Key result
Among 123 cardiovascular RCTs with positive primary outcomes, the median fragility index was 13, and in 30.1% of trials, the number of patients lost to follow-up exceeded the fragility index.
Why the study?
Standard efficacy measures are not always intuitive to clinicians, leading the authors to assess the robustness of cardiovascular RCTs reporting a statistically significant primary outcome using the fragility index.
Systematic Review (n=123)
Effect estimate: Median 13
Many cardiovascular RCTs have a low fragility index, often smaller than the number of patients lost to follow-up, suggesting that statistically significant results should be interpreted cautiously.
Many significant cardiovascular RCT results remain fragile to few event shifts; challenges P-value reliance and supports routine fragility index reporting.
Background: Efficacy of an intervention is commonly evaluated using P values, in addition to effect size measures such as absolute risk reduction, relative risk reduction, and numbers needed to treat. However, these measures are not always intuitive to clinicians. The fragility index (FI) is a more intuitive number that can facilitate interpretation but can only be used with binary outcomes. FI is the minimum number of patients who must be moved from the nonevent group to the event group to turn a significant result nonsignificant. In this retrospective analysis, we assessed the robustness of cardiovascular randomized controlled trials (RCTs), which report a positive (statistically significant) primary outcome by using the FI. Methods and Results: We searched Medline from 2007 to 2017 to identify cardiovascular RCTs published in 6 high impact journals ( The Lancet , New England Journal of Medicine , Journal of the American Medical Association , Circulation , Journal of the American College of Cardiology and European Heart Journal ). Only RCTs with sample sizes >500 and a 2-by-2 factorial design or dichotomous primary outcomes were selected. FI was calculated using a defined approach. Among the cohort of 123 RCTs that met inclusion criteria, median FI was 13 (interquartile range, 5–26). In 28 trials (22.8%), FI ranged between 1 and 4. In 37 trials (30.1%), number of patients lost to follow-up was higher than the FI. Pharmaceutical interventions had higher FI compared with other interventions, FI=19 (7–52; P =0.002). Median FI varied according to subspecialty (electrophysiology=2; heart failure=11; interventional cardiology=8; P =0.020) and multiregional RCTs had higher FI=22 (12–53.25; P =0.023). FI did not differ based on risk of bias indicators, funding, or publication year. Conclusions: Considerable variations in FI were observed among cardiovascular trials, suggesting the need for careful interpretation of results, particularly when number of patients lost to follow-up exceeds FI.
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Khan et al. (2019) conducted a systematic review in Cardiovascular randomized controlled trials (n=123). Cardiovascular RCTs was evaluated on Fragility index (Median 13). Among 123 cardiovascular RCTs with positive primary outcomes, the median fragility index was 13, and in 30.1% of trials, the number of patients lost to follow-up exceeded the fragility index.
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