Evidence Based Medicine on FHIR Implementation Guide
1.0.0-ballot - ballot
Evidence Based Medicine on FHIR Implementation Guide
1.0.0-ballot - ballot
This page is part of the Evidence Based Medicine on FHIR Implementation Guide (v1.0.0-ballot: STU1 Ballot 1) based on FHIR (HL7® FHIR® Standard) v5.0.0. . For a full list of available versions, see the Directory of published versions
| Active as of 2022-08-05 |
<Evidence xmlns="http://hl7.org/fhir">
<id value="7637"/>
<meta>
<versionId value="85"/>
<lastUpdated value="2023-12-08T00:02:06.315Z"/>
</meta>
<text>
<status value="extensions"/>
<div xmlns="http://www.w3.org/1999/xhtml"><p><b>Generated Narrative: Evidence</b><a name="7637"> </a></p><div style="display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%"><p style="margin-bottom: 0px">Resource Evidence "7637" Version "85" Updated "2023-12-08 00:02:06+0000" </p></div><p><b>StructureDefinition Work Group</b>: cds</p><p><b>url</b>: <code>https://fevir.net/resources/Evidence/7637</code></p><p><b>identifier</b>: FEvIR Object Identifier: 7637</p><p><b>version</b>: 1.0.0-ballot</p><p><b>name</b>: Critically_appraised_summary_of_primary_outcome_of_multi_platform_RCT_of_anticoagulation_for_non_critically_ill_patients_with_COVID_19</p><p><b>title</b>: Critically appraised summary of primary outcome of multi-platform RCT of anticoagulation for non-critically ill patients with COVID-19</p><p><b>citeAs</b>: <a href="Citation-7638.html">Citation/7638: Critically appraised summary of primary outcome of multi-platform RCT of anticoagulation for non-critically ill patients with COVID-19 [FHIR Resource]. Contributors: Brian S Alper, Harold Lehmann, Ahmad Sofi-Mahmudi, Joanne Dehnbostel, Ilkka Kunnamo [Authors], Janice Tufte, Vignesh Subbian, Bhagvan Kommadi, Alfonso Iorio, Muhammad Afzal, Kenneth J Wilkins, Surbhi Shah, Amy Price [Reviewers]. In: Fast Evidence Interoperability Resources (FEvIR) Platform, FOI 7637. Published August 05, 2021. Created August 05, 2021. Revised August 25, 2021. Available at: https://fevir.net/resources/Evidence/7637. Computable resource at: https://fevir.net/resources/Evidence/7637.</a></p><p><b>status</b>: active</p><p><b>date</b>: 2022-08-05 14:49:11+0000</p><p><b>publisher</b>: HL7 International / Clinical Decision Support</p><p><b>contact</b>: HL7 International / Clinical Decision Support: <a href="http://www.hl7.org/Special/committees/dss">http://www.hl7.org/Special/committees/dss</a></p><p><b>author</b>: Brian S. Alper: , Harold Lehmann: , Ahmad Sofi-Mahmudi: , Joanne Dehnbostel: , Ilkka Kunnamo: </p><p><b>reviewer</b>: Janice Tufte: , Vignesh Subbian: , Bhagvan Kommadi: , Alfonso Iorio: , Muhammad Afzal: , Kenneth J. Wilkins: , Surbhi Shah: , Amy Price: </p><h3>UseContexts</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Code</b></td><td><b>Value[x]</b></td></tr><tr><td style="display: none">*</td><td>Program (Details: http://terminology.hl7.org/CodeSystem/usage-context-type code program = 'Program', stated as 'Program')</td><td>Post-publication Review of Anticoagulation for non-critically ill patients hospitalized for COVID-19 <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> ()</span></td></tr></table><p><b>copyright</b>: https://creativecommons.org/licenses/by-nc-sa/4.0/</p><blockquote><p><b>relatedArtifact</b></p><p><b>type</b>: citation</p><p><b>label</b>: data source</p><p><b>display</b>: Anticoagulation for COVID-19 Combined RCTs in NEJM</p><p><b>citation</b>: Therapeutic Anticoagulation with Heparin in Noncritically Ill Patients with Covid-19 [Journal Article]. Contributors: The ATTACC, ACTIV-4a, and REMAP-CAP Investigators. In: The New England Journal of Medicine, DOI 10.1056/NEJMoa2105911. Published August 04, 2021. Available at: https://doi.org/10.1056/NEJMoa2105911.</p></blockquote><blockquote><p><b>relatedArtifact</b></p><p><b>type</b>: cites</p><p><b>citation</b>: Therapeutic Anticoagulation with Heparin in Noncritically Ill Patients with Covid-19 [Journal Article]. Contributors: The ATTACC, ACTIV-4a, and REMAP-CAP Investigators. In: The New England Journal of Medicine, DOI 10.1056/NEJMoa2105911. Published August 04, 2021. Available at: https://doi.org/10.1056/NEJMoa2105911.</p><blockquote><p><b>document</b></p></blockquote></blockquote><blockquote><p><b>relatedArtifact</b></p><p><b>type</b>: cite-as</p><p><b>citation</b>: Critically appraised summary of primary outcome of multi-platform RCT of anticoagulation for non-critically ill patients with COVID-19 [Evidence]. Contributors: Brian S. Alper, Harold Lehmann, Ahmad Sofi-Mahmudi, Joanne Dehnbostel, Ilkka Kunnamo [Authors/Creators]. Janice Tufte, Vignesh Subbian, Bhagvan Kommadi, Alfonso Iorio, Muhammad Afzal, Kenneth J. Wilkins, Surbhi Shah, Amy Price [Reviewers]. In: Fast Evidence Interoperability Resources (FEvIR) Platform, FOI 7637. Revised 2022-08-05. Available at: https://fevir.net/resources/Evidence/7637. Computable resource at: https://fevir.net/resources/Evidence/7637.</p></blockquote><p><b>description</b>: Patients who were hospitalized for COVID-19 and who were not critically ill were randomized in a response-adaptive manner to therapeutic-dose anticoagulation with heparin vs. usual-care pharmacologic thromboprophylaxis. The outcome reported here is the effect on organ support-free days (i.e. days without oxygen delivered by high-flow nasal cannula, noninvasive or invasive mechanical ventilation, or the use of vasopressors or inotropes). The statistical result was a median adjusted odds ratio 1.27 (95% credible interval 1.03 to 1.58), based on 1,740 events among 2,219 participants with known outcome out of 2,244 enrolled participants. The probability of superiority of therapeutic-dose anticoagulation with heparin was 98.6%. The risk of bias in this effect estimate is of extremely serious concern based on a serious concern for confounding covariate bias (confounding difference in calendar time), a very serious concern for performance bias (inadequate blinding of intervention deliverers who may determine the outcome based in part on exposure status), and very serious concern for analysis bias (bias related to selection of the analysis, and early trial termination).</p><p><b>assertion</b>: It is uncertain whether therapeutic-dose anticoagulation with heparin affects the rate of organ support-free days in patients hospitalized for COVID-19 who are not critically ill.</p><p><b>note</b>: Results not consistent with critically ill cohort., Title changed from 'Critically appraised summary of primary outcome of multi-platform RCT of anticoagulation for non-critically ill COVID-19' to 'Critically appraised summary of primary outcome of multi-platform RCT of anticoagulation for non-critically ill patients with COVID-19' on August 17, 2021.</p><blockquote><p><b>variableDefinition</b></p><p><b>VariableDefinitionVariableRoleCode</b>: population</p><p><b>description</b>: Patients who were hospitalized for COVID-19 and who were not critically ill</p><p><b>note</b>: critically ill defined as patients on respiratory or cardiovascular organ support (i.e., oxygen delivered by high-flow nasal cannula, noninvasive or invasive mechanical ventilation, or the use of vasopressors or inotropes) in an ICU, ATTACC and ACTIV-4a limited inclusion to patients with confirmed COVID-19 (and excluded initially entered participants who did not have confirmed SARS-CoV-2. REMAP-CAP however included patients with confirmed COVID-19 or suspected COVID-19 with intent to test for COVID-19., population</p><p><b>variableRole</b>: Use extension:variableRoleCode instead. <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://terminology.hl7.org/5.3.0/CodeSystem-variable-role.html">EvidenceVariableRole</a>#population "population")</span></p><p><b>observed</b>: <a href="Group-7750.html">Group/7750: Participants in Anticoagulation for COVID-19 Combined (ATTACC, ACTIV-4a, and REMAP-CAP) RCT</a> "Participants_in_Anticoagulation_for_COVID_19_Combined_ATTACC_ACTIV_4a_and_REMAP_CAP_RCT_hospitalized_not_critically_ill"</p><p><b>intended</b>: <a href="Group-7749.html">Group/7749: Patients who are hospitalized for COVID-19 and who are not critically ill</a> "Patients_who_are_hospitalized_for_COVID_19_and_who_are_not_critically_ill"</p><p><b>directnessMatch</b>: High quality match between observed and intended variable <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://terminology.hl7.org/5.3.0/CodeSystem-directness.html">EvidenceDirectness[1.0.0]</a>#high)</span></p></blockquote><blockquote><p><b>variableDefinition</b></p><p><b>VariableDefinitionVariableRoleCode</b>: exposure</p><p><b>VariableDefinitionComparatorCategory</b>: Usual-care pharmacologic thromboprophylaxis</p><p><b>description</b>: GroupAssignment: Therapeutic-dose anticoagulation with heparin vs. Usual-care pharmacologic thromboprophylaxis</p><p><b>note</b>: Therapeutic-dose anticoagulation with unfractionated or low-molecular-weight heparin was administered according to local protocols for the treatment of acute venous thromboembolism for up to 14 days or until recovery; the latter was defined as hospital discharge or a discontinuation of supplemental oxygen for at least 24 hours., Usual-care pharmacological thromboprophylaxis included both intermediate-intensity (in 27%) and prophylactic-intensity dosing (in 72%). Subgroup analyses may be informative to determine if there is a difference related to the intensity used in the control arm of the trial. Thromboprophylaxis was provided at a dose and duration determined by the treating clinician according to local practice., exposure</p><p><b>variableRole</b>: Use extension:variableRoleCode instead. <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://terminology.hl7.org/5.3.0/CodeSystem-variable-role.html">EvidenceVariableRole</a>#exposure "exposure")</span></p><p><b>observed</b>: <a href="EvidenceVariable-179784.html">EvidenceVariable/179784: GroupAssignment: Therapeutic-dose anticoagulation with heparin vs. Usual-care pharmacologic thromboprophylaxis</a> "Therapeutic_dose_anticoagulation_with_heparin_vs_Usual_care_pharmacologic_thromboprophylaxis"</p></blockquote><blockquote><p><b>variableDefinition</b></p><p><b>VariableDefinitionVariableRoleCode</b>: outcome</p><p><b>description</b>: Organ support-free days</p><p><b>note</b>: The primary outcome was organ support–free days, evaluated on an ordinal scale that combined in-hospital death and the number of days free of cardiovascular or respiratory organ support up to day 21 among patients who survived to hospital discharge. Patients who were discharged from the hospital before day 21 were assumed to be alive and free of organ support through day 21. Any death during the index hospitalization through 90 days was assigned the worst score on the outcome scale (–1). This end point reflects both the use of ICU-level interventions and survival, with higher values indicating better outcomes., Organ support was defined as oxygen delivered by high-flow nasal cannula, noninvasive or invasive mechanical ventilation, or the use of vasopressors or inotropes., The methods for one of the included trials stated "Organ Support is defined as receipt of invasive or non-invasive mechanical ventilation, high flow nasal oxygen, vasopressor therapy, or ECMO support", outcome</p><p><b>variableRole</b>: Use extension:variableRoleCode instead. <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://terminology.hl7.org/5.3.0/CodeSystem-variable-role.html">EvidenceVariableRole</a>#measuredVariable "measured variable")</span></p><p><b>observed</b>: <a href="EvidenceVariable-7753.html">EvidenceVariable/7753: Organ support-free days</a> "Organ_support_free_days"</p></blockquote><p><b>synthesisType</b>: integration of 3 trials into a single multiplatform trial <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-179423.html">Evidence Based Medicine on FHIR Implementation Guide Code System</a>#defined-in-text "Defined in text")</span></p><p><b>studyDesign</b>: Bayesian Adaptive Design (response-adaptive randomized controlled trial) <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-181513.html">Scientific Evidence Code System (SEVCO) -- EXAMPLE VERSION for EBMonFHIR Implementation Guide</a>#SEVCO:01009 "adaptive randomization")</span>, open label <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-179423.html">Evidence Based Medicine on FHIR Implementation Guide Code System</a>#defined-in-text "Defined in text")</span></p><blockquote><p><b>statistic</b></p><p><b>description</b>: median adjusted odds ratio 1.27 (95% credible interval 1.03 to 1.58)</p><p><b>note</b>: 939 out of 1171 (80.2%) in therapeutic-dose anticoagulation group, 801 out of 1048 (76.4%) in usual-care thromboprophylaxis group</p><p><b>statisticType</b>: Odds Ratio <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://terminology.hl7.org/5.3.0/CodeSystem-statistic-type.html">StatisticStatisticType[0.1.0]</a>#C16932)</span></p><p><b>quantity</b>: 1.27</p><p><b>numberOfEvents</b>: 1740</p><h3>SampleSizes</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Note</b></td><td><b>NumberOfStudies</b></td><td><b>NumberOfParticipants</b></td><td><b>KnownDataCount</b></td></tr><tr><td style="display: none">*</td><td>19 (1.6%) therapeutic-dose group and 6 (0.6%) usual-care group were excluded from primary analysis</td><td>3</td><td>2244</td><td>2219</td></tr></table><blockquote><p><b>attributeEstimate</b></p><p><b>type</b>: Credible interval <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://terminology.hl7.org/5.3.0/CodeSystem-attribute-estimate-type.html">StatisticAttribute Estimate Type[0.1.0]</a>#0000455)</span></p><p><b>level</b>: 0.95</p><p><b>range</b>: 1.03-1.58</p></blockquote><blockquote><p><b>attributeEstimate</b></p><p><b>type</b>: probability of superiority <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> ()</span></p><p><b>quantity</b>: 0.986</p></blockquote><blockquote><p><b>modelCharacteristic</b></p><p><b>code</b>: Hierarchical Bayesian Cumulative Logistic Regression with Dynamic Borrowing <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-179423.html">Evidence Based Medicine on FHIR Implementation Guide Code System</a>#defined-in-text "Defined in text")</span></p></blockquote><blockquote><p><b>modelCharacteristic</b></p><p><b>code</b>: weakly informative Dirichlet prior distributions for the number of days without organ support <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-179423.html">Evidence Based Medicine on FHIR Implementation Guide Code System</a>#defined-in-text "Defined in text")</span></p></blockquote><blockquote><p><b>modelCharacteristic</b></p><p><b>code</b>: The model was fitted with the use of a Markov chain Monte Carlo algorithm with 100,000 samples from the joint posterior distribution, which allowed for calculation of the posterior distributions for the proportional odds ratios, including medians and 95% credible intervals, and the posterior probabilities of superiority and futility for the comparison between therapeutic-dose anticoagulation and usual-care thromboprophylaxis. <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-179423.html">Evidence Based Medicine on FHIR Implementation Guide Code System</a>#defined-in-text "Defined in text")</span></p></blockquote><blockquote><p><b>modelCharacteristic</b></p><p><b>code</b>: median value used for reporting the effect estimate <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-179423.html">Evidence Based Medicine on FHIR Implementation Guide Code System</a>#defined-in-text "Defined in text")</span></p></blockquote><blockquote><p><b>modelCharacteristic</b></p><p><b>code</b>: Adjustment variables include age, sex, trial site, d-dimer cohort, and enrollment period (in 2-week intervals). <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://hl7.org/fhir/R5/codesystem-statistic-model-code.html">Statistic Model Code</a>#adjusted "Adjusted analysis")</span></p><blockquote><p><b>variable</b></p><p><b>variableDefinition</b>: <span>: age</span></p><p><b>handling</b>: continuous</p></blockquote><blockquote><p><b>variable</b></p><p><b>variableDefinition</b>: <span>: sex</span></p><p><b>handling</b>: dichotomous</p></blockquote><blockquote><p><b>variable</b></p><p><b>variableDefinition</b>: <span>: trial site</span></p><p><b>handling</b>: polychotomous</p></blockquote><blockquote><p><b>variable</b></p><p><b>variableDefinition</b>: <span>: d-dimer cohort</span></p><p><b>handling</b>: polychotomous</p></blockquote><blockquote><p><b>variable</b></p><p><b>variableDefinition</b>: <span>: enrollment period</span></p><p><b>handling</b>: ordinal</p></blockquote></blockquote></blockquote><blockquote><p><b>certainty</b></p><p><b>type</b>: Risk of bias <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://hl7.org/fhir/R5/codesystem-certainty-type.html">Evidence Certainty Type[5.0.0]</a>#RiskOfBias)</span></p><p><b>rating</b>: extremely serious concern <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://hl7.org/fhir/R5/codesystem-certainty-rating.html">Evidence Certainty Rating[5.0.0]</a>#extremely-serious-concern)</span></p><p><b>rater</b>: Brian S. Alper, Harold Lehmann, Ahmad Sofi-Mahmudi, Joanne Dehnbostel, Ilkka Kunnamo, Alfonso Iorio</p><blockquote><p><b>subcomponent</b></p><p><b>description</b>: Inclusion of suspected COVID-19 in 1 of 3 trials may introduce selection bias, but the impact appears limited.</p><p><b>note</b>: Definition of Selection Bias = A bias resulting from methods used to select subjects or data, factors that influence initial study participation, or differences between the study sample and the population of interest</p><p><b>type</b>: Selection Bias <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-181513.html">Scientific Evidence Code System (SEVCO) -- EXAMPLE VERSION for EBMonFHIR Implementation Guide</a>#SEVCO:00002)</span></p><p><b>rating</b>: no serious concern <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://hl7.org/fhir/R5/codesystem-certainty-rating.html">Evidence Certainty Rating[5.0.0]</a>#no-concern)</span></p><p><b>rater</b>: Brian S. Alper, Joanne Dehnbostel, Muhammad Afzal</p></blockquote><blockquote><p><b>subcomponent</b></p><p><b>description</b>: The study design used response-adaptive randomization in which group assignment ratios could be modified during the trial on the basis of response-adaptive interim analyses to favor the assignment of patients to the treatment group showing greater benefit. The confounding by time (imbalanced randomization with time period) is not adequately reported to determine the potential influence on results or adequacy of adjusted analyses.</p><p><b>note</b>: Definition of Confounding Covariate Bias = A situation in which the effect or association between an exposure and outcome is distorted by another variable. For confounding covariate bias to occur the distorting variable must be (1) associated with the exposure and the outcome, (2) not in the causal pathway between exposure and outcome, and (3) unequally distributed between the groups being compared., ATTACC implemented response-adaptive randomization on December 15, 2020, which led to imbalanced randomization. No data reported to determine if intervention-specific outcome rates were similar or different before and after December 15, 2020 in the ATTACC cohort., Insufficient details reported to judge whether there is an imbalance in outcomes related to the adaptive randomization which in turn could be used to judge the validity of adjustment methods in the statistical model for this concern and the appropriateness of any sensitivity analyses.</p><p><b>type</b>: Confounding Covariate Bias <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-181513.html">Scientific Evidence Code System (SEVCO) -- EXAMPLE VERSION for EBMonFHIR Implementation Guide</a>#SEVCO:00016)</span></p><p><b>rating</b>: serious concern <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://hl7.org/fhir/R5/codesystem-certainty-rating.html">Evidence Certainty Rating[5.0.0]</a>#serious-concern)</span></p><p><b>rater</b>: Brian S. Alper, Ilkka Kunnamo, Alfonso Iorio, Joanne Dehnbostel, Harold Lehmann, Kenneth Wilkins; clarifying explanation reviewed by Janice Tufte</p><blockquote><p><b>subcomponent</b></p></blockquote><blockquote><p><b>subcomponent</b></p></blockquote></blockquote><blockquote><p><b>subcomponent</b></p><p><b>description</b>: Awareness of treatment assignment may reduce clinical decision to initiate some types of "organ support" in patients with higher risk of major bleeding.</p><p><b>note</b>: Definition of Performance Bias = A bias resulting from differences between the received exposure and the intended exposure.</p><p><b>type</b>: Performance Bias <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-181513.html">Scientific Evidence Code System (SEVCO) -- EXAMPLE VERSION for EBMonFHIR Implementation Guide</a>#SEVCO:00017)</span></p><p><b>rating</b>: very serious concern <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://hl7.org/fhir/R5/codesystem-certainty-rating.html">Evidence Certainty Rating[5.0.0]</a>#very-serious-concern)</span></p><p><b>rater</b>: Brian S. Alper, Joanne Dehnbostel, Harold Lehmann, Muhammad Afzal</p><blockquote><p><b>subcomponent</b></p></blockquote><blockquote><p><b>subcomponent</b></p></blockquote><blockquote><p><b>subcomponent</b></p></blockquote></blockquote><blockquote><p><b>subcomponent</b></p><p><b>description</b>: The influence of awareness of treatment assignment by the treating clinicians on the initiation of organ support (which is the primary outcome) was already addressed as Performance Bias so is not repeated here as a bias in detecting the outcome.</p><p><b>note</b>: Definition of Detection Bias = A bias due to distortions in how variable values (data) are determined.</p><p><b>type</b>: Detection Bias <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-181513.html">Scientific Evidence Code System (SEVCO) -- EXAMPLE VERSION for EBMonFHIR Implementation Guide</a>#SEVCO:00020)</span></p><p><b>rating</b>: no serious concern <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://hl7.org/fhir/R5/codesystem-certainty-rating.html">Evidence Certainty Rating[5.0.0]</a>#no-concern)</span></p><p><b>rater</b>: Brian S. Alper, Joanne Dehnbostel, Muhammad Afzal</p></blockquote><blockquote><p><b>subcomponent</b></p><p><b>description</b>: Only 19 of 1190 (1.6%) therapeutic group and 6 of 1054 (0.6%) prophylactic group were excluded after randomization.</p><p><b>note</b>: Definition of Attrition Bias = A bias due to absence of expected participation or data collection after selection for study inclusion.</p><p><b>type</b>: Attrition Bias <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-181513.html">Scientific Evidence Code System (SEVCO) -- EXAMPLE VERSION for EBMonFHIR Implementation Guide</a>#SEVCO:00019)</span></p><p><b>rating</b>: no serious concern <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://hl7.org/fhir/R5/codesystem-certainty-rating.html">Evidence Certainty Rating[5.0.0]</a>#no-concern)</span></p><p><b>rater</b>: Brian S. Alper, Joanne Dehnbostel, Muhammad Afzal</p></blockquote><blockquote><p><b>subcomponent</b></p><p><b>description</b>: It is unknown if the results are sensitive to the analytic method, and the stopping criteria were based on statistical significance and not magnitude of effect.</p><p><b>note</b>: Definition of Analysis Bias = A bias related to the analytic process applied to the data.</p><p><b>type</b>: Analysis Bias <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="CodeSystem-181513.html">Scientific Evidence Code System (SEVCO) -- EXAMPLE VERSION for EBMonFHIR Implementation Guide</a>#SEVCO:00021)</span></p><p><b>rating</b>: very serious concern <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://hl7.org/fhir/R5/codesystem-certainty-rating.html">Evidence Certainty Rating[5.0.0]</a>#very-serious-concern)</span></p><p><b>rater</b>: Brian S. Alper, Joanne Dehnbostel, Muhammad Afzal, Janice Tufte</p><blockquote><p><b>subcomponent</b></p></blockquote><blockquote><p><b>subcomponent</b></p></blockquote></blockquote></blockquote></div>
</text>
<extension
url="http://hl7.org/fhir/StructureDefinition/structuredefinition-wg">
<valueCode value="cds"/>
</extension>
<url value="https://fevir.net/resources/Evidence/7637"/>
<identifier>
<type>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/v2-0203"/>
<code value="ACSN"/>
<display value="Accession ID"/>
</coding>
<text value="FEvIR Object Identifier"/>
</type>
<system value="https://fevir.net"/>
<value value="7637"/>
<assigner>
<display value="Computable Publishing LLC"/>
</assigner>
</identifier>
<version value="1.0.0-ballot"/>
<name
value="Critically_appraised_summary_of_primary_outcome_of_multi_platform_RCT_of_anticoagulation_for_non_critically_ill_patients_with_COVID_19"/>
<title
value="Critically appraised summary of primary outcome of multi-platform RCT of anticoagulation for non-critically ill patients with COVID-19"/>
<citeAsReference>🔗
<reference value="Citation/7638"/>
<type value="Citation"/>
<display
value="Critically appraised summary of primary outcome of multi-platform RCT of anticoagulation for non-critically ill patients with COVID-19 [FHIR Resource]. Contributors: Brian S Alper, Harold Lehmann, Ahmad Sofi-Mahmudi, Joanne Dehnbostel, Ilkka Kunnamo [Authors], Janice Tufte, Vignesh Subbian, Bhagvan Kommadi, Alfonso Iorio, Muhammad Afzal, Kenneth J Wilkins, Surbhi Shah, Amy Price [Reviewers]. In: Fast Evidence Interoperability Resources (FEvIR) Platform, FOI 7637. Published August 05, 2021. Created August 05, 2021. Revised August 25, 2021. Available at: https://fevir.net/resources/Evidence/7637. Computable resource at: https://fevir.net/resources/Evidence/7637."/>
</citeAsReference>
<status value="active"/>
<date value="2022-08-05T14:49:11.389Z"/>
<publisher value="HL7 International / Clinical Decision Support"/>
<contact>
<name value="HL7 International / Clinical Decision Support"/>
<telecom>
<system value="url"/>
<value value="http://www.hl7.org/Special/committees/dss"/>
</telecom>
</contact>
<author>
<name value="Brian S. Alper"/>
</author>
<author>
<name value="Harold Lehmann"/>
</author>
<author>
<name value="Ahmad Sofi-Mahmudi"/>
</author>
<author>
<name value="Joanne Dehnbostel"/>
</author>
<author>
<name value="Ilkka Kunnamo"/>
</author>
<reviewer>
<name value="Janice Tufte"/>
</reviewer>
<reviewer>
<name value="Vignesh Subbian"/>
</reviewer>
<reviewer>
<name value="Bhagvan Kommadi"/>
</reviewer>
<reviewer>
<name value="Alfonso Iorio"/>
</reviewer>
<reviewer>
<name value="Muhammad Afzal"/>
</reviewer>
<reviewer>
<name value="Kenneth J. Wilkins"/>
</reviewer>
<reviewer>
<name value="Surbhi Shah"/>
</reviewer>
<reviewer>
<name value="Amy Price"/>
</reviewer>
<useContext>
<code>
<system
value="http://terminology.hl7.org/CodeSystem/usage-context-type"/>
<code value="program"/>
<display value="Program"/>
</code>
<valueCodeableConcept>
<text
value="Post-publication Review of Anticoagulation for non-critically ill patients hospitalized for COVID-19"/>
</valueCodeableConcept>
</useContext>
<copyright value="https://creativecommons.org/licenses/by-nc-sa/4.0/"/>
<relatedArtifact>
<type value="citation"/>
<label value="data source"/>
<display value="Anticoagulation for COVID-19 Combined RCTs in NEJM"/>
<citation
value="Therapeutic Anticoagulation with Heparin in Noncritically Ill Patients with Covid-19 [Journal Article]. Contributors: The ATTACC, ACTIV-4a, and REMAP-CAP Investigators. In: The New England Journal of Medicine, DOI 10.1056/NEJMoa2105911. Published August 04, 2021. Available at: https://doi.org/10.1056/NEJMoa2105911."/>
</relatedArtifact>
<relatedArtifact>
<type value="cites"/>
<citation
value="Therapeutic Anticoagulation with Heparin in Noncritically Ill Patients with Covid-19 [Journal Article]. Contributors: The ATTACC, ACTIV-4a, and REMAP-CAP Investigators. In: The New England Journal of Medicine, DOI 10.1056/NEJMoa2105911. Published August 04, 2021. Available at: https://doi.org/10.1056/NEJMoa2105911."/>
<document>
<url value="https://www.nejm.org/doi/full/10.1056/NEJMoa2105911"/>
<title
value="Therapeutic Anticoagulation with Heparin in Noncritically Ill Patients with Covid-19"/>
</document>
</relatedArtifact>
<relatedArtifact>
<type value="cite-as"/>
<citation
value="Critically appraised summary of primary outcome of multi-platform RCT of anticoagulation for non-critically ill patients with COVID-19 [Evidence]. Contributors: Brian S. Alper, Harold Lehmann, Ahmad Sofi-Mahmudi, Joanne Dehnbostel, Ilkka Kunnamo [Authors/Creators]. Janice Tufte, Vignesh Subbian, Bhagvan Kommadi, Alfonso Iorio, Muhammad Afzal, Kenneth J. Wilkins, Surbhi Shah, Amy Price [Reviewers]. In: Fast Evidence Interoperability Resources (FEvIR) Platform, FOI 7637. Revised 2022-08-05. Available at: https://fevir.net/resources/Evidence/7637. Computable resource at: https://fevir.net/resources/Evidence/7637."/>
</relatedArtifact>
<description
value="Patients who were hospitalized for COVID-19 and who were not critically ill were randomized in a response-adaptive manner to therapeutic-dose anticoagulation with heparin vs. usual-care pharmacologic thromboprophylaxis. The outcome reported here is the effect on organ support-free days (i.e. days without oxygen delivered by high-flow nasal cannula, noninvasive or invasive mechanical ventilation, or the use of vasopressors or inotropes). The statistical result was a median adjusted odds ratio 1.27 (95% credible interval 1.03 to 1.58), based on 1,740 events among 2,219 participants with known outcome out of 2,244 enrolled participants. The probability of superiority of therapeutic-dose anticoagulation with heparin was 98.6%. The risk of bias in this effect estimate is of extremely serious concern based on a serious concern for confounding covariate bias (confounding difference in calendar time), a very serious concern for performance bias (inadequate blinding of intervention deliverers who may determine the outcome based in part on exposure status), and very serious concern for analysis bias (bias related to selection of the analysis, and early trial termination)."/>
<assertion
value="It is uncertain whether therapeutic-dose anticoagulation with heparin affects the rate of organ support-free days in patients hospitalized for COVID-19 who are not critically ill."/>
<note>
<text value="Results not consistent with critically ill cohort."/>
</note>
<note>
<text
value="Title changed from 'Critically appraised summary of primary outcome of multi-platform RCT of anticoagulation for non-critically ill COVID-19' to 'Critically appraised summary of primary outcome of multi-platform RCT of anticoagulation for non-critically ill patients with COVID-19' on August 17, 2021."/>
</note>
<variableDefinition>
<extension
url="http://hl7.org/fhir/uv/ebm/StructureDefinition/variable-definition-variable-role-code">
<valueCode value="population"/>
</extension>
<description
value="Patients who were hospitalized for COVID-19 and who were not critically ill"/>
<note>
<text
value="critically ill defined as patients on respiratory or cardiovascular organ support (i.e., oxygen delivered by high-flow nasal cannula, noninvasive or invasive mechanical ventilation, or the use of vasopressors or inotropes) in an ICU"/>
</note>
<note>
<text
value="ATTACC and ACTIV-4a limited inclusion to patients with confirmed COVID-19 (and excluded initially entered participants who did not have confirmed SARS-CoV-2. REMAP-CAP however included patients with confirmed COVID-19 or suspected COVID-19 with intent to test for COVID-19."/>
</note>
<note>
<text value="population"/>
</note>
<variableRole>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/variable-role"/>
<code value="population"/>
<display value="population"/>
</coding>
<text value="Use extension:variableRoleCode instead."/>
</variableRole>
<observed>🔗
<reference value="Group/7750"/>
<type value="Group"/>
<display
value="Participants in Anticoagulation for COVID-19 Combined (ATTACC, ACTIV-4a, and REMAP-CAP) RCT"/>
</observed>
<intended>🔗
<reference value="Group/7749"/>
<type value="Group"/>
<display
value="Patients who are hospitalized for COVID-19 and who are not critically ill"/>
</intended>
<directnessMatch>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/directness"/>
<version value="1.0.0"/>
<code value="high"/>
<display
value="High quality match between observed and intended variable"/>
<userSelected value="true"/>
</coding>
</directnessMatch>
</variableDefinition>
<variableDefinition>
<extension
url="http://hl7.org/fhir/uv/ebm/StructureDefinition/variable-definition-variable-role-code">
<valueCode value="exposure"/>
</extension>
<extension
url="http://hl7.org/fhir/uv/ebm/StructureDefinition/variable-definition-comparator-category">
<valueString value="Usual-care pharmacologic thromboprophylaxis"/>
</extension>
<description
value="GroupAssignment: Therapeutic-dose anticoagulation with heparin vs. Usual-care pharmacologic thromboprophylaxis"/>
<note>
<text
value="Therapeutic-dose anticoagulation with unfractionated or low-molecular-weight heparin was administered according to local protocols for the treatment of acute venous thromboembolism for up to 14 days or until recovery; the latter was defined as hospital discharge or a discontinuation of supplemental oxygen for at least 24 hours."/>
</note>
<note>
<text
value="Usual-care pharmacological thromboprophylaxis included both intermediate-intensity (in 27%) and prophylactic-intensity dosing (in 72%). Subgroup analyses may be informative to determine if there is a difference related to the intensity used in the control arm of the trial. Thromboprophylaxis was provided at a dose and duration determined by the treating clinician according to local practice."/>
</note>
<note>
<text value="exposure"/>
</note>
<variableRole>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/variable-role"/>
<code value="exposure"/>
<display value="exposure"/>
</coding>
<text value="Use extension:variableRoleCode instead."/>
</variableRole>
<observed>🔗
<reference value="EvidenceVariable/179784"/>
<type value="EvidenceVariable"/>
<display
value="GroupAssignment: Therapeutic-dose anticoagulation with heparin vs. Usual-care pharmacologic thromboprophylaxis"/>
</observed>
</variableDefinition>
<variableDefinition>
<extension
url="http://hl7.org/fhir/uv/ebm/StructureDefinition/variable-definition-variable-role-code">
<valueCode value="outcome"/>
</extension>
<description value="Organ support-free days"/>
<note>
<text
value="The primary outcome was organ support–free days, evaluated on an ordinal scale that combined in-hospital death and the number of days free of cardiovascular or respiratory organ support up to day 21 among patients who survived to hospital discharge. Patients who were discharged from the hospital before day 21 were assumed to be alive and free of organ support through day 21. Any death during the index hospitalization through 90 days was assigned the worst score on the outcome scale (–1). This end point reflects both the use of ICU-level interventions and survival, with higher values indicating better outcomes."/>
</note>
<note>
<text
value="Organ support was defined as oxygen delivered by high-flow nasal cannula, noninvasive or invasive mechanical ventilation, or the use of vasopressors or inotropes."/>
</note>
<note>
<text
value="The methods for one of the included trials stated "Organ Support is defined as receipt of invasive or non-invasive mechanical ventilation, high flow nasal oxygen, vasopressor therapy, or ECMO support""/>
</note>
<note>
<text value="outcome"/>
</note>
<variableRole>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/variable-role"/>
<code value="measuredVariable"/>
<display value="measured variable"/>
</coding>
<text value="Use extension:variableRoleCode instead."/>
</variableRole>
<observed>🔗
<reference value="EvidenceVariable/7753"/>
<type value="EvidenceVariable"/>
<display value="Organ support-free days"/>
</observed>
</variableDefinition>
<synthesisType>
<coding>
<system value="https://fevir.net/resources/CodeSystem/179423"/>
<code value="defined-in-text"/>
<display value="Defined in text"/>
</coding>
<text value="integration of 3 trials into a single multiplatform trial"/>
</synthesisType>
<studyDesign>
<coding>
<system value="https://fevir.net/resources/CodeSystem/181513"/>
<code value="SEVCO:01009"/>
<display value="adaptive randomization"/>
</coding>
<text
value="Bayesian Adaptive Design (response-adaptive randomized controlled trial)"/>
</studyDesign>
<studyDesign>
<coding>
<system value="https://fevir.net/resources/CodeSystem/179423"/>
<code value="defined-in-text"/>
<display value="Defined in text"/>
</coding>
<text value="open label"/>
</studyDesign>
<statistic>
<description
value="median adjusted odds ratio 1.27 (95% credible interval 1.03 to 1.58)"/>
<note>
<text
value="939 out of 1171 (80.2%) in therapeutic-dose anticoagulation group"/>
</note>
<note>
<text
value="801 out of 1048 (76.4%) in usual-care thromboprophylaxis group"/>
</note>
<statisticType>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/statistic-type"/>
<version value="0.1.0"/>
<code value="C16932"/>
<display value="Odds Ratio"/>
<userSelected value="true"/>
</coding>
</statisticType>
<quantity>
<value value="1.27"/>
</quantity>
<numberOfEvents value="1740"/>
<sampleSize>
<note>
<text
value="19 (1.6%) therapeutic-dose group and 6 (0.6%) usual-care group were excluded from primary analysis"/>
</note>
<numberOfStudies value="3"/>
<numberOfParticipants value="2244"/>
<knownDataCount value="2219"/>
</sampleSize>
<attributeEstimate>
<type>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/attribute-estimate-type"/>
<version value="0.1.0"/>
<code value="0000455"/>
<display value="Credible interval"/>
</coding>
</type>
<level value="0.95"/>
<range>
<low>
<value value="1.03"/>
</low>
<high>
<value value="1.58"/>
</high>
</range>
</attributeEstimate>
<attributeEstimate>
<type>
<text value="probability of superiority"/>
</type>
<quantity>
<value value="0.986"/>
</quantity>
</attributeEstimate>
<modelCharacteristic>
<code>
<coding>
<system value="https://fevir.net/resources/CodeSystem/179423"/>
<code value="defined-in-text"/>
<display value="Defined in text"/>
</coding>
<text
value="Hierarchical Bayesian Cumulative Logistic Regression with Dynamic Borrowing"/>
</code>
</modelCharacteristic>
<modelCharacteristic>
<code>
<coding>
<system value="https://fevir.net/resources/CodeSystem/179423"/>
<code value="defined-in-text"/>
<display value="Defined in text"/>
</coding>
<text
value="weakly informative Dirichlet prior distributions for the number of days without organ support"/>
</code>
</modelCharacteristic>
<modelCharacteristic>
<code>
<coding>
<system value="https://fevir.net/resources/CodeSystem/179423"/>
<code value="defined-in-text"/>
<display value="Defined in text"/>
</coding>
<text
value="The model was fitted with the use of a Markov chain Monte Carlo algorithm with 100,000 samples from the joint posterior distribution, which allowed for calculation of the posterior distributions for the proportional odds ratios, including medians and 95% credible intervals, and the posterior probabilities of superiority and futility for the comparison between therapeutic-dose anticoagulation and usual-care thromboprophylaxis."/>
</code>
</modelCharacteristic>
<modelCharacteristic>
<code>
<coding>
<system value="https://fevir.net/resources/CodeSystem/179423"/>
<code value="defined-in-text"/>
<display value="Defined in text"/>
</coding>
<text value="median value used for reporting the effect estimate"/>
</code>
</modelCharacteristic>
<modelCharacteristic>
<code>
<coding>
<system value="http://hl7.org/fhir/statistic-model-code"/>
<code value="adjusted"/>
<display value="Adjusted analysis"/>
<userSelected value="true"/>
</coding>
<text
value="Adjustment variables include age, sex, trial site, d-dimer cohort, and enrollment period (in 2-week intervals)."/>
</code>
<variable>
<variableDefinition>
<display value="age"/>
</variableDefinition>
<handling value="continuous"/>
</variable>
<variable>
<variableDefinition>
<display value="sex"/>
</variableDefinition>
<handling value="dichotomous"/>
</variable>
<variable>
<variableDefinition>
<display value="trial site"/>
</variableDefinition>
<handling value="polychotomous"/>
</variable>
<variable>
<variableDefinition>
<display value="d-dimer cohort"/>
</variableDefinition>
<handling value="polychotomous"/>
</variable>
<variable>
<variableDefinition>
<display value="enrollment period"/>
</variableDefinition>
<handling value="ordinal"/>
</variable>
</modelCharacteristic>
</statistic>
<certainty>
<type>
<coding>
<system value="http://hl7.org/fhir/certainty-type"/>
<version value="5.0.0"/>
<code value="RiskOfBias"/>
<display value="Risk of bias"/>
<userSelected value="true"/>
</coding>
</type>
<rating>
<coding>
<system value="http://hl7.org/fhir/certainty-rating"/>
<version value="5.0.0"/>
<code value="extremely-serious-concern"/>
<display value="extremely serious concern"/>
<userSelected value="true"/>
</coding>
</rating>
<rater
value="Brian S. Alper, Harold Lehmann, Ahmad Sofi-Mahmudi, Joanne Dehnbostel, Ilkka Kunnamo, Alfonso Iorio"/>
<subcomponent>
<description
value="Inclusion of suspected COVID-19 in 1 of 3 trials may introduce selection bias, but the impact appears limited."/>
<note>
<text
value="Definition of Selection Bias = A bias resulting from methods used to select subjects or data, factors that influence initial study participation, or differences between the study sample and the population of interest"/>
</note>
<type>
<coding>
<system value="https://fevir.net/resources/CodeSystem/181513"/>
<code value="SEVCO:00002"/>
<display value="Selection Bias"/>
</coding>
</type>
<rating>
<coding>
<system value="http://hl7.org/fhir/certainty-rating"/>
<version value="5.0.0"/>
<code value="no-concern"/>
<display value="no serious concern"/>
<userSelected value="true"/>
</coding>
</rating>
<rater value="Brian S. Alper, Joanne Dehnbostel, Muhammad Afzal"/>
</subcomponent>
<subcomponent>
<description
value="The study design used response-adaptive randomization in which group assignment ratios could be modified during the trial on the basis of response-adaptive interim analyses to favor the assignment of patients to the treatment group showing greater benefit. The confounding by time (imbalanced randomization with time period) is not adequately reported to determine the potential influence on results or adequacy of adjusted analyses."/>
<note>
<text
value="Definition of Confounding Covariate Bias = A situation in which the effect or association between an exposure and outcome is distorted by another variable. For confounding covariate bias to occur the distorting variable must be (1) associated with the exposure and the outcome, (2) not in the causal pathway between exposure and outcome, and (3) unequally distributed between the groups being compared."/>
</note>
<note>
<text
value="ATTACC implemented response-adaptive randomization on December 15, 2020, which led to imbalanced randomization. No data reported to determine if intervention-specific outcome rates were similar or different before and after December 15, 2020 in the ATTACC cohort."/>
</note>
<note>
<text
value="Insufficient details reported to judge whether there is an imbalance in outcomes related to the adaptive randomization which in turn could be used to judge the validity of adjustment methods in the statistical model for this concern and the appropriateness of any sensitivity analyses."/>
</note>
<type>
<coding>
<system value="https://fevir.net/resources/CodeSystem/181513"/>
<code value="SEVCO:00016"/>
<display value="Confounding Covariate Bias"/>
</coding>
</type>
<rating>
<coding>
<system value="http://hl7.org/fhir/certainty-rating"/>
<version value="5.0.0"/>
<code value="serious-concern"/>
<display value="serious concern"/>
<userSelected value="true"/>
</coding>
</rating>
<rater
value="Brian S. Alper, Ilkka Kunnamo, Alfonso Iorio, Joanne Dehnbostel, Harold Lehmann, Kenneth Wilkins; clarifying explanation reviewed by Janice Tufte"/>
<subcomponent>
<description
value="Response-adaptive randomization led to imbalanced randomization."/>
<note>
<text
value="Definition of Allocation Bias = A confounding covariate bias resulting from methods for assignment of the independent variable by the investigator to evaluate a response or outcome."/>
</note>
<note>
<text
value="ATTACC implemented response-adaptive randomization on December 15, 2020, which led to imbalanced randomization."/>
</note>
<type>
<coding>
<system value="https://fevir.net/resources/CodeSystem/181513"/>
<code value="SEVCO:00032"/>
<display value="Allocation Bias"/>
</coding>
</type>
<rating>
<coding>
<system value="https://fevir.net/resources/CodeSystem/179423"/>
<code value="defined-in-text"/>
<display value="Defined in text"/>
</coding>
<text
value="Adaptive randomization is not a concern by itself, only if it results in a confounding difference."/>
</rating>
<rater
value="Brian S. Alper, Joanne Dehnbostel, Harold Lehmann, Kenneth Wilkins"/>
</subcomponent>
<subcomponent>
<description
value="There is an unequal distribution of calendar time between the groups being compared."/>
<note>
<text
value="Definition of Confounding difference = A confounding covariate bias in which the unequal distribution of a potentially distorting variable is recognized."/>
</note>
<note>
<text
value="Incomplete reporting limits the determination of the potential degree of influence of calendar time."/>
</note>
<note>
<text
value="There is evidence of potential for calendar time to influence the results: In an observational study of 18,508 adults with laboratory-confirmed, COVID-19 associated hospitalization 'The percentage of hospitalized patients admitted to the ICU decreased from 37.8% in March to 20.5% in December' (Ann Intern Med 2021 Aug 10 https://www.acpjournals.org/doi/10.7326/M21-1991)."/>
</note>
<type>
<coding>
<system value="https://fevir.net/resources/CodeSystem/181513"/>
<code value="SEVCO:00034"/>
<display value="Confounding difference"/>
</coding>
</type>
<rating>
<coding>
<system value="http://hl7.org/fhir/certainty-rating"/>
<version value="5.0.0"/>
<code value="serious-concern"/>
<display value="serious concern"/>
<userSelected value="true"/>
</coding>
</rating>
<rater
value="Brian S. Alper, Joanne Dehnbostel, Harold Lehmann, Kenneth Wilkins"/>
</subcomponent>
</subcomponent>
<subcomponent>
<description
value="Awareness of treatment assignment may reduce clinical decision to initiate some types of "organ support" in patients with higher risk of major bleeding."/>
<note>
<text
value="Definition of Performance Bias = A bias resulting from differences between the received exposure and the intended exposure."/>
</note>
<type>
<coding>
<system value="https://fevir.net/resources/CodeSystem/181513"/>
<code value="SEVCO:00017"/>
<display value="Performance Bias"/>
</coding>
</type>
<rating>
<coding>
<system value="http://hl7.org/fhir/certainty-rating"/>
<version value="5.0.0"/>
<code value="very-serious-concern"/>
<display value="very serious concern"/>
<userSelected value="true"/>
</coding>
</rating>
<rater
value="Brian S. Alper, Joanne Dehnbostel, Harold Lehmann, Muhammad Afzal"/>
<subcomponent>
<description
value="Lack of blinding may explain reported differences in the primary outcome."/>
<note>
<text
value="The absolute difference in survival without intubation was 1%, so 3% of the 4% absolute difference in the primary outcome can be considered "organ support without intubation"."/>
</note>
<note>
<text
value="The specific "organ support without intubation" was not reported. The methods for one of the included trials stated "Organ Support is defined as receipt of invasive or non-invasive mechanical ventilation, high flow nasal oxygen, vasopressor therapy, or ECMO support""/>
</note>
<note>
<text
value="Awareness of treatment assignment may reduce clinical decision to initiate "organ support without intubation" in patients with higher risk of major bleeding."/>
</note>
<note>
<text
value="Definition of Inadequate blinding of intervention deliverers = A performance bias due to awareness of the allocated intervention by individuals providing or delivering the intervention."/>
</note>
<type>
<coding>
<system value="https://fevir.net/resources/CodeSystem/181513"/>
<code value="SEVCO:00036"/>
<display value="Inadequate blinding of intervention deliverers"/>
</coding>
</type>
<rating>
<coding>
<system value="http://hl7.org/fhir/certainty-rating"/>
<version value="5.0.0"/>
<code value="very-serious-concern"/>
<display value="very serious concern"/>
<userSelected value="true"/>
</coding>
</rating>
<rater
value="Brian S. Alper; clarifying explanation reviewed by Janice Tufte"/>
</subcomponent>
<subcomponent>
<description value="Crossover to other intervention in 20%"/>
<note>
<text
value="Therapeutic dose anticoagulation (in the first 24-48 hours following randomization) was reported in 79.6% of the therapeutic arm and 0.9% of the usual care arm. (Table S3)"/>
</note>
<note>
<text
value="Definition of Deviation from study intervention protocol = A performance bias in which the intervention received differs from the intervention specified in the study protocol."/>
</note>
<type>
<coding>
<system value="https://fevir.net/resources/CodeSystem/181513"/>
<code value="SEVCO:00037"/>
<display value="Deviation from study intervention protocol"/>
</coding>
</type>
<rating>
<coding>
<system value="https://fevir.net/resources/CodeSystem/179423"/>
<code value="defined-in-text"/>
<display value="Defined in text"/>
</coding>
<text value="degree of concern unclear"/>
</rating>
<rater value="Surbhi Shah, Brian S. Alper"/>
</subcomponent>
<subcomponent>
<description
value="We discussed whether they may be a bias related to limited adherence to anticoagulation. Because this was an inpatient population, we did not expect adherence problems that are more common with outpatient thromboprophylaxis."/>
<note>
<text
value="Initial adherence to the protocol-assigned anticoagulation dose after randomization was 88.3% in the therapeutic-dose anticoagulation group and 98.3% in the thromboprophylaxis group (Table S3)."/>
</note>
<note>
<text
value="Definition of Nonadherence of implementation = A performance bias in which the intervention deliverers do not completely adhere to the expected intervention."/>
</note>
<type>
<coding>
<system value="https://fevir.net/resources/CodeSystem/181513"/>
<code value="SEVCO:00039"/>
<display value="Nonadherence of implementation"/>
</coding>
</type>
<rating>
<coding>
<system value="https://fevir.net/resources/CodeSystem/179423"/>
<code value="defined-in-text"/>
<display value="Defined in text"/>
</coding>
<text value="limited concern"/>
</rating>
<rater
value="COVID-19 Knowledge Accelerator Working Group discussion with Brian S. Alper, Ilkka Kunnamo, Joanne Dehnbostel; Performance Bias concern initially suggested by Harold Lehmann"/>
</subcomponent>
</subcomponent>
<subcomponent>
<description
value="The influence of awareness of treatment assignment by the treating clinicians on the initiation of organ support (which is the primary outcome) was already addressed as Performance Bias so is not repeated here as a bias in detecting the outcome."/>
<note>
<text
value="Definition of Detection Bias = A bias due to distortions in how variable values (data) are determined."/>
</note>
<type>
<coding>
<system value="https://fevir.net/resources/CodeSystem/181513"/>
<code value="SEVCO:00020"/>
<display value="Detection Bias"/>
</coding>
</type>
<rating>
<coding>
<system value="http://hl7.org/fhir/certainty-rating"/>
<version value="5.0.0"/>
<code value="no-concern"/>
<display value="no serious concern"/>
<userSelected value="true"/>
</coding>
</rating>
<rater value="Brian S. Alper, Joanne Dehnbostel, Muhammad Afzal"/>
</subcomponent>
<subcomponent>
<description
value="Only 19 of 1190 (1.6%) therapeutic group and 6 of 1054 (0.6%) prophylactic group were excluded after randomization."/>
<note>
<text
value="Definition of Attrition Bias = A bias due to absence of expected participation or data collection after selection for study inclusion."/>
</note>
<type>
<coding>
<system value="https://fevir.net/resources/CodeSystem/181513"/>
<code value="SEVCO:00019"/>
<display value="Attrition Bias"/>
</coding>
</type>
<rating>
<coding>
<system value="http://hl7.org/fhir/certainty-rating"/>
<version value="5.0.0"/>
<code value="no-concern"/>
<display value="no serious concern"/>
<userSelected value="true"/>
</coding>
</rating>
<rater value="Brian S. Alper, Joanne Dehnbostel, Muhammad Afzal"/>
</subcomponent>
<subcomponent>
<description
value="It is unknown if the results are sensitive to the analytic method, and the stopping criteria were based on statistical significance and not magnitude of effect."/>
<note>
<text
value="Definition of Analysis Bias = A bias related to the analytic process applied to the data."/>
</note>
<type>
<coding>
<system value="https://fevir.net/resources/CodeSystem/181513"/>
<code value="SEVCO:00021"/>
<display value="Analysis Bias"/>
</coding>
</type>
<rating>
<coding>
<system value="http://hl7.org/fhir/certainty-rating"/>
<version value="5.0.0"/>
<code value="very-serious-concern"/>
<display value="very serious concern"/>
<userSelected value="true"/>
</coding>
</rating>
<rater
value="Brian S. Alper, Joanne Dehnbostel, Muhammad Afzal, Janice Tufte"/>
<subcomponent>
<description
value="A frequentist analysis is not reported so we cannot determine if the results are sensitive to the analytic method"/>
<note>
<text
value="Definition of Bias related to selection of the analysis = An analysis bias due to inappropriate choice of analysis methods before the analysis is applied."/>
</note>
<note>
<text
value="There was no pre-specified frequentist analysis. There was no posthoc frequentist analysis reported."/>
</note>
<note>
<text
value="It is uncertain what a frequentist analysis would show and uncertain whether the choice of Bayesian analysis or frequentist analysis has a substantial influence on the results."/>
</note>
<type>
<coding>
<system value="https://fevir.net/resources/CodeSystem/181513"/>
<code value="SEVCO:00022"/>
<display value="Bias related to selection of the analysis"/>
</coding>
</type>
<rating>
<coding>
<system value="http://hl7.org/fhir/certainty-rating"/>
<version value="5.0.0"/>
<code value="very-serious-concern"/>
<display value="very serious concern"/>
<userSelected value="true"/>
</coding>
</rating>
<rater
value="Brian S. Alper, Joanne Dehnbostel, Muhammad Afzal, Janice Tufte"/>
</subcomponent>
<subcomponent>
<description
value="The stopping criteria were based on statistical significance and not magnitude of effect."/>
<note>
<text
value="There was no “minimally important difference”. So a 99% probability of having an odds ratio > 1 (even if the magnitude of effect is infinitesimal) was used to decide it was time to stop the trial."/>
</note>
<type>
<coding>
<system value="https://fevir.net/resources/CodeSystem/181513"/>
<code value="SEVCO:00370"/>
<display value="Early Study Termination Bias"/>
</coding>
</type>
<rating>
<coding>
<system value="http://hl7.org/fhir/certainty-rating"/>
<version value="5.0.0"/>
<code value="very-serious-concern"/>
<display value="very serious concern"/>
<userSelected value="true"/>
</coding>
</rating>
<rater
value="Brian S. Alper, Joanne Dehnbostel, Muhammad Afzal, Janice Tufte"/>
</subcomponent>
</subcomponent>
</certainty>
</Evidence>
IG © 2022+ HL7 International / Clinical Decision Support. Package hl7.fhir.uv.ebm#1.0.0-ballot based on FHIR 5.0.0. Generated 2023-12-17
Links: Table of Contents |
QA Report
| Version History |
|
Propose a change