The impact of treatment preferences: A narrative review

Attending to treatment preferences is an element of person-centred care, reported as beneficial in improving treatment adherence, satisfaction, and outcome, in practice. The results of preference trials were inconsistent in supporting these benefits in intervention evaluation research. Informed by the conceptualisation of treatment preferences positing their indirect impact on outcomes, this narrative review aimed to summarise the evidence on the effects of preferences on enrolment; withdrawal or attrition; engagement, enactment, and satisfaction with treatment; and outcomes. The search yielded 72 studies (57 primary trials and 15 reviews). The results of vote counting indicated that (1) offering participants the opportunity to choose treatment enhances enrolment (reported in 87.5% of studies), and (2) providing treatments that match participants' preferences reduces attrition (48%); enhances engagement (67%), enactment (50%) and satisfaction with (43%) treatment; and improves outcomes (35%). The results are attributed to conceptual and methodological issues including less-than-optimal assessment of treatment preferences, which contributes to ill-identified preferences, accounting for withdrawal, low enactment, and limited satisfaction with treatment. These treatment processes, in turn, mediate the impact of treatment preferences on outcomes. It is important to refine and standardise the methods for assessing preferences and to examine their indirect impact (mediated by treatment processes) on outcomes in future preference trials to validly identify their benefits.

Strategies to Improve Enrollment and Participation in Pulmonary Rehabilitation Following a Hospitalization for COPD: RESULTS OF A NATIONAL SURVEY

PURPOSE

Pulmonary rehabilitation (PR) improves outcomes for patients with chronic obstructive pulmonary disease (COPD); however, very few patients attend. We sought to describe strategies used to promote participation in PR after a hospitalization for COPD.

METHODS

A random sample of 323 United States based PR programs was surveyed. Using a positive deviance approach, a 39-item survey was developed based on interviews with clinicians at hospitals demonstrating high rates of participation in PR. Items focused on strategies used to promote participation as well as relevant contextual factors.

RESULTS

Responses were received from 209 programs (65%), of which 88% (n = 184) were hospital-based outpatient facilities. Most (91%, n = 190) programs described enrolling patients continuously, and 80% (n = 167) reported a wait time from referral to the initial PR visit of <4 wk. Organization-level strategies to increase referral to PR included active surveillance (48%, n = 100) and COPD-focused staff (49%, n = 102). Provider-level strategies included clinician education (45%, n = 94), provider outreach (43%, n = 89), order sets (45%, n = 93), and automated referrals (23%, n = 48). Patient-level strategies included bedside education (53%, n = 111), flyers (49%, n = 103), motivational interviewing (33%, n = 69), financial counseling (64%, n = 134), and transportation assistance (35%, n = 73). Fewer than one-quarter (18%, n = 38) of PR programs reported using both bedside education and automatic referral, and 42% (n = 88) programs did not use either strategy.

CONCLUSIONS

This study describes current practices in the United States, and highlights opportunities for improvement at the organization, provider, and patient level. Future research needs to demonstrate the effectiveness of these strategies, alone or in combination.

Factors Associated With Enrollment into Inpatient Coronavirus Disease 2019 Randomized Controlled Trials: A Cross-sectional Analysis

Background

Clinical trials for coronavirus disease 2019 (COVID-19) have struggled to achieve diverse patient enrollment, despite underrepresented groups bearing the largest burden of the disease and, presumably, being most in need of the treatments under investigation.

Methods

To assess the willingness of patients to enroll into inpatient COVID-19 clinical trials when invited, we conducted a cross-sectional analysis of adults hospitalized with COVID-19 who were approached regarding enrollment. Associations between patient and temporal factors and enrollment were assessed by multivariable logistic regression analysis.

Results

A total of 926 patients were included in this analysis. Overall, Hispanic/Latinx ethnicity was associated with a nearly half-fold decrease in the likelihood to enroll (adjusted odds ratio [aOR], 0.60 [95% confidence interval {CI}, .41-.88]). Greater baseline disease severity (aOR, 1.09 [95% CI, 1.02-1.17]), age 40-64 years (aOR, 1.83 [95% CI, 1.03-3.25]), and age ≥65 years (aOR, 1.92 [95% CI, 1.08-3.42]) were each independently associated with higher likelihood to enroll. Over the course of the pandemic, patients were less likely to enroll during the summer 2021 wave in COVID-19-related hospitalizations (aOR, 0.14 [95% CI, .10-.19]) compared with patients from the first wave in winter 2020.

Conclusions

The decision to enroll into clinical trials is multifactorial. Amid a pandemic disproportionately affecting vulnerable groups, Hispanic/Latinx patients were less likely to participate when invited, whereas older adults were more likely. Future recruitment strategies must consider the nuanced perceptions and needs of diverse patient populations to ensure equitable trial participation that advances the quality of healthcare for all.

Considering Retention and Curricula in Reframing Pharmacy Enrollment Challenges

Enrollment in pharmacy education has been a topic of extensive discussions as the number of applications has declined. Some pharmacy programs have either not met enrollment goals or decreased incoming class sizes. This Commentary poses two questions that we must ask ourselves as an Academy. First, is it possible to realistically do more to recruit our way out of this situation in the next three to five years and beyond. Second, how, if possible, will pharmacy colleges and schools avoid the significant and transformative forces that could impact higher education in the future. Forces that are impacting higher education include changing demographics, transitioning from an industrial-based economy to a knowledge-based economy, and the continuing advances in technology with increased globalization as a component of all three of these forces. To address these questions, the concepts of student retention and success as well as considerations for reframing current curricular and pedagogical models and beliefs are challenged. In that pharmacy enrollment challenges are not likely to be easily resolved in the next few years, the Academy must place additional emphasis on issues related to student success and the design of our educational models and programs.

Recruitment of family caregivers of persons with dementia: Lessons learned from a pilot randomized controlled trial

Family caregivers play an essential role in supporting the health and well-being of older adults with dementia, a population projected to increase rapidly over the coming decades. Enrolling caregivers of people with dementia (PWD) in research studies is vital to generating the evidence necessary to support broader implementation of efficacious intervention programs in real-world care delivery, but a range of challenges impede recruitment and enrollment of sufficiently large and representative sample sizes. In this article, we characterize the challenges and lessons learned from recruiting caregivers of PWD to participate in a pilot randomized control trial. We utilize Bronfenbrenner's ecological model to categorize the challenges into three levels: individual (i.e., understanding caregivers' time constraints and motivations), community (i.e., reaching underrepresented populations and accessing caregiver support groups) and institutional (i.e., obtaining informed consent and navigating research registries). We found that establishing rapport and maintaining flexibility with participants was crucial for motivating individuals to enroll in our study. Building trust with local communities by collaborating with support group leaders, appointing a co-investigator who is already embedded within a given community, and establishing equitable partnerships with organizations increased recruitment rates. At the institutional level, engaging experts in regulatory affairs and geriatrics may help overcome barriers in obtaining approval from institutional review boards. We also recommend using research registries of individuals who offer their contact information to researchers. The lessons learned from our research-including the challenges and potential solutions to overcome them-may promote more effective and efficient recruitment in future research.

Enrollment and retention of female sex workers in HIV care in health facilities in Mbarara city

Background

Sex work is a global driver of the HIV epidemic, and the risk of acquiring HIV is 13 times higher for female sex workers (FSWs) compared to the general population. The enrollment and retention of FSWs in HIV care is a challenge and has been a major contributing factor to increased new HIV infections.

Methods

We conducted a qualitative study among 30 FSWs and 21 healthcare workers (HCWs) working in antiretroviral therapy (ART) clinics at the selected three primary health facilities in Mbarara City, Southwestern Uganda. The study participants were enrolled by both purposive and snowball sampling techniques. We obtained informed consent from all the participants, and data were collected using in-depth interviews and thematically analyzed.

Results

Three themes emerged as facilitators toward enrollment and retention of FSWs into HIV care, namely, (1) good health living, (2) receptive HCWs and availability of health services, and (3) community outreach services and peer support. The barriers are summarized into four major themes: (1) stigma, community discrimination, and beliefs; (2) social obstacles; (3) adverse effects of ART; and (4) inadequate services at the health facilities.

Conclusion

FSWs are challenged by unsupportive environments and communities where they live and work, which hinders their enrollment and retention in HIV care. Creating awareness of the utilization of HIV care services and extending such services to hotspot communities could enhance the response of HIV-positive FSWs to ART.

Barriers to Screening: An Analysis of Factors Impacting Screening for Type 1 Diabetes Prevention Trials

Context

Participants with stage 1 or 2 type 1 diabetes (T1D) qualify for prevention trials, but factors involved in screening for such trials are largely unknown.

Objective

To identify factors associated with screening for T1D prevention trials.

Methods

This study included TrialNet Pathway to Prevention participants who were eligible for a prevention trial: oral insulin (TN-07, TN-20), teplizumab (TN-10), abatacept (TN-18), and oral hydroxychloroquine (TN-22). Univariate and multivariate logistic regression models were used to examine participant, site, and study factors at the time of prevention trial accrual.

Results

Screening rates for trials were: 50% for TN-07 (584 screened/1172 eligible), 9% for TN-10 (106/1249), 24% for TN-18 (313/1285), 17% for TN-20 (113/667), and 28% for TN-22 (371/1336). Younger age and male sex were associated with higher screening rates for prevention trials overall and for oral therapies. Participants with an offspring with T1D showed lower rates of screening for all trials and oral drug trials compared with participants with other first-degree relatives as probands. Site factors, including larger monitoring volume and US site vs international site, were associated with higher prevention trial screening rates.

Conclusions

Clear differences exist between participants who screen for prevention trials and those who do not screen and between the research sites involved in prevention trial screening. Participant age, sex, and relationship to proband are significantly associated with prevention trial screening in addition to key site factors. Identifying these factors can facilitate strategic recruitment planning to support rapid and successful enrollment into prevention trials.

Enrollment of reproductive age women in community-based health insurance: An evidence from 2019 Mini Ethiopian Demographic and Health Survey

Background

Universal health coverage (UHC) is aimed at ensuring that everyone has access to high-quality healthcare without the risk of financial ruin. Community-based health insurance (CBHI) is one of the essential means to achieve the sustainable development goals (SDGs) global health priority of UHC. Thus, this study assessed health insurance enrollment and associated factors among reproductive age women in Ethiopia.

Methods

We computed the health insurance enrollment of reproductive-age women using secondary data from the recent Ethiopian Mini Demographic and Health Surveys (EMDHS) 2019. The EMDHS was a community-based cross-sectional study carried out in Ethiopia from March 21 to June 28, 2019. Cluster sampling with two stages was employed for the survey. The study comprised 8885 (weighted) reproductive-age women. STATA 14 was used for data processing and analysis. Bivariate and multivariable logistic regression analyses were conducted. Adjusted odds ratio (AOR) with 95% confidence interval (CI) was reported and statistical significance was set at a value of p < 0.05.

Results

Of the 8,885 study participants, 3,835 (43.2, 95% CI; 42.1, 44.2%) of women had health insurance. Women aged 20-24 years, 25-29 years, and 30-34 years less likely to enroll in health insurance compared to their younger counterparts (15-19 years). Women living in rural areas, had greater than five family sizes, living with a female household head, and having more than five living children were negatively associated with enrollment in health insurance. Besides, health insurance enrollment among reproductive-age women is significantly affected by region and religious variation.

Conclusion

The overall CBHI enrolment among reproductive-age women in Ethiopia was low. To achieve the SDGs of reducing maternal mortality ratio and neonatal mortality, improving reproductive-age women's access to health insurance is essential. The national, regional, and local officals, policymakers, NGOs, program planners, and other supporting organizations working on improving health insurance enrollment of reproductive age women need to create awareness and support them based on these significant factors.

Comparison of the Speed of Enrollment for Clinical Trials Conducted by Japanese and Global Pharmaceutical Companies

Since the establishment of the International Council for Harmonisation of Technical Requirements for Pharmaceuticals for Human Use (ICH), many countries in the world have rapidly improved their clinical trial performance, and the era has come to compare the clinical trial performance of each country. Japan's clinical trials are considered excellent quality, but costly and slow. In this study, we examined the speed of enrollment period in clinical trials. We surveyed clinical trials from January 1, 2010, to December 31, 2019, covering the top 10 pharmaceutical companies in each global sales ranking (Global 10) and the Japanese sales ranking (Japan 10). Clinical trial data were obtained from ClinicalTrials.gov, a clinical trial registration information database, and the speed of participant enrollment (cases/month) was compared for each phase of the trials. The number of clinical trials conducted during the 10 years was 8938 trials for Global 10 and 1439 trials for Japan 10. Comparing the speed of participant enrollment by phase, Japan 10 was significantly faster in phase 1 for both healthy subjects and oncology patients. [Japan 10: Global 10; 15.1 : 12.0 cases/month (healthy subjects) and 5.5 : 1.8 cases/month (oncology), respectively. p < 0.001]. Global 10 was also significantly faster in phase 3. [Japan 10: Global 10; 12.4: 36.9 cases/month, p < 0.001). No significant difference was observed in phase 2 and phase 4. There was a possibility that the speed of enrollment differed by phase between global companies and Japanese domestic companies.

Screening and enrollment of underrepresented ethnocultural and educational populations in the Alzheimer's Disease Neuroimaging Initiative (ADNI)

INTRODUCTION

An analysis of the ethnocultural and socioeconomic composition of Alzheimer's Disease Neuroimaging Initiative (ADNI) participants is needed to assess the generalizability of ADNI data to diverse populations.

METHODS

ADNI data collected between October 2004 and November 2020 were used to determine ethnocultural and educational composition of the sample and differences in the following metrics: screening, screen fails, enrollment, biomarkers.

RESULTS

Of 3739 screened individuals, 11% identified as being from ethnoculturally underrepresented populations (e.g., Black, Latinx) and 16% had <12 years of education. Of 2286 enrolled participants, 11% identified as ethnoculturally underrepresented individuals and 15% had <12 years of education. This participation is considerably lower than US Census data for adults 60+ (ethnoculturally underrepresented populations: 25%; <12 years of education: 4%). Individuals with <12 years of education failed screening at a higher rate.

DISCUSSION

Our findings suggest that ADNI results may not be entirely generalizable to ethnoculturally diverse and low education populations.

Clinical Trial Enrollment Among Adolescent and Young Adults with Primary Central Nervous System Tumors Treated at the Dana-Farber Cancer Institute

Purpose: In recent decades, the survival outcomes among adolescent and young adults (AYAs, 15-39 years) have not improved substantially, especially among AYAs with primary central nervous system (CNS) tumors. While this is likely multifactorial, low participation in clinical trials among AYAs is thought to be a critical contributing factor. In this study, we describe the pattern of clinical trial enrollment among AYAs with primary CNS tumors at our institution. Methods: We performed a retrospective, IRB-approved chart review of AYAs with CNS tumors treated at the Dana-Farber Cancer Institute (DFCI) between January 2009 and December 2018. We used logistic regression analyses and descriptive statistics to analyze this sample and determine the clinical trial enrollment at the pediatric affiliate (Dana-Farber/Boston Children's Cancer and Blood Disorders Center) and adult affiliate (Dana-Farber/Brigham and Women's Cancer Center). Results: Ninety-three AYA patients with primary CNS tumors were treated at the Dana-Farber/Boston Children's Cancer and Blood Disorders Center, while 507 patients with primary CNS gliomas were treated at the Dana-Farber/Brigham and Women's Cancer Center. At the pediatric affiliate, 35.4% (33/93) of AYAs were enrolled in a therapeutic clinical trial, while at the adult affiliate, 15.8% (80/507) of AYAs were enrolled in a clinical trial. High-grade gliomas were associated with significantly higher rates of enrollment in the adult affiliate. Conclusions: Clinical trial enrollment remains poor among AYAs with CNS tumors, and clinical trial enrollment participation is modestly higher in the pediatric setting. Our study demonstrates the continued need to evaluate and address factors associated with clinical trial enrollment among AYAs with CNS tumors.

Digital culturally tailored marketing for enrolling Latino participants in a web-based registry: Baseline metrics from the Brain Health Registry

INTRODUCTION

This culturally tailored enrollment effort aims to determine the feasibility of enrolling 5000 older Latino adults from California into the Brain Health Registries (BHR) over 2.25 years.

METHODS

This paper describes (1) the development and deployment of culturally tailored BHR websites and digital ads, in collaboration with a Latino community science partnership board and a marketing company; (2) an interim feasibility analysis of the enrollment efforts and numbers, and participant characteristics (primary aim); as well as (3) an exploration of module completion and a preliminary efficacy evaluation of the culturally tailored digital efforts compared to BHR's standard non-culturally tailored efforts (secondary aim).

RESULTS

In 12.5 months, 3603 older Latino adults were enrolled (71% of the total California Latino BHR initiative enrollment goal). Completion of all BHR modules was low (6%).

DISCUSSION

Targeted ad placement, culturally tailored enrollment messaging, and culturally tailored BHR websites increased enrollment of Latino participants in BHR, but did not translate to increased module completion.

HIGHLIGHTS

Culturally tailored social marketing and website improvements were implemented. The efforts enrolled 5662 Latino individuals in 12.5 months. The number of Latino Brain Health Registry (BHR) participants increased by 122.7%. We failed to adequately enroll female Latinos and Latinos with lower education. Future work will evaluate effects of a newly released Spanish-language BHR website.

Inclusion of patients with chronic kidney disease in randomized phase 3 clinical trials in patients with prostate, breast, lung, and colorectal cancer

The objective of this study was to determine the proportion of phase 3 clinical trials investigating a systemic therapy for patients with prostate, breast, lung, or colorectal cancer that excluded patients with Chronic Kidney Disease (CKD) and the exclusion criteria chosen, if any. A search was conducted using the ClinicalTrials.gov database to identify eligible studies. Of the 268 included trials, 185 (69%) had at least one renal exclusion criteria. Of these 185 trials, 116 (63%) had an undefined exclusion criterion. Only disease site was associated with exclusion of patients with CKD in the univariate analysis, but no factors in the multivariate analysis. There are several potential barriers to including patients with CKD in clinical trials. Nevertheless, solutions can be proposed to allow the inclusion of these patients. This would allow them to access to innovative therapeutic strategies, but also allow a better applicability of trial results to this patient population.

INFORMATION GAPS AND HEALTH INSURANCE ENROLLMENT: Evidence from the Affordable Care Act Navigator Programs

We studied the impact of Affordable Care Act navigator programs on health insurance coverage, using the 80 percent cut in program funding under the Trump administration as a natural experiment. Our study design exploited county-level differences in the program prior to funding cuts. We did not find that cuts to the program significantly decreased rates of marketplace coverage or any health insurance coverage by 2019; however, our estimates could not rule out marketplace coverage declines of up to 2.7 percent (point estimate -1.3 percent, 95 percent CI: 2.7 percent to 0.1 percent), or total coverage declines of up to 1.8 percentage points (point estimate -0.8 percentage points or -1.2 percent, 95 percent CI: -1.8 to 0.2). Cuts to the navigator program significantly decreased marketplace coverage and total coverage among lower-income adults, and significantly decreased total coverage among adults under age 45, Hispanic adults, and adults who speak a language other than English at home. We found no significant impact of the cuts on Medicaid enrollment (95 percent CI: -1.9 percentage points to 0.5 percentage points); most uninsured people in the states we studied lived in locations that had not implemented Medicaid eligibility expansions. These findings suggest that before the funding cuts, navigators were helping underserved consumers obtain coverage.

Increasing Latinx representation in the US medical schools: A top-ranked medical school's experience

Despite the increasing racial and ethnic diversity of the general US population, many, if not most, medical schools fall short of matriculating students reflective of this change in diversity. The Latinx community constitutes nearly 20% of the US population and is expected to rise substantially in the coming decades. Over the past 20 years, the number of Latinx students applying to and being admitted to medical school has grown but remains below 4% of the total medical student body composition. Several factors contribute to the under-representation of Latinx students in medical schools that include access to secondary education, finances, lack of mentorship or advice, and a multitude of other structural inequities and system-level biases. Diversity, equity, and inclusion are often named as key pillars of workforce development across the US medical schools and academic institutions. Despite significant efforts, medical schools continue to have low Latinx representation within their student body, and recruitment efforts often lack sustainability. In this manuscript, we share our experience of increasing Latinx student representation within a top-ranked medical school in the US southeast region. We have discussed the barriers we faced in enrolling and attracting Latinx students' amidst similar under-representation of Latinx faculty, staff, and leadership and the challenges of financial support for applicants and financial aid packages for admitted students. The strategies we implemented to achieve an increased representation of Latinx students in the School of Medicine (SOM) included revitalizing the Latino Medical Student Association (LMSA), ensuring Latinx student representation within the SOM admission committee that included Latinx faculty as active participants in recruitment and retention efforts, redesigning the medical Spanish course, and creating dedicated outreach plans during second look weekend for interested Latinx students and active outreach to applicants and accepted students by current students. In combination, these efforts led to a significant increase in Latinx representation in the SOM student body from 2.6% in 2009 to 12.2% in 2021. We will conclude by discussing our ongoing challenges and our approach to sustain and improve Latinx representation in our medical school.

Medicaid Disruption Among Transition-Age Youth on the Autism Spectrum

Enrollment in Medicaid facilitates access to needed services among transition-age youth on the autism spectrum and youth with intellectual disability (ID). There are long-standing programs to ensure that individuals with ID remain enrolled as they age; similar programs for autistic youth are newer, not as widespread, and may not be as effective. We compared Medicaid disenrollment and re-enrollment between transition-age youth on the autism spectrum, youth with ID, and youth with both diagnoses using a national claims-based prospective cohort study from 2008 through 2012. Autistic youth were most likely to disenroll and least likely to re-enroll. Disenrollment peaked for all three groups at ages 19 and 21. Transition-age youth on the autism spectrum experience more disruptions in access to Medicaid-reimbursed services than youth with ID. More equitable Medicaid enrollment options for autistic individuals are needed to ensure their access to critical health care as they age.

Screening for participants in the ISCHEMIA trial: Implications for clinical research

The International Study of Comparative Health Effectiveness with Medical and Invasive Approaches (ISCHEMIA) found that there was no statistical difference in cardiovascular events with an initial invasive strategy as compared with an initial conservative strategy of guideline-directed medical therapy for patients with moderate to severe ischemia on noninvasive testing. In this study, we describe the reasons that potentially eligible patients who were screened for participation in the ISCHEMIA trial did not advance to enrollment, the step prior to randomization. Of those who preliminarily met clinical inclusion criteria on screening logs submitted during the enrollment period, over half did not participate due to physician or patient refusal, a potentially modifiable barrier. This analysis highlights the importance of physician equipoise when advising patients about participation in randomized controlled trials.

Recruitment and Retention Strategies for the Diabetes RElated to Acute Pancreatitis and Its Mechanisms Study: From the Type 1 Diabetes in Acute Pancreatitis Consortium

ABSTRACT

Recruitment and retention of patients with acute pancreatitis (AP) in clinical studies can be challenging. While some obstacles are similar to other clinical conditions, some are unique to AP. Identifying potential barriers early and developing targeted solutions can help optimize recruitment and retention in AP studies. Such pre-emptive and detailed planning can help prospective, longitudinal studies focus on exocrine and endocrine complications of AP in accurately measuring outcomes. This article highlights the challenges in recruitment and retention strategies in AP studies and reviews available resources to create opportunities to address them. We describe the multifaceted approach used by the Recruitment and Retention Committee of the Type 1 Diabetes in Acute Pancreatitis Consortium, which builds upon earlier experiences to develop a recruitment and retention plan for the DREAM (Diabetes RElated to Acute pancreatitis and its Mechanisms) study.

Potential Impact of Revised NCI Eligibility Criteria Guidance: Prior Malignancy Exclusion in Breast Cancer Clinical Trials

BACKGROUND

Many individuals with cancer have survived a prior cancer and for this reason may have been excluded from clinical trials. Recent NCI guidance recommends including these individuals, especially when the risk of the prior malignancy interfering with either safety or efficacy endpoints is very low. Using breast cancer as an example, we determined the potential effect this policy change may have on clinical trial accrual.

PATIENTS AND METHODS

We reviewed protocols of NCI-sponsored breast cancer clinical trials activated in 1991 through 2016. We quantified prevalence of prior cancer-related exclusion criteria and assessed the association with trial characteristics using Fisher's exact tests. Using SEER data, we estimated the prevalence and timing of prior primary (nonbreast) cancer diagnoses among patients with breast cancer.

RESULTS

Among 87 clinical trials (total target enrollment, 137,253 patients), 77% excluded individuals with prior cancer, most commonly (79%) within the preceding 5 years. Among trials with radiographic response or toxicity endpoints, 69% excluded prior cancer. In SEER data, the prevalence of a prior (nonbreast) cancer diagnosis ranged from 5.7% to 7.7%, depending on breast cancer stage, of which 39% occurred within 5 years of the incident breast cancer. For trials excluding prior cancer, the estimated proportion of patients excluded for this reason ranged from 1.3% to 5.8%, with the estimated number of excluded patients ranging from 1 to 288.

CONCLUSIONS

More than three-fourths of NCI-sponsored breast cancer clinical trials exclude patients with prior cancer, including almost 70% of trials with response or toxicity endpoints. Given that >5% of patients with breast cancer have a history of prior cancer, in large phase III trials this practice may exclude hundreds of patients. Following recent NCI eligibility guidance, the inclusion of patients with prior cancer on breast cancer trials may have a meaningful impact on accrual.

The Need for Improved Recruitment to Neurosurgery Training: A Systematic Review of Enrollment Strategies

Neurosurgery is one of the cornerstones corresponding to a large scope of clinical pathologies and is a highly-regarded surgical specialty. However, there has been a decline in recruits into the neurosurgical residency due to many factors derailing the interest of medical students with an ambition to become neurosurgeons. Some of these issues encompass little or lack of early exposure to neurosurgery, lack of quality mentorship programs, and institutional curriculum entailing prolonged periods of training and study in neurosurgery. Therefore, this systematic review and meta-analysis aim to establish some strategic methodologies for increasing the recruitment to neurological surgery. Neurosurgery is an interestingly exciting specialty that integrates cutting-edge technology allowing for diversified subspecialization with an exceptional degree of variety. Nevertheless, several factors such as the duration of the required training, the kind of lifestyle, lack of early exposure to neurosurgery, and lack of mentors to a vast of medical students across the globe have curtailed the recruitment to neurological surgery. Despite an increased number of female representations in medical surgery, there has been a reported increase in students matching into neurosurgery, although the number is relatively below the expectation due to the factors highlighted earlier. As a result, many studies and surveys have been conducted to identify ways of improving neurosurgical recruitment.

Five electronic databases, including PubMed, Science Direct, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Google Scholar, MEDLINE, and Cochrane Library, were searched to provide pertinent information to the topic of study in strict compliance with the PRISMA (Preferred Reporting Items for Systematic Review and Meta-analysis) guidelines. Meta-analysis was then conducted on the included studies to determine their correlations based on the individual outcomes of each study. A total of 2,134 search results were obtained, screened, and reviewed against the exclusion and inclusion criteria to remain with 12 included studies detailing improving the recruitment to neurosurgical residency. The 12 studies were retrieved for their study characteristics based on the PICO (predetermined patient, intervention, control, and outcome) standards. Most of the studies were surveys (n = 8), retrospective and prospective studies (n = 2), and pilot and multifocal studies making up for the rest (n = 2). Several neurosurgery aspects need consideration to improve the recruitment of medical students to neurosurgical fields. Medical institutions, specialists, and other stakeholders should consider reconstructing the neurosurgical curriculum to ease the prolonged study time as well as to create and encourage structural programs aimed at acquainting medical students in neurosurgery and involving the students in conducting other research projects. In addition, mentorship programs and early exposure of medical students to neurological surgery play a key role in influencing the medical students' interest in choosing neurosurgical career paths.

Real time monitoring and prediction of time to endpoint maturation in clinical trials

In clinical trials, almost all key milestone dates can be defined in terms of time to endpoint maturation (TTEM). The real time monitoring and accurate prediction of TTEM have a significant impact on clinical trial planning and execution and can bring significant value to clinical trial practitioners. TTEM is defined as the time to achieve or observe a certain number or percentage of some endpoint of interest. It is a combination of time to site initiation, time to subject enrollment after site initiation and time to event of interest after subject enrollment. To better predict TTEM during the trial, the future site initiation and subject enrollment have to be taken into account while predicting the number of events. In this article, we propose a novel simulation-based framework combining time to site initiation, time to subject enrollment and time to event in order to predict TTEM. A nonhomogeneous Poisson process with a quadratic time-varying rate function is used to model site initiation and subject enrollment and more advanced time to event models had been explored and integrated on top of them, such as Weibull, piecewise exponential, and model averaging which is equivalent to a Bayesian model selection strategy. To evaluate the predictive performance of the proposed methodology, we conducted extensive simulations and applied the methodology to 14 randomly selected real oncology phase 2 and phase 3 studies in both solid tumor and hematology with a total 31 study-endpoint combinations. The predictive performance of the proposed methodology was then compared with popular and commonly available commercial software, for example, East (Cytel, Cambridge, MA, USA). From both simulation and real data, the proposed methodology can significantly improve the prediction accuracy by up to 54% compared to the commonly available method.

Sex disparities in enrollment and reporting of outcomes by sex in contemporary clinical trials of atrial fibrillation

BACKGROUND

Underrepresentation of females in randomized controlled trials (RCTs) limits generalizability and quality of the evidence guiding treatment of females. This study aimed to measure the sex disparities in participants' recruitment in RCTs of atrial fibrillation (AF) and determine associated factors, and to describe the frequency of outcomes reported by sex.

METHODS

MEDLINE was searched to identify RCTs of AF published between January 1, 2011, and November 20, 2021, in 12 top-tier journals. We measured the enrollment of females using the enrollment disparity difference (EDD) which is the difference between the proportion of females in the trial and the proportion of females with AF in the underlying general population (obtained from the Global Burden of Disease). Random-effects meta-analyses of the EDD were performed, and multivariable meta-regression was used to explore factors associated with disparity estimates. We also determined the proportion of trials that included sex-stratified results.

RESULTS

Out of 1133 records screened, 142 trials were included, reporting on a total of 133 532 participants. The random-effects summary EDD was -0.125 (95% confidence interval [CI] = -0.143 to -0.108), indicating that females were under-enrolled by 12.5 percentage points. Female enrollment was higher in trials with higher sample size (<250 vs. >750, adjusted odds ratio [aOR] 1.065, 95% CI: 1.008-1.125), higher mean participants' age (aOR: 1.006, 95% CI: 1.002-1.009), and lower in trials conducted in North America compared to Europe (aOR: 0.945, 95% CI: 0.898-0.995). Only 36 trials (25.4%) reported outcomes by sex, and of these 29 (80.6%) performed statistical testing of the sex-by-treatment interaction.

CONCLUSION

Females remain substantially less represented in RCTs of AF, and sex-stratified reporting of primary outcomes is infrequent. These findings call for urgent action to improve sex equity in enrollment and sex-stratified outcomes' reporting in RCTs of AF.

An integrated approach to improve clinical trial efficiency: Linking a clinical trial management system into the Research Integrated Network of Systems

Low-accruing clinical trials delay translation of research breakthroughs into the clinic, expose participants to risk without providing meaningful clinical insight, increase the cost of therapies, and waste limited resources. By tracking patient accrual, Clinical and Translational Science Awards hubs can identify at-risk studies and provide them the support needed to reach recruitment goals and maintain financial solvency. However, tracking accrual has proved challenging because relevant patient- and protocol-level data often reside in siloed systems. To address this fragmentation, in September 2020 the South Carolina Clinical and Translational Research Institute, with an academic home at the Medical University of South Carolina, implemented a clinical trial management system (CTMS), with its access to patient-level data, and incorporated it into its Research Integrated Network of Systems (RINS), which links study-level data across disparate systems relevant to clinical research. Within the first year of CTMS implementation, 324 protocols were funneled through CTMS/RINS, with more than 2600 participants enrolled. Integrated data from CTMS/RINS have enabled near-real-time assessment of patient accrual and accelerated reimbursement from industry sponsors. For institutions with bioinformatics or programming capacity, the CTMS/RINS integration provides a powerful model for tracking and improving clinical trial efficiency, compliance, and cost-effectiveness.

A Qualitative Analysis of Factors Influencing Critical Care Trial Enrollment Among Surrogates

BACKGROUND

We sought to identify factors that influence surrogate decision makers' decisions to enroll patients into a critical care randomized controlled trial.

METHODS

We conducted a qualitative study embedded within a randomized controlled trial testing the effect of a behavioral nudge intervention for surrogate decision makers on enrollment rate in a sham ventilatory weaning trial among patients with acute respiratory failure. Participants were adult surrogate decision makers of patients receiving mechanical ventilation for acute respiratory failure. The study was conducted in 10 ICUs across 2 urban hospitals within an academic medical center in Philadelphia, Pennsylvanaia, United States. Immediately following their trial enrollment decision, surrogate decision makers were asked to enter free-text responses about the factors that influenced their decision. Responses were analyzed using content analysis.

RESULTS

Of the 90 (49%) participants who provided free-text responses, the mean age was 54.9 years (SD 14.3), 69 (79%) were Caucasian, and 48 (53%) were the spouse of the eligible patient. We identified 5 themes influencing enrollment decisions: (i) trial characteristics, (ii) patient clinical condition, (iii) decision making processes, (iv) altruism, and (v) enrollment attempt. Among surrogates who enrolled the patient in the trial (n = 40), the most commonly cited factors were helping future patients (n = 24, 60%) and following the patient's wishes (n = 11, 28%). In contrast, those who declined enrollment (n = 50) most commonly reported that the patient was too sick (n = 27, 54%) and that they feared complicating the patient's condition (n = 11, 22%).

CONCLUSIONS

Surrogates who enroll patients into trials most often cite altruistic motivations, while those who decline enrollment are most often concerned with the severity of the patients' condition.

Barriers to Pediatric Oncologist Enrollment of Adolescents and Young Adults on a Cross-Network National Clinical Trials Network Supportive Care Cancer Clinical Trial

Few studies have explored interventions to improve adolescent and young adult (AYA) cancer care delivery. While many AYAs receive cancer care at NCI Community Oncology Research Program (NCORP) sites, few enroll on clinical trials. Barriers and facilitators to pediatric oncologist activation of and enrollment on an AYA cross-network National Clinical Trials Network (NCTN) supportive care trial were assessed using a survey that was administered to 162 stakeholders representing all 47 children's oncology group (COG) institutions affiliated to an NCORP. Fifty-eight stakeholders participated representing 62% of all sites surveyed. Approximately half of participants (45%) were unaware of the trial. Seven sites had the study open and one enrolled a patient. Reasons for not opening and enrolling on the trial included limited research staff and resources, low anticipated accrual, and lower prioritization of the trial. Enrollment facilitators included having a local "AYA champion," improving communication between pediatric and medical oncology, and having site education on available AYA trials. Interventions focused on increasing site and provider awareness of AYA trials and decreasing local barriers to AYA enrollment are needed.