Responsibility and accountability for well informed health-care decisions: a global challenge

Prevention of selective outcome reporting: let us start from the beginning

BACKGROUND

Healthcare professionals and patients could be negatively influenced in their judgments by articles and meta-analyses presenting selective outcome reporting. Clinical trials should be transparent from inception to the publication of results. To this end, trial prospective registration is an ethical and scientific requirement that have shown to be effective in preventing selective reporting of outcomes. However, even journals with a clear pre-registration policy publish trial results that were retrospectively registered.

SITUATION

Analyses of registration of randomized clinical trials recently published in top specialty journals and of meta-analyses with suspicion of including trials with outcome reporting bias have shown that retrospective registration is in the range from 56 to 76 %. This translates into publication of primary endpoints that differ from those included in the registry: some 30 % of trials showed discrepancies between the primary endpoint in the trial registry and the article. Furthermore, it has been shown that 8 % of all clinical trials published by 6 high-impact ICMJE-member journals was retrospectively registered after primary endpoint ascertainment could have had taken place, raising concerns that endpoints may not have been pre-specified, or were changed. With regards to meta-analyses, 34 % of Cochrane systematic reviews included one or more trials with a high suspicion of selective reporting bias for the primary outcome.

PROPOSAL

Retrospective registration of trials may foster selective outcome reporting unless journal editors implement specific quality control processes aiming to prevent or minimize this type of bias. Prospective registration of trials-and protocol public disclosure if proven effective in future studies-prevents outcome reporting bias, a must to ensure clinicians and patients have access to reliable clinical trial results. Journal editors should enforce, rather than encourage, appropriate measures to ensure publication of trials free of outcome reporting bias.

Better Outcomes through Learning, Data, Engagement, and Research (BOLDER) - a system for improving evidence and clinical practice in low and middle income countries

Despite the many thousands of research studies published every year, evidence for making clinical decisions is often lacking. The main problem is that the evidence available is generated in conditions very different from those that prevail in routine clinical practice and with patients who are different. This is particularly a problem for low and middle income countries as most evidence is generated in high income countries. A group of clinicians, researchers, and policy makers met at Bellagio in Italy to consider how more relevant evidence might be generated. One answer is to conduct more pragmatic trials-those undertaken in routine clinical practice. The group thought that this might best be achieved by developing "learning health systems" in low and middle income countries. Learning health systems develop in communities that include clinicians, patients, researchers, improvement specialists, information technology specialists, managers, and policy makers and have a governance system that gives a voice to all those in the community. The systems focus on improving outcomes for patients, use a common dataset, and promote quality improvement and pragmatic research. Plans have been developed to create at least two learning systems in Africa.