Practical help for specifying the target difference in sample size calculations for RCTs: the DELTA2 five-stage study, including a workshop

Data analytics in the football industry: a survey investigating operational frameworks and practices in professional clubs and national federations from around the world

The use of data and analytics in professional football organisations has grown steadily over the last decade. Nevertheless, how and whether these advances in sports analytics address the needs of professional football remain unexplored. Practitioners from national federations qualified for the FIFA World Cup Qatar 2022™ and professional football clubs from an international community of practitioners took part in a survey exploring the characteristics of their data analytics infrastructure, their role, and their value for elaborating player monitoring and positional data. Respondents from 29 national federations and 32 professional clubs completed the survey, with response rates of 90.6% and 77.1%, respectively. Summary information highlighted the underemployment of staff with expertise in applied data analytics across organisations. Perceptions regarding analytical capabilities and data governance framework were heterogenous, particularly in the case of national federations. Only a third of national federation respondents (~30%) perceived information on positional data from international sports data analytics providers to be sufficiently clear. The general resourcing limitations, the overall lack of expertise in data analytics methods, and the absence of operational taxonomies for reference performance metrics pose constraints to meaningful knowledge translations from raw data in professional football organisations.

The importance of clinical importance when determining the target difference in sample size calculations

Recently, it was argued that clinically important differences should play no role in sample size calculations. Instead, it was proposed that sample size calculations should focus on setting realistic estimates of treatment benefit. We disagree, and argue in this article that considering the importance of a target difference is necessary in the context of randomised controlled trials of effectiveness, particularly definitive phase III trials. Ignoring clinical importance could have serious ethical and practical consequences.

Most Placebo-Controlled Trials in Inflammatory Bowel Disease were Underpowered Because of Overestimated Drug Efficacy Rates: Results from a Systematic Review of Induction Studies

BACKGROUND AND AIMS

Most pharmaceutical clinical trials for inflammatory bowel disease [IBD] are placebo-controlled and require effect size estimation for a drug relative to placebo. We compared expected effect sizes in sample size calculations [SSCs] to actual effect sizes in IBD clinical trials.

METHODS

MEDLINE, EMBASE, CENTRAL and the Cochrane library were searched from inception to March 26, 2021, to identify placebo-controlled induction studies for luminal Crohn's disease [CD] and ulcerative colitis [UC] that reported an SSC and a primary endpoint of clinical remission/response. Expected effects were subtracted from actual effects, and interquartile ranges [IQRs] for each corresponding median difference were calculated. Linear regression was used to assess whether placebo or drug event rate misspecifications were responsible for these differences.

RESULTS

Of eligible studies, 36.9% [55/149] were excluded because of incomplete SSC reporting, yielding 94 studies [46 CD, 48 UC]. Treatment effects were overestimated in CD for remission (-12.6% [IQR: -16.3 to -1.6%]), in UC for remission (-10.2% [IQR: -16.5 to -5.6%]) and in CD for response (-15.3% [IQR: -27.1 to -5.8%]). Differences observed were due to overestimated drug event rates, whereas expected and actual placebo event rates were similar. A meta-regression demonstrated associations between overestimated treatment effect sizes and several trial characteristics: isolated ileal disease, longer CD duration, extensive colitis [UC], single-centre, phase 2 and no endoscopic endpoint component [UC].

CONCLUSION

Overestimation of IBD therapy efficacy rates resulted in smaller-than-expected treatment effects. These results should be used to inform SSCs and trial design for IBD drug development.

Exploring Health Literacy Categories in Patients With Heart Failure: A Latent Class Analysis

BACKGROUND

Although a growing number of studies have demonstrated that patients' health literacy is associated with health outcomes, the exact relationship between them is not clear.

AIMS AND OBJECTIVES

The aim of this study was to explore latent classes of health literacy in patients with heart failure and analyze the differences among different groups.

DESIGN AND METHODS

This is a cross-sectional survey. Patients diagnosed with heart failure were selected from 3 tertiary hospitals in Tianjin, China, from March 2019 to November 2019. We measured patients' health literacy using the Health Literacy Scale for Chronic Patients. Latent class analysis was carried out based on the patients' Health Literacy Scale for Chronic Patients scores. Multinomial logistic regression was used to identify the predictive indicators of the latent classes.

RESULTS

The health literacy of patients with heart failure was divided into 3 different latent classes, named "high health literacy group," "low literacy high dependence group," and "moderate literacy high willingness group." There were statistically significant differences in gender, age, smoking history, marital status, education level, household income level, and quality of life among different health literacy classes. Low education level and household income level predicted poor health literacy.

CONCLUSION

There were 3 latent classes for the health literacy of patients with heart failure. Different health literacy classes exhibited their own distinctive characteristics. Patients in the "moderate literacy high willingness group" had the worst quality of life. Understanding the specific types of health literacy in patients with heart failure facilitates targeted nursing interventions to improve their quality of life.

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

IMPORTANCE

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

OBJECTIVE

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

EVIDENCE REVIEW

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

FINDINGS

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

CONCLUSIONS AND RELEVANCE

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

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

IMPORTANCE

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

OBJECTIVE

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

EVIDENCE REVIEW

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

FINDINGS

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

CONCLUSIONS AND RELEVANCE

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

Inconsistencies in the Methodological Framework Throughout Published Studies in High-Impact Orthopaedic Journals: A Systematic Review

BACKGROUND

Both the Standard Protocol Items: Recommendations for Interventional Trials (SPIRIT) and Consolidated Standards of Reporting Trials (CONSORT) guidelines recommend that clinical trials follow a study framework that aligns with their objective to test the relative efficacy or safety (equality) or effectiveness (superiority, noninferiority, or equivalence) between interventions. We conducted a systematic review to assess the proportion of studies that demonstrated inconsistency between the framing of their research question, sample size calculation, and conclusion and those that should have framed their research question differently based on the compared interventions.

METHODS

We included studies from 5 high-impact-factor orthopaedic journals published in 2017 and 2019 that compared at least 2 interventions using patient-reported outcome measures.

RESULTS

We included 228 studies. The sample size calculation was reported in 60.5% (n = 138) of studies. Of these, 52.2% (n = 72) were inconsistent between the framing of their research question, sample size calculation, and conclusion. The majority (n = 137) of sample size calculations were for equality, but 43.8% of these studies concluded superiority, noninferiority, or equivalence. Studies that framed their research question as equality (n = 186) should have been framed as superiority (n = 129), equivalence (n = 52), or noninferiority (n = 3). Only 2 studies correctly framed their research question as equality.

CONCLUSIONS

Studies published in high-impact journals were inconsistent between the framing of their research question, sample size calculation, and conclusion. Authors may be misinterpreting research findings and making clinical recommendations solely based on p values. Researchers are encouraged to state and justify their methodological framework and choice of margin(s) in a publicly published protocol as they have implications for sample size and the applicability of conclusions.

CLINICAL RELEVANCE

The results of clinical research must be interpreted using confidence intervals, with careful consideration as to how the confidence intervals relate to clinically meaningful differences in outcomes between treatments. The more typical practice of relying on p values leaves the clinician at high risk of erroneous interpretation, recommendation, and/or action.

Sample Size Calculation When Planning Clinical Trials with Intercurrent Events

BACKGROUND

Missing data are not intercurrent events; missing data are consequences of intercurrent events. When planning clinical trials with potential missing data, a conventional approach is two stage: (1) to calculate a required sample size N without considering missing data; (2) to adjust the sample size using [Formula: see text], where r is the expected missing data rate. However, this approach is not estimand oriented.

METHODS

Clinical trial design should be aligned with estimand. Sample size calculation is a key step in clinical trial design, so methods for sample size calculation should be aligned with estimand.

RESULTS

ICH E9(R1) summarizes five strategies for dealing with intercurrent events. We consider five basic approaches for sample size calculation when planning clinical trials with intercurrent events, with each approach aligned with one of these five strategies. We extend the approaches to scenarios where some combination of multiple strategies is applied to deal with intercurrent events.

CONCLUSION

Being aligned with estimands and strategies for dealing with intercurrent events, these methods can be used for sample size calculations when planning clinical trials with intercurrent events.

Comparative assessment of the rate of orthodontic tooth movement in adolescent patients undergoing treatment by first bicuspid extraction and en mass retraction, associated with low-frequency mechanical vibrations in passive self-ligating and conventional brackets: A randomized controlled trial

BACKGROUND

Low-frequency vibrations are one of the many non-surgical modalities aimed at increasing the rate of orthodontic tooth movement.

OBJECTIVE

The present trial was conducted to assess the efficacy of low-frequency vibrations in increasing the rate of orthodontic tooth movement in adolescent patients undergoing fixed mechanotherapy with passive self-ligating brackets and conventional brackets.

MATERIALS AND METHODS

Setting and sample population: department of orthodontics and dentofacial orthopaedics in a nationally accredited dental college. Participants, study design and methods: 65 patients were randomly allocated to three groups. Two experimental groups consisted of passive self-ligating and conventionally ligated appliances received low-frequency vibrations. The control group did not receive any vibrations. Allocation ratio was 1:1:1.32. Eligibility criteria: adolescent patients with sound and healthy dentition, incisor irregularity<5mm.

PRIMARY OUTCOME

rate of orthodontic tooth movement in mm/month. Randomization and blinding: computer-generated random allocation sequencing was done and data assessor was blinded.

STATISTICS

the Q-Q plot and Shapiro-Wilks test judged the normality of the data. The parametric test included ANCOVA and post-hoc analysis.

RESULTS

No statistically significant enhancement of tooth movement was seen in the experimental groups, when comparison was done with the control group P>0.05. Comparison between the two experimental groups did not reveal any significant difference either.

CONCLUSION

No statistically significant increase of orthodontic tooth movement was seen with low-frequency vibrations and the mode of ligation did not have any effect in increasing the rate of tooth movement either.

Demystifying the estimand framework: a case study using patient-reported outcomes in oncology

Patient-reported outcome (PRO) measures describe how a patient feels or functions and are increasingly being used in benefit-risk assessments in the development of cancer drugs. However, PRO research objectives are often ill-defined in clinical cancer trials, which can lead to misleading conclusions about patient experiences. The estimand framework is a structured approach to aligning a clinical trial objective with the study design, including endpoints and analysis. The estimand framework uses a multidisciplinary approach and can improve design, analysis, and interpretation of PRO results. On the basis of the International Council for Harmonisation of Technical Requirements for Registration of Pharmaceuticals for Human Use E9(R1) addendum, we provide an overview of the estimand framework intended for a multistakeholder audience. We apply the estimand framework to a hypothetical trial for breast cancer, using physical function to develop specific PRO research objectives. This Policy Review is not an endorsement of a specific study design or outcome; rather, it is meant to show the application of principles of the estimand framework to research study design and add to ongoing discussion. Use of the estimand framework to review medical products and label PROs in oncology can improve communication between stakeholders and ultimately provide a clearer interpretation of patient experience in the development of oncological drugs.

Comparison of the clinical and cost effectiveness of two management strategies (rehabilitation versus surgical reconstruction) for non-acute anterior cruciate ligament (ACL) injury: study protocol for the ACL SNNAP randomised controlled trial

Background

Anterior cruciate ligament (ACL) rupture is a common knee injury that can lead to poor quality of life, decreased activity and increased risk of secondary osteoarthritis of the knee. Management of patients with a non-acute ACL injury can include a non-surgical (rehabilitation) or surgical (reconstruction) approach. However, insufficient evidence to guide treatment selection has led to high variation in treatment choice for patients with non-acute presentation of ACL injury.

The objective of the ACL SNNAP trial is to determine in patients with non-acute anterior cruciate ligament deficiency (ACLD) whether a strategy of non-surgical management (rehabilitation) (with option for later ACL reconstruction only if required) is more clinically effective and cost effective than a strategy of surgical management (reconstruction) without prior rehabilitation with all patients followed up at 18 months.

Methods

The study is a pragmatic, multi-centre, superiority, randomised controlled trial with two-arm parallel groups and 1:1 allocation. Patients with a symptomatic non-acute ACL deficient knee will be randomised to either non-surgical management (rehabilitation) or surgical management (reconstruction). We aim to recruit 320 patients from approximately 30 secondary care orthopaedic units from across the United Kingdom. Randomisation will occur using a web-based randomisation system. Blinding of patients and clinicians to treatment allocation will not be possible because of the nature of the interventions. Participants will be followed up via self-reported questionnaires at 6, 12 and 18 months. The primary outcome is the Knee injury and Osteoarthritis Outcome Score (KOOS) at 18 months post randomisation. Secondary outcomes will include a return to sport/activity, intervention-related complications, patient satisfaction, expectations of activity, generic health quality of life, knee specific quality of life and resource usage.

Discussion

At present, no evidence-based treatment of non-acute ACL deficiency exists, particularly in the NHS. Moreover, little consensus exists on the management approach for these patients. The proposed trial will address this gap in knowledge regarding the clinical and cost effectiveness of ACL treatment and inform future standards of care for this condition.

Trial registration

ISRCTN: 10110685. Registered on 16 November 2016. ClinicalTrials.gov: NCT02980367. Registered in December 2016.