Stopping randomized trials early for benefit and estimation of treatment effects: Systematic review and meta-regression analysis

Dirk Bassler, Matthias Briel, Victor M. Montori, Melanie Lane, Paul Glasziou, Qi Zhou, Diane Heels-Ansdell, Stephen D. Walter, Gordon H. Guyatt, David N. Flynn, Mohamed B. Elamin, Mohammad Hassan Murad, Nisrin O. Abu Elnour, Julianna F. Lampropulos, Amit Sood, Rebecca J. Mullan, Patricia J. Erwin, Clare R. Bankhead, Rafael Perera, Carolina Ruiz CulebroJohn J. You, Sohail M. Mulla, Jagdeep Kaur, Kara A. Nerenberg, Holger Schünemann, Deborah J. Cook, Kristina Lutz, Christine M. Ribic, Noah Vale, German Malaga, Elie A. Akl, Ignacio Ferreira-Gonzalez, Pablo Alonso-Coello, Gerard Urrutia, Regina Kunz, Heiner C. Bucher, Alain J. Nordmann, Heike Raatz, Suzana Alves Da Silva, Fabio Tuche, Brigitte Strahm, Benjamin Djulbegovic, Neill K.J. Adhikari, Edward J. Mills, Femida Gwadry-Sridhar, Haresh Kirpalani, Heloisa P. Soares, Paul J. Karanicolas, Karen E.A. Burns, Per Olav Vandvik, Fernando Coto-Yglesias, Pedro Paulo M. Chrispim, Tim Ramsay

Research output: Contribution to journalReview article

360 Scopus citations

Abstract

Context: Theory and simulation suggest that randomized controlled trials (RCTs) stopped early for benefit (truncated RCTs) systematically overestimate treatment effects for the outcome that precipitated early stopping. Objective: To compare the treatment effect from truncated RCTs with that from metaanalyses of RCTs addressing the same question but not stopped early (nontruncated RCTs) and to explore factors associated with overestimates of effect. Data Sources: Search of MEDLINE, EMBASE, Current Contents, and full-text journal content databases to identify truncatedRCTsupto January2007;search ofMEDLINE,Cochrane Database of Systematic Reviews, and Database of Abstracts of Reviews of Effects to identify systematic reviews from which individualRCTswere extractedupto January 2008. Study Selection: Selected studies were RCTs reported as having stopped early for benefit and matching nontruncated RCTs from systematic reviews. Independent reviewers with medical content expertise, working blinded to trial results, judged the eligibility of the nontruncated RCTs based on their similarity to the truncated RCTs. Data Extraction: Reviewers with methodological expertise conducted data extraction independently. Results: The analysis included 91 truncated RCTs asking 63 different questions and 424 matching nontruncated RCTs. The pooled ratio of relative risks in truncated RCTs vs matching nontruncated RCTs was 0.71 (95% confidence interval, 0.65-0.77). This difference was independent of the presence of a statistical stopping rule and the methodological quality of the studies as assessed by allocation concealment and blinding. Large differences in treatment effect size between truncated and nontruncated RCTs (ratio of relative risks <0.75) occurred with truncated RCTs having fewer than 500 events. In 39 of the 63 questions (62%), the pooled effects of the nontruncated RCTs failed to demonstrate significant benefit. Conclusions: Truncated RCTs were associated with greater effect sizes than RCTs not stopped early. This difference was independent of the presence of statistical stopping rules and was greatest in smaller studies.

Original languageEnglish (US)
Pages (from-to)1180-1187
Number of pages8
JournalJAMA - Journal of the American Medical Association
Volume303
Issue number12
DOIs
StatePublished - Mar 24 2010

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ASJC Scopus subject areas

  • Medicine(all)

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Bassler, D., Briel, M., Montori, V. M., Lane, M., Glasziou, P., Zhou, Q., Heels-Ansdell, D., Walter, S. D., Guyatt, G. H., Flynn, D. N., Elamin, M. B., Murad, M. H., Abu Elnour, N. O., Lampropulos, J. F., Sood, A., Mullan, R. J., Erwin, P. J., Bankhead, C. R., Perera, R., ... Ramsay, T. (2010). Stopping randomized trials early for benefit and estimation of treatment effects: Systematic review and meta-regression analysis. JAMA - Journal of the American Medical Association, 303(12), 1180-1187. https://doi.org/10.1001/jama.2010.310