possibly be used in Cochrane SRs. As of September 2019, the Cochrane Handbook recommends that SR teams consult resources that host relevant COS when choosing outcomes for the SR. Objectives: (1) Examine the extent to which authors are currently considering COS to inform outcome choice in Cochrane protocols and completed SRs. (2) Understand author barriers and facilitators of using COS in Cochrane protocols and completed SRs. Methods: We will examine the extent to which all Cochrane SRs published in the last 3 months of 2022 and all Cochrane protocols published in 2022: (a) cited a COS, (b) searched for COS, and (c) reported outcome inconsistency among included studies and/or noted the need for COS. One investigator will extract information from SRs and protocols; a second extractor will verify all information, discussing discrepancies to achieve consensus. Using Jisc Online Surveys ®, we will conduct an online anonymous survey of authors of all the included completed SRs and protocols to assess author awareness of COS and identify barriers and facilitators of using COS to inform outcome choice. Discussion: This study will provide key information regarding uptake of COS by Cochrane SR authors and the barriers and facilitators that they experience. Our findings will inform approaches to increasing awareness and uptake of COS in future SRs, both with and beyond Cochrane.

English translation and cross-cultural validation of the patient-reported outcome measurement-haemorrhoidal impact and satisfaction score (PROM-HISS)

AIM

The aim of this study was to translate the Dutch patient-reported outcome measure-haemorrhoidal impact and satisfaction score (PROM-HISS) to English and perform a cross-cultural validation.

METHOD

The ISPOR good practice guidelines for the cross-cultural validation of PROMs were followed and included two steps: (1) Two forward and two backward translations. The forward translation concerned the translation from the source language (Dutch) to the target language (English), performed by two independent English speakers, one medical doctor and one nonmedical. Subsequently, a discussion about discrepancies in the reconciled version was performed by a stakeholder group. (2) Cognitive interviews were held with patients with haemorrhoidal disease (HD), probing the comprehensibility and comprehensiveness of the PROM-HISS.

RESULTS

Discrepancies in the reconciled forward translation concerned the terminology of HD symptoms. Furthermore, special attention was paid to the response options, ranging from "not at all", indicating minor symptoms, to "a lot", implying many symptoms. Consensus among the stakeholder group about the final version of the translated PROM-HISS was reached. Interviews were conducted with 10 native English-speaking HD patients (30% female), with a mean age of 44 years (24-83) and primarily diagnosed with grade II HD (80%). The mean time to complete the PROM-HISS was 1 min 43 s. Patients showed a good understanding of the questions and response options, found all items relevant and did not miss important symptoms or topics.

CONCLUSION

The translated English language PROM-HISS is a valid tool to assess symptoms of HD, its impact on daily activities and patient satisfaction with HD treatment.

Common measures in mental health: a joint initiative by funders and journals

There is notable heterogeneity in how clinical and phenotypic data are measured by mental health researchers. There is a proliferation of self-report measures (eg, over 280 for depression alone), meaning it is challenging for researchers to compare findings across different studies from different laboratories. To begin to address this issue, a consortium of mental health research funders and journals has launched the Common Measures in Mental Health Science Initiative. The purpose of this endeavour is to identify common measures for mental health conditions that funders and journals can require all researchers to collect, in addition to any other measures they require for their specific study. These measures would not necessarily capture the full range of experiences of a given condition but could be used to link and compare across studies with different designs in different contexts. This Health Policy outlines the rationale, objectives, and potential challenges of this initiative, which aims to enhance the rigour and comparability of mental health research by promoting the adoption of standardised measures.

Irish funder guidance increased searching for, and uptake of, core outcome sets

OBJECTIVES

Assess the impact of the Health Research Board (HRB) Ireland guidance on the uptake of core outcome sets (COSs).

STUDY DESIGN AND SETTING

(1) Information on COS use, searching of the Core Outcome Measures in Effectiveness Trials (COMET) database, and rationale for outcome selection were extracted from HRB funding applications (2) COMET was searched for relevant COS availability at the time of application or developed since (3) principal investigator choices were explored through online surveys.

RESULTS

Out of 187 funding applications, 44% (n = 82) searched the COMET database, and 13% (n = 11) of those found a relevant COS to inform their outcomes. Four applicants proposed COS development. However, 84% (n = 156) of applications had no relevant COS available at the time of submission, as identified by subsequent author COMET search. Among 84 principal investigators who participated in the surveys, 10 (12%) found and used a COS and 19 (42%) of the 45 respondents who did not have reference to COMET had searched the COMET database. A new question in the application form prompted a rise in those reporting a search of the COMET database from 6% to 99%.

CONCLUSION

The study found low COS uptake in funding applications, but a new application question prompted an increase in reporting searches of the COMET database. Funder guidance promoted COS awareness and use, but more efforts are needed to facilitate COS development and adoption in clinical research.

The research status and progress of core outcome set in oral health

The core outcome set (COS) refers to the minimum set of outcomes that should be reported by all clinical trials in a particular health field. The use of COS in clinical studies can reduce the heterogeneity caused by using different outcomes across different clinical studies, facilitate the systematic review of different clinical studies on the same topic, reduce selective reporting bias, and increase the utility of clinical studies. The importance of COS in oral health has recently been recognized. This review summarizes the history, necessity, and key methodological points of COS development, with emphasis on the research status and existing problems in COS development, in the field of oral health.

COS-Speech: protocol to develop a core outcome set for dysarthria after stroke for use in clinical practice and research

BACKGROUND

Dysarthria after stroke is when speech intelligibility is impaired, and this occurs in half of all stroke survivors. Dysarthria often leads to social isolation, poor psychological well-being and can prevent return to work and social lives. Currently, a variety of outcome measures are used in clinical research and practice when monitoring recovery for people who have dysarthria. When research studies use different measures, it is impossible to compare results from trials and delays our understanding of effective clinical treatments. The aim of this study is to develop a core outcome set (COS) to agree what aspects of speech recovery should be measured for dysarthria after stroke (COS-Speech) in research and clinical practice.

METHODS

The COS-Speech study will include five steps: (1) development of a long list of possible outcome domains of speech that should be measured to guide the survey; (2) recruitment to the COS-Speech study of three key stakeholder groups in the UK and Australia: stroke survivors, communication researchers and speech and language therapists/pathologists; (3) two rounds of the Delphi survey process; (4) a consensus meeting to agree the speech outcomes to be measured and a follow-up consensus meeting to match existing instruments/measures (from parallel systematic review) to the agreed COS-Speech; (5) dissemination of COS-Speech.

DISCUSSION

There is currently no COS for dysarthria after stroke for research trials or clinical practice. The findings from this research study will be a minimum COS, for use in all dysarthria research studies and clinical practice looking at post-stroke recovery of speech. These findings will be widely disseminated using professional and patient networks, research and clinical forums as well as using a variety of academic papers, videos, accessible writing such as blogs and links on social media.

TRIAL REGISTRATION

COS-Speech is registered with the Core Outcome Measures in Effectiveness Trials (COMET) database, October 2021 https://www.comet-initiative.org/Studies/Details/1959 . In addition, "A systematic review of the psychometric properties and clinical utility of instruments measuring dysarthria after stroke" will inform the consensus meeting to match measures to COS-Speech. The protocol for the systematic reviews registered with the International Prospective Register of Systematic Reviews. PROSPERO registration number: CRD42022302998 .

Determining external randomised pilot trial feasibility in preparation for a definitive trial: a web-based survey of corresponding authors of external pilot trial publications

BACKGROUND

External randomised pilot trials aim to determine whether a future definitive randomised controlled trial (RCT) should be conducted, and if so, how. However, not every pilot trial that suggests that a definitive trial will be feasible will progress to a definitive study. In this study, we surveyed corresponding authors of external randomised pilot trial publications to assess pilot trial outcomes in terms of feasibility and progression.

METHODS

Web-based surveys were sent to corresponding authors of external randomised pilot trial publications, open for four weeks between January and February 2022. Four surveys were produced depending on whether the corresponding author had published a trial protocol or results publication, and whether progression criteria were reported. Surveys asked whether a future RCT was considered feasible, whether progression criteria were met (if applicable), what other factors informed the assessment of pilot trial feasibility, and whether the pilot trial has progressed to further research. Data was analysed using descriptive statistics and conventional content analysis.

RESULTS

98 of 276 corresponding authors completed the survey (average response rate of 36% across all surveys). Of these, 89 respondents indicated that their trial had completed. Ninety per cent of respondents who were corresponding authors of completed pilot trials stated that their pilot trial was either feasible (42/89, 47%) or feasible with changes to the trial design (38/89, 43%), yet only 66% (59/89) reported the intention to conduct a future definitive trial. Availability of funding for a future definitive trial and changing priorities of the Chief Investigator were the most common barriers to progression identified. Qualitative research findings was the most frequent factor considered both by corresponding authors who reported and who did not report progression criteria when determining trial feasibility.

CONCLUSIONS

Just under one quarter (21/89, 24%) of respondents who considered their external randomised pilot trial to be feasible, or feasible with changes, did not intend to conduct a definitive trial highlighting research inefficiency and waste.

TRIAL REGISTRATION

Open Science Framework osf.io/d28hr [20 December 2021].

A good use of time? Providing evidence for how effort is invested in primary and secondary outcome data collection in trials

BACKGROUND

Data collection is a substantial part of trial workload for participants and staff alike. How these hours of work are spent is important because stakeholders are more interested in some outcomes than others. The ORINOCO study compared the time spent collecting primary outcome data to the time spent collecting secondary outcome data in a cohort of trials.

METHODS

We searched PubMed for phase III trials indexed between 2015 and 2019. From these, we randomly selected 120 trials evaluating a therapeutic intervention plus an additional random selection of 20 trials evaluating a public health intervention. We also added eligible trials from a cohort of 189 trials in rheumatology that had used the same core outcome set. We then obtained the time taken to collect primary and secondary outcomes in each trial. We used a hierarchy of methods that included data in trial reports, contacting the trial team and approaching individuals with experience of using the identified outcome measures. We calculated the primary to secondary data collection time ratio and notional data collection cost for each included trial.

RESULTS

We included 161 trials (120 phase III; 21 core outcome set; 20 public health), which together collected 230 primary and 688 secondary outcomes. Full primary and secondary timing data were obtained for 134 trials (100 phase III; 17 core outcome set; 17 public health). The median time spent on primaries was 56.1 h (range: 0.0-10,746.7, IQR: 226.89) and the median time spent on secondaries was 190.7 hours (range: 0.0-1,356,832.9, IQR: 617.6). The median primary to secondary data collection time ratio was 1.0:3.0 (i.e. for every minute spent on primary outcomes, 3.0 were spent on secondaries). The ratio varied by trial type: phase III trials were 1.0:3.1, core outcome set 1.0:3.4 and public health trials 1.0:2.2. The median notional overall data collection cost was £8015.73 (range: £52.90-£31,899,140.70, IQR: £20,096.64).

CONCLUSIONS

Depending on trial type, between two and three times as much time is spent collecting secondary outcome data than collecting primary outcome data. Trial teams should explicitly consider how long it will take to collect the data for an outcome and decide whether that time is worth it given importance of the outcome to the trial.

Completeness and Mismatch of Patient-Important Outcomes After Trauma

To assess the completeness of the collection of patient-important outcomes and the mismatch between outcomes measured in research and patients' important issues after trauma.

Summary Background Data

To date, severe trauma has mainly been assessed using in-hospital mortality. Yet, with 80 to 90% survivors discharged from hospital, it is critical to assess the collection of patient important long-term outcomes of trauma.

Methods

Mixed methods study combining a systematic review of outcomes and their comparison with domains elicited by patients during a qualitative study. We searched Medline, EMBASE and clinicaltrials.gov from January 1, 2014 to September 30, 2019 and extracted all outcomes from reports including severe trauma. We compared these outcomes with 97 domains that matter to trauma survivors identified in a previous qualitative study. We defined as patient-important outcome as the 10 most frequently elicited domains in the qualitative study. We assessed the number of domains captured in each report to illustrate the completeness of the collection of patient-important outcomes. We also assessed the mismatch between outcomes collected and what matters to patients.

Findings

Among the 116 reports included in the systematic review, we identified 403 outcomes collected with 154 unique measurements tools. Beside mortality, measurement tools most frequently used were the Glasgow Outcome Scale (31.0%, n=36), questions on patients' return to work (20,7%, n=24) and the EQ-5D (19.0%, n=22). The comparison between the outcomes identified in the systematic review and the domains from the qualitative study found that 10.3% (n=12) reports did not collect any patient-important domains and one collected all 10 patient-important domains. By examining each of the 10 patient-important domains, none was collected in more than 72% of reports and only five were among the ten most frequently measured domains in studies.

Conclusion

The completeness of the collection of the long-term patient-important outcomes after trauma can be improved. There was a mismatch between the domains used in the literature and those considered important by patients during a qualitative study.

Comparison of published core outcome sets with outcomes recommended in regulatory guidance from the US Food and Drug Administration and European Medicines Agency: cross sectional analysis

Objective

To compare the outcomes in published core outcome sets with the outcomes recommended in corresponding guidance documents from the European Medicines Agency (EMA) and US Food and Drug Administration (FDA), matched by health condition.

Design

Cross sectional analysis.

Setting

US and Europe.

Population

Sample of core outcome sets related to drugs, devices, and gene therapy that involved patients in the consensus process, published between 1 January 2015 and 31 December 2019; and corresponding EMA and FDA guidance documents.

Main outcome measures

The extent of matches between outcomes included within core outcome sets and those recommended in corresponding EMA and FDA guidance documents were assessed. Matches were considered to be general (ie, non-specific) or specific (ie, exact). General matches were assessed to determine whether the core outcome set or guidance document outcome was narrower.

Results

Relevant guidance documents were found for for 38 (39%) of 98 eligible published core outcome sets. Among outcomes in core outcome sets, medians of 70% (interquartile range 48-86%) and 52% (33-77%) were matches with outcomes recommended in EMA and FDA documents, respectively. Medians of 46% (27-68%) and 26% (18-46%) were specific matches with outcomes in EMA and FDA documents, respectively. When outcomes were generally matched, the outcomes from core outcome sets were more frequently narrower than the regulatory outcomes (83% and 75% for EMA and FDA, respectively).

Conclusion

Greater adoption of, and reference to, core outcome sets in regulatory guidance documents can encourage clinical trialists, especially those in industry, to measure and report consistent and agreed outcomes and improve the quality of guidance. Given the overlap between outcomes in core outcome sets and regulatory guidance, and given that most core outcome sets now involve patients in the consensus process, these sets could serve as a useful resource for regulators when recommending outcomes for studies evaluating regulated products. Developers are encouraged to appraise recommended outcomes in salient regulatory documents when planning a core outcome set.

Developing a core outcome set for hospital deprescribing trials for older people under the care of a geriatrician

BACKGROUND

Half of older people are prescribed unnecessary/inappropriate medications that are not routinely deprescribed in hospital hence there is a need for deprescribing trials. We aimed to develop a Core Outcome Set (COS) for deprescribing trials for older people under the care of a geriatrician during hospital admission.

METHODS

We developed a list of potentially relevant outcomes from the literature. Using a two-round Delphi survey of stakeholder groups representing older people and carers, hospital clinicians, hospital managers, and ageing/deprescribing researchers, each outcome was scored according to Grading of Recommendations Assessment, Development and Evaluation, followed by two consensus workshops to finalise the COS.

RESULTS

Two hundred people completed Round 1 and 114 completed Round 2. Representing all stakeholder groups, 10 people participated in workshop 1 and 10 in workshop 2. Six outcomes were identified as most important, feasible and acceptable to collect in a trial: number of prescribed medicines stopped; number of prescribed medicines with dosage reduced; quality of life; mortality; adverse drug events and number of hospital stays. Three other outcomes were identified as important, but currently too burdensome to collect: number of potentially inappropriate medicines prescribed; burden from medication routine; and medication-related admissions to hospital.

CONCLUSIONS

A COS represents the minimum outcomes that should be collected and reported. Whilst uncommon practice for COS development, the value of considering outcome collection feasibility is demonstrated by the removal of three potential outcomes that, if included, may have compromised COS uptake due to challenges with collecting the data.

Review finds core outcome set uptake in new studies and systematic reviews needs improvement

OBJECTIVES

To review evidence about the uptake of core outcome sets (COS). A COS is an agreed standardized set of outcomes that should be measured and reported, as a minimum, in all clinical trials in a specific area of health or healthcare.

STUDY DESIGN AND SETTING

This article provides an analysis of what is known about the uptake of COS in research. Similarities between COS and outcomes recommended by stakeholders in the evidence ecosystem is reviewed and actions taken by them to facilitate COS uptake described.

RESULTS

COS uptake is low in most research areas. Common facilitators relate to trialist awareness and understanding. Common barriers were not including in the development process all specialties that might use the COS and the lack of recommendations for how to measure the outcomes. Increasingly, COS developers are considering strategies for promoting uptake earlier in the process, including actions beyond traditional dissemination approaches. An overlap between COS and outcomes in regulatory documents and health technology assessments is good. An increasing number and variety of organizations are recommending COS be considered.

CONCLUSION

We suggest actions for various stakeholders for improving COS uptake. Research is needed to assess the impact of these actions to identify effective evidence-based strategies.

Getting it wrong most of the time? Comparing trialists' choice of primary outcome with what patients and health professionals want

Background

Randomised trials support improved decision-making through the data they collect. One important piece of data is the primary outcome — so called because it is what the investigators decide is the most important. Secondary outcomes provide additional information to support decision-making. We were interested in knowing how important patients and healthcare professionals consider the outcomes (especially the primary outcome) measured in a selection of published trials.

Methods

The work had three stages: (1) We identified a body of late-stage trials in two clinical areas, breast cancer management and nephrology. (2) We identified the primary and secondary outcomes for these trials. (3) We randomly ordered these outcomes and presented them to patients and healthcare professionals (with experience of the clinical area), and we asked them to rank the importance of the outcomes. They were not told which outcomes trial authors considered primary and secondary.

Results

In our sample of 44 trials with 46 primary outcomes, 29 patients, one patient representative and 12 healthcare professionals together ranked the primary outcome as the most important outcome 13/46 times or 28%. Breast cancer patients and healthcare professionals considered the primary outcome to be the most important outcome for 8/21 primary outcomes chosen by trialists. For nephrology, the equivalent figure was 5/25. The primary outcome appeared in a respondent’s top 5 ranked outcomes 151/178 (85%) times for breast cancer and 225/259 (87%) times for nephrology even if the primary was not considered the most important outcome.

Conclusions

The primary outcome in a trial is the most important piece of data collected. It is used to determine how many participants are required, and it is the main piece of information used to judge whether the intervention is effective or not. In our study, patients and healthcare professionals agreed with the choice of the primary outcome made by trial teams doing late-stage trials in breast cancer management and nephrology 28% of the time.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-022-06348-z.

Usefulness of Cochrane Reviews in Clinical Guideline Development-A Survey of 585 Recommendations

The Danish Health Authority develops clinical practice guidelines to support clinical decision-making based on the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system and prioritizes using Cochrane reviews. The objective of this study was to explore the usefulness of Cochrane reviews as a source of evidence in the development of clinical recommendations. Evidence-based recommendations in guidelines published by the Danish Health Authority between 2014 and 2021 were reviewed. For each recommendation, it was noted if and how Cochrane reviews were utilized. In total, 374 evidence-based recommendations and 211 expert consensus recommendations were published between 2014 and 2021. Of the 374 evidence-based recommendations, 106 included evidence from Cochrane reviews. In 28 recommendations, all critical and important outcomes included evidence from Cochrane reviews. In 36 recommendations, a minimum of all critical outcomes included evidence from Cochrane reviews, but not all important outcomes. In 33 recommendations, some but not all critical outcomes included evidence from Cochrane reviews. Finally, in nine recommendations, some of the important outcomes included evidence from Cochrane reviews. In almost one-third of the evidence-based recommendations, Cochrane reviews were used to inform clinical recommendations. This evaluation should inform future evaluations of Cochrane review uptake in clinical practice guidelines concerning outcomes important for clinical decision-making.