Question | Answer | Rationale |
---|---|---|
Domain 1: Participants | ||
 1.1 Were appropriate data sources used, e.g., cohort, RCT or nested case–control study data? | No | Nested case–control without proper adjustment of the baseline hazard. |
 1.2 Were all inclusions and exclusions of participants appropriate? | Probably no | Having complete laboratory blood tests before receiving ART may lead to biased selection. |
Overall risk of bias of Domain 1 | High risk of bias | Â |
Domain 2: Predictors | ||
 2.1 Were predictors defined and assessed in a similar way for all participants? | Probably yes | Laboratory outcomes were obtained in a standardized manner, whereas self-reported data such as mode of HIV transmission might be subjected to bias from self-interpretation. Nevertheless, only laboratory outcomes were included in the final prognostic model. |
 2.2 Were predictor assessments made without knowledge of outcome data? | Yes | The outcome was death, and predictor data were collected at patients' enrollment. |
 2.3 Are all predictors available at the time the model is intended to be used? | Yes | All predictors (i.e., hemoglobin, CD4+ cell count, and HIV viral load) are routine laboratory assessment and easy to access. |
Overall risk of bias of Domain 2 | Low risk of bias | Â |
Domain 3: Outcome | ||
 3.1 Was the outcome determined appropriately? | Probably no | 1. Determination of AIDS-related death was unclear, so misclassification of outcomes might be possible. 2. Given that loss to follow-up was not mentioned in the paper, participants who were lost to follow-up might be misclassified as being alive. |
 3.2 Was a pre-specified or standard outcome definition used? | No information | Definition of AIDS-related death was not provided. |
 3.3 Were predictors excluded from the outcome definition? | Yes | The outcome was death, which is objective. |
 3.4 Was the outcome defined and determined in a similar way for all participants? | No information | The authors did not provide any information regarding how AIDS-related death was determined and whether it varied from patients to patients. |
 3.5 Was the outcome determined without knowledge of predictor information? | Yes | The outcome was death, which is objective. |
 3.6 Was the time interval between predictor assessment and outcome determination appropriate? | Yes | The time interval, from ART initiation till the end of follow-up (12 years in total) was long enough to observe the death outcome. |
Overall risk of bias of Domain 3 | High risk of bias | Â |
Domain 4: Analysis | ||
 4.1 Were there a reasonable number of participants with the outcome? | No | The number of events per variable = 105 death/35 = 3, which is too small. |
 4.2 Were continuous and categorical predictors handled appropriately? | Probably no | Continuous predictors (CD4+ and hemoglobin) were not examined for nonlinearity, but generally, these two variables are right skewed and should be log-transformed before entering the model. |
 4.3 Were all enrolled participants included in the analysis? | No | Among the 3584 patients in the control group, only 600 could be matched and included in analyses, whereas the remaining could not be successfully matched were excluded. |
 4.4 Were participants with missing data handled appropriately? | Probably no | Although multiple imputation was used, there was no explicit mention of the specific method used to analyze imputed data. |
 4.5 Was selection of predictors based on univariable analysis avoided? | No | Selection was entirely based on p values in univariate Cox analyses and ROC analyses. |
 4.6 Were complexities in the data (e.g., censoring, competing risks, sampling of controls) accounted for appropriately? | No | 1. Censored data were not mentioned and might not be handled properly. 2. Non-AIDS-related death was not accounted as a competing risk of AIDS-related death. 3. Propensity-score matching approach was misused. |
 4.7 Were relevant model performance measures evaluated appropriately? | Probably yes | Discrimination was assessed by the concordance index, and calibration curve was used to assess calibration. |
 4.8 Were model overfitting and optimism in model performance accounted for? | No | Internal validation consists only of a single random split sample of participant data and did not include all model development procedures including any variable selection. |
 4.9 Do predictors and their assigned weights in the final model correspond to the results from multivariable analysis? | No | The final model was based only on a selection of predictors from the reported multivariable regression analysis without refitting the smaller model. |
Overall risk of bias of Domain 4 | High risk of bias | Â |