Quality assessment of case reports in high‐impact urology journals using SCARE guideline

Abstract Background and Aims The usefulness of case reports is dependent on the complete, consistent, and rigorous reporting of these cases. In order to provide a standard guideline for reporting surgical case reports, the SCARE (Surgical CAse REport) guidelines were developed in 2016. The present study evaluated the completeness and transparency of published case reports in high‐impact urology journals based on the SCARE guideline. Methods This cross‐sectional study was performed on 100 case reports published in Urology, Urology Journal, BMC Urology, and Urology Case Reports journal. Two independent reviewers performed the scoring using the last version of SCARE statement. Each of the 34 items of SCARE guideline were classified as “yes” if the item was reported in the case report text. The SCARE items were classified as “no” when the authors of case reports had not reported that item or could not tell something about reporting the item. Completeness of reporting (COR) score was calculated for each case report. COR score (%) is defined as [“yes” answers/(“yes” answers + “no” answers)] × 100 for each case report. Results The mean COR score for all the assessed case reports was 49%, ranging from 21% to 79%. Topics with the highest mean COR score were introduction (77% ± 42%), additional information (75% ± 43%), patient information (65% ± 19%), and abstract (66% ± 24%). In contrast, topics with the lowest mean COR were patient perspective (1% ± 10%) and keywords (3% ± 17%). Conclusion The present study showed that case reports published in urology journals suffer from insufficient reporting. SCARE or CARE guidelines can provide a framework for assessing the reporting quality of case reports before publication. Nevertheless, further studies are highly recommended to better evaluate the efficacy of these guidelines' endorsement on the quality of case reports published in urology journals.


| INTRODUCTION
In general, case reports have been formally placed at the lowest level in the hierarchy of evidence. 1 However, they still have a profound role in the discovery of new diseases, advancements made in surgical interventions, and medical education. 2,3 In recent years, the number of case reports published in medical journals has significantly increased and over 2 million case reports are currently recorded in PubMed indexed journals. 4 Urology is no exception to this fact and such case reports have an important role in introducing new diseases and their natural history, introducing rare diseases or rare presentations of a disease, investigation and treatment of rare diseases, as well as reporting unique surgical complications and their management. 2,5 Moreover, a growing number of case reports in urology journals have led to the creation and launch of several international, peer-reviewed journals that explicitly publish case reports, for example, Urology Case Reports, International Journal of Urology (IJU) Case Reports, Case Reports in Urology, and Journal of Endourology Case Reports.
The usefulness of case reports is dependent on the complete, consistent, and rigorous reporting of these cases. Case reports written without considering the reporting standards are not fully approved to guide clinical practice or to assist in clinical study design. 6 Improved reporting, a complete description of clinical details, and explicit conclusions may lead to reduced "waste in research." 7 In order to provide a standard guideline for reporting case reports, the CARE (CAse REport) guidelines were developed in 2013 using the Delphi method. 6 CARE was the first guideline that was developed with the aim of improving the completeness, transparency, and quality of case reports. 8 Some researchers claimed that CARE is not surgically focused; hence, they developed the SCARE guideline by the Delphi expert consensus method to further improve the reporting quality of surgical case reports. The SCARE statements were developed in 2016 and updated in 2018. 5,9 To the authors' knowledge, only a limited number of studies to date have evaluated the completeness and quality of case reports. 8,[10][11][12] No study has yet focused on assessing the quality and transparency of reporting case reports in the field of Urology. Therefore, we conducted this study with the aim of evaluating the completeness and transparency of published case reports in highimpact urology journals based on the SCARE guideline.

| Selection of eligible case reports
This cross-sectional study was performed on case reports published in three urology journals (Urology, Urology Journal, and BMC Urology) from May 1, 2019 to May 1, 2020. These journals publish case reports along with other types of articles and have a higher impact factor among the various journals in the field of Urology. The journals' impact factors were obtained from the 2019 edition of the Science Citation Index Journal Citation Reports. Case reports that reported more than one patient were excluded from the present study. Two authors reviewed all issues of these journals in the mentioned study period for case reports. After the identification of all case reports, 50 case reports were randomly included using the random numbers generator. In addition, we also included 50 random case reports from the "Urology Case Reports" journal in the same time period. This journal has the highest impact factor among urology journals that only publish case reports.

| Data extraction
We used the method of Agha et al 5 for data extraction as a valid method. In brief, two independent reviewers (M.M. and A.G.) performed the scoring using the last version of SCARE statement. 9 Each of the 34 items of SCARE guideline (Table 1) were classified as "yes" if the item was reported in the case report text. The SCARE items were classified as "no" when the authors of case reports had not reported that item or could not tell something about reporting the item. Disagreement between the reviewers was dealt through consensus with a third researcher (B.S.).

| Statistical analysis
The data were analyzed with the Statistical Package of Social Sciences (SPSS, Chicago, Illinois) for Windows version 19. A P-value <.05 was considered as statistically significant. In this study, three types of analyses were performed: First, calculation of completeness of reporting (COR) score for each case report: COR score (%) is defined as ["yes" answers/("yes" answers + "no" answers)] Â 100 for each case report. 5 Of note, previous studies have shown that the COR score is an acceptable estimation for the analysis. 8,13 Second, descriptive analysis: the number and proportion of case reports reporting each of the SCARE items.
Thirdly, comparison of the COR score between journals that publish case reports only and journals that publish different types of articles using independent sample T-test.

| Ethical consideration
Although this study is a non-risk observational research, the study protocol was approved by the Ethics Committee of Iran University of Medical Sciences (ethical approval code: IR.IUMS.REC.1399.670).

| RESULTS
A total of 100 case reports were included in the present study. Of these, 50 articles were published in the Urology Case Reports journal, 19 in Urology (the Gold Journal), 11 case reports were published in the Urology journal, and 20 in BMC Urology journal.
The mean COR score for all the assessed case reports was 49%, ranging from 21% to 79%. Topics with the highest mean COR score were introduction (77% ± 42%), additional information (75% ± 43%), patient information (65% ± 19%), and abstract (66% ± 24%). In contrast, topics with the lowest mean COR were patient perspective (1% ± 10%) and keywords (3% ± 17%; Figure 1). The mean ± SD COR score was 52% ± 11% for case reports published in journals that publish different article types compared to 45% ± 7% for case reports published in "Urology Case Reports," as the urology journal that publishes case reports only (P = .0001). Table 2 summarizes the mean COR scores for each topic of the SCARE statement in the studied case reports. In the present study, "introduction," "additional information,"

| DISCUSSION
"patient information," and "abstract" were the most frequent items which were properly presented among the published case reports in high-quality urology journals. In contrast, "patient perspective" and "keywords" were reported in a small proportion of the studied case reports.
Based on the SCARE statement, "patient perspective" is defined as "the patients should share their perspective on the treatments they received." The low COR score for "patient perspective" is expectable since authors and reviewers are not usually familiar with this aspect in reporting a case report. To our surprise, the item "keywords" had the second lowest percentage among the different subordinate items in published case reports.
Low mean COR score for "keywords" is spectacular as in all the included journals the instructions for authors section recommends authors to provide some keywords in their manuscript. However, the reason for the low mean COR score for "keywords" is mainly related to the definition of keywords in the SCARE statement. SCARE recommends authors and journals to include the "case report" phrase as one of the keywords.
Most case reports in our study provided three to five keywords but did not include "case report" as one of them.
Interestingly, in the current study, the mean COR score was significantly higher for case reports published in journals that publish different article types in comparison to "Urology Case Report" journal, which publishes case reports only. None of these two journal groups had encouraged authors to follow CARE or SCARE statements before manuscript submission.
Over the recent decade, several new peer-reviewed journals have emerged focused on publishing case reports only. There is much debate on the value of these journals and some researchers believe that some case report journals are not reputable enough. 16 Although these journals still need to strongly improve their quality,

| CONCLUSIONS
The present study confirms that case reports published in urology journals suffer from insufficient and poor reporting quality. SCARE or CARE guidelines can provide a framework for authors, reviewers, and editors to assess the reporting quality of case reports before publication. Nevertheless, further studies are recommended to better evaluate the efficacy of these guidelines' endorsement on the quality of case reports published in urology journals.

CONFLICT OF INTEREST
The authors declare no conflict of interest in this study. Behnam Shakiba had full access to all of the data in this study and takes complete responsibility for the integrity of the data and the accuracy of the data analysis.

TRANSPARENCY STATEMENT
Behnam Shakiba affirms that this manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned (and, if relevant, registered) have been explained.

DATA AVAILABILITY STATEMENT
The authors confirm that the data supporting the findings of this study are available within the article.