Visualising harms in publications of randomised controlled trials: consensus and recommendations
Authors: Phillips Rachel , Cro Suzie , Wheeler Graham , Bond Simon , Morris Tim P , Creanor Siobhan , Hewitt Catherine , Love Sharon , Lopes Andre , Schlackow Iryna , Gamble Carrol , MacLennan Graeme , Habron Chris , Gordon Anthony C , Vergis Nikhil , Li Tianjing , Qureshi Riaz , Everett Colin C , Holmes Jane , Kirkham Amanda , Peckitt Clare , Pirrie Sarah , Ahmed Norin , Collett Laura , Cornelius Victoria 
Published: May 2022

Objective

To improve communication of harm in publications of randomised controlled trials via the development of recommendations for visually presenting harm outcomes.

Design

Consensus study.

Setting

15 clinical trials units registered with the UK Clinical Research Collaboration, an academic population health department, Roche Products, andTheBMJ.

Participants

Experts in clinical trials: 20 academic statisticians, one industry statistician, one academic health economist, one data graphics designer, and two clinicians.

Main outcome

measuresA methodological review of statistical methods identified visualisations along with those recommended by consensus group members. Consensus on visual recommendations was achieved (at least 60% of the available votes) over a series of three meetings with participants. The participants reviewed and critically appraised candidate visualisations against an agreed framework and voted on whether to endorse each visualisation. Scores marginally below this threshold (50-60%) were revisited for further discussions and votes retaken until consensus was reached.

Results

28 visualisations were considered, of which 10 are recommended for researchers to consider in publications of main research findings. The choice of visualisations to present will depend on outcome type (eg, binary, count, time-to-event, or continuous), and the scenario (eg, summarising multiple emerging events or one event of interest). A decision tree is presented to assist trialists in deciding which visualisations to use. Examples are provided of each endorsed visualisation, along with an example interpretation, potential limitations, and signposting to code for implementation across a range of standard statistical software. Clinician feedback was incorporated into the explanatory information provided in the recommendations to aid understanding and interpretation.

Conclusions

Visualisations provide a powerful tool to communicate harms in clinical trials, offering an alternative perspective to the traditional frequency tables. Increasing the use of visualisations for harm outcomes in clinical trial manuscripts and reports will provide clearer presentation of information and enable more informative interpretations. The limitations of each visualisation are discussed and examples of where their use would be inappropriate are given. Although the decision tree aids the choice of visualisation, the statistician and clinical trial team must ultimately decide the most appropriate visualisations for their data and objectives. Trialists should continue to examine crude numbers alongside visualisations to fully understand harm profiles.