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Standards for Reporting Randomized Controlled Trials in Medical Informatics Review Standards for reporting randomized controlled trials in medical informatics: a systematic review of CONSORT adherence in RCTs on clinical decision support K M Augestad,1,2 G Berntsen,1 K Lassen,2,4 J G Bellika,1,3 R Wootton,1 R O Lindsetmo,2,4 Study Group of Research Quality in Medical Informatics and Decision Support (SQUID) 1Department of Telemedicine ABSTRACT languages to facilitate awareness and dissemina- and Integrated Care, University Introduction The Consolidated Standards for Reporting tion. An extension of the CONSORT statement Hospital North Norway, Tromsø, Trials (CONSORT) were published to standardize was published in 2008, focusing on randomized Norway 6 2Department of Gastrointestinal reporting and improve the quality of clinical trials. The trials in non-pharmacologic treatment. Surgery, University Hospital objective of this study is to assess CONSORT adherence CONSORTconsists of a checklist of information to North Norway, Tromsø, Norway in randomized clinical trials (RCT) of disease specific include when reporting on an RCT; however, 3 Department of Computer clinical decision support (CDS). inadequate reporting remains common among Science, University of Tromsø, 6e12 Tromsø, Norway Methods A systematic search was conducted of the clinicians. Higher quality reports are likely to 4Institute of Clinical Medicine, Medline, EMBASE, and Cochrane databases. RCTs on improve RCT interpretation, minimize biased University of Tromsø, Tromsø, CDS were assessed against CONSORT guidelines and conclusions, and facilitate decision making in light Norway the Jadad score. of treatment effectiveness.1 Furthermore, there is Result 32 of 3784 papers identified in the primary evidence that studies of lower methodological Correspondence to Dr Knut Magne Augestad, search were included in the final review. 181 702 quality tend to report larger treatment effects than 13e15 Department of Telemedicine patients and 7315 physicians participated in the selected high quality studies. and Integrated Care, University trials. Most trials were performed in primary care (22), Research on clinical decision support (CDS) tools Hospital North Norway, 9037 including 897 general practitioner offices. RCTs has rapidly evolved in the last decade. CDS provides Breivika, Tromsø, Norway; knut. assessing CDS for asthma (4), diabetes (4), and fi [email protected] clinicians with patient speci c assessment or hyperlipidemia (3) were the most common. Thirteen CDS guidelines to aid clinical decision making16 and Received 31 May 2011 systems (40%) were implemented in electronic medical improve quality of care and patient outcome.17 18 Accepted 29 June 2011 records, and 14 (43%) provided automatic alerts. CDS has been shown to improve prescribing Published Online First CONSORT and Jadad scores were generally low; the practices,19 reduce serious medication errors,20 21 29 July 2011 mean CONSORT score was 30.75 (95% CI 27.0 to 34.5), enhance delivery of preventive care services,22 and median score 32, range 21e38. Fourteen trials (43%) did improve guidelines adherence,23 and likely results not clearly define the study objective, and 11 studies in lasting improvements in clinical practice.24 (34%) did not include a sample size calculation. Outcome However, clinical research on CDS tools faces e measures were adequately identified and defined in 23 various methodological problems25 28 and is (71%) trials; adverse events or side effects were not challenging to implement in the field of health reported in 20 trials (62%). Thirteen trials (40%) were of informatics.29 Guidelines for reporting studies in superior quality according to the Jadad score ($3 health informatics have been published,26 but there points). Six trials (18%) reported on long-term is no universal consensus. implementation of CDS. Numerous RCTs examining (disease specific) CDS Conclusion The overall quality of reporting RCTs was tools aimed at improving patient treatment have low. There is a need to develop standards for reporting been performed. It is unclear whether these studies RCTs in medical informatics. provided CONSORT statements when the trials were reported. Although several studies have eval- uated the quality of RCTs in medical journals,3 78to date none have been directed at medical informatics INTRODUCTION literature published in dedicated journals. The Randomized controlled trials (RCTs) are considered objective of this paper is to perform a systematic the gold standard for investigating the results of review of RCTs to assess the quality of clinical CDS clinical research because they inherently correct for research focusing on disease specific interventions. unknown confounders and minimize investigator fi 1e3 We aimed to score the identi ed RCTs according to bias. The results of these trials can have the CONSORT6 checklist and Jadad score.3 Finally, profound and immediate effects on patient care. we discuss the implications of these results in the When RCTs are reported, it is recommended that context of evidence-based medicine. the Consolidated Standards of Reporting Trials This paper is freely available (CONSORT)4 are followed. CONSORT was first online under the BMJ Journals unlocked scheme, see http:// published in 1996 and has been revised several MATERIALS AND METHODS 5 jamia.bmj.com/site/about/ times since. The CONSORT statement is widely The review followed the PRISMA statements unlocked.xhtml supported and has been translated into several (Preferred Reporting Items for Systematic Reviews J Am Med Inform Assoc 2012;19:13e21. doi:10.1136/amiajnl-2011-000411 13 Review and Meta-Analyses)30 and was divided into two work phases: (a) identification of RCT trials assessing disease specific CDS and (b) data extraction and assessment of RCT quality. The Study Group of Research Quality in Medical Informatics and Decision Support (SQUID) is a multidisciplinary study group. Members have expertise in hospital medicine (KL, ROL, KMA), RCTs in medicine (surgery) (KL),31 RCTs in telemedicine e (RW),32 trials of medical informatics (JGB, KMA),33 37 and e epidemiological research (GB).38 41 The group’s objective is to assess and improve the quality of clinical informatics research with special focus on randomized controlled trails aimed at enhancing physician performance. We defined CDS as ‘any electronic or non-electronic system designed to aid directly in clinical decision making, in which characteristics of individual patients are used to generate patient specific assessments or recommendations that are subsequently presented to clinicians for consideration.’42 We defined disease specific CDS as ‘a clinical decision support aimed at a specific disease, describing symptoms, diagnosis, treatment, and follow-up.’ Search strategy This systematic review is based on a PubMed, EMBASE, and Cochrane Controlled Trials Register search using EndNote X3 (EndNote, San Francisco, California, USA) for relevant publica- tions published through November 2010. We piloted search strategies and modified them to ensure they identified known eligible articles. We combined keywords and/or subject headings to identify CDS (clinical decision support system, computer-assisted Figure 1 Selection process of randomized controlled trials of disease decision making, computer-assisted diagnosis, hospital information specific clinical decision support. systems) in the area of RCTs (ie, randomized controlled trial). We searched publications accessible from the web pages of the Each article was then assessed for every item on the checklist International Journal of Medical Informatics, Journal of the American and scored independently by two observers (KMA and GB). The Medical Informatics Association, and BMC Medical Informatics and scores for the 22 items were added together and a percentage Decision Making. We systematically searched the reference lists of score for each trial was calculated. included studies. Reviews addressing CDS were investigated and e papers fulfilling the inclusion criteria were included.17 42 44 The Scoring according to Jadad searches were individually tailored for each database or journal. The Jadad scale is a 5-point scale for evaluating the quality of Experienced clinicians reviewed all search hits and decided randomized trials in which three points or more indicates whether a CDS was aimed at a specific disease and fulfilled superior quality.3 The Jadad scale is commonly used to evaluate inclusion criteria. The titles, index terms, and abstracts of the RCT quality.78The scale contains two questions each for identified references were studied and each paper was rated as randomization and masking, and one question evaluating ‘potentially relevant’ or ‘not relevant.’ Disagreements regarding reporting of withdrawals and dropouts. inclusion were resolved by discussion. Only trials performed the last 10 years were included. Scoring according to the sequential phases of a complex intervention Inclusion criteria were: An RCT evaluating a CDS tool is defined as a complex inter- < Randomized controlled trial vention, that is an intervention consisting of various inter- e < CDS describing specific diseases and treatment guidelines connecting parts.29 77 79 Cambell et al77 suggested four < CDS aimed at physicians. sequential phases for developing RCTs for complex interven- Exclusion criteria were: tions: theory, modeling, exploratory trial, definitive randomized < Papers published before the year 2000 controlled trial, and long-term implementation. Included trials were < Not published in English scored according to these
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