Highlights of WHO TRDS-TCM 2020
The WHO TRDS-TCM 2020 includes the fundamental concepts of TCM Pattern [17] and the features of three TCM interventions, namely CHM formula, acupuncture and moxibustion. With regard to the checklist, compared with WHO TRDS (V.1.3.1), the WHO TRDS-TCM 2020 elaborates on ten of the 24 TRDS items and one of the optional items. The total eleven items are: Source(s) of Monetary or Material Support (Item 4), Scientific Title (Item 10a and 10b), Countries of Recruitment (Item 11), Health Condition(s) or Problem(s) Studied (Item 12), Intervention(s) (Item 13a, 13b and 13c), Key Inclusion and Exclusion Criteria (Item 14), Primary and Key Secondary Outcomes (Item 19 to 20), and Lay Summary (B1). The checklist is presented in the Table 1; elaborations of TCM extensions are italicized. Explanations of corresponding items are given below, and available examples of good registration are provided in Additional file 3.
Table 1
Checklist of Items for Clinical Trial Registration of Traditional Chinese Medicine*
Number | Original Item/Label # | Explanatory text # | Extension for TCM |
1 | Primary Registry and Trial Identifying Number | | |
2 | Date of Registration in Primary Registry | | |
3 | Secondary Identifying Numbers | Other identifiers besides the Trial Identifying Number allocated by the Primary Registry, if any. These include: λ The Universal Trial Number (UTN) λ Identifiers assigned by the sponsor (record Sponsor name and Sponsor-issued trial number (e.g. protocol number)) λ Other trial registration numbers issued by other Registries (both Primary and Partner Registries in the WHO Registry Network, and other registries) λ Identifiers issued by funding bodies, collaborative research groups, regulatory authorities, ethics committees / institutional review boards, etc. All secondary identifiers will have 2 elements: an identifier for the issuing authority (e.g. NCT, ISRCTN, ACTRN) plus a number. There is no limit to the number of secondary identifiers that can be provided. | |
4 | Source(s) of Monetary or Material Support | Major source(s) of monetary or material support for the trial (e.g. funding agency, foundation, company, institution). | Statement of whether any conflicts of interest exist. |
5 | Primary Sponsor | The individual, organization, group or other legal entity which takes responsibility for initiating, managing and/or financing a study. The Primary Sponsor is responsible for ensuring that the trial is properly registered. The Primary Sponsor may or may not be the main funder. | |
6 | Secondary Sponsor(s) | Additional individuals, organizations or other legal persons, if any, that have agreed with the primary sponsor to take on responsibilities of sponsorship. A secondary sponsor may have agreed to: λ take on all the responsibilities of sponsorship jointly with the primary sponsor; or λ form a group with the Primary Sponsor in which the responsibilities of sponsorship are allocated among the members of the group; or λ act as the Primary Sponsor’s legal representative in relation to some or all of the trial sites. | |
7 | Contact for Public Queries | Email address, telephone number and postal address of the contact who will respond to general queries, including information about current recruitment status. | |
8 | Contact for Scientific Queries | Responsibility for scientific leadership must be clearly assigned to a named Principal Investigator. The PI may delegate responsibility for dealing with scientific enquiries to a scientific contact for the trial. This scientific contact will be listed in addition to the PI. The contact for scientific queries must therefore include: λ Name and title, email address, telephone number, postal address and affiliation of the Principal Investigator, and; λ Email address, telephone number, postal address and affiliation of the contact for scientific queries about the trial (if applicable). The details for the scientific contact may be generic (that is, there does not need to be a named individual): e.g. a generic email address for research team members qualified to answer scientific queries. | |
9 | Public Title | Title intended for the lay public in easily understood language. | |
10 | Scientific Title | Scientific title of the study as it appears in the protocol submitted for funding and ethical review. Include trial acronym if available. | 10a. Statement of whether the trial targets a TCM Pattern, or a Western medicine–defined disease, or a Western medicine–defined disease with a specific TCM Pattern. 10b. Illustration of the name of the TCM intervention, in terms of 1) Chinese herbal medicine (CHM) or CHM formula, 2) acupuncture, 3) moxibustion, or 4) other TCM therapies (i.e. cupping, Taichi, etc.). |
11 | Countries of Recruitment | The countries from which participants will be, are intended to be, or have been recruited at the time of registration. | The research setting(s) or centre(s) from which participants will be, are being, or have been recruited at the time of registration. |
12 | Health Condition(s) or Problem(s) Studied | Primary health condition(s) or problem(s) studied (e.g., depression, breast cancer, medication error). If the study is conducted on healthy human volunteers belonging to the target population of the intervention (e.g. preventive or screening interventions), enter the particular health condition(s) or problem(s) being prevented. | If the study is conducted on participants with a TCM Pattern, or a Western medicine–defined disease with a specific TCM Pattern, enter the specific name(s) of TCM Pattern(s) studied (e.g., qi deficiency pattern, deficiency of stomach yin pattern, qi stagnation pattern). |
13 | Intervention(s) | For each arm of the trial record a brief intervention name plus an intervention description. Intervention Name: For drugs use generic name; for other types of interventions provide a brief descriptive name. For investigational new drugs that do not yet have a generic name, a chemical name, company code or serial number may be used on a temporary basis. As soon as the generic name has been established, update the associated registered records accordingly. For non-drug intervention types, provide an intervention name with sufficient detail so that it can be distinguished from other similar interventions. Intervention Description: Must be sufficiently detailed for it to be possible to distinguish between the arms of a study (e.g. comparison of different dosages of drug) and/or among similar interventions (e.g. comparison of multiple implantable cardiac defibrillators). For example, interventions involving drugs may include dosage form, dosage, frequency and duration. If the intervention is one or more drugs, then use the International non-proprietary name for each drug if possible (not brand/trade names). For an unregistered drug, the generic name, chemical name, or company serial number is acceptable. If the intervention consists of several separate treatments, list them all in a series, separated by commas (e.g. "low-fat diet, exercise"). For controlled trials, the identity of the control arm should be clear. The control intervention(s) is/are the interventions against which the study intervention is evaluated (e.g. placebo, no treatment, active control). If an active control is used, be sure to enter in the name(s) of that intervention or enter "placebo" or "no treatment" as applicable. For each intervention, describe other intervention details (dose, duration, mode of administration, etc.). | 13a. Descriptions of TCM interventions. Details for the three most common interventions (Chinese herbal medicine formulas, acupuncture and moxibustion) are given below: λ Chinese herbal medicine formulas 1) For fixed CHM formulas: name (e.g., Chinese Pinyin, Latin, or English), source (if any), dosage form, dosage and administration route of the CHM formula; name and dosage of each medical substance. 2) For individualized CHM formulas: add the rationale/criteria for modifying the formula. 3) For patent proprietary CHM formulas: add a statement of whether the formula used in the trial is for a condition the formula is originally targeted. λ Acupuncture 1)The names (or location if without standard name) of points (uni/bilateral) used, in Chinese (Pinyin) and international code; depth estimation of insertion (if any); the criteria of response sought (e.g., De-qi or muscle twitch response); needle stimulation (e.g., methods of tonifying, or reduction, or even reinforcement and reduction); needle retention time; needle type, if applicable; number of treatment sessions, frequency and duration of treatment sessions. 2)For electroacupuncture, the planned implementation requirements or criterion (e.g., mode of stimulation (continuous, dense disperse), waveform and stimulus intensity). It is also recommended to provide, the brand and manufacturer of the utilized apparatus. λ Moxibustion The materials used for moxibustion; names (or location if no standard name) of points (uni/bilateral) used for moxibustion, in Chinese (Pinyin) and international code; procedure and technique for moxibustion; criteria for response sought (e.g., warm feeling); number of treatment sessions, frequency and duration of treatment sessions. 13b. Descriptions of control group(s). For interventions with the control group(s), descriptions of the control groups should include the following: λ For CHM formulas 1) Placebo control: name and amount of each ingredient (if applicable); description whether the placebo is the physical identical to the tested drug and pharmacological inert (if any); quality control and safety assessment (if any); administration route, regimen, and dosage; production information (e.g., planned manufacturer). 2) Active control: if a CHM formula was used, see recommendations for CHM formulas above; if a chemical drug was used, the name, administration route, dosage and regime should be reported. λ For acupuncture or moxibustion 1) Blank/waitlist control: special arrangement(s) during pre-treatment, treatment and post-treatment periods. 2) Sham acupuncture or sham moxibustion: details in accordance with the recommendations for acupuncture or moxibustion above. For example, key information of sham acupuncture control should include needling (penetrating or non-penetrating the skin), acupoint (non-acupoint/ irrelevant acupoint), and manipulation (non- or low- grade manipulation). 13c. Statement of the qualifications or experiences criteria of possible treatment providers, if applicable. |
14 | Key Inclusion and Exclusion Criteria | Inclusion and exclusion criteria for participant selection, including age and sex. Other selection criteria may relate to clinical diagnosis and co-morbid conditions; exclusion criteria are often used to ensure patient safety. If the study is conducted on healthy human volunteers not belonging to the target population (e.g. a preliminary safety study), enter "healthy human volunteer". | Statement of whether participants with a specific TCM Pattern will be recruited, in terms of 1) diagnostic criteria and 2) inclusion and exclusion criteria, if applicable. All criteria used should be universally recognized, or reference given to where detailed explanation can be found. |
15 | Study Type | Study type consists of: 1.Type of study (interventional or observational) 2.Study design including: Method of allocation (randomized/non-randomized) Masking (is masking used and, if so, who is masked) Assignment (single arm, parallel, crossover or factorial) Purpose 3.Phase (if applicable) For randomized trials: the allocation concealment mechanism and sequence generation will be documented. | |
16 | Date of First Enrollment | Anticipated or actual date of enrolment of the first participant. | |
17 | Sample Size | Sample Size consists of: 1.Number of participants that the trial plans to enrol in total. 2.Number of participants that the trial has enrolled. | |
18 | Recruitment Status | Recruitment status of this trial: 1.Pending: participants are not yet being recruited or enrolled at any site 2.Recruiting: participants are currently being recruited and enrolled 3.Suspended: there is a temporary halt in recruitment and enrolment 4.Complete: participants are no longer being recruited or enrolled 5.Other | |
19 | Primary Outcome(s) | Outcomes are events, variables, or experiences that are measured because it is believed that they may be influenced by the intervention. The Primary Outcome should be the outcome used in sample size calculations, or the main outcome(s) used to determine the effects of the intervention(s). Most trials should have only one primary outcome. For each primary outcome provide: 1.The name of the outcome (do not use abbreviations) 2.The metric or method of measurement used (be as specific as possible) 3.The timepoint(s) of primary interest Example: Outcome Name: Depression Metric/method of measurement: Beck Depression Score Timepoint: 18 weeks following end of treatment | If TCM-related outcome (e.g., Pattern outcome) involved, illustration of method of measurement in detail, if applicable.† |
20 | Key Secondary Outcomes | Secondary outcomes are outcomes which are of secondary interest or that are measured at timepoints of secondary interest. A secondary outcome may involve the same event, variable, or experience as the primary outcome, but measured at timepoints other than those of primary interest. As for primary outcomes, for each secondary outcome provide: 1.The name of the outcome (do not use abbreviations) 2.The metric or method of measurement used (be as specific as possible) 3.The timepoint(s) of interest |
21 | Ethics Review | The ethics review process information of the trial record in the primary register database. It consists of: 1.Status (possible values: Not approved, Approved, Not Available) 2.Date of approval 3.Name and contact details of Ethics committee(s) | |
22 | Completion date | The date on which the final data for a clinical study were collected (commonly referred to as, "last subject, last visit"). | |
23 | Summary Results | It consists of: 1.Date of posting of results summaries 2.Date of the first journal publication of results 3.URL hyperlink(s) related to results and publications 4.Baseline Characteristics: Data collected at the beginning of a clinical study for all participants and for each arm or comparison group. These data include demographics, such as age and sex, and study-specific measures. 5.Participant flow: Information to document the progress and numbers of research participants through each stage of a study in a flow diagram or tabular format. 6.Adverse events: An unfavorable change in the health of a participant, including abnormal laboratory findings, and all serious adverse events and deaths that happen during a clinical study or within a certain time period after the study has ended. This change may or may not be caused by the intervention being studied. 7.Outcome measures: A table of data for each primary and secondary outcome measure and their respective measurement of precision (eg a 95% confidence interval) by arm (that is, initial assignment of participants to arms or groups) or comparison group (that is, analysis groups), including the result(s) of scientifically appropriate statistical analyses that were performed on the outcome measure data, if any. 8.URL link to protocol file(s) with version and date 9.Brief summary | |
24 | IPD sharing statement | Statement regarding the intended sharing of deidentified individual clinical trial participant-level data (IPD). Should indicate whether or not IPD will be shared, what IPD will be shared, when, by what mechanism, with whom and for what types of analyses. It consists of: 1.Plan to share IPD (Yes, No, Undecided) 2.Plan description | |
Additional data items required |
A1 | URL | The unique URL of the trial record in the primary registry database. | |
Optional data items for collection by the registries |
B1 | Lay Summary | Short description of the primary purpose and background of the study followed by a description of the included participants, interventions to be tested and outcomes to be measured. Include a brief statement of the study hypothesis. This should be written in language intended to be read and understood by the lay public. Do not include the entire protocol; do not duplicate information recorded in other data elements. | Provide a brief statement regarding the specific TCM intervention for a TCM Pattern, a Western medicine–defined disease, or a Western medicine–defined disease with a specific TCM Pattern, as well as a short description of relevant rationale and selection principle of the utilized TCM intervention(s) with references. |
B2 | Approvals | Oversight entities that have approved the trial (or to which the trial has been submitted for approval). These include ethics committees and regulatory authorities. For each approving entity the name of the entity, the date and status of the approval should be reported. | |
* The original items of WHO Trial Registration Data Set (TRDS) (Version 1.3.1) are provided; elaborations for TCM extensions are in italicized text. We strongly recommend reading this checklist in conjunction with the “WHO International Standards for Clinical Trial Registries” [14] for important clarifications on all original items of WHO data set. |
# From the Reference 14. |
† This extension item is used for both original items 19 and 20. |
Explanations of WHO TRDS-TCM 2020
Item 4: Source(s) of Monetary or Material Support.
Original WHO TRDS item: Major source(s) of monetary or material support for the trial (e.g. funding agency, foundation, company, institution).
TCM Extension item: Statement of whether any conflicts of interest exist.
Authors should report the sources of funding for the trial, as this is essential information for readers assessing a trial. An increasing number of TCM clinical trials, especially CHM interventional trials, are funded by the pharmaceutical industry. Studies have shown that research sponsored by the pharmaceutical industry are more likely to produce results favoring the product made by the company sponsoring the research than studies funded by other sources [25]. The level of involvement by a funder and their influence on the design, conduct, analysis, and reporting of a trial varies. It is therefore important that the authors describe in detail the role of the funders [26]. For the records of trial registration, we advise researchers to report whether any conflicts of interest will possibly exist between the funder and research.
Item 10: Scientific Title.
Original WHO TRDS item: Scientific title of the study as it appears in the protocol submitted for funding and ethical review. Include trial acronym if available.
TCM extension items:
10a. Statement of whether the trial targets a TCM Pattern, or a Western medicine–defined disease, or a Western medicine–defined disease with a specific TCM Pattern.
10b. Illustration of the name of the TCM intervention, in terms of 1) Chinese herbal medicine (CHM) or CHM formula, 2) acupuncture, 3) moxibustion, or 4) other TCM therapies (i.e. cupping, Taichi, etc.).
Every trial should have a self-explanatory scientific title, which provides a first description of the trial design and research question. For trial registration, both public title (e.g., Item 9) and scientific title (e.g., Item 10) are needed. While the public title should be written to easily understood by the laymen, the scientific title is necessarily technical; it must include all elements of the PICOS (Participants, Intervention, Comparator, Outcomes and Study design). In general, the scientific title of a trial as it appears in the protocol submitted for funding and ethical review can be used [14]. For TCM trial registrations, the specific name of target disease and/or TCM Pattern and the TCM intervention(s) should be at least reported.
If the TCM pattern(s) will be involved in participant recruitment of a trial, the registered scientific title should provide the standard name(s), such as “spleen-deficiency syndrome”, or a generalized term of “TCM syndrome differentiation” or “TCM pattern-based”, indicating that various types of Patterns will be studied. For TCM interventions, we also recommend researchers to report the specific name (e.g., style of intervention), if applicable. For example, Chinese herbal medicines are typically administered as either single herbs or formulas; names of them can be presented in English, in Chinese Pinyin, or as the acronym [27], such as “Cordyceps sinensis”, “Xijiao Dihuang Decoction” [28], “PSORI-CM01(YXBCM01) Granule” [29], etc. In comparison, the non-herbal therapies include acupuncture, moxibustion, massage, cupping, Taichi, etc., and their names can be specified in terms of materials used and the details of procedures. With moxibustion as an example, the style of moxibustion used could be direct moxibustion, indirect moxibustion, medicinal moxibustion, heat-sensitive moxibustion, warming needle moxibustion, and natural moxibustion [16]. If a trial intends to include a broad category of TCM interventions (e.g., complex/comprehensive interventions), an overall, summary name, such as Chinese medicine antiviral therapy [30], could be used in the title; in such a case mentioning every intervention would result in an unreasonably long title.
Item 11: Countries of Recruitment.
Original WHO TRDS item: The countries from which participants will be, are intended to be, or have been recruited at the time of registration.
TCM extension item: The research setting(s) or centre(s) from which participants will be, are being, or have been recruited at the time of registration.
Although reporting the recruitment countries of a study would be sufficient at the time of registration, some registries require reporting the research settings or centres, at least provide the name(s). For example, the Chinese Clinical Trial Registry (ChiCTR) item, “Countries of recruitment and research settings”, requests information regarding Province, City, Institution hospital and Level of the institution as well as country [31]. The Clinical Research Information Service-Republic of Korea (CRiS) item, “Name of Study Site” [32]; International Standard Randomized Controlled Trial Number Register (ISRCTN) item, “Locations”, requests Countries of recruitment and Trial participating centre [33]. The Clinical Trials Registry-India (CTRI) requests “Countries of Recruitment and Sites of Study” [34]; the Iranian Registry of Clinical Trials (IRCT) and Pan African Clinical Trial Registry (PACTR) request “Recruitment centres” [35-36]. The research setting is a factor in assessing the nature and credibility of the trial will be conducted; also more generally it is used as a part of descriptions for trial design (e.g., single centre or multi-centre). Thus, we recommend researchers to provide information (e.g., name or total number) about the research setting(s) or centre(s), if applicable.
Item 12: Health Condition(s) or Problem(s) Studied.
Original WHO TRDS item: Primary health condition(s) or problem(s) studied (e.g., depression, breast cancer, medication error). If the study is conducted in healthy human volunteers belonging to the target population of the intervention (e.g. preventive or screening interventions), enter the particular health condition(s) or problem(s) being prevented.
TCM extension item: If the study is conducted on participants with a TCM Pattern, or a Western medicine–defined disease with a specific TCM Pattern, enter the specific name(s) of TCM Pattern(s) studied (e.g., qi deficiency pattern, deficiency of stomach yin pattern, qi stagnation pattern).
In our previous study, among 2,955 TCM interventional trials that registered from 2003 to 2017, there are 376 (12.7%) trials that included the TCM pattern [37]. In TCM clinical practice, accurate TCM pattern differentiation is vital for diagnosis and choice of TCM treatment [38]. If a trial will include TCM Pattern(s), or a Western medicine–defined disease with a specific TCM Pattern, researchers should report the name(s) of primary condition(s) and TCM Pattern(s) studied, such as “Leucopenia (deficiency of both qi and blood syndrome)” [39]. Furthermore, we recommend researchers to use the Pattern name(s) according to the international standards of “WHO International Standard Terminologies on Traditional Medicine in the West Pacific Region” [40] or the “International Standard Chinese-English Basic Nomenclature of Chinese Medicine” [41], which were published by World Federation of Chinese Medicine Societies in 2007. Different from Western condition(s)/disease(s), a TCM pattern may have different translations [42-45]. Thus, the use of internationally recognized, standardized terminology is highly recommended.
Item 13: Intervention(s).
Original WHO TRDS item: For each arm of the trial record a brief intervention name plus an intervention description. Intervention Name: If the intervention is one or more drugs, then use the International Non-Proprietary Name for each drug if possible (not brand/trade names). For an unregistered drug, the generic name, chemical name, or company serial number is acceptable.
As soon as the generic name has been established, update the associated registered records accordingly. For non-drug interventions, provide a name with sufficient detail so that it can be distinguished from other similar interventions. Intervention Description: For each intervention, describe details (dose, duration, mode of administration, etc.) in sufficient detail to distinguish between the arms of a study (e.g. comparison of different dosages of drug) and/or among similar interventions (e.g. comparison of multiple implantable cardiac defibrillators). If the intervention consists of several separate treatments, list them all in a single series, separated by commas (e.g. "low-fat diet, exercise"). For controlled trials, the identity of the control arm should be clear. The control intervention(s) is/are the interventions against which the study intervention is evaluated (e.g. placebo, no treatment, active control). If an active control is used, be sure to enter in the name(s) of that intervention or enter "placebo" or "no treatment" as applicable.
TCM extension items:
13a. Descriptions of TCM interventions.
Details for the three most common interventions (Chinese herbal medicine formulas, acupuncture and moxibustion) are given below:
- Chinese herbal medicine formulas
1) For fixed CHM formulas: name (e.g., Chinese Pinyin, Latin, or English), source (if any), dosage form, dosage and administration route of the CHM formula; name and dosage of each medical substance.
2) For individualized CHM formulas: add the rationale/criteria for modifying the formula.
3) For patent proprietary CHM formulas: add a statement of whether the formula used in the trial is for a condition the formula is originally targeted.
1) The names (or location, if without standard name) of points (uni/bilateral) used, in Chinese (Pinyin) and international code; depth estimation of insertion (if any); the criteria of response sought (e.g., De-qi or muscle twitch response); needle stimulation (e.g., methods of tonifying, or reduction, or even reinforcement and reduction); needle retention time; needle type, if applicable; number of treatment sessions, frequency and duration of treatment sessions.
2) For electroacupuncture, the planned implementation requirements or criteria (e.g., mode of stimulation (continuous, dense disperse), waveform and stimulus intensity). It is also recommended to provide, the brand and manufacturer of the utilized apparatus.
The materials used for moxibustion; names (or location if no standard name) of points (uni/bilateral) used for moxibustion, in Chinese (Pinyin) and international code; procedure and technique for moxibustion; criteria for response sought (e.g., warm feeling); number of treatment sessions, frequency and duration of treatment sessions.
A detailed description of TCM intervention(s) at the time of trial registration is beneficial to prevent publication bias and unnecessary duplication, as well as to keep data transparent for the public and healthcare professionals. Generally, the three most common interventions are CHM formulas, acupuncture and moxibustion. Therefore, item 13 (Interventions) is extended to include the registration recommendations for common types of CHM formulas (e.g., fixed, individualized, and patent proprietary), acupuncture (e.g., manual acupuncture and electroacupuncture), moxibustion and their controls (e.g., CHM placebo, active and sham acupuncture/moxibustion). During the development process, the checklist items of SPIRIT-TCM Extension 2018 [18], CONSORT-CHM Formulas 2017 [17], STRICTA (Revised STandards for Reporting Interventions in Clinical Trials of Acupuncture) [15] and STRICTOM (The STandards for Reporting Interventions in Clinical Trials Of Moxibustion) were referred, respectively [16]. Researchers can follow the extension items for each type of intervention.
In all cases, we understand there must be a balance between what is practical and what is ideal; nevertheless, striving for the ideal will improve reporting. In particular, for CHM formulas, the checklist does not set the information about processing, production, quality control and safety assessment as required reporting items in the registration, but this does not mean that such information can be ignored. From the beginning of trial registration, efforts should be made to produce data transparent, comprehensive and accurate. Taking quality control of a CHM formula as an example, reporting any pre-designed quantitative and/or qualitative testing method(s), or providing the name(s) of potential CHM manufacturer would be valuable.
13b. Descriptions of control group(s).
For interventions with the control group(s), descriptions of the control groups should include the following:
1) Placebo control: name and amount of each ingredient (if applicable); description whether the placebo is the physical identical to the tested drug and pharmacological inert (if any); quality control and safety assessment (if any); administration route, regimen, and dosage; production information (e.g., planned manufacturer).
2) Active control: if a CHM formula was used, see recommendations for CHM formulas above; if a chemical drug was used, the name, administration route, dosage and regime should be reported.
- For acupuncture or moxibustion
1) Blank/waitlist control: special arrangement(s) during pre-treatment, treatment and post-treatment periods.
2) Sham acupuncture or Sham moxibustion: details in accordance with the recommendations for acupuncture and moxibustion above. For example, key information of sham acupuncture control should include needling (penetrating or non-penetrating the skin), acupoint (non-acupoint/ irrelevant acupoint), and manipulation (non- or low- grade manipulation).
A control group is essential in clinical trials attempting to evaluate the efficacy of an intervention. Among these, the placebo design of TCM interventions has been the topic for years, specifically including placebos for CHM formula, sham acupuncture and sham moxibustion [46]. In our previous study, 889 CHM interventional trials were identified in WHO registries from 1999 to 2017, and 40.8% (363) of them included placebo control. Unfortunately, the quality of CHM placebo design and reporting is often poor [47]. Due to the unique color, taste and smell of CHM formulas, creating a quality placebo, that is, physically identical and pharmacologically inert, is quite difficult [48]. Thus, transparently reporting the details about the placebo, as suggested above, are essential for readers to assess the study design and results.
For sham acupuncture and sham moxibustion, a description of these control interventions, especially about the differences from interventions, should be provided. Specifically, information on penetrating or non-penetrating the skin, non-manipulation or low-grade manipulation, and any variation of the acupoint location should be described for the group of sham acupuncture [49]. For sham moxibustion, how the “sham” situation is achieved, e.g, by burning away from the traditional location or by adding insulation below the moxa, should be stated [16]. Particularly, we encourage researchers to describe what the sham acupuncture or moxibustion is intended to control for, such as for point specificity, or for the type and duration of stimulation. In addition, sources that led to the design of sham acupuncture or moxibustion, such as literature or expert opinion, should also be supplied.
13c. Statement of the qualifications or experiences criteria of possible treatment providers, if applicable.
The qualification and experience of treatment providers will influence the nature of the TCM intervention given and is therefore a variable that may significantly affect the trial outcome. Clinical doctors are not necessarily the clinical researchers, and not all researchers of TCM trials have the background of TCM knowledge. Therefore, it is necessary to provide the qualifications or experience of treatment providers, thus to make sure the readers understand who design and implement the trials. For trial registration, researchers could provide a list of who will implement the intervention as well as their qualifications. If not applicable, a pre-designed criteria of treatment providers should be provided, such as the requirements of qualification or professional title, years in TCM practice, or any other experience that may be relevant to the trial interventions. Besides, if the intervention requires patients to provide self-treatment, details of any training in advance or any other measures used for standardizing the intervention should be clearly reported.
Item 14: Key Inclusion and Exclusion Criteria.
Original WHO TRDS item: Inclusion and exclusion criteria for participant selection, including age and sex. Other selection criteria may relate to clinical diagnosis and co-morbid conditions; exclusion criteria are often used to ensure patient safety. If the study is conducted in healthy human volunteers not belonging to the target population (e.g. a preliminary safety study), enter "healthy human volunteer".
TCM extension item: Statement of whether participants with a specific TCM Pattern will be recruited, in terms of 1) diagnostic criteria and 2) inclusion and exclusion criteria, if applicable. All criteria used should be universally recognized, or reference given to where detailed explanation can be found.
If the Pattern concept is involved in the participant selection, information of how the Pattern is diagnosed and what criteria are used for including and excluding participants should be described. However, in our previous study, we found that among 376 TCM trial registrations that included Pattern(s) for participants, only 27 (7.2%) trials reported the diagnostic criteria for the Pattern studied. Furthermore, 61 (16.2%) trials did not provide the specific name of the Pattern studied [37]. Such vagueness prevents readers from properly interpreting results and reproducing the study. As recommendations in the CONSORT-CHM formulas 2017 [17], citing nationally or internationally recognized Pattern diagnosis criteria are important to TCM clinical trials. We herewith emphasize that the diagnostic criteria of Pattern should be reported at the time of trial registration, which enables researchers to apply these criteria consistently throughout the trial. We advise researchers to report the international Pattern standard for clustering of symptoms and signs; if necessary, with detailed explanation or reference(s) where explanations can be found.
Item 19: Primary Outcome(s) and Item 20: Key Secondary Outcomes.
Original WHO TRDS item: Outcomes are events, variables, or experiences that are measured because it is believed that they may be influenced by the intervention.
The Primary Outcome should be the outcome used in sample size calculations, or the main outcome(s) used to determine the effects of the intervention(s). Most trials should have only one primary outcome. For each primary outcome provide: 1. Name of the outcome (do not use abbreviations); 2. Metric or method of measurement used (be as specific as possible); 3. Timepoint(s) of primary interest.
Secondary outcomes are outcomes which are of secondary interest or that are measured at time points of secondary interest. A secondary outcome may involve the same event, variable, or experience as the primary outcome, but is measured at time points other than those of primary interest.
As for primary outcomes, for each secondary outcome provide: 1. Name of the outcome (do not use abbreviations); 2. Metric or method of measurement used (be as specific as possible); 3. Time point(s) of interest.
TCM extension item: If TCM-related outcome (e.g., Pattern outcome) involved, illustration of method of measurement in detail, if applicable.
The validity and reliability of trial outcomes are fundamental to interpretation of results; only valid, reliable results can reflect the true efficacy and safety of a given intervention [50]. The primary outcomes usually appear in the sample size calculation (Item 17), and the number of them should be as small as possible; while the remaining outcomes constitute the secondary outcomes. For TCM interventional trials, the commonly used outcomes can be categorized into Western medicine–specific outcomes and TCM-specific, or Pattern-based, outcomes [51]. The Pattern outcomes are more likely to include symptoms and signs assessed by TCM diagnostic methods [52-53], which can be measured in terms of occurrence (e.g., presence or absence of symptoms or signs), by a rating scale (e.g., score assessment), or an assessment questionnaire (e.g., validated Pattern survey). If a TCM interventional trial included Pattern outcome(s), the information about the name(s), measurement(s), time point(s) should be reported. The methods for measurements are particularly important. In different trials, even the same Pattern outcome could be assessed with various measures according to different rationale; some researchers may develop their own methods for outcome measurements. Thus, we recommend researchers to report the methods of measurement(s) in detail, such as the assessment procedures and supporting references. To improve the quality of assessment, it is better to provide a statement of who will evaluate Pattern outcome(s) (e.g., certified Chinese medicine practitioners or other trained professionals) and if there will be any special arrangements for Pattern outcome(s) evaluation (e.g., patient diary with series of symptoms and signs).
Optional data items for collection by the registries
B1: Lay Summary.
Original WHO TRDS item: Short description of the primary purpose and background of the study followed by a description of the included participants, interventions to be tested and outcomes to be measured. Include a brief statement of the study hypothesis. This should be written in language intended to be read and understood by the lay public. Do not include the entire protocol; do not duplicate information recorded in other data elements.
TCM extension item: Provide a brief statement regarding the specific TCM intervention for a TCM Pattern, a Western medicine–defined disease, or a Western medicine–defined disease with a specific TCM Pattern, as well as a short description of relevant rationale and selection principle of the utilized TCM intervention(s) with references.
This item is an optional data item for registry collection in WHO TRDS (v.1.3.1), which is not included in the required 24 items. Most registries, however, have individually included relevant registration items regarding “lay summary” of the trial. Different registries use different names. For example, ClinicalTrials.gov (registry of the United States) includes two items, “Brief Summary” and “Detailed Description”, which are related to the B1 item (Lay summary). Specifically, this item involves three reporting aspects: 1) study objective/hypothesis; 2) study background/rationale; and 3) description of participants, interventions, comparisons and outcomes (PICO). In our previous review, it was found that, of 2,955 TCM interventional trial registrations (1999-2017), 2,844 (96.2%) trials reported the study purpose, 1,644 (55.6%) trials provided a short description of PICO, and 972 (32.9%) reported the study background/rationale, particularly based on TCM theories [10]
Firstly, the objectives or hypotheses are the questions that the trial is designed to answer [54]. Whether the TCM intervention(s) targets a Western medicine–defined disease, a Pattern, or a Western medicine–defined disease with a specific Pattern should be clarified, and then readers can easily understand which conditions and treatments are targeted in the trial. Secondly, the background and underlying rationale of the research question can help readers to understand the significance of the trial. For a better understanding of TCM trials, it is recommended that the TCM rationale for selecting the TCM intervention(s) for a targeted disease and Pattern, as well as the therapeutic principles about both the Pattern and intervention should be provided, if applicable. To make this part concise, a literature review or relevant references could be cited. Thirdly, a brief description of the PICO must be clearly presented; this will facilitate application of the trial results in the future clinical practice. Regarding the description of TCM interventions and Patterns, easily understood layman’s language is recommended.