What's in a P-Value? A Fragility Analysis of RCTs in the AUA Guidelines for Benign Prostatic Hyperplasia

To use the fragility index (FI) and fragility quotient (FQ) to assess the strength of statistically significant findings for randomized controlled trials (RCTs) cited in the American Urological Association (AUA) guidelines for benign prostatic hyperplasia.

Two investigators independently screened the AUA guidelines for management of benign prostatic hyperplasia for RCTs cited as evidence for recommendations. Investigators extracted data related to event rate per group and loss to follow-up which was compared against the FI. Stata 17.0 was used to calculate the FI and FQ which was then summarized and reported according to primary or secondary endpoints.

Among the 373 citations in the AUA guidelines, 24 RCTs met inclusion criteria with 29 distinct outcomes analyzed. The median fragility index was 12 (IQR = 4-38), indicating that twelve alternative events to either study arm would nullify statistical significance. Six studies had a FI of ≤2, indicating that only 1-2 outcomes would need to be changed in order to render nonsignificance of results. In 10/24 RCTs, the number of patients lost to follow-up was greater than the FI.

The AUA Clinical Practice Guidelines for management of benign prostatic hyperplasia cite RCTs with more robust findings when compared to previous studies assessing fragility in the field of Urology. While several included studies had high fragility, the median FI in our analysis was approximately 4-5 times higher than comparable studies of urologic RCTs. However, there are areas where improvement is necessary to support the highest quality of evidence-based medicine.