{"id":88,"date":"2021-05-22T22:31:40","date_gmt":"2021-05-23T02:31:40","guid":{"rendered":"https:\/\/pressbooks.bccampus.ca\/rickyturgeon\/?post_type=chapter&#038;p=88"},"modified":"2022-01-12T22:57:18","modified_gmt":"2022-01-13T03:57:18","slug":"composite-outcome-was-the-primary-outcome-a-combination-of-outcomes","status":"publish","type":"chapter","link":"https:\/\/pressbooks.bccampus.ca\/rickyturgeon\/chapter\/composite-outcome-was-the-primary-outcome-a-combination-of-outcomes\/","title":{"raw":"Composite outcome: Was the primary outcome a combination of outcomes?","rendered":"Composite outcome: Was the primary outcome a combination of outcomes?"},"content":{"raw":"By combining several individual outcomes into a [pb_glossary id=\"359\"]composite outcome[\/pb_glossary] a trial can increase its ability to detect a difference between groups. However, [pb_glossary id=\"359\"]composite outcomes[\/pb_glossary] require careful interpretation of the individual components to avoid making erroneous conclusions.\r\n<h1>Checklist Questions<\/h1>\r\n<table class=\"grid\" style=\"border-collapse: collapse;width: 100%;height: 66px\" border=\"0\">\r\n<tbody>\r\n<tr style=\"height: 18px\">\r\n<td style=\"width: 100%;height: 18px\">Are the components of the [pb_glossary id=\"359\"]composite outcome[\/pb_glossary] all of similar importance to patients?<\/td>\r\n<\/tr>\r\n<tr style=\"height: 18px\">\r\n<td style=\"width: 100%;height: 18px\">Did the components occur with similar frequencies?<\/td>\r\n<\/tr>\r\n<tr style=\"height: 12px\">\r\n<td style=\"width: 100%;height: 12px\">Are the point estimates of treatment effect ([pb_glossary id=\"110\"]HR[\/pb_glossary], [pb_glossary id=\"103\"]OR[\/pb_glossary], [pb_glossary id=\"109\"]RR[\/pb_glossary]) similar between each component? Do the 95% <a href=\"https:\/\/pressbooks.bccampus.ca\/rickyturgeon\/back-matter\/appendix\/\" target=\"_blank\" rel=\"noopener\">CIs<\/a> overlap? Are they sufficiently narrow?<\/td>\r\n<\/tr>\r\n<tr style=\"height: 18px\">\r\n<td style=\"width: 100%;height: 18px\">Do the components share a similar underlying biological mechanism?<\/td>\r\n<\/tr>\r\n<\/tbody>\r\n<\/table>\r\n<h1><span class=\"TextRun SCXW115571336 BCX9\" lang=\"EN-US\" xml:lang=\"EN-US\" data-contrast=\"auto\"><span class=\"NormalTextRun SCXW115571336 BCX9\">Clinical importance: <\/span><\/span>Are the components of the composite outcome all of similar importance to patients?<\/h1>\r\n<div class=\"textbox shaded\">\r\n\r\n<em><em><span class=\"TextRun SCXW19164495 BCX9\" lang=\"EN-US\" xml:lang=\"EN-US\" data-contrast=\"auto\"><span class=\"NormalTextRun ContextualSpellingAndGrammarErrorV2 SCXW19164495 BCX9 DefaultHighlightTransition\">E.g.<\/span><span class=\"NormalTextRun SCXW19164495 BCX9\"> #1 <span class=\"TrackChangeTextInsertion TrackedChange SCXW215712025 BCX9\"><span class=\"TextRun SCXW215712025 BCX9\" lang=\"EN\" xml:lang=\"EN\" data-contrast=\"auto\"><span class=\"NormalTextRun SCXW215712025 BCX9\">The [pb_glossary id=\"1517\"]primary outcome[\/pb_glossary] of\u00a0<\/span><span class=\"FindHit SCXW215712025 BCX9\">DAPA<\/span><span class=\"NormalTextRun SCXW215712025 BCX9\">-HF (<a href=\"https:\/\/pressbooks.bccampus.ca\/rickyturgeon\/back-matter\/references\/\" target=\"_blank\" rel=\"noopener\">McMurray JJV et al.<\/a>), a trial <\/span><\/span><\/span><span class=\"TrackChangeTextInsertion TrackedChange SCXW215712025 BCX9\"><span class=\"TextRun SCXW215712025 BCX9\" lang=\"EN\" xml:lang=\"EN\" data-contrast=\"auto\"><span class=\"NormalTextRun SCXW215712025 BCX9\">comparing\u00a0<\/span><span class=\"FindHit SCXW215712025 BCX9\">dapa<\/span><span class=\"NormalTextRun SCXW215712025 BCX9\">gliflozin vs. placebo in patients with heart failure with reduced ejection fraction (<\/span><\/span><\/span><span class=\"TrackChangeTextInsertion TrackedChange SCXW215712025 BCX9\"><span class=\"TextRun SCXW215712025 BCX9\" lang=\"EN\" xml:lang=\"EN\" data-contrast=\"auto\"><span class=\"NormalTextRun SpellingErrorV2 SCXW215712025 BCX9\">HFrEF)<\/span><\/span><\/span><span class=\"TrackChangeTextInsertion TrackedChange SCXW215712025 BCX9\"><span class=\"TextRun SCXW215712025 BCX9\" lang=\"EN\" xml:lang=\"EN\" data-contrast=\"auto\"><span class=\"NormalTextRun SCXW215712025 BCX9\">,\u00a0<\/span><\/span><\/span><span class=\"TrackChangeTextInsertion TrackedChange SCXW215712025 BCX9\"><span class=\"TextRun SCXW215712025 BCX9\" lang=\"EN\" xml:lang=\"EN\" data-contrast=\"auto\"><span class=\"NormalTextRun SCXW215712025 BCX9\">was a [pb_glossary id=\"359\"]composite[\/pb_glossary] of:<\/span><\/span><\/span><\/span><\/span><\/em><\/em>\r\n<ul>\r\n \t<li><em><span class=\"TextRun SCXW19164495 BCX9\" lang=\"EN-US\" xml:lang=\"EN-US\" data-contrast=\"auto\"><span class=\"NormalTextRun SCXW19164495 BCX9\"><span class=\"TrackChangeTextInsertion TrackedChange SCXW215712025 BCX9\"><span class=\"TextRun SCXW215712025 BCX9\" lang=\"EN\" xml:lang=\"EN\" data-contrast=\"auto\"><span class=\"NormalTextRun SCXW215712025 BCX9\">Hospitalization for heart failure (<\/span><\/span><\/span><span class=\"TrackChangeTextInsertion TrackedChange SCXW215712025 BCX9\"><span class=\"TextRun SCXW215712025 BCX9\" lang=\"EN\" xml:lang=\"EN\" data-contrast=\"auto\"><span class=\"NormalTextRun SCXW215712025 BCX9\">HF)<\/span><\/span><\/span><span class=\"TrackChangeTextInsertion TrackedChange SCXW215712025 BCX9\"><span class=\"TextRun SCXW215712025 BCX9\" lang=\"EN\" xml:lang=\"EN\" data-contrast=\"auto\"><span class=\"NormalTextRun SCXW215712025 BCX9\">\u00a0resulting in\u00a0<\/span><\/span><\/span><span class=\"TrackChangeTextInsertion TrackedChange SCXW215712025 BCX9\"><span class=\"TextRun SCXW215712025 BCX9\" lang=\"EN\" xml:lang=\"EN\" data-contrast=\"auto\"><span class=\"NormalTextRun SCXW215712025 BCX9\">intravenous therapy<\/span><\/span><\/span><\/span><\/span><\/em><\/li>\r\n \t<li><em><span class=\"TextRun SCXW19164495 BCX9\" lang=\"EN-US\" xml:lang=\"EN-US\" data-contrast=\"auto\"><span class=\"NormalTextRun SCXW19164495 BCX9\"><span class=\"TrackChangeTextInsertion TrackedChange SCXW215712025 BCX9\"><span class=\"TextRun SCXW215712025 BCX9\" lang=\"EN\" xml:lang=\"EN\" data-contrast=\"auto\"><span class=\"NormalTextRun SCXW215712025 BCX9\">Urgent <\/span><\/span><\/span><span class=\"TrackChangeTextInsertion TrackedChange SCXW215712025 BCX9\"><span class=\"TextRun SCXW215712025 BCX9\" lang=\"EN\" xml:lang=\"EN\" data-contrast=\"auto\"><span class=\"NormalTextRun SCXW215712025 BCX9\">HF<\/span><\/span><\/span><span class=\"TrackChangeTextInsertion TrackedChange SCXW215712025 BCX9\"><span class=\"TextRun SCXW215712025 BCX9\" lang=\"EN\" xml:lang=\"EN\" data-contrast=\"auto\"><span class=\"NormalTextRun SCXW215712025 BCX9\">\u00a0visit<\/span><\/span><\/span><span class=\"TrackChangeTextInsertion TrackedChange SCXW215712025 BCX9\"><span class=\"TextRun SCXW215712025 BCX9\" lang=\"EN\" xml:lang=\"EN\" data-contrast=\"auto\"><span class=\"NormalTextRun SCXW215712025 BCX9\">\u00a0resulting in intravenous therapy<\/span><\/span><\/span><\/span><\/span><\/em><\/li>\r\n \t<li><em><span class=\"TextRun SCXW19164495 BCX9\" lang=\"EN-US\" xml:lang=\"EN-US\" data-contrast=\"auto\"><span class=\"NormalTextRun SCXW19164495 BCX9\"><span class=\"TrackChangeTextInsertion TrackedChange SCXW215712025 BCX9\"><span class=\"TextRun SCXW215712025 BCX9\" lang=\"EN\" xml:lang=\"EN\" data-contrast=\"auto\"><span class=\"NormalTextRun SCXW215712025 BCX9\">Death from cardiovascular (<\/span><\/span><\/span><span class=\"TrackChangeTextInsertion TrackedChange SCXW215712025 BCX9\"><span class=\"TextRun SCXW215712025 BCX9\" lang=\"EN\" xml:lang=\"EN\" data-contrast=\"auto\"><span class=\"NormalTextRun SCXW215712025 BCX9\">CV)<\/span><\/span><\/span><span class=\"TrackChangeTextInsertion TrackedChange SCXW215712025 BCX9\"><span class=\"TextRun SCXW215712025 BCX9\" lang=\"EN\" xml:lang=\"EN\" data-contrast=\"auto\"><span class=\"NormalTextRun SCXW215712025 BCX9\"> causes<\/span><\/span><\/span><\/span><\/span><\/em><\/li>\r\n<\/ul>\r\n<em><span class=\"TextRun SCXW19164495 BCX9\" lang=\"EN-US\" xml:lang=\"EN-US\" data-contrast=\"auto\"><span class=\"NormalTextRun SCXW19164495 BCX9\"><span class=\"TrackChangeTextInsertion TrackedChange SCXW215712025 BCX9\"><span class=\"TextRun SCXW215712025 BCX9\" lang=\"EN\" xml:lang=\"EN\" data-contrast=\"auto\"><span class=\"NormalTextRun SCXW215712025 BCX9\">These are all outcomes of significant importance to patients.\u00a0<\/span><\/span><\/span><\/span><\/span><\/em>\r\n\r\n<\/div>\r\n<div class=\"textbox shaded\">\r\n\r\n<em><em><span class=\"EOP SCXW19164495 BCX9\" data-ccp-props=\"{}\">E.g. #2 <span class=\"TrackChangeTextInsertion TrackedChange BCX9 SCXW165418290\"><span class=\"TextRun BCX9 SCXW165418290\" lang=\"EN\" xml:lang=\"EN\" data-contrast=\"auto\"><span class=\"NormalTextRun BCX9 SCXW165418290\">The [pb_glossary id=\"1517\"]primary outcome[\/pb_glossary] of\u00a0<\/span><\/span><\/span><span class=\"TrackChangeTextInsertion TrackedChange BCX9 SCXW165418290\"><span class=\"TextRun Highlight BCX9 SCXW165418290\" lang=\"EN\" xml:lang=\"EN\" data-contrast=\"auto\"><span class=\"NormalTextRun BCX9 SCXW165418290\">CONDOR (<a href=\"https:\/\/pressbooks.bccampus.ca\/rickyturgeon\/back-matter\/references\/\" target=\"_blank\" rel=\"noopener\">Chan FKL et al.<\/a>)<\/span><\/span><\/span><span class=\"TrackChangeTextInsertion TrackedChange BCX9 SCXW165418290\"><span class=\"TextRun BCX9 SCXW165418290\" lang=\"EN\" xml:lang=\"EN\" data-contrast=\"auto\"><span class=\"NormalTextRun BCX9 SCXW165418290\">, a trial comparing celecoxib vs NSAID+PPI, was a [pb_glossary id=\"359\"]composite[\/pb_glossary] of:<\/span><\/span><\/span><\/span><\/em><\/em>\r\n<ul>\r\n \t<li><em><span class=\"EOP SCXW19164495 BCX9\" data-ccp-props=\"{}\"><span class=\"TrackChangeTextInsertion TrackedChange BCX9 SCXW165418290\"><span class=\"TextRun BCX9 SCXW165418290\" lang=\"EN\" xml:lang=\"EN\" data-contrast=\"auto\"><span class=\"NormalTextRun BCX9 SCXW165418290\">Gastrointestinal (GI) bleed<\/span><\/span><\/span><\/span><\/em><\/li>\r\n \t<li><em><span class=\"EOP SCXW19164495 BCX9\" data-ccp-props=\"{}\"><span class=\"TrackChangeTextInsertion TrackedChange BCX9 SCXW165418290\"><span class=\"TextRun BCX9 SCXW165418290\" lang=\"EN\" xml:lang=\"EN\" data-contrast=\"auto\"><span class=\"NormalTextRun BCX9 SCXW165418290\">GI obstruction<\/span><\/span><\/span><\/span><\/em><\/li>\r\n \t<li><em><span class=\"EOP SCXW19164495 BCX9\" data-ccp-props=\"{}\"><span class=\"TrackChangeTextInsertion TrackedChange BCX9 SCXW165418290\"><span class=\"TextRun BCX9 SCXW165418290\" lang=\"EN\" xml:lang=\"EN\" data-contrast=\"auto\"><span class=\"NormalTextRun BCX9 SCXW165418290\">GI perforation<\/span><\/span><\/span><\/span><\/em><\/li>\r\n \t<li><em><span class=\"EOP SCXW19164495 BCX9\" data-ccp-props=\"{}\"><span class=\"TrackChangeTextInsertion TrackedChange BCX9 SCXW165418290\"><span class=\"TextRun BCX9 SCXW165418290\" lang=\"EN\" xml:lang=\"EN\" data-contrast=\"auto\"><span class=\"NormalTextRun BCX9 SCXW165418290\">Clinically significant anemia (decrease in hemoglobin\u00a0 \u2265 20 g\/L or decrease in hematocrit<\/span><span class=\"NormalTextRun BCX9 SCXW165418290\">\u00a0\u226510%)<\/span><\/span><\/span><\/span><\/em><\/li>\r\n<\/ul>\r\n<em><span class=\"EOP SCXW19164495 BCX9\" data-ccp-props=\"{}\"><span class=\"TrackChangeTextInsertion TrackedChange BCX9 SCXW165418290\"><span class=\"TextRun BCX9 SCXW165418290\" lang=\"EN\" xml:lang=\"EN\" data-contrast=\"auto\"><span class=\"NormalTextRun BCX9 SCXW165418290\">The latter of which was notably less important than the other components.<\/span><\/span><\/span><\/span><\/em>\r\n\r\n<\/div>\r\n<h1><span class=\"TextRun SCXW261278014 BCX9\" lang=\"EN-US\" xml:lang=\"EN-US\" data-contrast=\"auto\"><span class=\"NormalTextRun SCXW261278014 BCX9\">Statistical contribution: <\/span><\/span><span class=\"TextRun SCXW261278014 BCX9\" lang=\"EN-US\" xml:lang=\"EN-US\" data-contrast=\"auto\"><span class=\"NormalTextRun SCXW261278014 BCX9\">Did the component outcomes occur with similar frequencies?<\/span><\/span><span class=\"EOP SCXW261278014 BCX9\" data-ccp-props=\"{}\">\u00a0<\/span><\/h1>\r\n<div style=\"font-weight: 400\">\r\n<div class=\"textbox shaded\">\r\n<div style=\"font-weight: 400\">\r\n\r\n<em><span class=\"TrackChangeTextInsertion TrackedChange BCX9 SCXW50700698\"><span class=\"TextRun BCX9 SCXW50700698\" lang=\"EN\" xml:lang=\"EN\" data-contrast=\"auto\"><span class=\"NormalTextRun BCX9 SCXW50700698\">E.g. #1 C<\/span><\/span><\/span><span class=\"TrackChangeTextInsertion TrackedChange BCX9 SCXW50700698\"><span class=\"TextRun BCX9 SCXW50700698\" lang=\"EN\" xml:lang=\"EN\" data-contrast=\"auto\"><span class=\"NormalTextRun BCX9 SCXW50700698\">omponents of the [pb_glossary id=\"1517\"]primary outcome[\/pb_glossary] in <span class=\"FindHit BCX9 SCXW50700698\">DAPA<\/span>-HF <span class=\"TextRun SCXW19164495 BCX9\" lang=\"EN-US\" xml:lang=\"EN-US\" data-contrast=\"auto\"><span class=\"NormalTextRun SCXW19164495 BCX9\"><span class=\"TrackChangeTextInsertion TrackedChange SCXW215712025 BCX9\"><span class=\"TextRun SCXW215712025 BCX9\" lang=\"EN\" xml:lang=\"EN\" data-contrast=\"auto\"><span class=\"NormalTextRun SCXW215712025 BCX9\">(<a href=\"https:\/\/pressbooks.bccampus.ca\/rickyturgeon\/back-matter\/references\/\" target=\"_blank\" rel=\"noopener\">McMurray JJV et al.<\/a>) <\/span><\/span><\/span><\/span><\/span>and their <\/span><\/span><\/span><span class=\"TrackChangeTextInsertion TrackedChange BCX9 SCXW50700698\"><span class=\"TextRun BCX9 SCXW50700698\" lang=\"EN\" xml:lang=\"EN\" data-contrast=\"auto\"><span class=\"NormalTextRun BCX9 SCXW50700698\">rates for\u00a0<\/span><span class=\"FindHit BCX9 SCXW50700698\">dapa<\/span><span class=\"NormalTextRun BCX9 SCXW50700698\">gliflozin vs. placebo:<\/span><\/span><\/span><\/em>\r\n<ul>\r\n \t<li><em><span class=\"TrackChangeTextInsertion TrackedChange BCX9 SCXW50700698\"><span class=\"TextRun BCX9 SCXW50700698\" lang=\"EN\" xml:lang=\"EN\" data-contrast=\"auto\"><span class=\"NormalTextRun BCX9 SCXW50700698\">Hospitalization or urgent visit for HF <\/span><\/span><\/span><span class=\"TrackChangeTextInsertion TrackedChange BCX9 SCXW50700698\"><span class=\"TextRun BCX9 SCXW50700698\" lang=\"EN\" xml:lang=\"EN\" data-contrast=\"auto\"><span class=\"NormalTextRun BCX9 SCXW50700698\">(10<\/span><\/span><\/span><span class=\"TrackChangeTextInsertion TrackedChange BCX9 SCXW50700698\"><span class=\"TextRun BCX9 SCXW50700698\" lang=\"EN\" xml:lang=\"EN\" data-contrast=\"auto\"><span class=\"NormalTextRun BCX9 SCXW50700698\">% vs.<\/span><\/span><\/span><span class=\"TrackChangeTextInsertion TrackedChange BCX9 SCXW50700698\"><span class=\"TextRun BCX9 SCXW50700698\" lang=\"EN\" xml:lang=\"EN\" data-contrast=\"auto\"><span class=\"NormalTextRun BCX9 SCXW50700698\"> 14%)<\/span><\/span><\/span><\/em><\/li>\r\n \t<li><em><span class=\"TrackChangeTextInsertion TrackedChange BCX9 SCXW50700698\"><span class=\"TextRun BCX9 SCXW50700698\" lang=\"EN\" xml:lang=\"EN\" data-contrast=\"auto\"><span class=\"NormalTextRun BCX9 SCXW50700698\">Death from CV causes <\/span><\/span><\/span><span class=\"TrackChangeTextInsertion TrackedChange BCX9 SCXW50700698\"><span class=\"TextRun BCX9 SCXW50700698\" lang=\"EN\" xml:lang=\"EN\" data-contrast=\"auto\"><span class=\"NormalTextRun BCX9 SCXW50700698\">(10% vs. 12<\/span><\/span><\/span><span class=\"TrackChangeTextInsertion TrackedChange BCX9 SCXW50700698\"><span class=\"TextRun BCX9 SCXW50700698\" lang=\"EN\" xml:lang=\"EN\" data-contrast=\"auto\"><span class=\"NormalTextRun BCX9 SCXW50700698\">%)\u00a0<\/span><\/span><\/span><\/em><\/li>\r\n<\/ul>\r\n<em><span class=\"TrackChangeTextInsertion TrackedChange BCX9 SCXW50700698\"><span class=\"TextRun BCX9 SCXW50700698\" lang=\"EN\" xml:lang=\"EN\" data-contrast=\"auto\"><span class=\"NormalTextRun BCX9 SCXW50700698\">The most important endpoint (death from CV causes) occurred only slightly less frequently than the other component.<\/span><\/span><\/span><\/em>\r\n\r\n<\/div>\r\n<\/div>\r\n<div class=\"textbox shaded\">\r\n<p style=\"font-weight: 400\"><em>E.g. #2 Components of the [pb_glossary id=\"1517\"]primary outcome[\/pb_glossary] in CONDOR <span class=\"EOP SCXW19164495 BCX9\" data-ccp-props=\"{}\"><span class=\"TrackChangeTextInsertion TrackedChange BCX9 SCXW165418290\"><span class=\"TextRun Highlight BCX9 SCXW165418290\" lang=\"EN\" xml:lang=\"EN\" data-contrast=\"auto\"><span class=\"NormalTextRun BCX9 SCXW165418290\">(<a href=\"https:\/\/pressbooks.bccampus.ca\/rickyturgeon\/back-matter\/references\/\" target=\"_blank\" rel=\"noopener\">Chan FKL et al.<\/a>)<\/span><\/span><\/span><\/span> and their rates for celecoxib vs NSAID+PPI:\u00a0<\/em><\/p>\r\n\r\n<div style=\"font-weight: 400\">\r\n<ul>\r\n \t<li><em>GI bleed (0.2% vs. 0.2%) <\/em><\/li>\r\n \t<li><em style=\"text-align: initial;font-size: 0.9em\">GI obstruction (0% for both groups) <\/em><\/li>\r\n \t<li><em style=\"text-align: initial;font-size: 0.9em\">GI perforation (0% for both groups) <\/em><\/li>\r\n \t<li><em style=\"text-align: initial;font-size: 0.9em\">Clinically significant anemia (0.7% vs. 3%) <\/em><\/li>\r\n<\/ul>\r\n<em style=\"text-align: initial;font-size: 0.9em\">The greatest contributor of events (clinically significant anemia) drove the difference between groups was also the least clinically important.<\/em>\r\n\r\n<\/div>\r\n<\/div>\r\n<\/div>\r\n<h1>Consistency in effect of therapy: Are the point estimates of treatment effect between each component consistent? Do the 95% CIs overlap? Are they sufficiently narrow?<\/h1>\r\n<div class=\"textbox shaded\">\r\n\r\n<em>E.g. #1 [pb_glossary id=\"110\"]HRs[\/pb_glossary] in DAPA-HF (<a href=\"https:\/\/pressbooks.bccampus.ca\/rickyturgeon\/back-matter\/references\/\" target=\"_blank\" rel=\"noopener\">McMurray JJV et al.<\/a>) for dapagliflozin vs. placebo:<\/em>\r\n<ul>\r\n \t<li><em>[pb_glossary id=\"359\"]Composite[\/pb_glossary] [pb_glossary id=\"110\"]HR[\/pb_glossary] = 0.74 (95% <a href=\"https:\/\/pressbooks.bccampus.ca\/rickyturgeon\/back-matter\/appendix\/\" target=\"_blank\" rel=\"noopener\">CI<\/a> 0.65-0.85)<\/em><\/li>\r\n \t<li><em style=\"text-align: initial;font-size: 0.9em\">Hospitalization or urgent visit for heart failure [pb_glossary id=\"110\"]HR[\/pb_glossary] = 0.70 (95% <a href=\"https:\/\/pressbooks.bccampus.ca\/rickyturgeon\/back-matter\/appendix\/\" target=\"_blank\" rel=\"noopener\">CI<\/a> 0.59-0.83)<\/em><\/li>\r\n \t<li><em style=\"text-align: initial;font-size: 0.9em\">Cardiovascular death [pb_glossary id=\"110\"]HR[\/pb_glossary] = 0.82 (95% <a href=\"https:\/\/pressbooks.bccampus.ca\/rickyturgeon\/back-matter\/appendix\/\" target=\"_blank\" rel=\"noopener\">CI<\/a> 0.69-0.98)<\/em><\/li>\r\n<\/ul>\r\n<em>Since all the <a href=\"https:\/\/pressbooks.bccampus.ca\/rickyturgeon\/back-matter\/appendix\/\" target=\"_blank\" rel=\"noopener\">CIs<\/a> overlap and are sufficiently narrow, there can be greater confidence that the [pb_glossary id=\"359\"]composite outcome[\/pb_glossary] is not misleading.<\/em>\r\n\r\n<\/div>\r\n<div class=\"textbox shaded\">\r\n\r\n<em>E.g. #2 [pb_glossary id=\"1111\"]Relative risk reductions (RRRs)[\/pb_glossary] in CONDOR (<a href=\"https:\/\/pressbooks.bccampus.ca\/rickyturgeon\/back-matter\/references\/\" target=\"_blank\" rel=\"noopener\">Chan FKL et al.<\/a>) for celecoxib vs NSAID+PPI:<\/em>\r\n<ul>\r\n \t<li><em>[pb_glossary id=\"359\"]Composite[\/pb_glossary] [pb_glossary id=\"1111\"]RRR[\/pb_glossary] = 75% <\/em><\/li>\r\n \t<li><em style=\"text-align: initial;font-size: 0.9em\">GI bleed [pb_glossary id=\"1111\"]RRR[\/pb_glossary] = 0% <\/em><\/li>\r\n \t<li><em style=\"text-align: initial;font-size: 0.9em\">Clinically significant anemia [pb_glossary id=\"1111\"]RRR[\/pb_glossary] = 80%\u00a0<\/em><\/li>\r\n<\/ul>\r\n<em>Since there is a very large difference in the point estimates, it is better to consider the individual endpoints rather than the [pb_glossary id=\"359\"]composite endpoint[\/pb_glossary].<\/em>\r\n\r\n<\/div>\r\n<h1><span class=\"TextRun SCXW54353425 BCX9\" lang=\"EN-US\" xml:lang=\"EN-US\" data-contrast=\"auto\"><span class=\"NormalTextRun SCXW54353425 BCX9\">Biologic rationale:<\/span><\/span><span class=\"TextRun SCXW54353425 BCX9\" lang=\"EN-US\" xml:lang=\"EN-US\" data-contrast=\"auto\"><span class=\"NormalTextRun SCXW54353425 BCX9\">\u00a0<\/span><\/span><span class=\"TextRun SCXW54353425 BCX9\" lang=\"EN-US\" xml:lang=\"EN-US\" data-contrast=\"auto\"><span class=\"NormalTextRun SCXW54353425 BCX9\">Do the components of the composite outcome share a similar underlying biological mechanism?<\/span><\/span><span class=\"EOP SCXW54353425 BCX9\" data-ccp-props=\"{}\">\u00a0<\/span><\/h1>\r\n<div>\r\n<div class=\"textbox shaded\"><em>E.g. #1 In DAPA-HF <span class=\"TrackChangeTextInsertion TrackedChange BCX9 SCXW127455339\"><span class=\"TextRun BCX9 SCXW127455339\" lang=\"EN\" xml:lang=\"EN\" data-contrast=\"auto\"><span class=\"NormalTextRun BCX9 SCXW127455339\">(<span class=\"TrackChangeTextInsertion TrackedChange BCX9 SCXW50700698\"><span class=\"TextRun BCX9 SCXW50700698\" lang=\"EN\" xml:lang=\"EN\" data-contrast=\"auto\"><span class=\"NormalTextRun BCX9 SCXW50700698\"><span class=\"TextRun SCXW19164495 BCX9\" lang=\"EN-US\" xml:lang=\"EN-US\" data-contrast=\"auto\"><span class=\"NormalTextRun SCXW19164495 BCX9\"><span class=\"TrackChangeTextInsertion TrackedChange SCXW215712025 BCX9\"><span class=\"TextRun SCXW215712025 BCX9\" lang=\"EN\" xml:lang=\"EN\" data-contrast=\"auto\"><span class=\"NormalTextRun SCXW215712025 BCX9\"><a href=\"https:\/\/pressbooks.bccampus.ca\/rickyturgeon\/back-matter\/references\/\" target=\"_blank\" rel=\"noopener\">McMurray JJV et al.<\/a>)<\/span><\/span><\/span><\/span><\/span><\/span><\/span><\/span> for <\/span><\/span><span class=\"TextRun BCX9 SCXW127455339\" lang=\"EN\" xml:lang=\"EN\" data-contrast=\"auto\"><span class=\"FindHit BCX9 SCXW127455339\">dapa<\/span><\/span><span class=\"TextRun BCX9 SCXW127455339\" lang=\"EN\" xml:lang=\"EN\" data-contrast=\"auto\"><span class=\"NormalTextRun BCX9 SCXW127455339\">gliflozin vs. placebo all outcomes had a similar underlying mechanism, consisting of (i) h<\/span><\/span><\/span><span class=\"TrackChangeTextInsertion TrackedChange BCX9 SCXW127455339\"><span class=\"TextRun BCX9 SCXW127455339\" lang=\"EN\" xml:lang=\"EN\" data-contrast=\"auto\"><span class=\"NormalTextRun BCX9 SCXW127455339\">ospitalization or urgent visit for\u00a0<\/span><\/span><\/span><span class=\"TrackChangeTextInsertion TrackedChange BCX9 SCXW127455339\"><span class=\"TextRun BCX9 SCXW127455339\" lang=\"EN\" xml:lang=\"EN\" data-contrast=\"auto\"><span class=\"NormalTextRun BCX9 SCXW127455339\">heart fail<\/span><\/span><\/span><span class=\"TrackChangeTextInsertion TrackedChange BCX9 SCXW127455339\"><span class=\"TextRun BCX9 SCXW127455339\" lang=\"EN\" xml:lang=\"EN\" data-contrast=\"auto\"><span class=\"NormalTextRun BCX9 SCXW127455339\">u<\/span><\/span><\/span><span class=\"TrackChangeTextInsertion TrackedChange BCX9 SCXW127455339\"><span class=\"TextRun BCX9 SCXW127455339\" lang=\"EN\" xml:lang=\"EN\" data-contrast=\"auto\"><span class=\"NormalTextRun BCX9 SCXW127455339\">re and (ii) c<\/span><\/span><\/span><span class=\"TrackChangeTextInsertion TrackedChange BCX9 SCXW127455339\"><span class=\"TextRun BCX9 SCXW127455339\" lang=\"EN\" xml:lang=\"EN\" data-contrast=\"auto\"><span class=\"NormalTextRun BCX9 SCXW127455339\">ardiovascular death.<\/span><\/span><\/span><\/em><\/div>\r\n<\/div>\r\n<div>\r\n<div class=\"textbox shaded\"><em>E.g. #2 In CONDOR <span class=\"EOP SCXW19164495 BCX9\" data-ccp-props=\"{}\"><span class=\"TrackChangeTextInsertion TrackedChange BCX9 SCXW165418290\"><span class=\"TextRun Highlight BCX9 SCXW165418290\" lang=\"EN\" xml:lang=\"EN\" data-contrast=\"auto\"><span class=\"NormalTextRun BCX9 SCXW165418290\">(<a href=\"https:\/\/pressbooks.bccampus.ca\/rickyturgeon\/back-matter\/references\/\" target=\"_blank\" rel=\"noopener\">Chan FKL et al.<\/a>)<\/span><\/span><\/span><\/span> for celecoxib vs NSAID+PPI all outcomes also had a similar underlying mechanism, consisting of (i) GI bleed, (ii) GI obstruction, (iii) GI perforation, and (iv) clinically significant anemia. Despite this coherence in underlying mechanism the [pb_glossary id=\"359\"]composite outcome[\/pb_glossary] was inadequately chosen, for reasons discussed above.<\/em><\/div>\r\n<\/div>\r\n<div class=\"textbox shaded\"><em><span class=\"TextRun SCXW112435971 BCX9\" lang=\"EN-US\" xml:lang=\"EN-US\" data-contrast=\"auto\"><span class=\"NormalTextRun ContextualSpellingAndGrammarErrorV2 SCXW112435971 BCX9\">E.g.<\/span><span class=\"NormalTextRun SCXW112435971 BCX9\"> #3 In the UKPDS blood pressure target trial (<a href=\"https:\/\/pressbooks.bccampus.ca\/rickyturgeon\/back-matter\/references\/\" target=\"_blank\" rel=\"noopener\">UK Prospective Diabetes Study Group<\/a>), the [pb_glossary id=\"1517\"]primary outcome[\/pb_glossary] was a [pb_glossary id=\"359\"]composite[\/pb_glossary] of 21 outcomes including those resulting from vascular damage (<\/span><span class=\"NormalTextRun ContextualSpellingAndGrammarErrorV2 SCXW112435971 BCX9\">e.g.<\/span><span class=\"NormalTextRun SCXW112435971 BCX9\"> stroke, renal failure), malignancy, and extremes in plasma glucose. Only the vascular events have a biological rationale for being reduced by improved blood pressure control. As such, it is advisable to assess each of these outcomes individually rather than as a [pb_glossary id=\"359\"]composite[\/pb_glossary].<\/span><\/span><\/em><\/div>","rendered":"<p>By combining several individual outcomes into a <a class=\"glossary-term\" aria-haspopup=\"dialog\" aria-describedby=\"definition\" href=\"#term_88_359\">composite outcome<\/a> a trial can increase its ability to detect a difference between groups. However, <a class=\"glossary-term\" aria-haspopup=\"dialog\" aria-describedby=\"definition\" href=\"#term_88_359\">composite outcomes<\/a> require careful interpretation of the individual components to avoid making erroneous conclusions.<\/p>\n<h1>Checklist Questions<\/h1>\n<table class=\"grid\" style=\"border-collapse: collapse;width: 100%;height: 66px\">\n<tbody>\n<tr style=\"height: 18px\">\n<td style=\"width: 100%;height: 18px\">Are the components of the <a class=\"glossary-term\" aria-haspopup=\"dialog\" aria-describedby=\"definition\" href=\"#term_88_359\">composite outcome<\/a> all of similar importance to patients?<\/td>\n<\/tr>\n<tr style=\"height: 18px\">\n<td style=\"width: 100%;height: 18px\">Did the components occur with similar frequencies?<\/td>\n<\/tr>\n<tr style=\"height: 12px\">\n<td style=\"width: 100%;height: 12px\">Are the point estimates of treatment effect (<a class=\"glossary-term\" aria-haspopup=\"dialog\" aria-describedby=\"definition\" href=\"#term_88_110\">HR<\/a>, <a class=\"glossary-term\" aria-haspopup=\"dialog\" aria-describedby=\"definition\" href=\"#term_88_103\">OR<\/a>, <a class=\"glossary-term\" aria-haspopup=\"dialog\" aria-describedby=\"definition\" href=\"#term_88_109\">RR<\/a>) similar between each component? Do the 95% <a href=\"https:\/\/pressbooks.bccampus.ca\/rickyturgeon\/back-matter\/appendix\/\" target=\"_blank\" rel=\"noopener\">CIs<\/a> overlap? Are they sufficiently narrow?<\/td>\n<\/tr>\n<tr style=\"height: 18px\">\n<td style=\"width: 100%;height: 18px\">Do the components share a similar underlying biological mechanism?<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<h1><span class=\"TextRun SCXW115571336 BCX9\" lang=\"EN-US\" xml:lang=\"EN-US\" data-contrast=\"auto\"><span class=\"NormalTextRun SCXW115571336 BCX9\">Clinical importance: <\/span><\/span>Are the components of the composite outcome all of similar importance to patients?<\/h1>\n<div class=\"textbox shaded\">\n<p><em><em><span class=\"TextRun SCXW19164495 BCX9\" lang=\"EN-US\" xml:lang=\"EN-US\" data-contrast=\"auto\"><span class=\"NormalTextRun ContextualSpellingAndGrammarErrorV2 SCXW19164495 BCX9 DefaultHighlightTransition\">E.g.<\/span><span class=\"NormalTextRun SCXW19164495 BCX9\"> #1 <span class=\"TrackChangeTextInsertion TrackedChange SCXW215712025 BCX9\"><span class=\"TextRun SCXW215712025 BCX9\" lang=\"EN\" xml:lang=\"EN\" data-contrast=\"auto\"><span class=\"NormalTextRun SCXW215712025 BCX9\">The <a class=\"glossary-term\" aria-haspopup=\"dialog\" aria-describedby=\"definition\" href=\"#term_88_1517\">primary outcome<\/a> of\u00a0<\/span><span class=\"FindHit SCXW215712025 BCX9\">DAPA<\/span><span class=\"NormalTextRun SCXW215712025 BCX9\">-HF (<a href=\"https:\/\/pressbooks.bccampus.ca\/rickyturgeon\/back-matter\/references\/\" target=\"_blank\" rel=\"noopener\">McMurray JJV et al.<\/a>), a trial <\/span><\/span><\/span><span class=\"TrackChangeTextInsertion TrackedChange SCXW215712025 BCX9\"><span class=\"TextRun SCXW215712025 BCX9\" lang=\"EN\" xml:lang=\"EN\" data-contrast=\"auto\"><span class=\"NormalTextRun SCXW215712025 BCX9\">comparing\u00a0<\/span><span class=\"FindHit SCXW215712025 BCX9\">dapa<\/span><span class=\"NormalTextRun SCXW215712025 BCX9\">gliflozin vs. placebo in patients with heart failure with reduced ejection fraction (<\/span><\/span><\/span><span class=\"TrackChangeTextInsertion TrackedChange SCXW215712025 BCX9\"><span class=\"TextRun SCXW215712025 BCX9\" lang=\"EN\" xml:lang=\"EN\" data-contrast=\"auto\"><span class=\"NormalTextRun SpellingErrorV2 SCXW215712025 BCX9\">HFrEF)<\/span><\/span><\/span><span class=\"TrackChangeTextInsertion TrackedChange SCXW215712025 BCX9\"><span class=\"TextRun SCXW215712025 BCX9\" lang=\"EN\" xml:lang=\"EN\" data-contrast=\"auto\"><span class=\"NormalTextRun SCXW215712025 BCX9\">,\u00a0<\/span><\/span><\/span><span class=\"TrackChangeTextInsertion TrackedChange SCXW215712025 BCX9\"><span class=\"TextRun SCXW215712025 BCX9\" lang=\"EN\" xml:lang=\"EN\" data-contrast=\"auto\"><span class=\"NormalTextRun SCXW215712025 BCX9\">was a <a class=\"glossary-term\" aria-haspopup=\"dialog\" aria-describedby=\"definition\" href=\"#term_88_359\">composite<\/a> of:<\/span><\/span><\/span><\/span><\/span><\/em><\/em><\/p>\n<ul>\n<li><em><span class=\"TextRun SCXW19164495 BCX9\" lang=\"EN-US\" xml:lang=\"EN-US\" data-contrast=\"auto\"><span class=\"NormalTextRun SCXW19164495 BCX9\"><span class=\"TrackChangeTextInsertion TrackedChange SCXW215712025 BCX9\"><span class=\"TextRun SCXW215712025 BCX9\" lang=\"EN\" xml:lang=\"EN\" data-contrast=\"auto\"><span class=\"NormalTextRun SCXW215712025 BCX9\">Hospitalization for heart failure (<\/span><\/span><\/span><span class=\"TrackChangeTextInsertion TrackedChange SCXW215712025 BCX9\"><span class=\"TextRun SCXW215712025 BCX9\" lang=\"EN\" xml:lang=\"EN\" data-contrast=\"auto\"><span class=\"NormalTextRun SCXW215712025 BCX9\">HF)<\/span><\/span><\/span><span class=\"TrackChangeTextInsertion TrackedChange SCXW215712025 BCX9\"><span class=\"TextRun SCXW215712025 BCX9\" lang=\"EN\" xml:lang=\"EN\" data-contrast=\"auto\"><span class=\"NormalTextRun SCXW215712025 BCX9\">\u00a0resulting in\u00a0<\/span><\/span><\/span><span class=\"TrackChangeTextInsertion TrackedChange SCXW215712025 BCX9\"><span class=\"TextRun SCXW215712025 BCX9\" lang=\"EN\" xml:lang=\"EN\" data-contrast=\"auto\"><span class=\"NormalTextRun SCXW215712025 BCX9\">intravenous therapy<\/span><\/span><\/span><\/span><\/span><\/em><\/li>\n<li><em><span class=\"TextRun SCXW19164495 BCX9\" lang=\"EN-US\" xml:lang=\"EN-US\" data-contrast=\"auto\"><span class=\"NormalTextRun SCXW19164495 BCX9\"><span class=\"TrackChangeTextInsertion TrackedChange SCXW215712025 BCX9\"><span class=\"TextRun SCXW215712025 BCX9\" lang=\"EN\" xml:lang=\"EN\" data-contrast=\"auto\"><span class=\"NormalTextRun SCXW215712025 BCX9\">Urgent <\/span><\/span><\/span><span class=\"TrackChangeTextInsertion TrackedChange SCXW215712025 BCX9\"><span class=\"TextRun SCXW215712025 BCX9\" lang=\"EN\" xml:lang=\"EN\" data-contrast=\"auto\"><span class=\"NormalTextRun SCXW215712025 BCX9\">HF<\/span><\/span><\/span><span class=\"TrackChangeTextInsertion TrackedChange SCXW215712025 BCX9\"><span class=\"TextRun SCXW215712025 BCX9\" lang=\"EN\" xml:lang=\"EN\" data-contrast=\"auto\"><span class=\"NormalTextRun SCXW215712025 BCX9\">\u00a0visit<\/span><\/span><\/span><span class=\"TrackChangeTextInsertion TrackedChange SCXW215712025 BCX9\"><span class=\"TextRun SCXW215712025 BCX9\" lang=\"EN\" xml:lang=\"EN\" data-contrast=\"auto\"><span class=\"NormalTextRun SCXW215712025 BCX9\">\u00a0resulting in intravenous therapy<\/span><\/span><\/span><\/span><\/span><\/em><\/li>\n<li><em><span class=\"TextRun SCXW19164495 BCX9\" lang=\"EN-US\" xml:lang=\"EN-US\" data-contrast=\"auto\"><span class=\"NormalTextRun SCXW19164495 BCX9\"><span class=\"TrackChangeTextInsertion TrackedChange SCXW215712025 BCX9\"><span class=\"TextRun SCXW215712025 BCX9\" lang=\"EN\" xml:lang=\"EN\" data-contrast=\"auto\"><span class=\"NormalTextRun SCXW215712025 BCX9\">Death from cardiovascular (<\/span><\/span><\/span><span class=\"TrackChangeTextInsertion TrackedChange SCXW215712025 BCX9\"><span class=\"TextRun SCXW215712025 BCX9\" lang=\"EN\" xml:lang=\"EN\" data-contrast=\"auto\"><span class=\"NormalTextRun SCXW215712025 BCX9\">CV)<\/span><\/span><\/span><span class=\"TrackChangeTextInsertion TrackedChange SCXW215712025 BCX9\"><span class=\"TextRun SCXW215712025 BCX9\" lang=\"EN\" xml:lang=\"EN\" data-contrast=\"auto\"><span class=\"NormalTextRun SCXW215712025 BCX9\"> causes<\/span><\/span><\/span><\/span><\/span><\/em><\/li>\n<\/ul>\n<p><em><span class=\"TextRun SCXW19164495 BCX9\" lang=\"EN-US\" xml:lang=\"EN-US\" data-contrast=\"auto\"><span class=\"NormalTextRun SCXW19164495 BCX9\"><span class=\"TrackChangeTextInsertion TrackedChange SCXW215712025 BCX9\"><span class=\"TextRun SCXW215712025 BCX9\" lang=\"EN\" xml:lang=\"EN\" data-contrast=\"auto\"><span class=\"NormalTextRun SCXW215712025 BCX9\">These are all outcomes of significant importance to patients.\u00a0<\/span><\/span><\/span><\/span><\/span><\/em><\/p>\n<\/div>\n<div class=\"textbox shaded\">\n<p><em><em><span class=\"EOP SCXW19164495 BCX9\" data-ccp-props=\"{}\">E.g. #2 <span class=\"TrackChangeTextInsertion TrackedChange BCX9 SCXW165418290\"><span class=\"TextRun BCX9 SCXW165418290\" lang=\"EN\" xml:lang=\"EN\" data-contrast=\"auto\"><span class=\"NormalTextRun BCX9 SCXW165418290\">The <a class=\"glossary-term\" aria-haspopup=\"dialog\" aria-describedby=\"definition\" href=\"#term_88_1517\">primary outcome<\/a> of\u00a0<\/span><\/span><\/span><span class=\"TrackChangeTextInsertion TrackedChange BCX9 SCXW165418290\"><span class=\"TextRun Highlight BCX9 SCXW165418290\" lang=\"EN\" xml:lang=\"EN\" data-contrast=\"auto\"><span class=\"NormalTextRun BCX9 SCXW165418290\">CONDOR (<a href=\"https:\/\/pressbooks.bccampus.ca\/rickyturgeon\/back-matter\/references\/\" target=\"_blank\" rel=\"noopener\">Chan FKL et al.<\/a>)<\/span><\/span><\/span><span class=\"TrackChangeTextInsertion TrackedChange BCX9 SCXW165418290\"><span class=\"TextRun BCX9 SCXW165418290\" lang=\"EN\" xml:lang=\"EN\" data-contrast=\"auto\"><span class=\"NormalTextRun BCX9 SCXW165418290\">, a trial comparing celecoxib vs NSAID+PPI, was a <a class=\"glossary-term\" aria-haspopup=\"dialog\" aria-describedby=\"definition\" href=\"#term_88_359\">composite<\/a> of:<\/span><\/span><\/span><\/span><\/em><\/em><\/p>\n<ul>\n<li><em><span class=\"EOP SCXW19164495 BCX9\" data-ccp-props=\"{}\"><span class=\"TrackChangeTextInsertion TrackedChange BCX9 SCXW165418290\"><span class=\"TextRun BCX9 SCXW165418290\" lang=\"EN\" xml:lang=\"EN\" data-contrast=\"auto\"><span class=\"NormalTextRun BCX9 SCXW165418290\">Gastrointestinal (GI) bleed<\/span><\/span><\/span><\/span><\/em><\/li>\n<li><em><span class=\"EOP SCXW19164495 BCX9\" data-ccp-props=\"{}\"><span class=\"TrackChangeTextInsertion TrackedChange BCX9 SCXW165418290\"><span class=\"TextRun BCX9 SCXW165418290\" lang=\"EN\" xml:lang=\"EN\" data-contrast=\"auto\"><span class=\"NormalTextRun BCX9 SCXW165418290\">GI obstruction<\/span><\/span><\/span><\/span><\/em><\/li>\n<li><em><span class=\"EOP SCXW19164495 BCX9\" data-ccp-props=\"{}\"><span class=\"TrackChangeTextInsertion TrackedChange BCX9 SCXW165418290\"><span class=\"TextRun BCX9 SCXW165418290\" lang=\"EN\" xml:lang=\"EN\" data-contrast=\"auto\"><span class=\"NormalTextRun BCX9 SCXW165418290\">GI perforation<\/span><\/span><\/span><\/span><\/em><\/li>\n<li><em><span class=\"EOP SCXW19164495 BCX9\" data-ccp-props=\"{}\"><span class=\"TrackChangeTextInsertion TrackedChange BCX9 SCXW165418290\"><span class=\"TextRun BCX9 SCXW165418290\" lang=\"EN\" xml:lang=\"EN\" data-contrast=\"auto\"><span class=\"NormalTextRun BCX9 SCXW165418290\">Clinically significant anemia (decrease in hemoglobin\u00a0 \u2265 20 g\/L or decrease in hematocrit<\/span><span class=\"NormalTextRun BCX9 SCXW165418290\">\u00a0\u226510%)<\/span><\/span><\/span><\/span><\/em><\/li>\n<\/ul>\n<p><em><span class=\"EOP SCXW19164495 BCX9\" data-ccp-props=\"{}\"><span class=\"TrackChangeTextInsertion TrackedChange BCX9 SCXW165418290\"><span class=\"TextRun BCX9 SCXW165418290\" lang=\"EN\" xml:lang=\"EN\" data-contrast=\"auto\"><span class=\"NormalTextRun BCX9 SCXW165418290\">The latter of which was notably less important than the other components.<\/span><\/span><\/span><\/span><\/em><\/p>\n<\/div>\n<h1><span class=\"TextRun SCXW261278014 BCX9\" lang=\"EN-US\" xml:lang=\"EN-US\" data-contrast=\"auto\"><span class=\"NormalTextRun SCXW261278014 BCX9\">Statistical contribution: <\/span><\/span><span class=\"TextRun SCXW261278014 BCX9\" lang=\"EN-US\" xml:lang=\"EN-US\" data-contrast=\"auto\"><span class=\"NormalTextRun SCXW261278014 BCX9\">Did the component outcomes occur with similar frequencies?<\/span><\/span><span class=\"EOP SCXW261278014 BCX9\" data-ccp-props=\"{}\">\u00a0<\/span><\/h1>\n<div style=\"font-weight: 400\">\n<div class=\"textbox shaded\">\n<div style=\"font-weight: 400\">\n<p><em><span class=\"TrackChangeTextInsertion TrackedChange BCX9 SCXW50700698\"><span class=\"TextRun BCX9 SCXW50700698\" lang=\"EN\" xml:lang=\"EN\" data-contrast=\"auto\"><span class=\"NormalTextRun BCX9 SCXW50700698\">E.g. #1 C<\/span><\/span><\/span><span class=\"TrackChangeTextInsertion TrackedChange BCX9 SCXW50700698\"><span class=\"TextRun BCX9 SCXW50700698\" lang=\"EN\" xml:lang=\"EN\" data-contrast=\"auto\"><span class=\"NormalTextRun BCX9 SCXW50700698\">omponents of the <a class=\"glossary-term\" aria-haspopup=\"dialog\" aria-describedby=\"definition\" href=\"#term_88_1517\">primary outcome<\/a> in <span class=\"FindHit BCX9 SCXW50700698\">DAPA<\/span>-HF <span class=\"TextRun SCXW19164495 BCX9\" lang=\"EN-US\" xml:lang=\"EN-US\" data-contrast=\"auto\"><span class=\"NormalTextRun SCXW19164495 BCX9\"><span class=\"TrackChangeTextInsertion TrackedChange SCXW215712025 BCX9\"><span class=\"TextRun SCXW215712025 BCX9\" lang=\"EN\" xml:lang=\"EN\" data-contrast=\"auto\"><span class=\"NormalTextRun SCXW215712025 BCX9\">(<a href=\"https:\/\/pressbooks.bccampus.ca\/rickyturgeon\/back-matter\/references\/\" target=\"_blank\" rel=\"noopener\">McMurray JJV et al.<\/a>) <\/span><\/span><\/span><\/span><\/span>and their <\/span><\/span><\/span><span class=\"TrackChangeTextInsertion TrackedChange BCX9 SCXW50700698\"><span class=\"TextRun BCX9 SCXW50700698\" lang=\"EN\" xml:lang=\"EN\" data-contrast=\"auto\"><span class=\"NormalTextRun BCX9 SCXW50700698\">rates for\u00a0<\/span><span class=\"FindHit BCX9 SCXW50700698\">dapa<\/span><span class=\"NormalTextRun BCX9 SCXW50700698\">gliflozin vs. placebo:<\/span><\/span><\/span><\/em><\/p>\n<ul>\n<li><em><span class=\"TrackChangeTextInsertion TrackedChange BCX9 SCXW50700698\"><span class=\"TextRun BCX9 SCXW50700698\" lang=\"EN\" xml:lang=\"EN\" data-contrast=\"auto\"><span class=\"NormalTextRun BCX9 SCXW50700698\">Hospitalization or urgent visit for HF <\/span><\/span><\/span><span class=\"TrackChangeTextInsertion TrackedChange BCX9 SCXW50700698\"><span class=\"TextRun BCX9 SCXW50700698\" lang=\"EN\" xml:lang=\"EN\" data-contrast=\"auto\"><span class=\"NormalTextRun BCX9 SCXW50700698\">(10<\/span><\/span><\/span><span class=\"TrackChangeTextInsertion TrackedChange BCX9 SCXW50700698\"><span class=\"TextRun BCX9 SCXW50700698\" lang=\"EN\" xml:lang=\"EN\" data-contrast=\"auto\"><span class=\"NormalTextRun BCX9 SCXW50700698\">% vs.<\/span><\/span><\/span><span class=\"TrackChangeTextInsertion TrackedChange BCX9 SCXW50700698\"><span class=\"TextRun BCX9 SCXW50700698\" lang=\"EN\" xml:lang=\"EN\" data-contrast=\"auto\"><span class=\"NormalTextRun BCX9 SCXW50700698\"> 14%)<\/span><\/span><\/span><\/em><\/li>\n<li><em><span class=\"TrackChangeTextInsertion TrackedChange BCX9 SCXW50700698\"><span class=\"TextRun BCX9 SCXW50700698\" lang=\"EN\" xml:lang=\"EN\" data-contrast=\"auto\"><span class=\"NormalTextRun BCX9 SCXW50700698\">Death from CV causes <\/span><\/span><\/span><span class=\"TrackChangeTextInsertion TrackedChange BCX9 SCXW50700698\"><span class=\"TextRun BCX9 SCXW50700698\" lang=\"EN\" xml:lang=\"EN\" data-contrast=\"auto\"><span class=\"NormalTextRun BCX9 SCXW50700698\">(10% vs. 12<\/span><\/span><\/span><span class=\"TrackChangeTextInsertion TrackedChange BCX9 SCXW50700698\"><span class=\"TextRun BCX9 SCXW50700698\" lang=\"EN\" xml:lang=\"EN\" data-contrast=\"auto\"><span class=\"NormalTextRun BCX9 SCXW50700698\">%)\u00a0<\/span><\/span><\/span><\/em><\/li>\n<\/ul>\n<p><em><span class=\"TrackChangeTextInsertion TrackedChange BCX9 SCXW50700698\"><span class=\"TextRun BCX9 SCXW50700698\" lang=\"EN\" xml:lang=\"EN\" data-contrast=\"auto\"><span class=\"NormalTextRun BCX9 SCXW50700698\">The most important endpoint (death from CV causes) occurred only slightly less frequently than the other component.<\/span><\/span><\/span><\/em><\/p>\n<\/div>\n<\/div>\n<div class=\"textbox shaded\">\n<p style=\"font-weight: 400\"><em>E.g. #2 Components of the <a class=\"glossary-term\" aria-haspopup=\"dialog\" aria-describedby=\"definition\" href=\"#term_88_1517\">primary outcome<\/a> in CONDOR <span class=\"EOP SCXW19164495 BCX9\" data-ccp-props=\"{}\"><span class=\"TrackChangeTextInsertion TrackedChange BCX9 SCXW165418290\"><span class=\"TextRun Highlight BCX9 SCXW165418290\" lang=\"EN\" xml:lang=\"EN\" data-contrast=\"auto\"><span class=\"NormalTextRun BCX9 SCXW165418290\">(<a href=\"https:\/\/pressbooks.bccampus.ca\/rickyturgeon\/back-matter\/references\/\" target=\"_blank\" rel=\"noopener\">Chan FKL et al.<\/a>)<\/span><\/span><\/span><\/span> and their rates for celecoxib vs NSAID+PPI:\u00a0<\/em><\/p>\n<div style=\"font-weight: 400\">\n<ul>\n<li><em>GI bleed (0.2% vs. 0.2%) <\/em><\/li>\n<li><em style=\"text-align: initial;font-size: 0.9em\">GI obstruction (0% for both groups) <\/em><\/li>\n<li><em style=\"text-align: initial;font-size: 0.9em\">GI perforation (0% for both groups) <\/em><\/li>\n<li><em style=\"text-align: initial;font-size: 0.9em\">Clinically significant anemia (0.7% vs. 3%) <\/em><\/li>\n<\/ul>\n<p><em style=\"text-align: initial;font-size: 0.9em\">The greatest contributor of events (clinically significant anemia) drove the difference between groups was also the least clinically important.<\/em><\/p>\n<\/div>\n<\/div>\n<\/div>\n<h1>Consistency in effect of therapy: Are the point estimates of treatment effect between each component consistent? Do the 95% CIs overlap? Are they sufficiently narrow?<\/h1>\n<div class=\"textbox shaded\">\n<p><em>E.g. #1 <a class=\"glossary-term\" aria-haspopup=\"dialog\" aria-describedby=\"definition\" href=\"#term_88_110\">HRs<\/a> in DAPA-HF (<a href=\"https:\/\/pressbooks.bccampus.ca\/rickyturgeon\/back-matter\/references\/\" target=\"_blank\" rel=\"noopener\">McMurray JJV et al.<\/a>) for dapagliflozin vs. placebo:<\/em><\/p>\n<ul>\n<li><em><a class=\"glossary-term\" aria-haspopup=\"dialog\" aria-describedby=\"definition\" href=\"#term_88_359\">Composite<\/a> <a class=\"glossary-term\" aria-haspopup=\"dialog\" aria-describedby=\"definition\" href=\"#term_88_110\">HR<\/a> = 0.74 (95% <a href=\"https:\/\/pressbooks.bccampus.ca\/rickyturgeon\/back-matter\/appendix\/\" target=\"_blank\" rel=\"noopener\">CI<\/a> 0.65-0.85)<\/em><\/li>\n<li><em style=\"text-align: initial;font-size: 0.9em\">Hospitalization or urgent visit for heart failure <a class=\"glossary-term\" aria-haspopup=\"dialog\" aria-describedby=\"definition\" href=\"#term_88_110\">HR<\/a> = 0.70 (95% <a href=\"https:\/\/pressbooks.bccampus.ca\/rickyturgeon\/back-matter\/appendix\/\" target=\"_blank\" rel=\"noopener\">CI<\/a> 0.59-0.83)<\/em><\/li>\n<li><em style=\"text-align: initial;font-size: 0.9em\">Cardiovascular death <a class=\"glossary-term\" aria-haspopup=\"dialog\" aria-describedby=\"definition\" href=\"#term_88_110\">HR<\/a> = 0.82 (95% <a href=\"https:\/\/pressbooks.bccampus.ca\/rickyturgeon\/back-matter\/appendix\/\" target=\"_blank\" rel=\"noopener\">CI<\/a> 0.69-0.98)<\/em><\/li>\n<\/ul>\n<p><em>Since all the <a href=\"https:\/\/pressbooks.bccampus.ca\/rickyturgeon\/back-matter\/appendix\/\" target=\"_blank\" rel=\"noopener\">CIs<\/a> overlap and are sufficiently narrow, there can be greater confidence that the <a class=\"glossary-term\" aria-haspopup=\"dialog\" aria-describedby=\"definition\" href=\"#term_88_359\">composite outcome<\/a> is not misleading.<\/em><\/p>\n<\/div>\n<div class=\"textbox shaded\">\n<p><em>E.g. #2 <a class=\"glossary-term\" aria-haspopup=\"dialog\" aria-describedby=\"definition\" href=\"#term_88_1111\">Relative risk reductions (RRRs)<\/a> in CONDOR (<a href=\"https:\/\/pressbooks.bccampus.ca\/rickyturgeon\/back-matter\/references\/\" target=\"_blank\" rel=\"noopener\">Chan FKL et al.<\/a>) for celecoxib vs NSAID+PPI:<\/em><\/p>\n<ul>\n<li><em><a class=\"glossary-term\" aria-haspopup=\"dialog\" aria-describedby=\"definition\" href=\"#term_88_359\">Composite<\/a> <a class=\"glossary-term\" aria-haspopup=\"dialog\" aria-describedby=\"definition\" href=\"#term_88_1111\">RRR<\/a> = 75% <\/em><\/li>\n<li><em style=\"text-align: initial;font-size: 0.9em\">GI bleed <a class=\"glossary-term\" aria-haspopup=\"dialog\" aria-describedby=\"definition\" href=\"#term_88_1111\">RRR<\/a> = 0% <\/em><\/li>\n<li><em style=\"text-align: initial;font-size: 0.9em\">Clinically significant anemia <a class=\"glossary-term\" aria-haspopup=\"dialog\" aria-describedby=\"definition\" href=\"#term_88_1111\">RRR<\/a> = 80%\u00a0<\/em><\/li>\n<\/ul>\n<p><em>Since there is a very large difference in the point estimates, it is better to consider the individual endpoints rather than the <a class=\"glossary-term\" aria-haspopup=\"dialog\" aria-describedby=\"definition\" href=\"#term_88_359\">composite endpoint<\/a>.<\/em><\/p>\n<\/div>\n<h1><span class=\"TextRun SCXW54353425 BCX9\" lang=\"EN-US\" xml:lang=\"EN-US\" data-contrast=\"auto\"><span class=\"NormalTextRun SCXW54353425 BCX9\">Biologic rationale:<\/span><\/span><span class=\"TextRun SCXW54353425 BCX9\" lang=\"EN-US\" xml:lang=\"EN-US\" data-contrast=\"auto\"><span class=\"NormalTextRun SCXW54353425 BCX9\">\u00a0<\/span><\/span><span class=\"TextRun SCXW54353425 BCX9\" lang=\"EN-US\" xml:lang=\"EN-US\" data-contrast=\"auto\"><span class=\"NormalTextRun SCXW54353425 BCX9\">Do the components of the composite outcome share a similar underlying biological mechanism?<\/span><\/span><span class=\"EOP SCXW54353425 BCX9\" data-ccp-props=\"{}\">\u00a0<\/span><\/h1>\n<div>\n<div class=\"textbox shaded\"><em>E.g. #1 In DAPA-HF <span class=\"TrackChangeTextInsertion TrackedChange BCX9 SCXW127455339\"><span class=\"TextRun BCX9 SCXW127455339\" lang=\"EN\" xml:lang=\"EN\" data-contrast=\"auto\"><span class=\"NormalTextRun BCX9 SCXW127455339\">(<span class=\"TrackChangeTextInsertion TrackedChange BCX9 SCXW50700698\"><span class=\"TextRun BCX9 SCXW50700698\" lang=\"EN\" xml:lang=\"EN\" data-contrast=\"auto\"><span class=\"NormalTextRun BCX9 SCXW50700698\"><span class=\"TextRun SCXW19164495 BCX9\" lang=\"EN-US\" xml:lang=\"EN-US\" data-contrast=\"auto\"><span class=\"NormalTextRun SCXW19164495 BCX9\"><span class=\"TrackChangeTextInsertion TrackedChange SCXW215712025 BCX9\"><span class=\"TextRun SCXW215712025 BCX9\" lang=\"EN\" xml:lang=\"EN\" data-contrast=\"auto\"><span class=\"NormalTextRun SCXW215712025 BCX9\"><a href=\"https:\/\/pressbooks.bccampus.ca\/rickyturgeon\/back-matter\/references\/\" target=\"_blank\" rel=\"noopener\">McMurray JJV et al.<\/a>)<\/span><\/span><\/span><\/span><\/span><\/span><\/span><\/span> for <\/span><\/span><span class=\"TextRun BCX9 SCXW127455339\" lang=\"EN\" xml:lang=\"EN\" data-contrast=\"auto\"><span class=\"FindHit BCX9 SCXW127455339\">dapa<\/span><\/span><span class=\"TextRun BCX9 SCXW127455339\" lang=\"EN\" xml:lang=\"EN\" data-contrast=\"auto\"><span class=\"NormalTextRun BCX9 SCXW127455339\">gliflozin vs. placebo all outcomes had a similar underlying mechanism, consisting of (i) h<\/span><\/span><\/span><span class=\"TrackChangeTextInsertion TrackedChange BCX9 SCXW127455339\"><span class=\"TextRun BCX9 SCXW127455339\" lang=\"EN\" xml:lang=\"EN\" data-contrast=\"auto\"><span class=\"NormalTextRun BCX9 SCXW127455339\">ospitalization or urgent visit for\u00a0<\/span><\/span><\/span><span class=\"TrackChangeTextInsertion TrackedChange BCX9 SCXW127455339\"><span class=\"TextRun BCX9 SCXW127455339\" lang=\"EN\" xml:lang=\"EN\" data-contrast=\"auto\"><span class=\"NormalTextRun BCX9 SCXW127455339\">heart fail<\/span><\/span><\/span><span class=\"TrackChangeTextInsertion TrackedChange BCX9 SCXW127455339\"><span class=\"TextRun BCX9 SCXW127455339\" lang=\"EN\" xml:lang=\"EN\" data-contrast=\"auto\"><span class=\"NormalTextRun BCX9 SCXW127455339\">u<\/span><\/span><\/span><span class=\"TrackChangeTextInsertion TrackedChange BCX9 SCXW127455339\"><span class=\"TextRun BCX9 SCXW127455339\" lang=\"EN\" xml:lang=\"EN\" data-contrast=\"auto\"><span class=\"NormalTextRun BCX9 SCXW127455339\">re and (ii) c<\/span><\/span><\/span><span class=\"TrackChangeTextInsertion TrackedChange BCX9 SCXW127455339\"><span class=\"TextRun BCX9 SCXW127455339\" lang=\"EN\" xml:lang=\"EN\" data-contrast=\"auto\"><span class=\"NormalTextRun BCX9 SCXW127455339\">ardiovascular death.<\/span><\/span><\/span><\/em><\/div>\n<\/div>\n<div>\n<div class=\"textbox shaded\"><em>E.g. #2 In CONDOR <span class=\"EOP SCXW19164495 BCX9\" data-ccp-props=\"{}\"><span class=\"TrackChangeTextInsertion TrackedChange BCX9 SCXW165418290\"><span class=\"TextRun Highlight BCX9 SCXW165418290\" lang=\"EN\" xml:lang=\"EN\" data-contrast=\"auto\"><span class=\"NormalTextRun BCX9 SCXW165418290\">(<a href=\"https:\/\/pressbooks.bccampus.ca\/rickyturgeon\/back-matter\/references\/\" target=\"_blank\" rel=\"noopener\">Chan FKL et al.<\/a>)<\/span><\/span><\/span><\/span> for celecoxib vs NSAID+PPI all outcomes also had a similar underlying mechanism, consisting of (i) GI bleed, (ii) GI obstruction, (iii) GI perforation, and (iv) clinically significant anemia. Despite this coherence in underlying mechanism the <a class=\"glossary-term\" aria-haspopup=\"dialog\" aria-describedby=\"definition\" href=\"#term_88_359\">composite outcome<\/a> was inadequately chosen, for reasons discussed above.<\/em><\/div>\n<\/div>\n<div class=\"textbox shaded\"><em><span class=\"TextRun SCXW112435971 BCX9\" lang=\"EN-US\" xml:lang=\"EN-US\" data-contrast=\"auto\"><span class=\"NormalTextRun ContextualSpellingAndGrammarErrorV2 SCXW112435971 BCX9\">E.g.<\/span><span class=\"NormalTextRun SCXW112435971 BCX9\"> #3 In the UKPDS blood pressure target trial (<a href=\"https:\/\/pressbooks.bccampus.ca\/rickyturgeon\/back-matter\/references\/\" target=\"_blank\" rel=\"noopener\">UK Prospective Diabetes Study Group<\/a>), the <a class=\"glossary-term\" aria-haspopup=\"dialog\" aria-describedby=\"definition\" href=\"#term_88_1517\">primary outcome<\/a> was a <a class=\"glossary-term\" aria-haspopup=\"dialog\" aria-describedby=\"definition\" href=\"#term_88_359\">composite<\/a> of 21 outcomes including those resulting from vascular damage (<\/span><span class=\"NormalTextRun ContextualSpellingAndGrammarErrorV2 SCXW112435971 BCX9\">e.g.<\/span><span class=\"NormalTextRun SCXW112435971 BCX9\"> stroke, renal failure), malignancy, and extremes in plasma glucose. Only the vascular events have a biological rationale for being reduced by improved blood pressure control. As such, it is advisable to assess each of these outcomes individually rather than as a <a class=\"glossary-term\" aria-haspopup=\"dialog\" aria-describedby=\"definition\" href=\"#term_88_359\">composite<\/a>.<\/span><\/span><\/em><\/div>\n<div class=\"glossary\"><span class=\"screen-reader-text\" id=\"definition\">definition<\/span><template id=\"term_88_359\"><div class=\"glossary__definition\" role=\"dialog\" data-id=\"term_88_359\"><div tabindex=\"-1\"><p>An outcome which consists of multiple component endpoints. For example, a cardiovascular composite may include stroke, myocardial infarction, and death.<\/p>\n<\/div><button><span aria-hidden=\"true\">&times;<\/span><span class=\"screen-reader-text\">Close definition<\/span><\/button><\/div><\/template><template id=\"term_88_110\"><div class=\"glossary__definition\" role=\"dialog\" data-id=\"term_88_110\"><div tabindex=\"-1\"><p>Hazard ratios are a relative measure of effect. Hazards refer to average instantaneous incidence rate at every point during the trial. This differentiates it from other measures, such as relative risk, which rely only on cumulative event rates. See <a href=\"https:\/\/pressbooks.bccampus.ca\/rickyturgeon\/back-matter\/appendix\/\">here<\/a> for a more detailed discussion.<\/p>\n<\/div><button><span aria-hidden=\"true\">&times;<\/span><span class=\"screen-reader-text\">Close definition<\/span><\/button><\/div><\/template><template id=\"term_88_103\"><div class=\"glossary__definition\" role=\"dialog\" data-id=\"term_88_103\"><div tabindex=\"-1\"><p>Odds ratios are the ratio of odds (events divided by non-events) in the intervention group to the odds in the comparator group. For example, if the odds of an event in the treatment group is 0.2 and the odds in the comparator group is 0.1, then the OR is 2 (0.2\/0.1). See <a href=\"https:\/\/pressbooks.bccampus.ca\/rickyturgeon\/back-matter\/appendix\/\">here<\/a> for a more detailed discussion.<\/p>\n<\/div><button><span aria-hidden=\"true\">&times;<\/span><span class=\"screen-reader-text\">Close definition<\/span><\/button><\/div><\/template><template id=\"term_88_109\"><div class=\"glossary__definition\" role=\"dialog\" data-id=\"term_88_109\"><div tabindex=\"-1\"><p>Relative risk (or risk ratio) is the risk in one group relative to (divided by) risk in another group. For example, if 10% in the treatment group and 20% in the placebo group have the outcome of interest, the relative risk in the treatment group is 0.5 (10% \u00f7 20%; half) the risk in the placebo group. See <a href=\"https:\/\/pressbooks.bccampus.ca\/rickyturgeon\/back-matter\/appendix\/\">here<\/a> for a more detailed discussion.<\/p>\n<\/div><button><span aria-hidden=\"true\">&times;<\/span><span class=\"screen-reader-text\">Close definition<\/span><\/button><\/div><\/template><template id=\"term_88_1517\"><div class=\"glossary__definition\" role=\"dialog\" data-id=\"term_88_1517\"><div tabindex=\"-1\"><p>A primary outcome is an outcome from which trial design choices are based (e.g. sample size calculations). Primary outcomes are not necessarily the most important outcomes.<\/p>\n<\/div><button><span aria-hidden=\"true\">&times;<\/span><span class=\"screen-reader-text\">Close definition<\/span><\/button><\/div><\/template><template id=\"term_88_1111\"><div class=\"glossary__definition\" role=\"dialog\" data-id=\"term_88_1111\"><div tabindex=\"-1\"><p>The difference between two relative risks (RRs). If the intervention has a RR of 70% and the comparator a risk of 100%, then the relative risk reduction is 30% (100% - 70%).<\/p>\n<\/div><button><span aria-hidden=\"true\">&times;<\/span><span class=\"screen-reader-text\">Close definition<\/span><\/button><\/div><\/template><\/div>","protected":false},"author":1318,"menu_order":4,"template":"","meta":{"pb_show_title":"on","pb_short_title":"","pb_subtitle":"","pb_authors":[],"pb_section_license":""},"chapter-type":[],"contributor":[],"license":[],"class_list":["post-88","chapter","type-chapter","status-publish","hentry"],"part":3,"_links":{"self":[{"href":"https:\/\/pressbooks.bccampus.ca\/rickyturgeon\/wp-json\/pressbooks\/v2\/chapters\/88","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/pressbooks.bccampus.ca\/rickyturgeon\/wp-json\/pressbooks\/v2\/chapters"}],"about":[{"href":"https:\/\/pressbooks.bccampus.ca\/rickyturgeon\/wp-json\/wp\/v2\/types\/chapter"}],"author":[{"embeddable":true,"href":"https:\/\/pressbooks.bccampus.ca\/rickyturgeon\/wp-json\/wp\/v2\/users\/1318"}],"version-history":[{"count":26,"href":"https:\/\/pressbooks.bccampus.ca\/rickyturgeon\/wp-json\/pressbooks\/v2\/chapters\/88\/revisions"}],"predecessor-version":[{"id":1887,"href":"https:\/\/pressbooks.bccampus.ca\/rickyturgeon\/wp-json\/pressbooks\/v2\/chapters\/88\/revisions\/1887"}],"part":[{"href":"https:\/\/pressbooks.bccampus.ca\/rickyturgeon\/wp-json\/pressbooks\/v2\/parts\/3"}],"metadata":[{"href":"https:\/\/pressbooks.bccampus.ca\/rickyturgeon\/wp-json\/pressbooks\/v2\/chapters\/88\/metadata\/"}],"wp:attachment":[{"href":"https:\/\/pressbooks.bccampus.ca\/rickyturgeon\/wp-json\/wp\/v2\/media?parent=88"}],"wp:term":[{"taxonomy":"chapter-type","embeddable":true,"href":"https:\/\/pressbooks.bccampus.ca\/rickyturgeon\/wp-json\/pressbooks\/v2\/chapter-type?post=88"},{"taxonomy":"contributor","embeddable":true,"href":"https:\/\/pressbooks.bccampus.ca\/rickyturgeon\/wp-json\/wp\/v2\/contributor?post=88"},{"taxonomy":"license","embeddable":true,"href":"https:\/\/pressbooks.bccampus.ca\/rickyturgeon\/wp-json\/wp\/v2\/license?post=88"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}