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Authors' reply

Published online by Cambridge University Press:  02 January 2018

Laurent Boyer
Affiliation:
Aix-Marseille University, EA 3279 – Public Health, Chronic Diseases and Quality of Life – Research Unit, Marseille, France. Email: laurent.boyer@ap-hm.fr
Karine Baumstarck
Affiliation:
Aix-Marseille University, EA 3279 – Public Health, Chronic Diseases and Quality of Life – Research Unit, Marseille
Julie Berbis
Affiliation:
Aix-Marseille University, EA 3279 – Public Health, Chronic Diseases and Quality of Life – Research Unit, Marseille
Nathalie Parola
Affiliation:
Department of Psychiatry, Sainte-Marguerite University Hospital, Marseille
Christophe Lançon
Affiliation:
Aix-Marseille University, EA 3279 – Public Health, Chronic Diseases and Quality of Life – Research Unit, Marseille, France
Pascal Auquier
Affiliation:
Aix-Marseille University, EA 3279 – Public Health, Chronic Diseases and Quality of Life – Research Unit, Marseille, France
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Abstract

Type
Columns
Copyright
Copyright © Royal College of Psychiatrists, 2014

We are in agreement with Langford & Badenoch’s general comment on the need for holistic assessment in psychiatry. It is currently established that patients’ views, and especially quality of life (QoL) measures, should supplement the usual indicators of quality in healthcare.Reference Boyer, Baumstarck, Boucekine, Blanc, Lancon and Auquier1 However, we are doubtful about the relevance of their criticisms.

Langford & Badenoch denounced the following sentence: ‘Global satisfaction was significantly higher in the QoL feedback group […] compared with the standard psychiatric assessment […] and QoL assessment groups’.Reference Boyer, Lançon, Baumstarck, Parola, Berbis and Auquier2 This assumption was derived, however, directly from our results (i.e. the proportions of very satisfied patients were 73% in the QoL feedback group, 45% in the QoL assessment group and 68% in the standard group). The comparison performed using a chi-squared test was statistically significant (P = 0.025), allowing us to state that global satisfaction significantly differed between the three groups. As we have written in our Discussion, this finding did not prohibit us from suggesting that integrating QoL assessment and feedback with standard psychiatric assessment seemed relevant or that priority should be given to strategies that implement QoL measurements in routine practice.

Moreover, this assumption was in agreement with our study design (i.e. three arms) and the sample size calculation performed for this design. However, we recognise that multiple treatment arms in randomised controlled trials (RCTs) are sources of misunderstanding,Reference Baron, Perrodeau, Boutron and Ravaud3 especially because there are several possible comparisons.Reference Schulz and Grimes4 Langford & Badenoch re-wrote our primary outcome for a two-arm RCT as follows: ‘level of patient satisfaction in the QoL feedback group compared with standard psychiatric assessment’, implying pairwise chi-squared tests. However, our primary outcome and analysis were defined in accordance with the primary objective integrating the three-arm design. The objective was to globally determine the ‘positions’ of QoL feedback, QoL without feedback and the control group with respect to their relationships to satisfaction; we did not aim to question the relevance of using the QoL measure (which is already recognised in the literature) in 2×2 comparisons between the different arms. The primary criterion was thus analysed using a global chi-squared test, determined a priori; it was not analysed using pairwise chi-squared tests (as recommended by Langford & Badenoch), which were not planned and for which the alpha error risk was not controlled. It is also widely recognised that bias may be introduced if decisions regarding data analysis are driven by the data.Reference Baron, Perrodeau, Boutron and Ravaud3

Langford & Badenoch also claim that ‘The conclusions drawn by the authors, that their findings “provide strong support […]” and that “priority should be given to strategies to implement QoL” […] seem particularly unfounded’. We did not conclude with these two sentences, which were taken from the Discussion (the function of which differs from the conclusionReference Skelton and Edwards5) without heed to what was written before and after. In fact, we stated that ‘Priority should be given to strategies to implement QoL measurements in routine practice’, especially because ‘clinicians did not optimally use the QoL feedback’ and ‘obtaining QoL data in an efficient, real-time manner is difficult and rare in clinical practice’.

Last, we were pleased to read that Langford & Badenoch felt that the existence of a nocebo effect in the QoL assessment group with feedback was the most salient finding, as this was an issue that we extensively discussed in our manuscript.

In conclusion, it is important to insist that any result reported in a study must be interpreted considering the objective and the design of the study and, more globally, in the context of current scientific knowledge. In agreement with Karl Popper, we believe that scientific objectivity is based on intersubjectivity and the ethics of discussion. We hope that our answer will close the gap between our scientific work and the understanding of Langford & Badenoch.

References

1 Boyer, L Baumstarck, K Boucekine, M Blanc, J Lancon, C Auquier, P Measuring quality of life in patients with schizophrenia: an overview. Expert Rev Pharmacoecon Outcomes Res 2013; 13: 343349.CrossRefGoogle ScholarPubMed
2 Boyer, L Lançon, C Baumstarck, K Parola, N Berbis, J Auquier, P Evaluating the impact of a quality of life assessment with feedback to clinicians in patients with schizophrenia: randomised controlled trial. Br J Psychiatry 2013; 202: 447453.CrossRefGoogle ScholarPubMed
3 Baron, G Perrodeau, E Boutron, I Ravaud, P Reporting of analyses from randomized controlled trials with multiple arms: a systematic review. BMC Med 2013; 11: 84.CrossRefGoogle ScholarPubMed
4 Schulz, KF Grimes, DA. Multiplicity in randomised trials. I: endpoints and treatments. Lancet 2005; 365: 15911595.CrossRefGoogle ScholarPubMed
5 Skelton, JR Edwards, SJ. The function of the discussion section in academic medical writing. BMJ 2000; 320: 12691270.CrossRefGoogle ScholarPubMed
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