Assessing the Empirical Evidence of Associations between Internal Vali

On September 15, 2009, Paul Shekelle made this presentation at the 2009 Annual Conference. Select to access the PowerPoint® presentation (212 KB) (Plugin Software Help).

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Assessing the Empirical Evidence of Associations between Internal Validity and Effect Sizes in Randomized Controlled Trials

AHRQ contract HHSA 290 2007 10062 I
 

Paul G. Shekelle, M.D., Ph.D.
Southern California EPC

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Bias

• Widespread belief that design and execution factors are related to bias in trials
  • Systematic deviation of an estimate, e.g. observed treatment effect in individual study from true value

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Quality

• These internal validity features for RCTs are commonly used:
  • Jadad scale (1996):
    • Randomization
    • Double-blinding
    • Description of dropouts
  • Allocation Concealment (e.g. Colditz et al., 1989)
    • Assignment generated by independent person not responsible for determining eligibility of patients

   

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  Evidence of bias

  • Schulz et al. (1995) assessed 250 trials in 33 meta-analyses
    • Inadequate concealment of allocation accounted for a 41% increase in effect sizes
    • Lack of double blinding showed a 17% increase in reported treatment effect
  • Moher et al. (1998) using 11 meta-analyses including 127 RCTs
    • Studies with inadequate concealment showed a 37% increased effect compared to concealed treatment allocation trials
    • "low quality" trials showed a 34% increase in effect

   

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  Cochrane Risk of Bias Tool

  • Recently, Cochrane has proposed a new tool to assess bias:
    • Sequence generation
    • Allocation concealment
    • Blinding of participants, personnel and outcome assessors
    • Incomplete outcome data
    • Selective outcome reporting
    • Other sources of bias
  • Cochrane also recommends a global summary score

   

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  Some Conflicting Evidence

  • Balk & colleagues (2002)
    • Used 24 existing quality measures and assessed 276 RCTs from 26 meta-analyses
    • No association of measures with bias across conditions (cardiovascular disease, infectious disease, pediatrics, and surgery)
  • Wood, Egger, Gluud, Schulz, Juni, Altman, Gluud, Martin, Wood & Sterne (2009)
    • utilized 146 meta-analyses (1346 RCTs) examining wide range of interventions and outcomes re allocation concealment and reported blinding
    • Bias effects vary by outcomes

   

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  Cochrane Back Group Approach

  • Extensive quality item list proposed by Cochrane Back Group editorial to assess controlled trials
    • Randomization sequence
    • Allocation concealment
    • Patient blinding
    • Care provider blinding
    • Assessor blinding
    • Dropouts (description, adequateness)
    • ITT analysis
    • Selective outcome reporting
    • Baseline comparability
    • Similarity of Co-Interventions
    • Compliance
    • Timing of outcome assessment

   

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  All RCTs in Cochrane Back Group Reviews

  Reviewed 261 Trials 216 Trials

  • 45 Trials Unable to Calculate Effect Size
  • 128 Trials compared treatments to other treatments
  • 122 Trials compared treatments to placebo/usual care

  64% of trials reported short-term pain outcomes

   

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  Effect of Internal Validity Items on Bias

  Validity Item	Yes	No	Effect Size Difference (95% CI)
  A. randomization	104	112	0.02 (-0.12, 0.16)
  B. concealment	69	147	-0.08 (-0.23, 0.07)
  C. baseline differences	135	81	-0.10 (-0.24, 0.05)
  D. blinding - patient	82	134	-0.03 (-0.18, 0.11)
  E. blinding - care provider	57	159	-0.10 (-0.26, 0.06)
  F. blinding - outcome	123	93	-0.10 (-0.25, 0.04)
  G. co-interventions	92	124	-0.09 (-0.23, 0.05)
  H. compliance	76	140	-0.01 (-0.15, 0.14)
  I. dropouts	150	66	-0.13 (-0.29, 0.02)
  J. timing	198	18	-0.17 (-0.43, 0.10)
  K. ITT	118	98	-0.10 (-0.24, 0.04)

  Effect Size Difference
  Higher quality have smaller effect
  Lower quality have smaller effect
   

   

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  SC EPC Data Sets

  • Quality and effect sizes of all 267 trials in 15 Meta-Analyses of Cochrane Back Review Group analyzed
    • Threshold analysis
    • Significant differences in effect sizes between high and low quality RCTs

  • Trials of existing EPC evidence reports assessed with extensive quality item list
    • 166 trials, diverse set of topics, pharmacological therapies / behavior modification interventions
    • Effects of quality varied across conditions
    • • Including blinding, allocation concealment
      • No overall effect of quality on effect sizes across conditions or outcomes

   

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  New SC EPC Data Set

  • To investigate the differing results from two large datasets, we are now testing a third dataset where we know that Jadad scale and allocation concealment items influence effect sizes in the expected direction.

   

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  Analysis

  • New dataset can be merged with existing datasets
    • To investigate effects that were hindered by lack of variance in previous samples
    • • E.g., many trials report not enough information in order to judge the quality feature, large sample needed
    • To find empirical groupings of quality criteria
    • • Quality features do not seem to be independent from another, e.g. studies with adequate allocation concealment rarely use an inappropriate sequence generation
    • To investigate factors that can explain the observed differences in results across samples
    • • Moderator effects in meta-regression

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Proposed Moderators

• Size of overall treatment effect
  • Strong treatment effect may obliterate effects of quality
• Condition being treated
  • Quality may influence reported effect sizes more in some clinical fields than others
• Type of analyzed outcome
  • E.g., subjective vs. objective data, see also Wood et al.
• Variance of quality across studies
  • Some quality features show little variance across trials (e.g. differential timing very rare)

Quality ---------------> Effect Size
 

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Conclusion

• Effect of quality feature on individual RCT results important finding
  • Quality of RCT varies, empirical evidence of bias
• Some conflicting results in literature
  • Some samples show large effects of quality on effect sizes, some show no consistent effect
• Current research needs to focus on investigating conditions for risk of bias
  • When is which quality feature associated with bias

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Recommendations

• Pending any new analyses, for now review groups can probably have most confidence in using the following items to assess bias:
  • Jadad Criteria
  • Concealment of Allocation Or
  • Cochrane Risk of Bias Tool

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Graph: Effect of Internal Validity Items on Bias

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Graph: Effect of Internal Validity Items on Bias