Case reports are the smallest publishable unit in a medical journal.[1,2] It is scientific documentation detailing the signs and symptoms, diagnosis, treatment and follow-up of a single clinical observation.[3,4] Case reports are vital to identify new, rare and unknown diseases, evaluating new therapeutic interventions, adverse events, surveillance, cost of treatment and advancing scientific medical knowledge. Case reports could provide the hypothesis for future observational or interventional studies also.[6,7]
Case reports have been inconsistently reported in medical journals, reducing its usefulness in the medical literature. Case Report (CARE) guidelines 2016 have been provided to facilitate systematic reporting of case reports.[2,8,9] Despite many medical journals endorsing the CARE guidelines, the quality of reporting case reports has not been found to be satisfactory.[5,10] Hence, the present study was undertaken with a primary objective to assess the adherence of case reports to CARE guidelines amongst selected Indian Medical Journals (IMJs) published in the year 2020–2021. The secondary objective was to assess the completeness of reporting (COR) amongst journals endorsing CARE guidelines.
MATERIAL AND METHODS
The present study was undertaken to evaluate the completeness of case reports published in the selected IMJs between 2020 and 2021. Case reports were selected using the PubMed search engine.
IMJs selected for the study were Indian Journal of Dermatology, Venerology and Leprology (IJDVL), Indian Journal of Anaesthesia (IJA), Indian Journal of Ophthalmology (IJO), Indian Journal of Orthopaedics (IJOS), Indian Journal of Otorhinolaryngology and Head and Neck Surgery (IJOHN), Indian Paediatrics (IP), Indian Journal of Pharmacology (IJP), Indian Journal of Psychiatry (IJPsy), Indian Journal of Surgery (IJS), Journal of Association of Physicians India (JAPI), Journal of Obstetrics and Gynaecology (JOG) and Lung India (LI).
The journals were selected based on (1) indexing in PubMed across various medical specialities, (2) Indian journals publishing case reports in 2020 and 2021, (3) Indian journals currently active and have an impact factor and (4) Indian journals publishing in both online and printed format.
The online editions of the case reports were accessed and the full-text versions of the reports published from January 2020 to December 2021 were downloaded. The CARE-2016 checklist was used to evaluate the overall completeness of case reports.
CARE-2016 checklist consists of 14 items and each of the items was categorised as “yes” for reporting and “no” for not reporting. COR score was calculated for each case report as a proportion of the ‘yes’ to the ‘yes + no’ answers by using the following equation-
COR score (%) = (yes/[yes + no]) × 100
The mean COR score was calculated for all items of the CARE-2016 checklist, as well as per individual journals.
The journals were evaluated for the endorsement of the CARE-2016 checklist and the impact of endorsement on the mean COR score was assessed. At the time of the present study, it was observed that only five of the IMJs studied, namely IJDVL, IJO, IJS, JAPI and JOG had endorsed the CARE checklist. The other seven IMJs did not endorse the CARE checklist. The journals were classified into those with an impact factor more than 1 or <1. At the time of the present study, it was observed that eight of the IMJs studied namely, IJDVL, IJA, IJO, IJOS, IP, IJP, IJPsy and JOG had an impact factor more than 1. The other four journals had an impact factor <1.
Descriptive statistics were used to analyse the data, namely means, standard deviations and percentages. McNemar Chi-square test was used to analyse the overall completeness in reporting the variation in reporting between journals endorsing and not endorsing the CARE-2016 checklist. Binomial logistic regression was used to assess the effect of endorsement on the overall completeness in reporting. Microsoft Excel version 2013 (Microsoft, Washington, USA) and Statistical Package for the Social Sciences (SPSS) software version 20 (IBM, Washington, USA) were used to analyse the data.
A total of 590 case reports were assessed from the IMJs published from January 2020 to December 2021 (Table 1). Case reports published in 2020 and 2021 were 363 and 227, respectively. Majority of the case reports were published in IJO (30.9%) and IJS (20.4%). The mean COR score was 69.5% ± 14% and 65.4% ± 14% for the year 2020 and 2021, respectively. The overall mean COR score was 67.4% ± 14%. The mean COR score of individual journals is as depicted in Table 2. The adherence of case reports to the different domains of CARE 2016 checklist, namely title, keywords, abstract, introduction, timeline, patient information, physical examination, diagnostic assessment, interventions, follow-up and outcomes, discussion, patient perspective, informed consent and additional information in the year 2020 and 2021 is as depicted in Table 3.
Of the case reports, 26.5% had mentioned as case report in their title. None of the case reports had mentioned the timeline and the patient perspective. 41.43% of the case reports had mentioned regarding patient follow-up and outcomes. Only 44.6% of the case reports had included informed consent. Amongst the IMJs studied IJDVL, IJO, IJS, JAPI and JOG endorsed the CARE checklist. The mean COR score of the journals endorsing and not endorsing the CARE 2016 checklist was 66.3% and 69.8%, respectively. The adherence to CARE parameters amongst journals endorsing and non-endorsing the CARE-2016 checklist is as listed in Table 4.
Case reports have been the most under-appreciated form of publication, even though they contribute to a significant proportion of published medical literature. Inadequate reporting is a widespread problem that has been frequently observed in the publications of clinical reports. Reporting of case reports according to the guidelines of the CARE-2016 checklist could be a potential way to reduce ‘waste in research’ and to bring about uniformity in case reporting.
The present study depicted that the overall completeness of case reports published in the selected IMJs was 68%. A similar type of study conducted in 2015 concluded that adherence to CARE guidelines amongst selected Indian Journals was 61%. The present study noted a slight improvement in adherence to guidelines. Amongst high-impact journals, COR was noted to be 81%.
Sections with the highest COR were patient information, physical examination, diagnostic assessment, interventions, discussion, additional information, introduction, keywords and abstract. Sections with lowest COR were title, timeline, informed consent and patient perspective.
The clinical information in the case reports was almost complete. However, under-reporting was noted in identifying the case report in the title and providing a timeline for the report. The timeline in the form of a table or a figure with specific dates and times of the important events would unfold the key events of the case report. Hence, more emphasis needs to be given for this section. Obtaining informed consent for case report is ethically imperative and should be stated in the case report. The under-reporting of informed consent may be because the consent was not obtained or consent was obtained but not reported. The patient perspective gives an opportunity to specify patient-reported outcomes and in achieving a meaningful patient partnership for ethical research. This improves the effectiveness of the outcome and should be mentioned in the report.
Although the other sections of the CARE guidelines were well reported, strengths and limitations of the case report could have been included under discussion. This section provides the final takeaway message about the report.[13,14]
There was no significant variation in the mean COR score between journals that endorsed the CARE guidelines compared with those that did not. There was no significant difference in the COR scoring between journals with an impact factor of more than 1 and <1. Previous literature noted better quality of reporting amongst journals endorsing CARE guidelines and having an impact factor of more than 1.
There are few limitations in our study. Our study included only those articles published under the ‘case report’ section of journals. We could have thus missed out case reports published under other sections such as ‘letter to the editor’ and ‘images in medicine.’ We conducted a single data extraction from a single database (PubMed) and there might have been errors in the process despite our best efforts.
The quality of case reporting with respect to CARE 2016 checklist in the IMJs published in the years 2020–2021 was about 68%. This could be further improved by mandatory endorsing of CARE guidelines and stringent implementation by authors, editors and peer reviewers.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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