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Alternative analyses for handling incomplete follow-up in the intention-to-treat analysis: the randomized controlled trial of balloon kyphoplasty versus non-surgical care for vertebral compression fracture (FREE).

Ranstam, Jonas; Turkiewicz, Aleksandra; Boonen, Steven; Van Meirhaeghe, Jan; Bastian, Leonard; Wardlaw, Douglas

Authors

Jonas Ranstam

Aleksandra Turkiewicz

Steven Boonen

Jan Van Meirhaeghe

Leonard Bastian

Douglas Wardlaw



Abstract

Background - Clinical trial participants may be temporarily absent or withdraw from trials, leading to missing data. In intention-to-treat (ITT) analyses, several approaches are used for handling the missing information - complete case (CC) analysis, mixed-effects model (MM) analysis, last observation carried forward (LOCF) and multiple imputation (MI). This report discusses the consequences of applying the CC, LOCF and MI for the ITT analysis of published data (analysed using the MM method) from the Fracture Reduction Evaluation (FREE) trial. Methods - The FREE trial was a randomised, non-blinded study comparing balloon kyphoplasty with non-surgical care for the treatment of patients with acute painful vertebral fractures. Patients were randomised to treatment (1:1 ratio), and stratified for gender, fracture aetiology, use of bisphosphonates and use of systemic steroids at the time of enrolment. Six outcome measures - Short-form 36 physical component summary (SF-36 PCS) scale, EuroQol 5-Dimension Questionnaire (EQ-5D), Roland-Morris Disability (RMD) score, back pain, number of days with restricted activity in last 2 weeks, and number of days in bed in last 2 weeks - were analysed using four methods for dealing with missing data: CC, LOCF, MM and MI analyses. Results There were no missing data in baseline covariates values, and only a few missing baseline values in outcome variables. The overall missing-response level increased during follow-up (1 month: 14.5%; 24 months: 28%), corresponding to a mean of 19% missing data during the entire period. Overall patterns of missing response across time were similar for each treatment group. Almost half of all randomised patients were not available for a CC analysis, a maximum of 4% were not included in the LOCF analysis, and all randomised patients were included in the MM and MI analyses. Improved estimates of treatment effect were observed with LOCF, MM and MI compared with CC; only MM provided improved estimates across all six outcomes considered. Conclusions - The FREE trial results are robust as the alternative methods used for substituting missing data produced similar results. The MM method showed the highest statistical precision suggesting it is the most appropriate method to use for analysing the FREE trial data. Trial Registration This trial is registered with ClinicalTrials.gov (number NCT00211211).

Journal Article Type Article
Publication Date Dec 31, 2013
Journal BMC medical research methodology
Electronic ISSN 1471-2288
Publisher Springer (part of Springer Nature)
Peer Reviewed Peer Reviewed
Volume 12
Article Number 35
Institution Citation RANSTAM, J., TURKIEWICZ, A., BOONEN, S., VAN MEIRHAEGHE, J., BASTIAN, L. and WARDLAW, D. 2012. Alternative analyses for handling incomplete follow-up in the intention-to-treat analysis: the randomized controlled trial of balloon kyphoplasty versus non-surgical care for vertebral compression fracture (FREE). BMC medical research methodology [online], 12, article 35. Available from: https://doi.org/10.1186/1471-2288-12-35
DOI https://doi.org/10.1186/1471-2288-12-35
Keywords Clinical trial; Intention to treat; Balloon kyphoplasty; Nonsurgical care; Vertebral fractures

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