Evidence map›Paper›PMID 32577611›Full record

ArticleEClinicalMedicine2020

Weights for ordinal analyses of the modified Rankin Scale in stroke trials: A population-based cohort study.

Aravind Ganesh, Ramon Luengo-Fernandez, Sarah T Pendlebury, Peter M Rothwell, Oxford Vascular Study

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Article in EClinicalMedicine, 2020. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 13 papers, 2 of them syntheses that pooled it.

0numbers the graph read from it
0cells of the map it votes in
13citing papers in PubMed, 2 pooled it
–field-weighted citation impact
1 · What the graph read from it

What it found

Each row is one number read from the abstract, on the scale the paper reported it, with its interval. Left of the dashed line favours the treatment, right favours the comparator. Under each row is the sentence it came from. New to these charts? A ten-minute tutorial.

The abstract states no effect estimate the extractor could read, or names no intervention and outcome on the map, so this paper lights no cell and moves no belief. It is still indexed, cited and linked below.

2 · The registry

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3 · Its place in the literature

Who cites it

13 citing papers in PubMed, 2 syntheses or guidelines pooled it.

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4 · The record

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5 · Who and what money

Authors and funding

5 authors.

Aravind GaneshCentre for Prevention of Stroke and Dementia, Nuffield Department of Clinical Neurosciences, University of Oxford, Level 6, West Wing, John Radcliffe Hospital, Oxford OX3 9DU, United Kingdom.
Ramon Luengo-FernandezCentre for Prevention of Stroke and Dementia, Nuffield Department of Clinical Neurosciences, University of Oxford, Level 6, West Wing, John Radcliffe Hospital, Oxford OX3 9DU, United Kingdom.
Sarah T PendleburyCentre for Prevention of Stroke and Dementia, Nuffield Department of Clinical Neurosciences, University of Oxford, Level 6, West Wing, John Radcliffe Hospital, Oxford OX3 9DU, United Kingdom.
Peter M RothwellCentre for Prevention of Stroke and Dementia, Nuffield Department of Clinical Neurosciences, University of Oxford, Level 6, West Wing, John Radcliffe Hospital, Oxford OX3 9DU, United Kingdom.
Oxford Vascular Study

Funding

Wellcome Trust
6 · The paper itself

Abstract

backgroundOrdinal/shift analyses of ordered measures like the modified Rankin Scale(mRS) are underused as primary trial outcomes for neurological disorders - despite statistical advantages - potentially hindered by poor clinical interpretability versus dichotomies, and by valuing state-transitions equally (linear scale). Weighted ordinal analyses incorporating step-changes at key transitions might have greater statistical validity and clinical applicability.

methodsIn a prospective population-based cohort of ischaemic stroke (Oxford Vascular Study, recruited 2002-2014), we stratified 5-year outcomes of death, dementia, and/or institutionalization, health/social-care costs, and EuroQol-derived quality-adjusted life-expectancy(QALE) by 3-month mRS. We compared root-mean-square errors(RMSEs) from linear regressions for these outcomes with the mRS coded as a linear scale versus incorporating a spline at transitions 1-2, 2-3, or 3-4. We derived 3-month mRS weights for probability of 5-year death/dementia/institutionalization using age/sex-adjusted logistic regressions, and cost and QALE weights from 1000-bootstraps. We applied these weights to analyse recent trials of thrombectomy for acute ischaemic stroke.

findingsAmong 1,607 patients, a non-linear (S-shaped) relationship was observed between 3-month mRS and each 5-year outcome, with RMSEs 18-73% lower using a spline at mRS 2-3 versus a linear representation. Age/sex-adjusted probability weights for 5-year death/dementia/institutionalization were: mRS 0=0.19; 1=0.27; 2=0.41; 3=0.73; 4=0.77; 5=0.94 (mRS 6=1 by definition). Similar trends were seen with costs; estimated 5-year QALEs were: mRS 0=3.88; 1=3.49; 2=3.01; 3=1.87; 4=1.30; 5=0.06; 6=0. Results were similar stratifying by age/sex, and excluding pre-morbidly disabled patients. Using a weighted ordinal approach, estimates of thrombectomy impact were more favourable than estimates with dichotomous approaches, 5-year cost reductions being 29% higher than with 0-2/3-6, and over three-fold higher than with 0-1/2-6 dichotomy.

interpretationOur findings favour weighting the mRS in ordinal analyses for stroke and other neurological disorders, as state-transitions differ in clinical prognosis, quality-of-life, and costs. These weights could also be used for prognostication and cost-effectiveness analyses.

fundingWellcome Trust, Wolfson Foundation, NIHR Oxford Biomedical Research Centre, Rhodes Trust.

Indexed as

All Cerebrovascular disease/StrokeClinical trials Methodology/study designCohort studiesOutcome researchPrognosis

Identifiers

PMID32577611
PMCPMC7300241

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Read under generation 80e0d062 · epoch 390. Bibliography from PubMed, PubMed Central and OpenAlex; grants from NIH RePORTER; trial links from ClinicalTrials.gov; estimates, votes and beliefs from the OpenQuestion graph.