Percent total attrition: a poor metric for study rigor in hosted intervention designs

Health behavior interventions delivered at point of service include those that yoke an intervention protocol with existing systems of care (e.g., clinical care, social work, or case management). Though beneficial in a number of ways, such "hosted" intervention studies may be unable to retain participants that specifically discontinue their use of the hosting service. In light of recent practices that use percent total attrition as indicative of methodological flaws, hosted interventions targeting hard-to-reach populations may be excluded from consideration in effective intervention compendiums or research synthesis because of high attrition rates that may in fact be secondary to the natural flow of service use or unrelated to differential attrition or internal design flaws. Better methods to characterize rigor are needed.