The methodological quality of 176,620 randomized controlled trials published between 1966 and 2018 reveals a positive trend but also an urgent need for improvement

PLoS Biol. 2021 Apr 19;19(4):e3001162. doi: 10.1371/journal.pbio.3001162. eCollection 2021 Apr.


Many randomized controlled trials (RCTs) are biased and difficult to reproduce due to methodological flaws and poor reporting. There is increasing attention for responsible research practices and implementation of reporting guidelines, but whether these efforts have improved the methodological quality of RCTs (e.g., lower risk of bias) is unknown. We, therefore, mapped risk-of-bias trends over time in RCT publications in relation to journal and author characteristics. Meta-information of 176,620 RCTs published between 1966 and 2018 was extracted. The risk-of-bias probability (random sequence generation, allocation concealment, blinding of patients/personnel, and blinding of outcome assessment) was assessed using a risk-of-bias machine learning tool. This tool was simultaneously validated using 63,327 human risk-of-bias assessments obtained from 17,394 RCTs evaluated in the Cochrane Database of Systematic Reviews (CDSR). Moreover, RCT registration and CONSORT Statement reporting were assessed using automated searches. Publication characteristics included the number of authors, journal impact factor (JIF), and medical discipline. The annual number of published RCTs substantially increased over 4 decades, accompanied by increases in authors (5.2 to 7.8) and institutions (2.9 to 4.8). The risk of bias remained present in most RCTs but decreased over time for allocation concealment (63% to 51%), random sequence generation (57% to 36%), and blinding of outcome assessment (58% to 52%). Trial registration (37% to 47%) and the use of the CONSORT Statement (1% to 20%) also rapidly increased. In journals with a higher impact factor (>10), the risk of bias was consistently lower with higher levels of RCT registration and the use of the CONSORT Statement. Automated risk-of-bias predictions had accuracies above 70% for allocation concealment (70.7%), random sequence generation (72.1%), and blinding of patients/personnel (79.8%), but not for blinding of outcome assessment (62.7%). In conclusion, the likelihood of bias in RCTs has generally decreased over the last decades. This optimistic trend may be driven by increased knowledge augmented by mandatory trial registration and more stringent reporting guidelines and journal requirements. Nevertheless, relatively high probabilities of bias remain, particularly in journals with lower impact factors. This emphasizes that further improvement of RCT registration, conduct, and reporting is still urgently needed.

Publication types

  • Historical Article
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Bias
  • Bibliometrics
  • Data Accuracy
  • Data Management / history
  • Data Management / methods
  • Data Management / standards
  • Data Management / trends
  • Databases, Bibliographic / history
  • Databases, Bibliographic / standards
  • Databases, Bibliographic / trends
  • History, 20th Century
  • History, 21st Century
  • Humans
  • Outcome Assessment, Health Care
  • Public Reporting of Healthcare Data
  • Publications* / history
  • Publications* / standards
  • Publications* / statistics & numerical data
  • Publications* / trends
  • Quality Improvement / history
  • Quality Improvement / trends
  • Randomized Controlled Trials as Topic / history
  • Randomized Controlled Trials as Topic / methods*
  • Randomized Controlled Trials as Topic / statistics & numerical data*
  • Systematic Reviews as Topic

Grant support

This work was supported by The Netherlands Organisation for Health Research and Development (ZonMw) grant “Fostering Responsible Research Practices” (445001002) (CV,JT,WO). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.