How evidence based are recruitment strategies to randomized controlled trials in primary care? Experience from seven studies

Multicentre cluster randomised trial comparing a community group exercise programme and home-based exercise with usual care for people aged 65 years and over in primary care

BACKGROUND

Regular physical activity (PA) reduces the risk of falls and hip fractures, and mortality from all causes. However, PA levels are low in the older population and previous intervention studies have demonstrated only modest, short-term improvements.

OBJECTIVE

To evaluate the impact of two exercise promotion programmes on PA in people aged ≥ 65 years.

DESIGN

The ProAct65+ study was a pragmatic, three-arm parallel design, cluster randomised controlled trial of class-based exercise [Falls Management Exercise (FaME) programme], home-based exercise [Otago Exercise Programme (OEP)] and usual care among older people (aged ≥ 65 years) in primary care.

SETTING

Forty-three UK-based general practices in London and Nottingham/Derby.

PARTICIPANTS

A total of 1256 people ≥ 65 years were recruited through their general practices to take part in the trial.

INTERVENTIONS

The FaME programme and OEP. FaME included weekly classes plus home exercises for 24 weeks and encouraged walking. OEP included home exercises supported by peer mentors (PMs) for 24 weeks, and encouraged walking.

MAIN OUTCOME MEASURES

The primary outcome was the proportion that reported reaching the recommended PA target of 150 minutes of moderate to vigorous physical activity (MVPA) per week, 12 months after cessation of the intervention. Secondary outcomes included functional assessments of balance and falls risk, the incidence of falls, fear of falling, quality of life, social networks and self-efficacy. An economic evaluation including participant and NHS costs was embedded in the clinical trial.

RESULTS

In total, 20,507 patients from 43 general practices were invited to participate. Expressions of interest were received from 2752 (13%) and 1256 (6%) consented to join the trial; 387 were allocated to the FaME arm, 411 to the OEP arm and 458 to usual care. Primary outcome data were available at 12 months after the end of the intervention period for 830 (66%) of the study participants. The proportions reporting at least 150 minutes of MVPA per week rose between baseline and 12 months after the intervention from 40% to 49% in the FaME arm, from 41% to 43% in the OEP arm and from 37.5% to 38.0% in the usual-care arm. A significantly higher proportion in the FaME arm than in the usual-care arm reported at least 150 minutes of MVPA per week at 12 months after the intervention [adjusted odds ratio (AOR) 1.78, 95% confidence interval (CI) 1.11 to 2.87; p = 0.02]. There was no significant difference in MVPA between OEP and usual care (AOR 1.17, 95% CI 0.72 to 1.92; p = 0.52). Participants in the FaME arm added around 15 minutes of MVPA per day to their baseline physical activity level. In the 12 months after the close of the intervention phase, there was a statistically significant reduction in falls rate in the FaME arm compared with the usual-care arm (incidence rate ratio 0.74, 95% CI 0.55 to 0.99; p = 0.042). Scores on the Physical Activity Scale for the Elderly showed a small but statistically significant benefit for FaME compared with usual care, as did perceptions of benefits from exercise. Balance confidence was significantly improved at 12 months post intervention in both arms compared with the usual-care arm. There were no statistically significant differences between intervention arms and the usual-care arm in other secondary outcomes, including quality-adjusted life-years. FaME is more expensive than OEP delivered with PMs (£269 vs. £88 per participant in London; £218 vs. £117 in Nottingham). The cost per extra person exercising at, or above, target was £1919.64 in London and £1560.21 in Nottingham (mean £1739.93).

CONCLUSION

The FaME intervention increased self-reported PA levels among community-dwelling older adults 12 months after the intervention, and significantly reduced falls. Both the FaME and OEP interventions appeared to be safe, with no significant differences in adverse reactions between study arms.

TRIAL REGISTRATION

This trial is registered as ISRCTN43453770.

FUNDING

This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 18, No. 49. See the NIHR Journals Library website for further project information.

Factors associated with participation in research conducted in a pediatric emergency department

OBJECTIVE

To examine the association of demographic and study characteristics in eligible subjects who agree to participate compared with those who did not participate in clinical research studies in a pediatric emergency department (PED).

METHODS

Information for all families approached for participation in PED-based clinical research studies during a 6-year period was recorded in an electronic database. This included demographic factors, decision to participate, primary reason for not participating, and study characteristics. Forty studies were included in this analysis. Differences in participation rate among demographic and study characteristics were examined. Multivariable logistic regression was used to predict the likelihood of participation.

RESULTS

Participation rates were similar with respect to sex (50.1% in male vs 49.9% in female), whereas families with younger children were more likely to participate (mean age, 8.5 years vs 10.2 years among nonparticipants P < 0.001). White patients were more likely to participate than African American patients (54.7% vs 45.6% in African Americans, P < 0.001). The presence of compensation, brief time requirement, and older children was negatively associated with participation for moderate to very invasive studies. However, for noninvasive and mildly invasive studies, the presence of compensation and the time required were not associated with participation.

CONCLUSIONS

Study characteristics including invasiveness, time required of patients, and whether compensation is offered, along with demographic factors, influence participation in clinical studies conducted in the PED. When designing a research study in the PED, these, along with novel approaches to including all races and ethnicities in PED research, should be considered.

Researching in the community: the value and contribution of nurses to community based or primary health care research

AIM

To describe the role, contribution and value of research nurses in New Zealand community-based or primary health care research.

BACKGROUND

Research nurses are increasingly recognised as having a key role in undertaking successful research in hospitals and clinical trial units however only limited work has been undertaken to examine their role in community-based research. Undertaking health research in the community has unique challenges particularly in relation to research design and recruitment and retention of participants.

METHODS

We describe four community-based research projects involving research nurses, each with particular recruitment, retention and logistical problems. Vignettes are used to illustrate the role, contribution and value of research nurses in a diverse range of community research projects.

FINDINGS

The knowledge and skills used by research nurses in these projects included familiarity with communities, cultural competence, health care systems and practice philosophies and in particular with vulnerable populations. Their research actions and activities include competence with a broad range of research methodologies, organisational efficiency, family-centred approach, along with advocacy and flexibility. These are underpinned by nursing knowledge and clinical expertise contributing to an ability to work autonomously. These four projects demonstrate that research nurses in community-based research possess specific attributes which facilitate successful study development, implementation and outcome.

Experiences of recruiting to a pilot trial of Cardiac Rehabilitation In patients with Bowel cancer (CRIB) with an embedded process evaluation: lessons learned to improve recruitment

Background

Recruitment to randomised controlled trials (RCTs) is a perennial problem. Calls have been made for trialists to make recruitment performance publicly available. This article presents our experience of recruiting to a pilot RCT of cardiac rehabilitation for patients with bowel cancer with an embedded process evaluation.

Methods

Recruitment took place at three UK hospitals. Recruitment figures were based on the following: i) estimated number of patient admissions, ii) number of patients likely to meet inclusion criteria from clinician input and iii) recruitment rates in previous studies. The following recruitment procedure was used:

Nurse assessed patients for eligibility.

Patients signed a screening form indicating interest in and agreement to be approached by a researcher about the study.

An appointment was made at which the patient signed a consent form and was randomised to the intervention or control group.

Information about all patients considered for the study and subsequently included or excluded at each stage of the recruitment process and reasons given were recorded.

Results

There were variations in the time taken to award Research Management approval to run the study at the three sites (45–359 days). Sixty-two percent of the original recruitment estimate was reached. The main reason for under-recruitment was due to over-estimation of the number of patient admissions; other reasons were i) not assessing all patients for eligibility, ii) not completing a screening form for eligible patients and iii) patients who signed a screening form being lost to the study before consenting and randomisation.

Conclusions

Pilot trials should not simply aim to improve recruitment estimates but should also identify factors likely to influence recruitment performance in a future trial and inform the development of that trial’s recruitment strategies. Pilot trials are a crucial part of RCT design. Nevertheless, pilot trials are likely to be small scale, involving only a small number of sites, and contextual differences between sites are likely to impact recruitment performance in any future trial. This means that ongoing monitoring and evaluation in trials are likely to be required.

Trial registration

ISRCTN63510637; UKCRN id 14092.

Barriers and facilitators to patient recruitment to a cluster randomized controlled trial in primary care: lessons for future trials

Background

Primary-care based randomized controlled trials (RCTs) build an important evidence base for general practice but little evidence exists about barriers to recruitment which often hamper such trials.

We investigated the issues that impeded and facilitated recruitment to a clinical trial in general practice.

Methods

GPs participating in a cluster RCT that tested interventions for improving medication adherence and asthma control completed a survey comprising quantitative and free text questions about their recruitment experiences. We used backward regression to analyze quantitative data and coded free text responses into themes.

Results

40/55 of enrolled GPs recruited patients, but only one-third reached the planned recruitment target (5 patients/GP). In univariate analyses, poor patient recruitment by GPs was significantly associated with longer time to first patient enrolment, GP-perceived poor access to eligible patients and GP working in a practice training medical students. In regression analysis, only the first was significant (p = 0.001); the explained variance of the model was 48%. Themes from free text responses described recruitment barriers at the level of GP (e.g. GPs excluding patients for whom research appeared too challenging), practice (e.g. practice cultures disempowered GPs), patient (e.g. reluctance to change treatment for research) and study (e.g. protocol requirements complicating recruitment). Facilitators included GPs perceiving good support from the research team.

Conclusion

Targeted recruitment support early in the recruitment phase may enhance recruitment rates. Over time, interventions to enhance a general practice research culture are also likely to enhance skills to recruit patients, even for complex interventions. We recommend systematic evaluation of recruitment approaches and outcomes in future RCTs to optimize feasibility and success of these important trials.

Trial registration

Australian and New Zealand Clinical Trials Registry ACTRN12610000854033 (date registered 14/10/2010).

Feasibility of a randomized controlled trial to evaluate the impact of decision boxes on shared decision-making processes

Background

Decision boxes (DBoxes) are two-page evidence summaries to prepare clinicians for shared decision making (SDM). We sought to assess the feasibility of a clustered Randomized Controlled Trial (RCT) to evaluate their impact.

Methods

A convenience sample of clinicians (nurses, physicians and residents) from six primary healthcare clinics who received eight DBoxes and rated their interest in the topic and satisfaction. After consultations, their patients rated their involvement in decision-making processes (SDM-Q-9 instrument). We measured clinic and clinician recruitment rates, questionnaire completion rates, patient eligibility rates, and estimated the RCT needed sample size.

Results

Among the 20 family medicine clinics invited to participate in this study, four agreed to participate, giving an overall recruitment rate of 20%. Of 148 clinicians invited to the study, 93 participated (63%). Clinicians rated an interest in the topics ranging 6.4-8.2 out of 10 (with 10 highest) and a satisfaction with DBoxes of 4 or 5 out of 5 (with 5 highest) for 81% DBoxes. For the future RCT, we estimated that a sample size of 320 patients would allow detecting a 9% mean difference in the SDM-Q-9 ratings between our two arms (0.02 ICC; 0.05 significance level; 80% power).

Conclusions

Clinicians’ recruitment and questionnaire completion rates support the feasibility of the planned RCT. The level of interest of participants for the DBox topics, and their level of satisfaction with the Dboxes demonstrate the acceptability of the intervention. Processes to recruit clinics and patients should be optimized.

Electronic supplementary material

The online version of this article (doi:10.1186/s12911-015-0134-x) contains supplementary material, which is available to authorized users.

A cluster randomised controlled trial evaluating the effectiveness of eHealth-supported patient recruitment in primary care research: the TRANSFoRm study protocol

BACKGROUND

Opportunistic recruitment is a highly laborious and time-consuming process that is currently performed manually, increasing the workload of already busy practitioners and resulting in many studies failing to achieve their recruitment targets. The Translational Medicine and Patient Safety in Europe (TRANSFoRm) platform enables automated recruitment, data collection and follow-up of patients, potentially improving the efficiency, time and costs of clinical research. This study aims to assess the effectiveness of TRANSFoRm in improving patient recruitment and follow-up in primary care trials.

METHODS/DESIGN

This multi-centre, parallel-arm cluster randomised controlled trial will compare TRANSFoRm-supported with standard opportunistic recruitment. Participants will be general practitioners and patients with gastro-oesophageal reflux disease from 40 primary care centres in five European countries. Randomisation will take place at the care centre level. The intervention arm will use the TRANSFoRm tools for recruitment, baseline data collection and follow-up. The control arm will use web-based case report forms and paper self-completed questionnaires. The primary outcome will be the proportion of eligible patients successfully recruited at the end of the 16-week recruitment period. Secondary outcomes will include the proportion of recruited patients with complete baseline and follow-up data and the proportion of participants withdrawn or lost to follow-up. The study will also include an economic evaluation and measures of technology acceptance and user experience.

DISCUSSION

The study should shed light on the use of eHealth to improve the effectiveness of recruitment and follow-up in primary care research and provide an evidence base for future eHealth-supported recruitment initiatives. Reporting of results is expected in October 2015.

TRIAL REGISTRATION

EudraCT: 2014-001314-25.

Factors affecting recruitment into depression trials: Systematic review, meta-synthesis and conceptual framework

BACKGROUND

Depression is common and clinical trials are crucial for evaluating treatments. Difficulties in recruiting participants into depression trials are well-documented, yet no study has examined the factors affecting recruitment. This review aims to identify the factors affecting recruitment into depression trials and to develop a conceptual framework through systematic assessment of published qualitative research.

METHODS

Systematic review and meta-synthesis of published qualitative studies. Meta-synthesis involves a synthesis of themes across a number of qualitative studies to produce findings that are "greater than the sum of the parts". ASSIA, CINAHL, Embase, Medline and PsychInfo were searched up to April 2013. Reference lists of included studies, key publications and relevant reviews were also searched. Quality appraisal adopted the "prompts for appraising qualitative research".

RESULTS

7977 citations were identified, and 15 studies were included. Findings indicate that the decision to enter a depression trial is made by patients and gatekeepers based on the patient׳s health state at the time of being approached to participate; on their attitude towards the research and trial interventions; and on the extent to which patients become engaged with the trial. Our conceptual framework highlights that the decision to participate by both the patient and the gatekeeper involves a judgement between risk and reward.

LIMITATIONS

Only English language publications were included in this review.

CONCLUSIONS

Findings from this review have implications for the design of interventions to improve recruitment into depression trials. Such interventions may aim to diminish the perceived risks and increase the perceived rewards of participation.

Practical aspects to undertaking research in the primary care setting: experience from two studies

AIMS

To discuss the practical aspects of conducting research in a primary care setting, from the perspectives of the practitioner and the research team.

METHODS

Various issues are discussed, including the relevance of research questions being generated in this setting, the advantages to both parties and the processes involved in conducting a study in specialist practice. This paper describes two recent studies (a randomized clinical trial and a qualitative study) conducted within specialist practice, to illustrate some of the potential difficulties.

CONCLUSIONS

The success of conducting a study in primary care is determined by a variety of factors, including an interested specialist practitioner, motivated staff in a well-organized practice and the close support of an academic-based research team.

Challenges in recruitment to a randomized controlled study of cardiovascular disease reduction in sleep apnea: an analysis of alternative strategies

STUDY OBJECTIVES

A challenge in conducting randomized controlled trials of sleep apnea is the timely recruitment of participants to active and control arms. This study assesses the costs and efficiencies of alternative recruitment methods.

DESIGN

Analysis of recruitment data from the Best Apnea Intervention in Research planning study.

SETTING

Sleep clinics and cardiology practices.

PARTICIPANTS

One hundred forty-eight individuals with an apnea-hypopnea index > 15 and cardiovascular (CV) risk factors randomized from a pool of more than 30,000 potentially eligible patients.

INTERVENTIONS

Comparisons: (1) modes of recruitment: face-to-face (F2F) recruitment versus mail-based recruitment (MBR); (2) recruitment source (sleep versus cardiology clinics).

MEASUREMENTS AND RESULTS

Recruitment yield was defined as the ratio of the number of subjects randomized to the number of screened records. Recruitment costs were estimated based on staff time. Of the 148 randomized subjects, 25 were recruited from sleep clinics using F2F recruitment and 123 were recruited from cardiology using a F2F (n = 35) or MBR (n = 88) strategy. F2F recruitment yields were 0.17% and 0.30% for sleep versus cardiology sources, respectively (P = 0.04). A comparison of F2F to MBR showed recruitment yields of 1.11% and 0.90% and costs per randomized subject of $2,139 and $647, respectively.

CONCLUSIONS

Large resources may be needed to meet the recruitment goals of sleep apnea intervention trials. Recruitment source and mode influence efficiencies. For a trial comparing active versus sham continuous positive airway pressure in patients with CV risk factors, recruiting from cardiology was more efficient than from sleep clinics. MBR was three times less costly than F2F recruitment.

Using a content analysis to identify study eligibility criteria concepts in cancer nursing research

The aims of this study were to (1) identify and categorize study eligibility criteria concepts used in cancer nursing randomized controlled trials and (2) determine the extent to which a previously identified set of study eligibility criteria, based primarily on medical randomized controlled trials, were represented in cancer nursing randomized controlled trials. A total of 145 articles of cancer nursing randomized controlled trials indexed in PubMed or Cumulative Index to Nursing and Allied Health Literature and published in English from 1986 to 2010 were screened, and 114 were eligible. Directed content analysis was conducted until data saturation was achieved. Forty-three concepts categorized into eight domains were extracted from 49 articles published in 27 different journals. Most of the concepts identified were related to health status, treatment, and demographics domains. Although many concepts matched to the previously identified study eligibility concepts based on medical research, new concepts may need to be added to fully represent cancer nursing research. This study provides a solid foundation for future study of mapping the concepts to existing standardized terminologies to identify which systems can be adopted. Nursing researchers can use these eligibility criteria concepts as a guideline in structuring the eligibility criteria for their studies.

Recruiting and retaining general practitioners to a primary care asthma-intervention study in Australia

The need for more evidence-based interventions in primary care is clear. However, it is challenging to recruit general practitioners (GPs) for interventional research. This paper reports on the evaluation of three methods of recruitment that were sequentially used to recruit GPs for a randomised controlled trial of an asthma communication and education intervention in Australia. The recruitment methods (RMs) were: general practices were contacted by project staff from a Department of General Practice, University of Sydney (RM1); general practices were contacted by staff from an independent research organisation (RM2); and general practices were contacted by a medical peer (chief investigator) (RM3). A GP was defined as 'recruited' once they consented and were randomised to a group, and 'retained' if they provided baseline data and did not notify staff of their intention to withdraw at any time during the 12-month study. RM1 was used for the first 6 months, during which 34 (4%) GPs were recruited and 21 (62%) retained from a total of 953 invitations. RM2 was then used for the next 5 months, during which 32 (6%) GPs were recruited and 26 (81%) were retained. Finally over the next 7 months, RM3 recruited 84 (12%) GPs and retained 75 (89%) GPs. In conclusion, use of a medical peer as the first contact was associated with the highest recruitment and retention rate.

An evaluation of the effectiveness of recruitment methods: the staying well after depression randomized controlled trial

BACKGROUND

Randomized controlled trials (RCTs) are widely accepted as being the most efficient way of investigating the efficacy of psychological therapies. However, researchers conducting RCTs commonly report difficulties in recruiting an adequate sample within planned timescales. In an effort to overcome recruitment difficulties, researchers often are forced to expand their recruitment criteria or extend the recruitment phase, thus increasing costs and delaying publication of results. Research investigating the effectiveness of recruitment strategies is limited, and trials often fail to report sufficient details about the recruitment sources and resources utilized.

PURPOSE

We examined the efficacy of strategies implemented during the Staying Well after Depression RCT in Oxford to recruit participants with a history of recurrent depression.

METHODS

We describe eight recruitment methods utilized and two further sources not initiated by the research team and examine their efficacy in terms of (1) the return, including the number of potential participants who contacted the trial and the number who were randomized into the trial; (2) cost-effectiveness, comprising direct financial cost and manpower for initial contacts and randomized participants; and (3) comparison of sociodemographic characteristics of individuals recruited from different sources.

RESULTS

Poster advertising, web-based advertising, and mental health worker referrals were the cheapest methods per randomized participant; however, the ratio of randomized participants to initial contacts differed markedly per source. Advertising online, via posters, and on a local radio station were the most cost-effective recruitment methods for soliciting participants who subsequently were randomized into the trial. Advertising across many sources (saturation) was found to be important.

LIMITATIONS

It may not be feasible to employ all the recruitment methods used in this trial to obtain participation from other populations, such as those currently unwell, or in other geographical locations. Recruitment source was unavailable for participants who could not be reached after the initial contact. Thus, it is possible that the efficiency of certain methods of recruitment was poorer than estimated. Efficacy and costs of other recruitment initiatives, such as providing travel expenses to the in-person eligibility assessment and making follow-up telephone calls to candidates who contacted the recruitment team but could not be screened promptly, were not analysed.

CONCLUSION

Website advertising resulted in the highest number of randomized participants and was the second cheapest method of recruiting. Future research should evaluate the effectiveness of recruitment strategies for other samples to contribute to a comprehensive base of knowledge for future RCTs.

Researchers' and clinicians' perceptions of recruiting participants to clinical research: a thematic meta-synthesis

Background

Recruiting the desired number of research participants is frequently problematic with resulting financial and clinical implications. The views of individuals responsible for participant recruitment have not been previously reviewed. This systematic review and thematic meta-synthesis explores researchers’ and clinicians’ experiences and perceptions of recruiting participants to clinical research, with the aim of informing improved recruitment systems and strategies.

Methods

Studies published between January 1995 and May 2013 were identified from: Ovid MEDLINE, Ovid EMBASE, Ovid PSYCHINFO, ASSIA, British Nursing Index, Scopus, Web of Science, CINAHL and PubMed. Included studies were original peer reviewed research, with qualitative methodologies and an aim of exploring the views of clinicians and/or researchers on recruitment to clinical research. Studies discussing the recruitment of patients unable to give informed consent were excluded. The findings sections of the relevant studies were free coded to identify key concepts which were grouped into hierarchical themes. The quality of the identified studies was assessed and the relative contribution of each paper was checked to ensure individual studies did not dominate in any theme.

Results

Eighteen relevant papers were identified which examined the views of researchers and clinicians in 10 clinical specialties. Five main themes emerged: building a research community, securing resources, the nature of research, professional identities and recruitment strategies. The views of researchers and clinicians were similar, although the role of ‘researcher’ was inconsistently defined.

Conclusions

The general experience of recruiting participants to clinical research was one of competition and compromise. Competition arose over funding, staffing and participants, and between clinical and research responsibilities. Compromise was needed to create study designs that were acceptable to patients, clinicians and researchers. Forging relationships between clinical and research teams featured extensively, however the involvement of patients and the public within the research community was rarely discussed.

Exploring recruitment barriers and facilitators in early cancer detection trials: the use of pre-trial focus groups

BACKGROUND

Recruiting to randomized controlled trials is fraught with challenges; with less than one third recruiting to their original target. In preparation for a trial evaluating the effectiveness of a blood test to screen for lung cancer (the ECLS trial), we conducted a qualitative study to explore the potential barriers and facilitators that would impact recruitment.

METHODS

Thirty two people recruited from community settings took part in four focus groups in Glasgow and Dundee (UK). Thematic analysis was used to code the data and develop themes.

RESULTS

Three sub-themes were developed under the larger theme of recruitment strategies. The first of these themes, recruitment options, considered that participants largely felt that the invitation to participate letter should come from GPs, with postal reminders and face-to-face reminders during primary care contacts. The second theme dealt with understanding randomization and issues related to the control group (where bloods were taken but not tested). Some participants struggled with the concept or need for randomization, or for the need for a control group. Some reported that they would not consider taking part if allocated to the control group, but others were motivated to take part even if allocated to the control group by altruism. The final theme considered perceived barriers to participation and included practical barriers (such as flexible appointments and reimbursement of travel expenses) and psychosocial barriers (such as feeling stigmatized because of their smoking status and worries about being coerced into stopping smoking).

CONCLUSIONS

Focus groups provided useful information which resulted in numerous changes to proposed trial documentation and processes. This was in order to address participants information needs, improve comprehension of the trial documentation, enhance facilitators and remove barriers to participation. The modifications made in light of these findings may enhance trial recruitment and future trials may wish to consider use of pretrial focus groups.

Methodological survey of designed uneven randomization trials (DU-RANDOM): a protocol

Background

Although even randomization (that is, approximately 1:1 randomization ratio in study arms) provides the greatest statistical power, designed uneven randomization (DUR), (for example, 1:2 or 1:3) is used to increase participation rates. Until now, no convincing data exists addressing the impact of DUR on participation rates in trials. The objective of this study is to evaluate the epidemiology and to explore factors associated with DUR.

Methods

We will search for reports of RCTs published within two years in 25 general medical journals with the highest impact factor according to the Journal Citation Report (JCR)-2010. Teams of two reviewers will determine eligibility and extract relevant information from eligible RCTs in duplicate and using standardized forms. We will report the prevalence of DUR trials, the reported reasons for using DUR, and perform a linear regression analysis to estimate the association between the randomization ratio and the associated factors, including participation rate, type of informed consent, clinical area, and so on.

Discussion

A clearer understanding of RCTs with DUR and its association with factors in trials, for example, participation rate, can optimize trial design and may have important implications for both researchers and users of the medical literature.

The effect of different methods of remuneration on the behaviour of primary care dentists

BACKGROUND

Methods of remuneration have been linked with the professional behaviour of primary care physicians. In dentistry, this can be exacerbated as clinicians operate their practices as businesses and take the full financial risk of the provision of services. The main methods for remunerating primary care dentists include fee-for-service, fixed salary and capitation payments. The aim of this review was to determine the impact that these remuneration mechanisms have upon primary care dentists' behaviour.

OBJECTIVES

To evaluate the effects of different methods of remuneration on the level and mix of activities provided by primary care dentists and the impact this has on patient outcomes.

SEARCH METHODS

We searched the Cochrane Effective Practice and Organisation of Care (EPOC) Group Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 7, 2013); MEDLINE (Ovid) (1947 to 11 June 2013); EMBASE (Ovid) (1947 to 11 June 2013); EconLit (1969 to 11 June 2013); the NHS Economic Evaluation Database (EED) (11 June 2013); and the Health Economic Evaluations Database (HEED) (11 June 2013). We conducted cited reference searches for the included studies in ISI Web of Knowledge; searched grey literature sources; handsearched selected journals; and contacted authors of relevant studies.

SELECTION CRITERIA

Primary care dentists were defined as clinicians that deliver routine or mainstream dental care in a primary care environment. We included randomised controlled trials (RCTs), non-randomised controlled clinical trials (NRCTs), controlled before-after (CBA) studies and interrupted time series (ITS) studies. The methods of remuneration that we considered were: fee-for-service, fixed salary and capitation payments. Primary outcome measures were: measures of clinical activity; volume of clinical activity undertaken; time taken and clinical session length, or both; clinician type utilised; measures of health service utilisation; access and attendance as a proportion of the population; re-attendance rates; recall frequency; levels of oral health inequalities; non-attendance rates; healthcare costs; measures of patient outcomes; disease reduction; health maintenance; and patient satisfaction. We also considered measures of practice profitability/income and any reported unintended effects of the included methods of remuneration.

DATA COLLECTION AND ANALYSIS

Three of the review authors (PRB, JP, AMG) independently reviewed titles and abstracts and resolved disagreements by discussion. The same three review authors undertook data extraction and assessed the quality of the evidence from all the studies that met the selection criteria, according to Cochrane Collaboration procedures.

MAIN RESULTS

Two cluster-RCTs, with data from 503 dental practices, representing 821 dentists and 4771 patients, met the selection criteria. We judged the risk of bias to be high for both studies and the overall quality of the evidence was low/very low for all outcomes, as assessed using the GRADE approach.One study used a factorial design to investigate the impact of fee-for-service and an educational intervention on the placement of fissure sealants in permanent molar teeth. The authors reported a statistically significant increase in clinical activity in the arm that was incentivised with a fee-for-service payment. However, the study was conducted in the four most deprived areas of Scotland, so the applicability of the findings to other settings may be limited. The study did not report data on measures of health service utilisation or measures of patient outcomes.The second study used a parallel group design undertaken over a three-year period to compare the impact of capitation payments with fee-for-service payments on primary care dentists' clinical activity. The study reported on measures of clinical activity (mean percentage of children receiving active preventive advice, health service utilisation (mean number of visits), patient outcomes (mean number of filled teeth, mean percentage of children having one or more teeth extracted and the mean number of decayed teeth) and healthcare costs (mean expenditure). Teeth were restored at a later stage in the disease process in the capitation system and the clinicians tended to see their patients less frequently and tended to carry out fewer fillings and extractions, but also tended to give more preventive advice.There was insufficient information regarding the cost-effectiveness of the different remuneration methods.

AUTHORS' CONCLUSIONS

Financial incentives within remuneration systems may produce changes to clinical activity undertaken by primary care dentists. However, the number of included studies is limited and the quality of the evidence from the two included studies was low/very low for all outcomes. Further experimental research in this area is highly recommended given the potential impact of financial incentives on clinical activity, and particular attention should be paid to the impact this has on patient outcomes.

The National Cancer Institute-American Society of Clinical Oncology Cancer Trial Accrual Symposium: summary and recommendations

INTRODUCTION

Many challenges to clinical trial accrual exist, resulting in studies with inadequate enrollment and potentially delaying answers to important scientific and clinical questions.

METHODS

The National Cancer Institute (NCI) and the American Society of Clinical Oncology (ASCO) cosponsored the Cancer Trial Accrual Symposium: Science and Solutions on April 29-30, 2010 to examine the state of accrual science related to patient/community, physician/provider, and site/organizational influences, and identify new interventions to facilitate clinical trial enrollment. The symposium featured breakout sessions, plenary sessions, and a poster session including 100 abstracts. Among the 358 attendees were clinical investigators, researchers of accrual strategies, research administrators, nurses, research coordinators, patient advocates, and educators. A bibliography of the accrual literature in these three major areas was provided to participants in advance of the meeting. After the symposium, the literature in these areas was revisited to determine if the symposium recommendations remained relevant within the context of the current literature.

RESULTS

Few rigorously conducted studies have tested interventions to address challenges to clinical trials accrual. Attendees developed recommendations for improving accrual and identified priority areas for future accrual research at the patient/community, physician/provider, and site/organizational levels. Current literature continues to support the symposium recommendations.

CONCLUSIONS

A combination of approaches addressing both the multifactorial nature of accrual challenges and the characteristics of the target population may be needed to improve accrual to cancer clinical trials. Recommendations for best practices and for future research developed from the symposium are provided.

Lessons learned from the conduct of a multisite cluster randomized practical trial of decision aids in rural and suburban primary care practices

Background

The decision aids for diabetes (DAD) trial explored the feasibility of testing the effectiveness of decision aids (DAs) about coronary prevention and diabetes medications in community-based primary care practices, including rural clinics that care for patients with type 2 diabetes.

Methods

As originally designed, we invited clinicians in eight practices to participate in the trial, reviewed the patient panel of clinicians who accepted our invitation for potentially eligible patients, and contacted these patients by phone, enrolling those who accepted our invitation. As enrollment failed to meet targets, we recruited four new practices. After discussing the study with the clinicians and receiving their support, we reviewed all clinic panels for potentially eligible patients. Clinicians were approached to confirm participation and patient eligibility, and patients were approached before their visit to provide written informed consent. This in-clinic approach required study coordinators to travel and stay longer at the clinics as well as to screen more patient records for eligibility. The in-clinic approach was associated with better recruitment rates, lower patient retention and outcome completion rates, and a better intervention effect.

Results

We drew four lessons: 1) difficulties identifying potentially eligible patients threaten the viability of practical trials of DAs; 2) to improve the recruitment yield, recruit clinicians and patients for the study at the clinic, just before their visit; 3) approaches that improve recruitment may be associated with reduced retention and survey response; and 4) procedures that involve working closely with the practice may improve recruitment and may also affect the quality of the implementation of the interventions.

Conclusion

Success in practice-based trials in usual primary care including rural clinics may require the smallest possible research footprint on the practice while implementing a streamlined protocol favoring in-clinic, in-person interactions with clinicians and patients.

Trial registration

ClinicalTrials.gov NCT01029288

An evaluation of the impact and costs of three strategies used to recruit acutely unwell young children to a randomised controlled trial in primary care

Background

Recruitment to primary care trials, particularly those involving young children, is known to be difficult. There are limited data available to inform researchers about the effectiveness of different trial recruitment strategies and their associated costs.

Purpose

To describe, evaluate, and investigate the costs of three strategies for recruiting febrile children to a community-based randomised trial of antipyretics.

Methods

The three recruitment strategies used in the trial were termed as follows: (1) ‘local’, where paediatric research nurses stationed in primary care sites invited parents of children to participate; (2) ‘remote’, where clinicians at primary care sites faxed details of potentially eligible children to the trial office; and (3) ‘community’, where parents, responding to trial publicity, directly contacted the trial office when their child was unwell.

Results

Recruitment rates increased in response to the sequential introduction of three recruitment strategies, which were supplemented by additional recruiting staff, flexible staff work patterns, and improved clinician reimbursement schemes. The three strategies yielded different randomisation rates. They also appeared to be interdependent and highly effective together. Strategy-specific costs varied from £297 to £857 per randomised participant and represented approximately 10% of the total trial budget.

Limitations

Because the recruitment strategies were implemented sequentially, it was difficult to measure their independent effects. The cost analysis was performed retrospectively.

Conclusions

Trial recruiter expertise and deployment of several interdependent, illness-specific strategies were key factors in achieving rapid recruitment of young children to a community-based randomised controlled trial (RCT). The ‘remote’ recruitment strategy was shown to be more cost-effective compared to ‘community’ and ‘local’ strategies in the context of this trial. Future trialists should report recruitment costs to facilitate a transparent evaluation of recruitment strategy cost-effectiveness.

Lessons learnt during a complex, multicentre cluster randomised controlled trial: the ProAct65+ trial

Background

Failure to recruit to target or schedule is common in randomized controlled trials (RCTs). Innovative interventions are not always fully developed before being tested, and maintenance of fidelity to the intervention during trials can be problematic. Missing data can compromise analyses, and inaccurate capture of risks to participants can influence reporting of intervention harms and benefits.

In this paper we describe how challenges of recruitment and retention of participants, standardisation and quality control of interventions and capture of adverse events were overcome in the ProAct65+ cluster RCT. This trial compared class-based and home-based exercise with usual care in people aged 65 years and over, recruited through general practice. The home-based exercise participants were supported by Peer Mentors.

Results

(1) Organisational factors, including room availability in general practices, slowed participant recruitment so the recruitment period was extended and the number invited to participate increased. (2) Telephone pre-screening was introduced to exclude potential participants who were already very active and those who were frequent fallers. (3) Recruitment of volunteer peer mentors was difficult and time consuming and their acceptable case load less than expected. Lowering the age limit for peer mentors and reducing their contact schedule with participants did not improve recruitment. (4) Fidelity to the group intervention was optimised by introducing quality assurance observation of classes by experienced exercise instructors. (5) Diaries were used to capture data on falls, service use and other exercise-related costs, but completion was variable so their frequency was reduced. (6) Classification of adverse events differed between research sites so all events were assessed by both sites and discrepancies discussed.

Conclusions

Recruitment rates for trials in general practice may be limited by organisational factors and longer recruitment periods should be allowed for. Exercise studies may be attractive to those who least need them; additional screening measures can be employed to avoid assessment of ineligible participants. Enrolment of peer mentors for intervention support is challenging and needs to be separately tested for feasibility. Standardisation of exercise interventions is problematic when exercise programmes are tailored to participants’ capabilities; quality assurance observations may assure fidelity of the intervention. Data collection by diaries can be burdensome to participants, resulting in variable and incomplete data capture; compromises in completion frequency may reduce missing data. Risk assessments are essential in exercise promotion studies, but categorisation of risks can vary between assessors; methods for their standardisation can be developed.

Trial registration

ISRCTN43453770

Systems intervention to promote colon cancer screening in safety net settings: protocol for a community-based participatory randomized controlled trial

BACKGROUND

Colorectal cancer is a leading cause of cancer mortality. Screening can be effective but is underutilized. System- or multi-level interventions could be effective at increasing screening, but most have been implemented and evaluated in higher-resource settings such as health maintenance organizations. Given the disparities evident for colorectal cancer and the potential for screening to improve outcomes, there is a need to expand this work to include diverse settings, including those who treat economically disadvantaged patients. This paper describes the study protocol for a trial designed to increase colorectal cancer screening in those 'safety-net' health centers that serve underinsured and uninsured patients. This trial was designed and is being implemented using a community-based participatory approach.

METHODS/DESIGN

We developed a practical clinical cluster-randomized controlled trial. We will recruit 16 community health centers to this trial. This systems-level intervention consists of a menu of evidence-based implementation strategies for increasing colorectal cancer screening. Health centers in the intervention arm then collaborate with the study team to tailor strategies to their own setting in order to maximize fit and acceptability. Data are collected at the organizational level through interviews, and at the provider and patient levels through surveys. Patients complete a survey about their healthcare and screening utilization at baseline, six months, and twelve months.

OUTCOMES

The primary outcome is colorectal cancer screening by patient self-report, supplemented by a chart-audit in a subsample of patients. Implementation outcomes informed by the Reach, Efficacy/Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) conceptual framework will be measured at patient, provider, and practice levels.

DISCUSSION

Our study is one of the first to integrate community participatory strategies to a randomized controlled trial in a healthcare setting. The multi-level approach will support the ability of the intervention to affect screening through multiple avenues. The participatory approach will strengthen the chance that implementation strategies will be maintained after study completion and, supports external validity by increasing health center interest and willingness to participate.

TRIAL REGISTRATION

NCT01299493.

Methods to improve recruitment to randomised controlled trials: Cochrane systematic review and meta-analysis

This review is an abridged version of a Cochrane Review previously published in the Cochrane Database of Systematic Reviews 2010, Issue 4, Art. No.: MR000013 DOI: 10.1002/14651858.MR000013.pub5 (see www.thecochranelibrary.com for information). Cochrane Reviews are regularly updated as new evidence emerges and in response to feedback, and Cochrane Database of Systematic Reviews should be consulted for the most recent version of the review.

OBJECTIVE

To identify interventions designed to improve recruitment to randomised controlled trials, and to quantify their effect on trial participation.

DESIGN

Systematic review.

DATA SOURCES

The Cochrane Methodology Review Group Specialised Register in the Cochrane Library, MEDLINE, EMBASE, ERIC, Science Citation Index, Social Sciences Citation Index, C2-SPECTR, the National Research Register and PubMed. Most searches were undertaken up to 2010; no language restrictions were applied.

STUDY SELECTION

Randomised and quasi-randomised controlled trials, including those recruiting to hypothetical studies. Studies on retention strategies, examining ways to increase questionnaire response or evaluating the use of incentives for clinicians were excluded. The study population included any potential trial participant (eg, patient, clinician and member of the public), or individual or group of individuals responsible for trial recruitment (eg, clinicians, researchers and recruitment sites). Two authors independently screened identified studies for eligibility.

RESULTS

45 trials with over 43 000 participants were included. Some interventions were effective in increasing recruitment: telephone reminders to non-respondents (risk ratio (RR) 1.66, 95% CI 1.03 to 2.46; two studies, 1058 participants), use of opt-out rather than opt-in procedures for contacting potential participants (RR 1.39, 95% CI 1.06 to 1.84; one study, 152 participants) and open designs where participants know which treatment they are receiving in the trial (RR 1.22, 95% CI 1.09 to 1.36; two studies, 4833 participants). However, the effect of many other strategies is less clear, including the use of video to provide trial information and interventions aimed at recruiters.

CONCLUSIONS

There are promising strategies for increasing recruitment to trials, but some methods, such as open-trial designs and opt-out strategies, must be considered carefully as their use may also present methodological or ethical challenges. Questions remain as to the applicability of results originating from hypothetical trials, including those relating to the use of monetary incentives, and there is a clear knowledge gap with regard to effective strategies aimed at recruiters.

Recruiting patients and collecting data for an observational study using computerised record pop-up prompts: the PROG-RES study

BACKGROUND AND AIM

Engagement of general practitioners (GPs) and recruitment of patients are ever present problems in primary care studies. This paper seeks to demonstrate that electronic prompts represent one method of easing the burden on GPs to recruit individual patients to studies and also provide the opportunity to collect research data during a normal consultation.

METHODS

Older adults consulting for non-inflammatory musculoskeletal pain from five general practices in Cheshire were recruited to a prospective cohort study (the PROG-RES study). Recruitment of patients was aided by a computer prompt during relevant consultations. When triggered by an appropriate Read code, a pop-up template appeared on the consultation screen prompting the GPs to record the answers to seven brief questions. A self-complete questionnaire was mailed to patients who had completed templates by the Keele GP Research Network team and permission was sought to access their medical records. A feasibility study suggested that the potential number of activated templates in the practice within four months would be 636.

RESULTS

The 44 GPs completed 650 electronic templates during the four-month recruitment period. Almost 40% of recruitment was within four weeks and greater than 95% of recruitment was within 16 weeks. Practices A-D completed electronic templates at a similar rate (1.61-1.86 templates per 1000 patients), although practice E completed templates at a lower frequency (0.76) due to internal difficulties. Completion of individual items ranged from 98% to 83% and completion of all seven questions was recorded in 63% of patients; 4% of patients had three or fewer responses recorded. Conclusion Templates activated by appropriate codes in the GP consultation can facilitate recruitment to observational studies in primary care. It is possible to collect high-quality research data within a normal consultation. This may be a model for use in future studies in primary care.

Learning from failure--rationale and design for a study about discontinuation of randomized trials (DISCO study)

BACKGROUND

Randomized controlled trials (RCTs) may be discontinued because of apparent harm, benefit, or futility. Other RCTs are discontinued early because of insufficient recruitment. Trial discontinuation has ethical implications, because participants consent on the premise of contributing to new medical knowledge, Research Ethics Committees (RECs) spend considerable effort reviewing study protocols, and limited resources for conducting research are wasted. Currently, little is known regarding the frequency and characteristics of discontinued RCTs.

METHODS/DESIGN

Our aims are, first, to determine the prevalence of RCT discontinuation for specific reasons; second, to determine whether the risk of RCT discontinuation for specific reasons differs between investigator- and industry-initiated RCTs; third, to identify risk factors for RCT discontinuation due to insufficient recruitment; fourth, to determine at what stage RCTs are discontinued; and fifth, to examine the publication history of discontinued RCTs.We are currently assembling a multicenter cohort of RCTs based on protocols approved between 2000 and 2002/3 by 6 RECs in Switzerland, Germany, and Canada. We are extracting data on RCT characteristics and planned recruitment for all included protocols. Completion and publication status is determined using information from correspondence between investigators and RECs, publications identified through literature searches, or by contacting the investigators. We will use multivariable regression models to identify risk factors for trial discontinuation due to insufficient recruitment. We aim to include over 1000 RCTs of which an anticipated 150 will have been discontinued due to insufficient recruitment.

DISCUSSION

Our study will provide insights into the prevalence and characteristics of RCTs that were discontinued. Effective recruitment strategies and the anticipation of problems are key issues in the planning and evaluation of trials by investigators, Clinical Trial Units, RECs and funding agencies. Identification and modification of barriers to successful study completion at an early stage could help to reduce the risk of trial discontinuation, save limited resources, and enable RCTs to better meet their ethical requirements.

Improving the recruitment activity of clinicians in randomised controlled trials: a systematic review

Background Poor recruitment to randomised controlled trials (RCTs) is a widespread problem. Provision of interventions aimed at supporting or incentivising clinicians may improve recruitment to RCTs. Objectives To quantify the effects of strategies aimed at improving the recruitment activity of clinicians in RCTs, complemented with a synthesis of qualitative evidence related to clinicians' attitudes towards recruiting to RCTs. Data sources A systematic review of English and non-English articles identified from: The Cochrane Library, Ovid MEDLINE, Ovid EMBASE, Ovid PsycINFO, Ebsco CINAHL, Index to Theses and Open SIGLE from 2001 to March 2011. Additional reports were identified through citation searches of included articles. Study eligibility criteria Quantitative studies were included if they evaluated interventions aimed at improving the recruitment activity of clinicians or compared recruitment by different groups of clinicians. Information about host trial, study design, participants, interventions, outcomes and host RCT was extracted by one researcher and checked by another. Studies that met the inclusion criteria were assessed for quality using a standardised tool, the Effective Public Health Practice Project tool. Qualitative studies were included if they investigated clinicians' attitudes to recruiting patients to RCTs. All results/findings were extracted, and content analysis was carried out. Overarching themes were abstracted, followed by a metasummary analysis. Studies that met the inclusion criteria were assessed for quality using the Critical Appraisal Skills Programme qualitative checklist. Data extraction Data extraction was carried out by one researcher using predefined data fields, including study quality indicators, and verified by another. Results Eight quantitative studies were included describing four interventions and a comparison of recruiting clinicians. One study was rated as strong, one as moderate and the remaining six as weak when assessed for quality using the Effective Public Health Practice Project tool. Effective interventions included the use of qualitative research to identify and overcome barriers to recruitment, reduction of the clinical workload associated with participation in RCTs and the provision of extra training and protected research time. Eleven qualitative studies were identified, and eight themes were abstracted from the data: understanding of research, communication, perceived patient barriers, patient-clinician relationship, effect on patients, effect on clinical practice, individual benefits for clinicians and methods associated with successful recruitment. Metasummary analysis identified the most frequently reported subthemes to be: difficulty communicating trial methods, poor understanding of research and priority given to patient well-being. Overall, the qualitative studies were found to be of good quality when assessed using the Critical Appraisal Skills Programme checklist. Conclusions There were few high-quality trials that tested interventions to improve clinicians' recruitment activity in RCTs. The most promising intervention was the use of qualitative methods to identify and overcome barriers to clinician recruitment activity. More good quality studies of interventions are needed to add to the evidence base. The metasummary of qualitative findings identified understanding and communicating RCT methods as a key target for future interventions to improve recruitment. Reinforcement of the potential benefits, both for clinicians and for their patients, could also be a successful factor in improving recruitment. A bias was found towards investigating barriers to recruitment, so future work should also encompass a focus on successfully recruiting trials.

Recruitment challenges of a multicenter randomized controlled varicocelectomy trial

OBJECTIVE

To review reasons for suboptimal recruitment for a randomized controlled trial (RCT) of varicocelectomy versus intrauterine insemination (IUI) for treatment of male infertility and to suggest means for improving future study recruitment.

DESIGN

Survey of Reproductive Medicine Network (RMN) participating sites.

SETTING

Reproductive Medicine Network.

PATIENT(S)

None.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Ascertain reasons for inadequate recruitment and suggest improvements for future varicocelectomy trails.

RESULT(S)

This study screened seven and enrolled three couples, with the first couple randomized on June 30, 2010. The study was subsequently stopped on March 30, 2011. The following themes were cited most frequently by sites and therefore determined to be most likely to have played a role in suboptimal recruitment: [1] men must be screened at the beginning of a couple's infertility evaluation, [2] inclusion of infertile women who had failed previous fertility interventions appeared to be associated with the couple's intolerance of a placebo arm, and [3] an apparent bias against the use of unstimulated IUI cycles indicated a prejudicial preference for surgical intervention in the male partner.

CONCLUSION(S)

Improved recruitment may be realized through screening infertile men as early as possible while minimizing study-related time commitments. Focused patient education may promote improved equipoise and acceptance of a placebo arm in male infertility studies. Creative approaches to implementing varicocelectomy trials must be considered in addition to having a network of motivated researchers who carry a high volume of possible study participants because very large numbers may need to be screened to complete the clinical trial enrollment.

Competing for patients: an ethical framework for recruiting patients with brain tumors into clinical trials

With more rapid advances in potential treatments for brain tumours, the number of clinical trials for brain tumour patients is rising. In the context of the challenges of recruitment and enrollment of patients with brain tumors, the dichotomy between the paucity of subjects and abundance of clinical trials creates a unique ethical dilemma, whereby a single patient may be eligible for several studies. Here, we identify and present three approaches for recruiting and enrolling patients who may be eligible for several trials. The ethical implications of the full disclosure, paternalistic, and random approaches are discussed. The full disclosure approach presents information to patients regarding all ongoing concurrent trials, allowing them to make an informed decision, while the paternalistic approach allows the healthcare providers to select the trial for which they believe the patient is most suitable. These introduce the biases into circumstances where equipoise is necessary and risk selection bias in study design. The random approach randomly allocates patients to each trial, which may erode patient autonomy and decrease trial enrollment. Brain tumor patients comprise a vulnerable population and it remains incumbent on healthcare providers to maintain the highest ethical standards when approaching them for clinical research. Changes in clinical trial design are required to mitigate the conflicts created by competition for patients.

Process evaluation of recruitment for a cancer screening trial in primary care

Many cancer screening studies are conducted in primary care settings, yet few systematically analyze recruitment challenges found at these sites. During a randomized trial promoting colorectal cancer screening, we implemented a process evaluation of recruitment. Recruiters maintained logs that registered the numbers of patients entering the clinic, approached by recruiters, declining to participate, and reasons for nonapproach and nonparticipation. One half of age-eligible patients were approached (n = 1,489), and half of those who met basic eligibility requirements agreed to engage further (n = 527). A small proportion of patients (n = 98) completed the 15-min assessment before their appointment. Major reasons for nonapproach included previous approach, patients called to the exam room, and appearing ill. The major reason for nonparticipation was "not interested"; a few patients did not want to share contact information. Some participants exited the assessment midway because of further ineligibility or time limitations. Best-practice recommendations for recruitment in primary care are discussed.

Using patient monetary incentives and electronically derived patient lists to recruit patients to a clinical trial

PURPOSE

To report using electronic medical record (EMR) data to identify patients eligible for a clinical trial and the impact of providing an honorarium and deadline on accrual.

METHODS

Six practices using a common EMR participated in a cluster-randomized trial testing a self-administered, web-based familial risk assessment tool. EMR-derived lists of eligible patients were made available for provider review. An honorarium and deadline for responding in the patient recruitment letter were implemented in the last half of the recruitment process.

RESULTS

We identified 22,376 potentially eligible patients. Lists not returned by providers accounted for 9840 (44%) patients. We mailed invitations to 11,956 patients; 2398 (20%) requested more information and a consent document, 1489 (12.5%) consented to participate, and 1305 (11%) completed the baseline data collection. Patients receiving the additional $2 and a deadline compared with those receiving the personal invitation alone had significantly higher interest in participating (25% vs. 17%, P = .0001) but were less likely to complete baseline data collection (57% vs. 65% P = .01). Once consented, 85% completed the study with no significant difference by recruitment approach.

CONCLUSIONS

Using EMR data reduces the burden to identify potentially eligible patients. However, some providers still did not review and return the lists. Adding a $2 incentive and deadline for responding did not improve the rate of eligible patients consenting and completing the study. Other patient recruitment methods to get better response by providers and population from primary care offices must be explored.

A qualitative investigation of the views of primary care dentists on participating in prospective studies in the North-West of England

BACKGROUND

There is a poor understanding of to how to recruit and involve primary care dentists in clinical trials.

AIM

To use a qualitative paradigm to explore the views of primary care dentists towards participating in clinical trials and develop an understanding of the factors that facilitate and prevent their involvement. DESIGN, SETTING, SUBJECTS AND METHODS: An iterative approach was undertaken using a focus group (n = 6) followed by phased semi-structured interviews (n = 18). Data were analysed using thematic analysis and constant comparative analysis.

FINDINGS

The semi-structured interviews generated nine codes which were organised into three themes: technical issues for trials in primary dental care, practical issues for research in primary dental care and primary care dentists as research consumers. Overall, primary care dentists had a poor understanding of research methodology and clinical research. Barriers to participation included loss of clinical freedom and control, practice disruption, patient welfare, staff workload, financial loss and time.

CONCLUSIONS

Barriers to primary dental care research need to be overcome through appropriate protocols, funding, training and support. Joint working of primary dental care teams and academic researchers is essential, along with a constructive and open dialogue, if clinical trials are to be successfully undertaken in a practice environment.

Barriers and facilitators to recruitment of physicians and practices for primary care health services research at one centre

BACKGROUND

While some research has been conducted examining recruitment methods to engage physicians and practices in primary care research, further research is needed on recruitment methodology as it remains a recurrent challenge and plays a crucial role in primary care research. This paper reviews recruitment strategies, common challenges, and innovative practices from five recent primary care health services research studies in Ontario, Canada.

METHODS

We used mixed qualitative and quantitative methods to gather data from investigators and/or project staff from five research teams. Team members were interviewed and asked to fill out a brief survey on recruitment methods, results, and challenges encountered during a recent or ongoing project involving primary care practices or physicians. Data analysis included qualitative analysis of interview notes and descriptive statistics generated for each study.

RESULTS

Recruitment rates varied markedly across the projects despite similar initial strategies. Common challenges and creative solutions were reported by many of the research teams, including building a sampling frame, developing front-office rapport, adapting recruitment strategies, promoting buy-in and interest in the research question, and training a staff recruiter.

CONCLUSIONS

Investigators must continue to find effective ways of reaching and involving diverse and representative samples of primary care providers and practices by building personal connections with, and buy-in from, potential participants. Flexible recruitment strategies and an understanding of the needs and interests of potential participants may also facilitate recruitment.

Impact of study design on recruitment of patients to a primary care trial: an observational time series analysis of the Birmingham Atrial Fibrillation Treatment of the Aged (BAFTA) study

BACKGROUND

recruitment targets to randomized controlled trials (RCTs) are often not met. Many interventions are used to improve recruitment but there is little empirical evidence on whether these approaches work.

OBJECTIVE

to examine whether changes to the design and conduct of a primary care-based RCT were associated with changes in patient recruitment.

METHODS

an observational time series analysis of recruitment to a primary care-based multi-centre RCT of aspirin versus warfarin for stroke prevention, which involved 330 practices. Several changes to the trial protocol and procedures were made over the 4 years of patient recruitment. For each quarter throughout the recruitment period, the recruitment rate per 1000 total population in active practices was calculated.

RESULTS

the recruitment target of 930 patients was exceeded. Fluctuations in recruitment rate occurred during the recruitment period. Following protocol changes aimed to reduce clinical workload, there was a significant increase in recruitment during the final 6 months of the study, during a period when there was not a similarly large increase in the total population available.

CONCLUSIONS

these findings suggest that the conduct of a trial is an important consideration if studies are to recruit successfully. Expanding the number of centres may not be the most effective way to improve recruitment.

Strategies to engage clinical staff in subject recruitment

PURPOSE: In many countries, meeting subject recruitment goals is challenging for researchers relying on clinical staff members (CSMs) to identify or recruit subjects. This paper describes research strategies that improved staff engagement in three different studies conducted in US clinical settings. METHOD: The recruitment strategies described in this paper were identified during the process of consultation among three US researchers recruiting via CSMs. Strategies which successfully engaged CSMs are described. RESULTS: Our approach improved engagement with CSMs in three different US studies. Early engagement strategies included establishing trust, gathering input from CSMs, and using succinct training procedures as well as a study logo. Middle phase strategies included assigning recruitment, publishing a study newsletter, giving the CSMs compensation and appreciation for their participation, and expanding the subject pool. Completion strategies included closing with an appreciation meeting and adding merit letters to personnel files. CONCLUSION: Recruitment of an adequate number of subjects is often challenging, even within clinical settings where subject populations are abundant. CSMs have rightly prioritised clinical care over directing subjects to research studies. It is therefore critical that researchers recruiting in such clinical settings anticipate recruitment challenges and plan to implement appropriate engagement strategies in all phases of research.

Effective and cost-effective clinical trial recruitment strategies for postmenopausal women in a community-based, primary care setting

INTRODUCTION

Little evidence exists to guide investigators on the effectiveness and cost-effectiveness of various recruitment strategies in primary care research. The purpose of this study is to describe the effectiveness and cost-effectiveness of eight clinical trial recruitment methods for postmenopausal women in a community-based setting.

METHODS

A retrospective analysis of the yield and cost of eight different recruitment methods: 1) family physician (FP) recruiters, 2) FP referrals, 3) community presentations, 4) community events, 5) newsletters, 6) direct mailings, 7) posters, and 8) newspaper advertisements that were used to recruit postmenopausal women to a randomized clinical trial (RCT) evaluating the effectiveness of gabapentin in treating hot flashes.

RESULTS

We recruited 197 postmenopausal women from a total of 904 screened, with 291 of the remainder being ineligible and 416 declining to participate. Of the 904 women screened, 34 (3.8%) were from FP recruiters and 35 (3.9%) were from other FP referrals while 612 (67.7%) resulted from newspaper advertisements. Of the 197 women enrolled, 141 (72%) were from newspaper advertisements, with 26 (13%) following next from posters. Word of mouth was identified as an additional unanticipated study recruitment strategy. Metropolitan newspaper advertising at $112.73 (Canadian) per enrolled participant and posters at $119.98 were found to be cost-effective recruitment methods.

CONCLUSION

Newspaper advertisements were the most successful method to recruit postmenopausal women into a community-based, primary care RCT.

Patient satisfaction with GP-led melanoma follow-up: a randomised controlled trial

BACKGROUND

There are no universally accepted guidelines for the follow-up of individuals with cutaneous melanoma. Furthermore, to date, there have been no randomised controlled trials of different models of melanoma follow-up care. This randomised controlled trial was conducted to evaluate the effects of GP-led melanoma follow-up on patient satisfaction, follow-up guideline compliance, anxiety and depression, as well as health status.

METHODS

A randomised controlled trial of GP-led follow-up of cutaneous melanoma was conducted over a period of 1 year with assessment by self-completed questionnaires and review of general practice-held medical records at baseline and 12 months later. It took place in 35 general practices in North-east Scotland. Subjects were 142 individuals (51.4% women 48.6% men; mean (s.d.) age 59.2 (15.2) years previously treated for cutaneous melanoma and free of recurrent disease. The intervention consisted of protocol-driven melanoma reviews in primary care, conducted by trained GPs and supported by centralised recall, rapid access pathway to secondary care and a patient information booklet. The main outcome measure was patient satisfaction measured by questionnaire. Secondary outcomes were adherence to guidelines, health status measured by Short Form-36 and the Hospital Anxiety and Depression Scale.

RESULTS

There were significant improvements in 5 out of 15 aspects of patient satisfaction during the study year in those receiving GP-led melanoma follow-up (all P<or=0.01). The intervention group was significantly more satisfied with 7 out of 15 aspects of care at follow-up after adjustment for potential confounders. There was significantly greater adherence to guidelines in the intervention group during the study year. There was no significant difference in health status or anxiety and depression between intervention and control groups at either baseline or outcome.

CONCLUSIONS

GP-led follow-up is feasible, engenders greater satisfaction in those patients who receive it, permits closer adherence to guidelines and does not result in adverse effects on health status or anxiety and depression when compared with traditional hospital-based follow-up for melanoma.

Strategies to improve recruitment to randomised controlled trials

BACKGROUND

Recruiting participants to trials can be extremely difficult. Identifying strategies that improve trial recruitment would benefit both trialists and health research.

OBJECTIVES

To quantify the effects of strategies to improve recruitment of participants to randomised controlled trials.

SEARCH STRATEGY

We searched the Cochrane Methodology Review Group Specialised Register - CMR (The Cochrane Library (online) Issue 1 2008) (searched 20 February 2008); MEDLINE, Ovid (1950 to date of search) (searched 06 May 2008); EMBASE, Ovid (1980 to date of search) (searched 16 May 2008); ERIC, CSA (1966 to date of search) (searched 19 March 2008); Science Citation Index Expanded, ISI Web of Science (1975 to date of search) (searched 19 March 2008); Social Sciences Citation Index, ISI Web of Science (1975 to date of search) (searched 19 March 2008); and National Research Register (online) (Issue 3 2007) (searched 03 September 2007); C2-SPECTR (searched 09 April 2008). We also searched PubMed (25 March 2008) to retrieve "related articles" for 15 studies included in a previous version of this review.

SELECTION CRITERIA

Randomised and quasi-randomised controlled trials of methods to increase recruitment to randomised controlled trials. This includes non-healthcare studies and studies recruiting to hypothetical trials. Studies aiming to increase response rates to questionnaires or trial retention, or which evaluated incentives and disincentives for clinicians to recruit patients were excluded.

DATA COLLECTION AND ANALYSIS

Data were extracted on the method evaluated; country in which the study was carried out; nature of the population; nature of the study setting; nature of the study to be recruited into; randomisation or quasi-randomisation method; and numbers and proportions in each intervention group. We used risk ratios and their 95% confidence intervals to describe the effects in individual trials, and assessed heterogeneity of these ratios between trials.

MAIN RESULTS

We identified 27 eligible trials with more than 26,604 participants. There were 24 studies involving interventions aimed directly at trial participants, while three evaluated interventions aimed at people recruiting participants. All studies were in health care. Some interventions were effective in increasing recruitment: telephone reminders to non-respondents (RR 2.66, 95% CI 1.37 to 5.18), use of opt-out, rather than opt-in, procedures for contacting potential trial participants (RR 1.39, 95% CI 1.06 to 1.84) and open designs where participants know which treatment they are receiving in the trial (RR 1.25, 95% CI 1.18 to 1.34). However, some of these strategies have disadvantages, which may limit their widespread use. For example, opt-out procedures are controversial and open designs are by definition unblinded. The effects of many other recruitment strategies are unclear; examples include the use of video to provide trial information to potential participants and modifying the training of recruiters. Many studies looked at recruitment to hypothetical trials and it is unclear how applicable these results are to real trials.

AUTHORS' CONCLUSIONS

Trialists can increase recruitment to their trials by using the strategies shown to be effective in this review: telephone reminders; use of opt-out, rather than opt-in; procedures for contacting potential trial participants and open designs. Some strategies (e.g. open trial designs) need to be considered carefully before use because they also have disadvantages. For example, opt-out procedures are controversial and open designs are by definition unblinded.

Strategies to improve recruitment to randomised controlled trials

BACKGROUND

Recruiting participants to trials can be extremely difficult. Identifying strategies that improve trial recruitment would benefit both trialists and health research.

OBJECTIVES

To quantify the effects of strategies to improve recruitment of participants to randomised controlled trials.

SEARCH STRATEGY

We searched the Cochrane Methodology Review Group Specialised Register - CMR (The Cochrane Library (online) Issue 1 2008) (searched 20 February 2008); MEDLINE, Ovid (1950 to date of search) (searched 06 May 2008); EMBASE, Ovid (1980 to date of search) (searched 16 May 2008); ERIC, CSA (1966 to date of search) (searched 19 March 2008); Science Citation Index Expanded, ISI Web of Science (1975 to date of search) (searched 19 March 2008); Social Sciences Citation Index, ISI Web of Science (1975 to date of search) (searched 19 March 2008); and National Research Register (online) (Issue 3 2007) (searched 03 September 2007); C2-SPECTR (searched 09 April 2008). We also searched PubMed (25 March 2008) to retrieve "related articles" for 15 studies included in a previous version of this review.

SELECTION CRITERIA

Randomised and quasi-randomised controlled trials of methods to increase recruitment to randomised controlled trials. This includes non-healthcare studies and studies recruiting to hypothetical trials. Studies aiming to increase response rates to questionnaires or trial retention, or which evaluated incentives and disincentives for clinicians to recruit patients were excluded.

DATA COLLECTION AND ANALYSIS

Data were extracted on the method evaluated; country in which the study was carried out; nature of the population; nature of the study setting; nature of the study to be recruited into; randomisation or quasi-randomisation method; and numbers and proportions in each intervention group. We used risk ratios and their 95% confidence intervals to describe the effects in individual trials, and assessed heterogeneity of these ratios between trials.

MAIN RESULTS

We identified 27 eligible trials with more than 26,604 participants. There were 24 studies involving interventions aimed directly at trial participants, while three evaluated interventions aimed at people recruiting participants. All studies were in health care. Some interventions were effective in increasing recruitment: telephone reminders to non-respondents (RR 2.66, 95% CI 1.37 to 5.18), use of opt-out, rather than opt-in, procedures for contacting potential trial participants (RR 1.39, 95% CI 1.06 to 1.84) and open designs where participants know which treatment they are receiving in the trial (RR 1.25, 95% CI 1.18 to 1.34). However, some of these strategies have disadvantages, which may limit their widespread use. For example, opt-out procedures are controversial and open designs are by definition unblinded. The effects of many other recruitment strategies are unclear; examples include the use of video to provide trial information to potential participants and modifying the training of recruiters. Many studies looked at recruitment to hypothetical trials and it is unclear how applicable these results are to real trials.

AUTHORS' CONCLUSIONS

Trialists can increase recruitment to their trials by using the strategies shown to be effective in this review: telephone reminders; use of opt-out, rather than opt-in; procedures for contacting potential trial participants and open designs. Some strategies (e.g. open trial designs) need to be considered carefully before use because they also have disadvantages. For example, opt-out procedures are controversial and open designs are by definition unblinded.

A cost-effectiveness analysis of subject recruitment strategies in the HIPAA era: results from a colorectal cancer screening adherence trial

BACKGROUND

Changes in regulatory standards that restrict use of identifiable health information can reduce patient recruitment to clinical trials and increase recruitment costs.

PURPOSE

To compare subject accrual rates and costs of three recruitment strategies that comply with new regulatory standards within the context of a clinical trial evaluating the impact of shared decision-making on colorectal cancer screening adherence.

METHODS

Sequential cohorts of English-speaking, average-risk patients due for colorectal cancer screening were allocated to one of three recruitment strategies: (1) a provider-initiated electronic 'opt-in' referral (Click) method; (2) a provider-mediated 'opt-in' referral letter (Letter) method; and (3) an investigator-initiated direct contact 'opt-out' (Call) method.

RESULTS

During distinct 6-month recruitment periods between March 2005 and April 2006, 100 potential subjects were identified using the Click method, 847 by the Letter method, and 758 by the Call method. After excluding ineligible prescreened patients, accrual rates were higher for the Call method (188 of 531 [35.4%]) than either the Click (12 of 72 [16.7%]; p = 0.002) or Letter (17 of 816 [2.1%]; p < 0.001) methods. The average cost per patient enrolled for the Call ($156) method was competitive with the Click ($129) and substantially lower than the Letter ($1967) methods; the Call method was least expensive if combined with automated patient identification ($99). Data extrapolation suggest it would take 2.4 years at an overall cost of $138,518 to recruit a target sample of 900 patients by the Call method, 40.5 years at $62,419 for the Click method and 27.9 years at $1,737,757 for the Letter method.

LIMITATIONS

The study was nonrandomized and findings may not be generalizable to other research settings.

CONCLUSION

The investigator-initiated direct contact 'opt-out' strategy is significantly more cost-effective and feasible than provider-initiated and provider-mediated 'opt-in' strategies for patient recruitment to clinical trials.

Comparing recruitment strategies in a study of acupuncture for chronic back pain

Background

Meeting recruitment goals is challenging for many clinical trials conducted in primary care populations. Little is known about how the use of different recruitment strategies affects the types of individuals choosing to participate or the conclusions of the study.

Methods

A secondary analysis was performed using data from participants recruited to a clinical trial evaluating acupuncture for chronic back pain among primary care patients in a large integrated health care organization. We used two recruitment methods: mailed letters of invitation and an advertisement in the health plan's magazine. For these two recruitment methods, we compared recruitment success (% randomized, treatment completers, drop outs and losses to follow-up), participant characteristics, and primary clinical outcomes. A linear regression model was used to test for interaction between treatment group and recruitment method.

Results

Participants recruited via mailed letters closely resembled those responding to the advertisement in terms of demographic characteristics, most aspects of their back pain history and current episode and beliefs and expectations about acupuncture. No interaction between method of recruitment and treatment group was seen, suggesting that study outcomes were not affected by recruitment strategy.

Conclusion

In this trial, the two recruitment strategies yielded similar estimates of treatment effectiveness. However, because this finding may not apply to other recruitment strategies or trial circumstances, trials employing multiple recruitment strategies should evaluate the effect of recruitment strategy on outcome.

Trial registration

Clinical Trials.gov NCT00065585.

Effectiveness of strategies to encourage general practitioners to accept an offer of free access to online evidence-based information: a randomised controlled trial

Background

This study examined the effectiveness of seven different interventions designed to increase the proportion of general practitioners (GPs) accepting an offer of free access to an online evidence-based resource.

Methods

Australian GPs (n = 14,000) were randomly selected and assigned to seven intervention groups, with each receiving a different letter. Seven different strategies were used to encourage GPs to accept an offer of two years free access to an online evidence-based resource (BMJ Clinical Evidence). The first group received a standard letter of offer with no experimental demands. Groups two to seven received a standard letter of offer outlining the requirements of the study. They were asked to complete an initial online questionnaire, agree to complete a 12-month follow-up questionnaire, and agree to having data about their usage of the online evidence-based resource provided to researchers. Groups three to seven also had additional interventions included in the letter of offer: access to an online tutorial in use of the resource (group three); provision of a pamphlet with statements from influential opinion leaders endorsing the resource (group four); offer of eligibility to receive professional development points (group five); offer of eligibility for a prize of $500 for registration at a medical conference of their choice (group six); and a combination of some of the above interventions (group seven).

Results

In the group with no research demands, 27% accepted the offer. Average acceptance across all other groups was 10%. There was no advantage in using additional strategies such as financial incentives, opinion leader support, offer of professional development points, or an educational aid over a standard letter of offer to increase acceptance rates.

Conclusion

This study showed low acceptance rates of the offer of access to the online resource when there was an associated requirement of response to a short online questionnaire and non-obtrusive monitoring of GP behaviour in terms of accessing the resource. If we are to improve care and encourage evidence-based practice, we need to find effective ways of motivating doctors and other health professionals to take part in research that can inform our implementation efforts.

Improving recruitment to health research in primary care

BACKGROUND

Recruitment to health research is known to be problematic. However, evidence concerning ways of improving recruitment is sparse.

OBJECTIVE

To outline the process of recruitment, factors impacting on recruitment success and key areas for further research and development.

METHODS

Narrative literature review.

RESULTS

This paper argues that three ways of improving recruitment should form the focus of future work: developing a repository of evidence-based techniques and methods which can be introduced by research teams; developing the infrastructure to support recruitment, especially new technologies around the electronic patient record; and increasing public engagement with research, to improve participation by both clinicians and patients.

CONCLUSION

Recruitment to health research in primary care remains a major hurdle, and key research and development priorities must be addressed.

Strategies for improving patient recruitment to focus groups in primary care: a case study reflective paper using an analytical framework

Background

Recruiting to primary care studies is complex. With the current drive to increase numbers of patients involved in primary care studies, we need to know more about successful recruitment approaches. There is limited evidence on recruitment to focus group studies, particularly when no natural grouping exists and where participants do not regularly meet. The aim of this paper is to reflect on recruitment to a focus group study comparing the methods used with existing evidence using a resource for research recruitment, PROSPeR (Planning Recruitment Options: Strategies for Primary Care).

Methods

The focus group formed part of modelling a complex intervention in primary care in the Resources for Effective Sleep Treatment (REST) study. Despite a considered approach at the design stage, there were a number of difficulties with recruitment. The recruitment strategy and subsequent revisions are detailed.

Results

The researchers' modifications to recruitment, justifications and evidence from the literature in support of them are presented. Contrary evidence is used to analyse why some aspects were unsuccessful and evidence is used to suggest improvements. Recruitment to focus group studies should be considered in two distinct phases; getting potential participants to contact the researcher, and converting those contacts into attendance. The difficulty of recruitment in primary care is underemphasised in the literature especially where people do not regularly come together, typified by this case study of patients with sleep problems.

Conclusion

We recommend training GPs and nurses to recruit patients during consultations. Multiple recruitment methods should be employed from the outset and the need to build topic related non-financial incentives into the group meeting should be considered. Recruitment should be monitored regularly with barriers addressed iteratively as a study progresses.

A qualitative study exploring practice nurses’ experience of participating in a primary care–based randomised controlled trial

Abstract

The aim of this study is to explore the views of practice nurses’ recruiting into a primary care–based randomised controlled trial, and to investigate factors that influence the success of trial recruitment. It is known that time pressures, forgetfulness and lack of interest in the research topic negatively influence recruitment into research trials by General Practitioners (GPs), but no studies appear to have explored practice nurses’ experience of recruiting into trials. Semi-structured telephone interviews were conducted with a non-random purposive sample of 10 practice nurses who had participated in recruiting patients for the trial, and data were analysed using a thematic framework approach. Nurses who had been asked to take part in the study found it a positive experience, and had decided to take part because the area of research was of interest and could potentially benefit patients. Nurses who had been delegated the role of recruitment by the GP felt put upon and recruited less well. None of the nurses reported difficulties remembering to recruit patients and developed useful strategies to aid memory. Nurses often acted as gatekeepers, selecting which patients they offered the intervention to. Nurses with dedicated time for research recruited more successfully. For nurses who recruited during routine consultation, it was often the patient’s lack of interest in taking part in the trial, rather than time limitations that hindered recruitment. Overall, nurses were positive about recruiting into the trial, particularly if the research area could benefit patients and if directly asked to take part.

Identifying strategies to maximise recruitment and retention of practices and patients in a multicentre randomised controlled trial of an intervention to optimise secondary prevention for coronary heart disease in primary care

Background

Recruitment and retention of patients and healthcare providers in randomised controlled trials (RCTs) is important in order to determine the effectiveness of interventions. However, failure to achieve recruitment targets is common and reasons why a particular recruitment strategy works for one study and not another remain unclear. We sought to describe a strategy used in a multicentre RCT in primary care, to report researchers' and participants' experiences of its implementation and to inform future strategies to maximise recruitment and retention.

Methods

In total 48 general practices and 903 patients were recruited from three different areas of Ireland to a RCT of an intervention designed to optimise secondary prevention of coronary heart disease. The recruitment process involved telephoning practices, posting information, visiting practices, identifying potential participants, posting invitations and obtaining consent. Retention involved patients attending reviews and responding to questionnaires and practices facilitating data collection.

Results

We achieved high retention rates for practices (100%) and for patients (85%) over an 18-month intervention period. Pilot work, knowledge of the setting, awareness of change in staff and organisation amongst participant sites, rapid responses to queries and acknowledgement of practitioners' contributions were identified as being important. Minor variations in protocol and research support helped to meet varied, complex and changing individual needs of practitioners and patients and encouraged retention in the trial. A collaborative relationship between researcher and practice staff which required time to develop was perceived as vital for both recruitment and retention.

Conclusion

Recruiting and retaining the numbers of practices and patients estimated as required to provide findings with adequate power contributes to increased confidence in the validity and generalisability of RCT results. A continuous dynamic process of monitoring progress within trials and tailoring strategies to particular circumstances, whilst not compromising trial protocols, should allow maximal recruitment and retention.

Trial registration

ISRCTN24081411

Offering payments, reimbursement and incentives to patients and family doctors to encourage participation in research

Sometimes researchers fail to meet their recruitment targets, and sometimes it is predicted that recruitment may prove difficult but it is not obvious what ethical latitude researchers have to boost participation by, for instance, paying participants to take part or by paying family doctors to recruit patients to participate. In this paper, we distinguish between payment, reimbursement and inducement. We look first at the ethics of paying research participants. We conclude that payment raises all kinds of ethical difficulties, but that reimbursement-whilst not completely unproblematic-is an ethical requirement. We then look at whether some inducement to participate is acceptable and conclude that it is. We continue by asking whether the same arguments can be applied to encouraging family doctors to recruit patients. We conclude that it is right for family doctors to be reimbursed for the costs of recruiting research participants and also argue that there are fewer problems with paying family doctors to recruit patients than there are with paying research participants. Given, however, that there is a fine line between reimbursement and payment, given the potential for conflicts of interests to arise, and given that even suspicion of such a conflict might undermine trust in doctors, systems of both payment and reimbursement need to be transparent.