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Br J Surg
Br J Surg
bjs
The British Journal of Surgery
0007-1323
1365-2168
Oxford University Press UK

10.1093/bjs/znae218
znae218
Correspondence
AcademicSubjects/MED00910
Bjs/9
Bjs/11
Bjs/2
Response: Enhancing the validity and applicability of study for health-related quality of life in patients with conditions affecting the hand
https://orcid.org/0000-0002-2045-2923
Geoghegan Luke Department of Surgery and Cancer, Imperial College London, London, UK

Harrison Conrad J Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK

Rodrigues Jeremy N Department of Plastic and Reconstructive Surgery, Stoke Mandeville Hospital, Aylesbury, UK
Warwick Clinical Trials Unit, University of Warwick, Coventry, UK

Correspondence to: Luke Geoghegan, Department of Surgery and Cancer, Imperial College London, Exhibition Road, London SW7 2AZ, UK (e-mail: lg1813@ic.ac.uk)
9 2024
02 9 2024
02 9 2024
111 9 znae21822 7 2024
06 8 2024
© The Author(s) 2024. Published by Oxford University Press on behalf of BJS Foundation Ltd.
2024
https://creativecommons.org/licenses/by/4.0/ This is an Open Access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted reuse, distribution, and reproduction in any medium, provided the original work is properly cited.
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pmcDear Editor

We thank Chen et al. for their correspondence and criticism of our work. We acknowledge the importance of publication bias on interpretation of our findings; however, statistical tests for publication bias must be used with caution. Egger’s test can be used to indicate funnel plot asymmetry, although it fails to account for between-study heterogeneity. Differences in baseline condition severity, co-morbidities, functional status, employment and even handedness may all impact on health utility estimates even when the same valuation technique is used. We highlight between-study heterogeneity as an inherent limitation of pooled utility estimates and advise that estimates be used by analysts with caution. The trim-and-fill method is an impractical solution as it assumes publication bias as the sole reason for funnel plot asymmetry, which in the present meta-analysis is an unrealistic assumption1.

We agree that condition severity, valuation techniques and respondent characteristics are all likely to account for between-study heterogeneity and have attempted to account for these in our meta-analysis. Lack of primary data and non-standardized condition severity reporting among primary studies precludes meaningful substratification by all factors likely to influence health utility scores.

The EQ-5D has been shown to have poor responsiveness in hand conditions and its use in cost–utility analyses of interventions for hand conditions is indeed questionable. The authors state that incorporation of condition-specific preference-based measures could prove more ‘accurate’, although, to date, a value set for hand-specific patient-reported outcome measures is yet to be derived.

Finally, our search was not geographically restricted, and predominance of Western studies likely reflects global publication trends.
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Reference

1 Mavridis  D, Salanti  G. How to assess publication bias: funnel plot, trim-and-fill method and selection models. Evid Based Ment Health  2014;17 :30 24477535
