Abstract
BackgroundPalliative care trials have higher rates of attrition. The MORECare guidance recommends applying classifications of attrition to report attrition to help interpret trial results. The guidance separates attrition into three categories: attrition due to death, illness or at random. The aim of our study is to apply the MORECare classifications on reported attrition rates in trials.MethodsA systematic review was conducted and attrition classifications retrospectively applied. Four databases, EMBASE; Medline, CINHAL and PsychINFO, were searched for randomised controlled trials of palliative care populations from 01.01.2010 to 08.10.2016. This systematic review is part of a larger review looking at recruitment to randomised controlled trials in palliative care, from January 1990 to early October 2016. We ran random-effect models with and without moderators and descriptive statistics to calculate rates of missing data.ResultsOne hundred nineteen trials showed a total attrition of 29% (95% CI 28 to 30%). We applied the MORECare classifications of attrition to the 91 papers that contained sufficient information. The main reason for attrition was attrition due to death with a weighted mean of 31.6% (SD 27.4) of attrition cases. Attrition due to illness was cited as the reason for 17.6% (SD 24.5) of participants. In 50.8% (SD 26.5) of cases, the attrition was at random. We did not observe significant differences in missing data between total attrition in non-cancer patients (26%; 95% CI 18–34%) and cancer patients (24%; 95% CI 20–29%). There was significantly more missing data in outpatients (29%; 95% CI 22–36%) than inpatients (16%; 95% CI 10–23%). We noted increased attrition in trials with longer durations.ConclusionReporting the cause of attrition is useful in helping to understand trial results. Prospective reporting using the MORECare classifications should improve our understanding of future trials.
Highlights
Palliative care trials have higher rates of attrition
Missing data can be classified into three categories (Table 1): completely missing at random (CMAR), missing at random (MAR) and missing not at-random (MNAR), but in palliative care populations, missing data could mostly likely to be classified as MNAR because the patients being too unwell to complete a trial [1]
The MORECare classifications provided a useful tool in highlighting attrition due to death in a readily accessible manner
Summary
Palliative care trials have higher rates of attrition. The MORECare guidance recommends applying classifications of attrition to report attrition to help interpret trial results. Missing data can be classified into three categories (Table 1): completely missing at random (CMAR), missing at random (MAR) and missing not at-random (MNAR), but in palliative care populations, missing data could mostly likely to be classified as MNAR because the patients being too unwell to complete a trial [1] This is likely to be as a result of health deterioration, comorbidities and frailty [6], which are not random events [1, 7]. A barrier to the development of good practice in palliative care is the lack of quality research and evidence [8] For this reason the MORECare guidance has been developed to identify research standards to aid future studies [8]. The inclusion of the MORECare guidance in the EQUATOR Network website could help to enhance the use of this guidance to improve the reliability of research in palliative care
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