Subgroup analyses in randomised controlled trials: cohort study on trial protocols and journal publications.

OBJECTIVE To investigate the planning of subgroup analyses in protocols of randomised controlled trials and the agreement with corresponding full journal publications. DESIGN Cohort of protocols of randomised controlled trial and subsequent full journal publications. SETTING Six research ethics committees in Switzerland, Germany, and Canada. DATA SOURCES 894 protocols of randomised controlled trial involving patients approved by participating research ethics committees between 2000 and 2003 and 515 subsequent full journal publications. RESULTS Of 894 protocols of randomised controlled trials, 252 (28.2%) included one or more planned subgroup analyses. Of those, 17 (6.7%) provided a clear hypothesis for at least one subgroup analysis, 10 (4.0%) anticipated the direction of a subgroup effect, and 87 (34.5%) planned a statistical test for interaction. Industry sponsored trials more often planned subgroup analyses compared with investigator sponsored trials (195/551 (35.4%) v 57/343 (16.6%), P<0.001). Of 515 identified journal publications, 246 (47.8%) reported at least one subgroup analysis. In 81 (32.9%) of the 246 publications reporting subgroup analyses, authors stated that subgroup analyses were prespecified, but this was not supported by 28 (34.6%) corresponding protocols. In 86 publications, authors claimed a subgroup effect, but only 36 (41.9%) corresponding protocols reported a planned subgroup analysis. CONCLUSIONS Subgroup analyses are insufficiently described in the protocols of randomised controlled trials submitted to research ethics committees, and investigators rarely specify the anticipated direction of subgroup effects. More than one third of statements in publications of randomised controlled trials about subgroup prespecification had no documentation in the corresponding protocols. Definitive judgments regarding credibility of claimed subgroup effects are not possible without access to protocols and analysis plans of randomised controlled trials.

Completion and Publication Rates of Randomized Controlled Trials in Surgery: An Empirical Study.

OBJECTIVE: To investigate the prevalence of discontinuation and nonpublication of surgical versus medical randomized controlled trials (RCTs) and to explore risk factors for discontinuation and nonpublication of surgical RCTs. BACKGROUND: Trial discontinuation has significant scientific, ethical, and economic implications. To date, the prevalence of discontinuation of surgical RCTs is unknown. METHODS: All RCT protocols approved between 2000 and 2003 by 6 ethics committees in Canada, Germany, and Switzerland were screened. Baseline characteristics were collected and, if published, full reports retrieved. Risk factors for early discontinuation for slow recruitment and nonpublication were explored using multivariable logistic regression analyses. RESULTS: In total, 863 RCT protocols involving adult patients were identified, 127 in surgery (15%) and 736 in medicine (85%). Surgical trials were discontinued for any reason more often than medical trials [43% vs 27%, risk difference 16% (95% confidence interval [CI]: 5%-26%); P = 0.001] and more often discontinued for slow recruitment [18% vs 11%, risk difference 8% (95% CI: 0.1%-16%); P = 0.020]. The percentage of trials not published as full journal article was similar in surgical and medical trials (44% vs 40%, risk difference 4% (95% CI: -5% to 14%); P = 0.373). Discontinuation of surgical trials was a strong risk factor for nonpublication (odds ratio = 4.18, 95% CI: 1.45-12.06; P = 0.008). CONCLUSIONS: Discontinuation and nonpublication rates were substantial in surgical RCTs and trial discontinuation was strongly associated with nonpublication. These findings need to be taken into account when interpreting surgical literature. Surgical trialists should consider feasibility studies before embarking on full-scale trials.

An analysis of protocols and publications suggested that most discontinuations of clinical trials were not based on preplanned interim analyses or stopping rules.

OBJECTIVES To investigate the frequency of interim analyses, stopping rules, and data safety and monitoring boards (DSMBs) in protocols of randomized controlled trials (RCTs); to examine these features across different reasons for trial discontinuation; and to identify discrepancies in reporting between protocols and publications. STUDY DESIGN AND SETTING We used data from a cohort of RCT protocols approved between 2000 and 2003 by six research ethics committees in Switzerland, Germany, and Canada. RESULTS Of 894 RCT protocols, 289 prespecified interim analyses (32.3%), 153 stopping rules (17.1%), and 257 DSMBs (28.7%). Overall, 249 of 894 RCTs (27.9%) were prematurely discontinued; mostly due to reasons such as poor recruitment, administrative reasons, or unexpected harm. Forty-six of 249 RCTs (18.4%) were discontinued due to early benefit or futility; of those, 37 (80.4%) were stopped outside a formal interim analysis or stopping rule. Of 515 published RCTs, there were discrepancies between protocols and publications for interim analyses (21.1%), stopping rules (14.4%), and DSMBs (19.6%). CONCLUSION Two-thirds of RCT protocols did not consider interim analyses, stopping rules, or DSMBs. Most RCTs discontinued for early benefit or futility were stopped without a prespecified mechanism. When assessing trial manuscripts, journals should require access to the protocol.

Premature Discontinuation of Randomized Trials in Critical and Emergency Care: A Retrospective Cohort Study.

OBJECTIVES Randomized clinical trials that enroll patients in critical or emergency care (acute care) setting are challenging because of narrow time windows for recruitment and the inability of many patients to provide informed consent. To assess the extent that recruitment challenges lead to randomized clinical trial discontinuation, we compared the discontinuation of acute care and nonacute care randomized clinical trials. DESIGN Retrospective cohort of 894 randomized clinical trials approved by six institutional review boards in Switzerland, Germany, and Canada between 2000 and 2003. SETTING Randomized clinical trials involving patients in an acute or nonacute care setting. SUBJECTS AND INTERVENTIONS We recorded trial characteristics, self-reported trial discontinuation, and self-reported reasons for discontinuation from protocols, corresponding publications, institutional review board files, and a survey of investigators. MEASUREMENTS AND MAIN RESULTS Of 894 randomized clinical trials, 64 (7%) were acute care randomized clinical trials (29 critical care and 35 emergency care). Compared with the 830 nonacute care randomized clinical trials, acute care randomized clinical trials were more frequently discontinued (28 of 64, 44% vs 221 of 830, 27%; p = 0.004). Slow recruitment was the most frequent reason for discontinuation, both in acute care (13 of 64, 20%) and in nonacute care randomized clinical trials (7 of 64, 11%). Logistic regression analyses suggested the acute care setting as an independent risk factor for randomized clinical trial discontinuation specifically as a result of slow recruitment (odds ratio, 4.00; 95% CI, 1.72-9.31) after adjusting for other established risk factors, including nonindustry sponsorship and small sample size. CONCLUSIONS Acute care randomized clinical trials are more vulnerable to premature discontinuation than nonacute care randomized clinical trials and have an approximately four-fold higher risk of discontinuation due to slow recruitment. These results highlight the need for strategies to reliably prevent and resolve slow patient recruitment in randomized clinical trials conducted in the critical and emergency care setting.

Planning and reporting of quality-of-life outcomes in cancer trials.

BACKGROUND Information about the impact of cancer treatments on patients' quality of life (QoL) is of paramount importance to patients and treating oncologists. Cancer trials that do not specify QoL as an outcome or fail to report collected QoL data, omit crucial information for decision making. To estimate the magnitude of these problems, we investigated how frequently QoL outcomes were specified in protocols of cancer trials and subsequently reported. DESIGN Retrospective cohort study of RCT protocols approved by six research ethics committees in Switzerland, Germany, and Canada between 2000 and 2003. We compared protocols to corresponding publications, which were identified through literature searches and investigator surveys. RESULTS Of the 173 cancer trials, 90 (52%) specified QoL outcomes in their protocol, 2 (1%) as primary and 88 (51%) as secondary outcome. Of the 173 trials, 35 (20%) reported QoL outcomes in a corresponding publication (4 modified from the protocol), 18 (10%) were published but failed to report QoL outcomes in the primary or a secondary publication, and 37 (21%) were not published at all. Of the 83 (48%) trials that did not specify QoL outcomes in their protocol, none subsequently reported QoL outcomes. Failure to report pre-specified QoL outcomes was not associated with industry sponsorship (versus non-industry), sample size, and multicentre (versus single centre) status but possibly with trial discontinuation. CONCLUSIONS About half of cancer trials specified QoL outcomes in their protocols. However, only 20% reported any QoL data in associated publications. Highly relevant information for decision making is often unavailable to patients, oncologists, and health policymakers.

Pollen record from Kleiner Mochowsee, Germany

A Holocene pollen diagram from Kleiner Mochowsee (northern Niederlausitz, East Germany) shows pine as an important constituent of the woodland south of the Schwielochsee. Oak woodland was widespread since the Atlantic. Betula lost its importance at the end of the Preboreal. Fagus is represented continuously in the pollen record since the Atlantic, Carpinus since the Subboreal. However, the two latter tree species remain without great importance throughout the whole pollen record. The poor sandy soils are furthermore reflected by the low values of Corylus during the Boreal, comparable to other records from Berlin and its surrounding area. The 'classical' elm decline could be shown for the Niederlausitz, radiocarbon dates assume a contemporaneous age for this event with other records from northern Germany. Only small-scaled human impact is indicated in prehistoric times, during the migration period it seems to have ceased completely. Later, in the Medieval, deforestation and tillage can be shown. Secale was cultivated since the early Medieval; an accompanying weed flora appeared at the same time. Cultivation of Fagopyrum and Linum usitatissimum could be shown for the late Medieval times.

Pollen record and age determination of a sediment profile from Frengstadsetra, Norway

Innerdalen was once a mountain valley (ca. 780 m a.s.l.) with birch forests, bogs and several summer farms. Today it is a 6.5 km**2 artifical lake. In 1980 and 1981 archaeological and palynological investigations were carried out due to the hydroelectric power plans. Radiocarbon dated pollen diagrams from 9 different localities in Innerdalen provide information on a mountain environment which has been exploited to varying degrees by human groups for thousands of years. In the Birch Zone, ca. 9500-8500 years B.P., the deglaciated surface is vegetated by the normal sequence of pioneering species, first show-bed communities, then shrub/dwarf-shrub communities, and finally a birch forest community. In the Pine Zone, ca. 8500-7500 years B.P., the mixed Birch-Pine forest which prevailed at the end of the Birch Zone is replaced by a dense pine forest. The tree limit was higher than it is today. In the Alder Zone, ca. 7500-4000 years B.P., the newly arrived alder gradually succeeded pine, particularily on good soils. This alder forest has a modem analog in the pre-alpine gray alder forests in Norway. In the last part of the Alder Zone, ca. 6000-4000 years B.P., elm and hazel are nominally present on particularily rich soils, marking the edaphic and climatic optimum in Innerdalen. During this time the first evidence of human impact on the vegetation is apparent in the pollen diagrams. At both Sætersetra in the south of the valley and Liabekken in the north, forest clearance and the development of grazed grass meadows is documented, and human impact continues until the present. The Herb Zone, ca. 4000 years B.P. to 1600 A.D., is characterized by the rapid decline of alder. The forest is increasingly open, and bog formation is initiated. The sub-alpine belt of birch forest is established, probably due to the shift to a cooler, moister climate. Human activity can also have influenced the vegetational changes, although at 4 of the localities human activity also is first apparent after the alder decline. Some localities show measurably less human impact on the vegetation ca. 2600-2000 years B.P. Grazing intensity increases ca. 2000 years B.P. At the end of the Herb Zone rye and barley pollen is registered at Sætersetra and Flonan, indicating contact between the grazing activities of Innerdal and grain cultivation activities outside the valley. The Spruce Zone, ca. 1600 A.D. to the present, does not begin synchronously since the presence of long-distance transported spruce pollen at a locality is entirely dependent on the density of the vegetation ie. degree of human impact. The youngest spruce rise is ca. 1500 A.D. at Røstvangen, when summerfarming is initiated. Summerfarming activities in Innerdal produce an increasingly open landscape. Rye and barley pollen at several localities may indicate limited local cultivation, but is more likely long-distance transport via humans and domesticated animals from cultivated areas outside Innerdalen.

Pollen records from Elbe-Weser Dreieck

A long-running interdisciplinary research project on the development of landscape, prehistoric habitation and the history of vegetation within a "siedlungskammer" (limited habitation areal from neolithic to modern times has been carried out in the NW German lowlands, The siedlungskammer Flögeln is situated between the rivers Weser and EIbe and comprises about 23.5 km^2. It is an isolated pleistocene area surrounded by bogs, the soils consisting mainly of poor sands. In this siedlungskammer large-seale archaeological excavations and mappings have been performed, parallel to pedological, historical and above all pollen analytical investigations. The aim of the project is to record the individual phases in time, to delimit the respective settlement areas and to reconstruct the conditions of life and economy for each time period. A dense network of 10 pollen diagrams has been constructed. Several of them derive from the marginal area and from the centre of the large raised bog north of the siedlungskammer. These diagrams reflect the history of vegetation and habitation of a large region; due to the large pollen source area the habitation phases in the diagrams are poorly defined. Even in the utmost marginal diagram of this woodless bog, a great village with adjoining fields, situated only 100 m away from it, is registered with only low values of anthropogenic indicators. In contrast to this, the numerous pollen diagrams from kettle-hole bogs inside the siedlungskammer yield an exact picture of the habitation of the siedlungskammer and their individual parts. Early traces of habitation can be identified in the pollen diagram soon after the elm decline (around 5190 BP). Some time later in the middle neolithic period there follows a marked habitation phase, which starts between 4500 and 4400 BP and reflects the immigration of the trichterbecher culture. It corresponds to the landnam phase of Iversen in Denmark and begins with a sharp decline of the pollen curves of lime and oak, followed by the increase of anthropogenic indicators pointing to arable and pastural farming. High values of wild grasses and Calluna witness extensive forest grazing. This middle to late neolithic habitation is also registered archaeologically by settlements and numerous graves. After low human activity during Bronze Age and Older Iron Age times the archaeological and pollen analytical records of Roman and Migration periods is again very strong. This is followed by a gap in habitation during the 6th and 7th centuries and afterwards in the western part of the siedlungskammer from about 700 AD until the 14th century by the activity of the medieval village of Dalem, that was also excavated and whose fields were recorded by phosphate mapping to a size of 117 hectares. This medieval settlement phase is marked by much cereal cultivation (mainly rye). The dense network of pollen diagrams offers an opportunity to register the dispersion of the anthropogenic indicators from the areas of settlement to different distances and thus to obtain quantitative clues for the assessment of these anthropogenic indicators in pollen diagrams. In fig. 4 the reflection of the neolithic culture in the kettle-hole bogs and the large raised bog is shown in 3 phases: a) pre landnam, b) TRB-landnam, c) post landnam. Among arboreal pollen the reaction of Quercus is sharp close to the settlement but is not found at more distant profiles, whilst in contrast to this Tilia shows a significant decline even far away from the settlements. The record of most anthropogenic indicators outside the habitation area is very low, in particular cereal pollen is poorly dispersed; much more certain as an indicator for habitation (also for arable farming!) is Plantago lanceolata. A strong increase of wild grasses (partly Calluna aswell) some distance from the habitation areas indicates far reaching forest grazing. Fig. 5 illustrates the reflection of the anthropogenie indicators from the medieval village Dalem. In this instance the field area could be mapped exactly using phosphate investigations, and it has been possible to indicate the precise distances of the profile sites from the medieval fields. Here also, there is a clear correlation between decreasing anthropogenic indicators and increasing distance. In a kettle-hole bog (FLH) a distance of 3000 m away this marked settlement phase is not registered. The contrast between the pollen diagrams SWK and FLH (fig. 2 + 3, enclosure), illustrates the strong differences between diagrams from kettlehole bogs close to and distant from the settlements, for the neolithic as well as for the medieval period. On the basis of the examples presented here, implications concerning the interpretation of pollen diagrams with respect to habitation phases are discussed.