Risk of bias in nonrandomized studies of interventions showed low inter-rater reliability and challenges in its application

Objective: To assess the inter-rater reliability (IRR)and usability of the risk of bias in nonrandomized studies of interventions tool (ROBINS-I). Study Design and Setting: We designed a cross-sectional study. Five raters independently applied ROBINS-I to the nonrandomized cohort studies in three systematic reviews on vaccines, opiate abuse, and rehabilitation. We calculated Fleiss' Kappa for multiple raters as a measure of IRR and discussed the application of ROBINS-I to identify difficulties and possible reasons for disagreement. Results: Thirty one studies were included (195 evaluations). IRRs were slight for overall judgment (IRR 0.06, 95% CI 0.001 to 0.12)and individual domains (from 0.04, 95% CI −0.04 to 0.12 for the domain “selection of reported results” to 0.18, 95% CI 0.10 to 0.26 for the domain “deviation from intended interventions”). Mean time to apply the tool was 27.8 minutes (SD 12.6)per study. The main difficulties were due to poor reporting of primary studies, misunderstanding of the question, translation of questions into a final judgment, and incomplete guidance. Conclusion: We found ROBINS-I difficult and demanding, even for raters with substantial expertise in systematic reviews. Calibration exercises and intensive training before its application are needed to improve reliability.