Bias in Before–After Studies: Narrative Overview for Anesthesiologists

Before–after study designs are effective research tools and in some cases, have changed practice. These designs, however, are inherently susceptible to bias (ie, systematic errors) that are sometimes subtle but can invalidate their conclusions. This overview provides examples of before–after studies relevant to anesthesiologists to illustrate potential sources of bias, including selection/assignment, history, regression to the mean, test–retest, maturation, observer, retrospective, Hawthorne, instrumentation, attrition, and reporting/publication bias. Mitigating strategies include using a control group, blinding, matching before and after cohorts, minimizing the time lag between cohorts, using prospective data collection with consistent measuring/reporting criteria, time series data collection, and/or alternative study designs, when possible. Improved reporting with enforcement of the Enhancing Quality and Transparency of Health Research (EQUATOR) checklists will serve to increase transparency and aid in interpretation. By highlighting the potential types of bias and strategies to improve transparency and mitigate flaws, this overview aims to better equip anesthesiologists in designing and/or critically appraising before–after studies. Accepted for publication October 13, 2017. Funding: None. The authors declare no conflicts of interest. Reprints will not be available from the authors. Address correspondence to Glenio B. Mizubuti, MD, MSc, Department of Anesthesiology and Perioperative Medicine, Victory 2, Kingston General Hospital, Queen's University, 76 Stuart St, Kingston, Ontario K7L 2V7, Canada. Address e-mail to gleniomizubuti@hotmail.com. © 2017 International Anesthesia Research Society

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