Issues in statistical reviewing       Jonas Ranstam PhD
Authors and editors have the same goalsAdvancement of scientific understanding and improvementin the treatment and prevent...
Poor research methods, unnecessary research, redundant orduplicate publication, thinly sliced study results, selectiverepo...
Douglas G Altman. JAMA 2002;287:2765
Systematic reviews of orthopedic literatureThe ITT principle was recognized in 96 of 274 (35%)published randomized trials....
Systematic reviews of orthopedic literatureA high proportion (42%) of clinical studies in high-impact-factor orthopedic jo...
Systematic reviews of laboratory literatureA systematic review of 44 animal studies on fluidresuscitation shows ... that o...
Altman et al. JAMA 2002;287:2817-2820
The ultimate interpretation anddecision about the value of anarticle rests with the reader.Gehlbach SH. Interpreting the M...
The responsibilities of a statistical reviewer“To make sure that the authors spell out for thereader the limitations impos...
General statistical considerationsAttention all co-editorsRegardless of whether manuscripts describe anobservational clini...
Study aimWhat is the aim of the study?- To confirm a pre-specified hypothesis, or- To generate new hypothesesA confirmator...
Statistical methodsEvaluation of sampling/measurement uncertainty- What methods were used?- What assumption were made?- Ho...
ResultsObservationsIndividual- Dotplots, stem and leaf plots, scattergrams, etc.Aggregated- Central tendency (mean, median...
ResultsInterpretationUncertainty evaluation is based on1) Effect/difference2) Variability between independent observations...
The number of observations is important27 hips from 21 patients or 130 pieces of cartilage from 5patients indicate that no...
Within-subject variation                                       Analytic variabilityBetween-subject variation           (me...
ResultsObservations and interpretations should not be confused- observed variability (SD) and- estimation uncertainty (SEM...
Statistical vs. clinical significanceAll statistically significant effects are not clinically important.(like a 6% reducti...
Statistical vs. clinical significanceClinical significance is statistically important for thei) sample size calculation,ii...
Uncertainty evaluationHypothesis tests (p-values)- Type-1 (only false positive) errorsInterval estimation- Confidence leve...
P-values vs. confidence intervals             P-values                  Conclusion from confidence intervals              ...
ResultsP-values- should, unless p<0.001, be presented as p=0.023- not like p=0.000, p>0.05, p<0.05, ns, or *, **, ***. (No...
In what direction is medical    research heading?
Medical research as a modern scienceRandomised controlled trial (1948)Medical Research Council. Streptomycin in Tuberculos...
Recent developmentsA. ICH harmonized tripartite guidelines (1998)- E9 Statistical principles for clinical trials,- Note fo...
Using resources more efficientlyPoorly written and unclear manuscripts waste both author and reviewresources:a) it takes t...
Using resources more efficientlyAuthor completed checklists will help authors write bettermanuscripts as well as facilitat...
Acta Orthopedica and reportingguidelineswhich, how, when?
Odense 2010
Odense 2010
Odense 2010
Odense 2010
Odense 2010
Odense 2010
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Odense 2010

  1. 1. Issues in statistical reviewing Jonas Ranstam PhD
  2. 2. Authors and editors have the same goalsAdvancement of scientific understanding and improvementin the treatment and prevention of disease.
  3. 3. Poor research methods, unnecessary research, redundant orduplicate publication, thinly sliced study results, selectivereporting, and scientific fraud, as well as a general tendencyto inflate the importance of the results, should all be resistedvigorously.In particular, methodological review should be implementedmuch more widely.Douglas G Altman. JAMA 2002;287:2765
  4. 4. Douglas G Altman. JAMA 2002;287:2765
  5. 5. Systematic reviews of orthopedic literatureThe ITT principle was recognized in 96 of 274 (35%)published randomized trials.Herman A, Botser IB, Tenenbaum S, and Chechick A.Intention-to-treat analysis and accounting for missingdata in orthopaedic randomized clinical trials. J BoneJoint Surg Am. 2009;91:2137-2143.
  6. 6. Systematic reviews of orthopedic literatureA high proportion (42%) of clinical studies in high-impact-factor orthopedic journals involve the inappropriate use ofmultiple observations from single individualsBryant et al. How Many Patients? How Many Limbs?Analysis of Patients or Limbs in the Orthopaedic Literature.JBJS Am 2006;88:41-45.
  7. 7. Systematic reviews of laboratory literatureA systematic review of 44 animal studies on fluidresuscitation shows ... that only two of the reviewedpapers described how experimental units were allocatedto treatment.Roberts I, Kwan I, Evans P, Haig S. Does animalexperimentation inform human healthcare? Observationsfrom a systematic review of international animalexperiments on fluid resuscitation. Br Med J 2002;324:474e6.
  8. 8. Altman et al. JAMA 2002;287:2817-2820
  9. 9. The ultimate interpretation anddecision about the value of anarticle rests with the reader.Gehlbach SH. Interpreting the Medical Litera-ture: A Clinician’s Guide. 3rd ed. New York, NY:McGraw-Hill; 1993.
  10. 10. The responsibilities of a statistical reviewer“To make sure that the authors spell out for thereader the limitations imposed upon theconclusions by the design of the study, thecollection of data, and the analyses performed.”Shor S. The responsibilities of a statistical reviewer. Chest 1972;61:486-487.
  11. 11. General statistical considerationsAttention all co-editorsRegardless of whether manuscripts describe anobservational clinical study or a laboratory experimentconsider these comments.
  12. 12. Study aimWhat is the aim of the study?- To confirm a pre-specified hypothesis, or- To generate new hypothesesA confirmatory study protects the type-1 error rate, and thiscan only be achieved in an experiment (on cells, animals orpatients).Do the authors conclusion reflect their study aim?
  13. 13. Statistical methodsEvaluation of sampling/measurement uncertainty- What methods were used?- What assumption were made?- How was the assumption fulfillment checked?- Where any departures indicated?
  14. 14. ResultsObservationsIndividual- Dotplots, stem and leaf plots, scattergrams, etc.Aggregated- Central tendency (mean, median, mode)- Dispersion (SD, interquartile distance, range)- Number of observations!!!!!
  15. 15. ResultsInterpretationUncertainty evaluation is based on1) Effect/difference2) Variability between independent observations3) Number of observations!!!!!
  16. 16. The number of observations is important27 hips from 21 patients or 130 pieces of cartilage from 5patients indicate that not all observations are independent.Many statistical techniques (but not all) are based on anassumption of independent observations.
  17. 17. Within-subject variation Analytic variabilityBetween-subject variation (measurement errors)
  18. 18. ResultsObservations and interpretations should not be confused- observed variability (SD) and- estimation uncertainty (SEM)- clinical significance (practical/clinical relevance)- statistical significance (degree of uncertainty)NoteOnly presenting p-values is not meaningful!!!Results should be presented in terms of effect size, andtheir uncertainty should be indicated.
  19. 19. Statistical vs. clinical significanceAll statistically significant effects are not clinically important.(like a 6% reduction in body hair growth rate)All clinically important effects are not statistically significant.(like a 20% increase in systolic blood pressure)
  20. 20. Statistical vs. clinical significanceClinical significance is statistically important for thei) sample size calculation,ii) performance of the statistical analysis, andiii) interpretation of the results.
  21. 21. Uncertainty evaluationHypothesis tests (p-values)- Type-1 (only false positive) errorsInterval estimation- Confidence level, allows interpretation in terms of false positive as well as false negative errors. (This is of course also important for the interpretation of differences with unknown clinical consequences)
  22. 22. P-values vs. confidence intervals P-values Conclusion from confidence intervals Statistically and clinically significant effect p < 0.05 p < 0.05 Statistically, but not necessarily clinically, significant effect n.s. Inconclusive n.s. Neither statistically nor clinically significant effect p < 0.05 Statistically significant reversed effectEffect 0 Clinically significant effects
  23. 23. ResultsP-values- should, unless p<0.001, be presented as p=0.023- not like p=0.000, p>0.05, p<0.05, ns, or *, **, ***. (Note that “ns” is the SI-unit for nanosecond)“Negative” results (statistical insignificance)- “there was no difference”- absence of evidence is not evidence of absence- similarity may be presented using confidence intervals
  24. 24. In what direction is medical research heading?
  25. 25. Medical research as a modern scienceRandomised controlled trial (1948)Medical Research Council. Streptomycin in Tuberculosis TrialsCommittee. Streptomycin treatment of pulmonary tuberculosis.BMJ 1948;2:769-83.Observational cohort study (1950)Doll R, Hill AB. Smoking and carcinoma of the lung. Preliminaryreport, BMJ 1950;2:739-748.Case-control study (1954)Doll R, Hill AB. The mortality of doctors in relation to their smokinghabits. BMJ 1954;228:1451-5
  26. 26. Recent developmentsA. ICH harmonized tripartite guidelines (1998)- E9 Statistical principles for clinical trials,- Note for guidance, Points to consider, etc.B. Public registration of study protocols (2005)- ClinicalTrials.gov, etc.- WHO ICTRPC. Reporting guidelines (1996 - 2010)- CONSORT (RTCs)- PRISMA (Systematiska reviews)- STROBE (Observationella studier)- STARD (Diagnostiska studier)- ARRIVE (Djurförsök)
  27. 27. Using resources more efficientlyPoorly written and unclear manuscripts waste both author and reviewresources:a) it takes too much time to understand what the authors have not described or explainedb) clarifying what has actually been done takes one or more manuscript revisions, and these require further reviewingc) when the authors mistakes and misunderstandings have been clearly exposed the revised or re-revised manuscript may be rejected
  28. 28. Using resources more efficientlyAuthor completed checklists will help authors write bettermanuscripts as well as facilitate the reviewing of themCONSORT (RCTs)PRISMA (Systematic reviews)STROBE (Observational studies)STARD (Studies on diagnostic accuracy)ARRIVE (In vitro experiments)
  29. 29. Acta Orthopedica and reportingguidelineswhich, how, when?
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