Author Affiliations: Departments of Social and Preventive Medicine (Drs Huwiler-Müntener, Junker, and Egger) and Rheumatology and Clinical Immunology (Dr Jüni), University of Bern, Bern, Switzerland; and MRC Health Services Research Collaboration, Department of Social Medicine, University of Bristol, Bristol, England (Drs Jüni and Egger).
Context The evaluation of the methodologic quality of randomized controlled
trials (RCTs) is central to evidence-based health care. Important methodologic
detail may, however, be omitted from published reports, and the quality of
reporting is therefore often used as a proxy measure for methodologic quality.
We examined the relationship between reporting quality and methodologic quality
of published RCTs.
Methods Study of 60 reports of placebo-controlled trials published in English-language
journals from 1985 to 1997. Reporting quality was measured using a 25-item
scale based on the 1996 issue of the Consolidated Standards of Reporting Trials
(CONSORT). Concealment of allocation, appropriate blinding, and analysis according
to the intention-to-treat principle were indicators of methodologic quality.
Methodologic quality was compared between groups of trials defined by reporting
quality scores of low, intermediate, and high. Reporting quality scores were
compared between groups defined by high and low methodologic quality.
Results Among 23 trials of low reporting quality (median score, 9 [range, 3.5-10.5]),
allocation concealment was unclear for all but 1 trial, but there were 16
trials (70%) with adequate blinding and 9 trials (39%) that had been analyzed
according to the intention-to-treat principle. Among 18 trials of high reporting
quality (median score, 18 [range 16.5-22.0]), there were 8 trials (44%) with
adequate allocation concealment, 16 trials (89%) with adequate blinding, and
13 trials (72%) analyzed according to the intention-to-treat principle. The
median reporting score was 15.0 for the 33 trials that were analyzed according
to intention-to-treat principle and 14.5 for the 14 trials with on-treatment
analyses (P = .67).
Conclusions Similar quality of reporting may hide important differences in methodologic
quality, and well-conducted trials may be reported badly. A clear distinction
should be made between these 2 dimensions of the quality of RCTs.
The randomized controlled trial (RCT) is the design of choice for evaluating
the effectiveness of health care interventions, but trials are not immune
to bias. The validity of their results is threatened by the subversion of
randomization, resulting in biased allocation to comparison groups, the unequal
provision of care apart from the intervention under evaluation, the biased
assessment of outcomes, and the inadequate handling of dropouts and losses
to follow-up. Several studies1 have recently
documented these biases. For example, Schulz et al2
demonstrated, for trials with binary outcomes included in meta-analyses from
the Cochrane Pregnancy and Childbirth Database, that trials in which randomization
was inadequately concealed yielded exaggerated estimates of treatment effect
in comparison with trials that reported adequate concealment and found a similar
(but smaller) overestimation of treatment effects for trials that were not
Information on trial quality is important for peer review, when considering
the results from individual trials and for the conduct of unbiased systematic
reviews. The assessment of the methodologic quality of a trial is closely
intertwined with the quality of reporting, that is, the extent to which a
report provides information about the design, conduct, and analysis of the
trial. Trial reports often omit important methodologic details. A widely used
approach to this problem consists in treating reporting quality as a proxy
measure for methodologic quality. This could be justified if the assumption
were correct that faulty reporting reflects faulty methods.3
The objective of our study was to examine the relationship between the quality
of reporting and the methodologic quality of RCTs.
This analysis is based on a sample of 60 reports of placebo-controlled
trials assembled in the context of a study4
that examined the interrater reliability of quality scales. We aimed to include
a wide range of journals, disciplines, and authors through the use of a database
of controlled trials that had been assembled within the framework of a study
of language bias.5 Described in detail elsewhere,6 the database included 89 reports of placebo-controlled
trials published from 1985 to 1997 in 29 English-language specialist journals
by authors based in German-speaking Europe. We searched MEDLINE to identify
89 additional reports of placebo-controlled trials published in the same journals
around the same time by authors from English-speaking countries. Twenty trials
were randomly selected from each of these 2 samples (computer-generated random
numbers). Finally, we searched MEDLINE to identify another 89 placebo-controlled
trials that were published in 1997 in 1 of the 5 leading general medicine
journals (Annals of Internal Medicine, BMJ, JAMA, New England Journal of Medicine, and The Lancet). We again selected 20 reports at random.
We used concealment of allocation, blinding, and analysis according
to the intention-to-treat principle as indicators of methodologic quality
and classified these indicators as adequate, inadequate, or unclear. For concealment,
the following approaches to prevent foreknowledge of allocation were considered
adequate: sequentially numbered, sealed, opaque envelopes; coded drug packs
prepared by an independent pharmacy; and central randomization. Other methods,
such as the use of an open random number table, were considered inadequate.
For blinding, a trial was classified as adequate if it was described as "double-blind"
or the blinding of both patients and outcome assessors was mentioned. The
analysis was considered adequate if all randomized patients were included
in the analysis in the group they had been allocated to (intention-to-treat
analysis). An on-treatment analysis was considered inadequate.
We developed a 30-item scale based on the 1996 Consolidated Standards
of Reporting Trials (CONSORT) statement7 to
assess reporting quality.4 For this analysis,
we excluded 5 items that were closely related to our indicators of methodologic
quality (Table 1). All questions
were answered with yes or no, and each yes answer earned 1 point, for a maximum
of 25 points.
Two observers (K.H.-M., C.J.) assessed reports. For each article, we
calculated the average reporting quality score from the 2 independent assessments.
Discrepancies in the assessment of methodologic quality were resolved by consensus.
Interobserver agreement was high: the intraclass correlation coefficient for
the summary score was 0.81 (95% confidence interval [CI], 0.69-0.88). The κ
values for allocation concealment was 0.96 (95% CI, 0.70-1.00); for blinding,
0.94 (95% CI, 0.69-1.00); and for intention-to-treat analysis, 0.93 (95% CI,
0.68-1.00). We compared the methodologic quality among 3 similarly sized groups
of trials defined by low, intermediate, and high reporting quality scores
and reporting quality scores among groups defined by high and low methodologic
quality. We calculated χ2tests and Kruskal-Wallis tests using
Stata version 7 statistical software (Stata Corp, College Station, Tex).
The average quality of reporting was low (median score, 12.5). The distribution
of scores was bimodal (Figure 1),
which was explained by better reporting in the 5 general medicine journals
compared with the specialist journals (median scores, 10.5 vs 17.0; P = .0001 by Kruskal-Wallis test). The median score was
9.0 (range, 3.50-10.5) for the low-reporting-quality group (23 trials), 12.5
(range, 11.5-16.0) for the intermediate-reporting-quality group (19 trials),
and 18 (range, 16.5-22.0) for the high-reporting-quality group (18 trials).
Associations between reporting quality and methodologic quality were evident
for all 3 indicators of methodologic quality (Table 2), which is not surprising considering that there were many
trials with unclear methodologic assessments. This was the case for allocation
concealment in 45 trials (75%), for blinding in 12 trials (20%), and for intention-to-treat
analysis in 13 trials (22%). The poor quality of reporting meant that for
allocation concealment and blinding it was only possible to distinguish between
trials with appropriate and unclear methods, whereas trials with appropriate
intention-to-treat analyses, inappropriate on-treatment analyses, and unclear
analyses were identified.
Although reporting quality is associated with methodologic quality,
using reporting quality as a proxy measure for methodologic quality would
result in misclassification of a considerable proportion of trials. For example,
most trials of low reporting quality were adequately blinded (16 [70%]), and
9 (39%) were analyzed according to the intention-to-treat principle. On the
other hand, 5 (28%) of the trials of high reporting quality had presented
inappropriate on-treatment analyses rather than intention-to-treat analyses
(Table 2). The quality of reporting
was similar in trials analyzed appropriately and inappropriately: the median
reporting score was 15.0 for the 33 trials that were analyzed according to
the intention-to-treat principle and 14.5 for the 14 trials with on-treatment
analyses (P = .67). Finally, even among trials of
high reporting quality, most reports (56%) did not indicate whether allocation
had been concealed.
The evaluation of the methodologic quality of RCTs is central to the
appraisal of individual trials and the conduct of unbiased systematic reviews.8 Assessments of methodologic quality depend on the
quality of reporting, and incomplete reporting is often interpreted as low
methodologic quality. We attempted to disentangle the relationship between
reporting quality and methodologic quality by using a scale based on the CONSORT
statement and by separately assessing 3 central dimensions of methodologic
quality. Our results document once again that trial reports frequently omit
important methodologic detail: in most trials, it was unclear whether the
allocation of participants had been concealed appropriately. The poor reporting
on concealment may be due to the fact that many trials were published before
Schulz et al2 demonstrated the importance of
adequate concealment of allocation for prevention of bias in RCT research.
The generally low quality of reporting in specialist journals must be of concern
and underscores the importance of the CONSORT statement both for specialist
and general medical journals.
As could be expected, the strength of the association between overall
quality of reporting and methodologic quality depended on the proportion of
trials with unclear reporting on the 3 indicators of methodologic quality.
The reporting score thus measured what it was supposed to measure; but is
it also a good proxy measure for methodologic quality? Our results demonstrate
that based on reporting quality alone, the true quality of a substantial proportion
of well-conducted trials and of trials of low methodologic quality will be
misjudged. Indeed, the quality of reporting of trials that were analyzed according
to the intention-to-treat principle was not different from that of trials
presenting on-treatment analyses only. The intention-to-treat approach is,
of course, essential to maintain treatment groups that are similar apart from
random variation, and this crucial feature may be lost if the analysis is
not performed on the groups initially produced by the randomization process.9
Our study has a number of limitations. The trials analyzed were published
several years ago and may no longer reflect current reporting practices. There
is evidence that the quality of reporting has improved in journals that have
adopted CONSORT.10 This would not, however,
invalidate our findings on the relationship between reporting quality and
methodologic quality. On the contrary, with increasing quality of reporting,
scales based on reporting quality will become less accurate measures of methodologic
quality. Our reporting scale was based on the 1996 CONSORT statement rather
than the revised version published recently.11
It is possible that a scale based on the 2001 version of CONSORT would measure
reporting quality more precisely, but it is unlikely that it would be a better
measure of methodologic quality. Finally, we assumed that blinding was appropriate
if the authors stated that the trial was "double-blind." This term has since
been shown to be ambiguous and should no longer be used.8,12
In conclusion, reporting quality is associated with methodologic quality,
but similar quality of reporting may hide important differences in methodologic
quality and well-conducted trials may be reported badly. A clear distinction
should therefore be made between reporting and methodologic quality of trials.
Scales that predominantly measure reporting quality, for example, the scales
developed by Jadad et al13 or Chalmers et al,14 should not be used to measure methodologic quality.
Rather, the important methodologic aspects should be identified a priori and
assessed individually. This should generally include the key domains of concealment
of treatment allocation, blinding of outcome assessment, and handling of attrition
in the analysis. Finally, continued efforts are required to improve the quality
of reporting of randomized trials.
Huwiler-Müntener K, Jüni P, Junker C, Egger M. Quality of Reporting of Randomized Trials as a Measure of Methodologic Quality. JAMA. 2002;287(21):2801-2804. doi:10.1001/jama.287.21.2801