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General medicine
Thresholds for interpreting the fragility index derived from sample of randomised controlled trials in cardiology: a meta-epidemiologic study
  1. Mohammad Hassan Murad1,2,
  2. Abdalla Kara Balla2,
  3. Muhammad Shahzeb Khan3,
  4. Asim Shaikh4,
  5. Samer Saadi2,
  6. Zhen Wang2
  1. 1Division of Public Health, Infectious Diseases and Occupational Medicine, Mayo Clinic, Rochester, MN, USA
  2. 2Evidence-based Practice Center, Mayo Clinic, Rochester, Minnesota, USA
  3. 3Division of Cardiology, Duke University School of Medicine, Durham, North Carolina, USA
  4. 4Department of Internal Medicine, Dow University of Health Sciences, Karachi, Pakistan
  1. Correspondence to Dr Mohammad Hassan Murad, Public Health, Infectious Diseases and Occupational Medicine, Mayo Clinic, Rochester, Minnesota, 55905, USA; murad.mohammad{at}mayo.edu

Abstract

The fragility index (FI) was proposed as a simplified way to communicate robustness of statistically significant results and their susceptibility to a change of a handful number of events. While this index is intuitive, it is not anchored by a cut-off or a guide for interpretation. We identified cardiovascular trials published in six high impact journals from 2007 to 2021 (500 or more participants and a dichotomous statistically significant primary outcome). We estimated area under curve (AUC) to determine FI value that best predicts whether the treatment effect was precise, defined as adequately powered for a plausible relative risk reduction (RRR) of 25% or 30% or having a CI that is sufficiently narrow to exclude a risk reduction that is too small (close to the null, <0.05). The median FI of 201 included cardiovascular trials was 13 (range 1–172). FI exceeded the number of patients lost to follow-up in 46/201 (22.89%) trials. FI values of 19 and 22 predicted that trials would be precise (powered for RRR of 30% and 25%; respectively, combined with CI that excluded risk reduction <0.05). AUC for meeting these precision criteria was 0.90 (0.86–0.94). In conclusion, FI values that range 19–22 may meet various definitions of precision and can be used as a rule of thumb to suggest that a treatment effect is likely precise and less susceptible to random error. The number of patients lost to follow-up should be presented alongside FI to better illustrate fragility.

  • cardiology
  • epidemiology
  • methods

Data availability statement

All data relevant to the study are included in the article or uploaded as supplementary information.

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Data availability statement

All data relevant to the study are included in the article or uploaded as supplementary information.

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Footnotes

  • Contributors MHM, ZW and AKB conceived the idea. AKB, MSK, AS and SS selected studies and extracted data. ZW conducted the analysis. MHM is the guarantor of this work.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.