Core Outcome Measures in Effectiveness Trials .

Core Outcome Measures in Effectiveness Trials

www.comet-initiative.org

Acknowledgements• COMET Management Group:

Doug Altman, Jane Blazeby, Mike Clarke, Paula Williamson

• COMET project coordinator: Elizabeth Gargon

• Funding: MRC, FP7

• Collaborators: Peter Tugwell, Maarten Boers, Caroline Terwee, Holger Schunemann, Michael Rose, Sunita Vohra, Roberto D’Amico, Lorenzo Moja

Health care research is untidy

• It needs to be tidied up if it is to achieve its aim of helping practitioners and patients to improve health care and health

• This needs initiatives such as The Cochrane Collaboration for the preparation and maintenance of systematic reviews and COMET for core outcome sets

4

Systematic review of evidence on selective outcome reporting

• Studies reporting positive or significant results are more likely to be published

• Outcomes that are statistically significant are more likely to be fully reported

• 40–62% of publications had at least one primary outcome changed, newly introduced or omitted compared to protocol

[Dwan et al, PLoS ONE 2008]

5

Interviews with trialists (n=59)

• Discussion of outcomes listed in their protocol but not their trial report

• 29% trials displayed outcome reporting bias• All trialists mentioned either - outcomes not measured - outcomes measured but not analysed - Lack of clarity about importance or feasibility of

measurement for outcomes chosen[Smyth et al, BMJ 2010]

Core outcome set

• An agreed standardised set of outcomes that should be measured and reported, as a minimum, in all clinical trials in specific areas of health or health care

• Consider both benefits and harms

• The minimum (other outcomes can be collected)

• Focus is on trials of effectiveness

• “What” to measure, then “How”

Core outcome set

Scope of the COS • “The specific area of health or healthcare that the COS is to apply

to, in terms of health condition, population and types of interventions needs to be determined.”

• All stages or severity of a specific health condition or focussed on a particular disease category

- e.g. in colorectal cancer, a COS might be developed for all patients or it may focus on patients with metastatic disease

• All treatment types or for a particular intervention - e.g. in morbid obesity, a COS may be created to use in trials of all

interventions or just bariatric surgery alone

Advantages of core outcome sets

• Increases consistency across trials• Maximise potential for trial to

contribute to systematic reviews of these key outcomes

• Much more likely to measure appropriate outcomes

• Major reduction in selective reporting

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Improvements over time (Kirkham et al, Trials 2013)

Studies reporting full RA COS (%)

WHO/ILARRA COS

EMAguideline

FDAguideline

100

80

60

40

20

1985 1990 1995 2000 2005 2010

0

Mean number of clinical outcomes

6.0

6.5

7.0

0.0

drug studies

non-drug studies

The COMET Initiative • To raise awareness of current problems with

outcomes in clinical trials• To encourage COS development and uptake• To provide resources to allow practitioners to

develop COS, e.g. COMET database

• An international network of trialists, systematic reviewers, health service users, practitioners, editors, funders, policy makers, regulators

COMET Initiative

• ‘What’ to measure

• ‘How’ to measure (validity, reliability, feasibility) - COSMIN

- PROMIS- PROQOLID- TREAT-NMD ROM

Website

Background

COMET Database• A publically accessible internet-based

resource to collate the knowledge base for core outcome set development

• To include planned and ongoing work, as well as published core outcome set development

• 200+ published, 50+ ongoing

Search results

ScopeIdentifying existing knowledgeStakeholder involvementConsensus methodsAchieving global consensusRegular review, feedback, updatingImplementation Clear presentation

Stakeholder involvement

• Health care practitioners • Patients, carers, representatives • Regulators• Industry representatives • Researchers • Stage of involvement may vary by group

Patient and public involvement

• Impact of involvement– Rheumatology (OMERACT): fatigue – Chronic pain (IMMPACT): expansion of

previously proposed core outcome domains

– Multiple sclerosis: fatigue, continence– Paediatric asthma

Comparison of studies SINHA ET AL

REDDELL ET AL BUSSE ET AL

5-11 years 12+ years

TOP 6 PARENTS +/- CLINICIANS ESSENTIAL OPTIONAL ESSENTIAL OPTIONAL ESSENTIAL OPTIONAL

Symptoms

√ √ √

Exacerbations

√ √ √ √

QoL

√ √ √ √

Death

√ √

Normal activities

√ √

Exercise ability

√

Reliever use

√ √

Lung function

√ √ √

Tx side effects

√

Healthcare utilisation

√ √ √

Biomarkers

√

Hyper-responsiveness

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Professor Hywel Williams, Chair of the NIHR HTA Commissioning Board: ‘Patients and professionals making decisions about health care need access to reliable evidence. The new COMET database will help researchers across the NIHR family and beyond when choosing the outcomes to include in the studies that will establish this evidence base'.

• Since the COMET website and database were launched in August 2011:– 3800+ searches have been undertaken– 12000+ individuals visited – 110+ countries visiting the site

Impact

www.comet-initiative.org

e.gargon@liv.ac.uk

Twitter: @COMETinitiative