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Boaz A, Goodenough B, Hanney S, Soper B. If health organisations and staff engage in research, does healthcare improve? Strengthening the evidence base through systematic reviews. Health Res Policy Syst 2024; 22:113. [PMID: 39160553 DOI: 10.1186/s12961-024-01187-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2024] [Accepted: 07/22/2024] [Indexed: 08/21/2024] Open
Abstract
BACKGROUND There is an often-held assumption that the engagement of clinicians and healthcare organizations in research improves healthcare performance at various levels. Previous reviews found up to 28 studies suggesting a positive association between the engagement of individuals and healthcare organizations in research and improvements in healthcare performance. The current study sought to provide an update. METHODS We updated our existing published systematic review by again addressing the question: Does research engagement (by clinicians and organizations) improve healthcare performance? The search covered the period 1 January 2012 to March 2024, in two phases. First, the formal updated search ran from 1 January 2012 to 31 May 2020, in any healthcare setting or country and focussed on English language publications. In this phase two searches identified 66 901 records. Later, a further check of key journals and citations to identified papers ran from May 2020 to March 2024. In total, 168 papers progressed to full-text appraisal; 62 were identified for inclusion in the update. Then we combined papers from our original and updated reviews. RESULTS In the combined review, the literature is dominated by papers from the United States (50/95) and mostly drawn from the Global North. Papers cover various clinical fields, with more on cancer than any other field; 86 of the 95 papers report positive results, of which 70 are purely positive and 16 positive/mixed, meaning there are some negative elements (i.e. aspects where there is a lack of healthcare improvement) in their findings. CONCLUSIONS The updated review collates a substantial pool of studies, especially when combined with our original review, which are largely positive in terms of the impact of research engagement on processes of care and patient outcomes. Of the potential engagement mechanisms, the review highlights the important role played by research networks. The review also identifies various papers which consider how far there is a "dose effect" from differing amounts of research engagement. Additional lessons come from analyses of equity issues and negative papers. This review provides further evidence of contributions played by systems level research investments such as research networks on processes of care and patient outcomes.
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Affiliation(s)
- Annette Boaz
- Health and Social Care Workforce Research Unit, King's Policy Institute, King's College London, Virginia Woolf Building, 20 Kingsway, London, United Kingdom.
| | | | | | - Bryony Soper
- Brunel University London, Uxbridge, United Kingdom
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Matetic A, Kuchtaruk A, Siudak Z, Ullah W, Elbadawi A, Elgendy IY, Zaman S, Bang V, Rao S, Bagur R, Mamas MA. 30-Day unplanned readmission rates, causes and outcomes of patients hospitalized for acute coronary syndrome based on the trial participation status. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2024:S1553-8389(24)00607-9. [PMID: 39095290 DOI: 10.1016/j.carrev.2024.07.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2024] [Revised: 06/24/2024] [Accepted: 07/25/2024] [Indexed: 08/04/2024]
Abstract
BACKGROUND This study aimed to investigate the association between index trial participation status and 30-day unplanned readmission rates, causes, and outcomes in acute coronary syndrome (ACS) patients. METHODS The National Readmission Database was analysed for all index hospitalizations with a principal diagnosis of ACS between October 2015 to November 2019, stratified by index trial participation status (International Classification of Diseases - 10th edition code: Z00.6). The 30-day unplanned readmission rates, causes and outcomes were analysed, including the assessment of factors associated with readmission. Multivariable regression analyses were reported as adjusted odds ratios (aOR) with 95 % confidence intervals (95 % CI). All analyses were weighted and utilized hierarchical multi-level organization. RESULTS A total of 2,066,328 cases with a principal diagnosis of ACS were included in the study, of which there were 4061 trial participants (0.2 %) and 189,240 (9.2 %) cases experienced unplanned 30-day readmission. Rates of unplanned 30-day readmission were similar between trial participants and non-participants (9.8 % vs. 9.2 %, p = 0.16). Consistently, after multivariable adjustment, there was no significant association between trial participation and unplanned 30-day readmissions (aOR 0.96, 95 % CI 0.86-1.07, p = 0.45). Compared with trial participants, the majority of readmissions in non-participants were related to cardiovascular conditions (55.2 % vs. 46.7 %, p = 0.005, respectively). There was no significant difference in all-cause mortality (5.5 % vs. 4.6 %, p = 0.368, respectively), but trial participants were more likely to develop major bleeding (3.5 % vs. 2.1 %, p = 0.044), ischemic stroke (4.0 % vs. 2.1 %, p = 0.008) and haemorrhagic stroke (2.0 % vs. 0.6 %, p < 0.001) at readmissions. CONCLUSION Overall rates of unplanned 30-day readmissions after ACS are similar between trial participants and non-participants, but non-participation in trials was associated with a higher likelihood of cardiovascular readmission.
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Affiliation(s)
- Andrija Matetic
- Department of Cardiology, University Hospital of Split, Split, Croatia; Keele Cardiovascular Research Group, Keele University, Keele, United Kingdom
| | - Adrian Kuchtaruk
- London Health Sciences Centre, Western University, London, Ontario, Canada
| | - Zbigniew Siudak
- Collegium Medicum, Jan Kochanowski University, Kielce, Poland
| | - Waqas Ullah
- Thomas Jefferson University Hospitals, Philadelphia, United States of America
| | - Ayman Elbadawi
- Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, TX, United States of America
| | - Islam Y Elgendy
- Division of Cardiovascular Medicine, Gill Heart Institute, University of Kentucky, Lexington, KY, United States of America
| | - Sarah Zaman
- Westmead Applied Research Centre, The University of Sydney Faculty of Medicine and Health, Sydney, New South Wales, Australia
| | - Vijay Bang
- Lilavati Hospital and Research Center, Mumbai, India
| | - Sarita Rao
- Department of Cardiology, Apollo Hospitals, Indore, India
| | - Rodrigo Bagur
- London Health Sciences Centre, Western University, London, Ontario, Canada
| | - Mamas A Mamas
- Keele Cardiovascular Research Group, Keele University, Keele, United Kingdom; National Institute for Health and Care Research (NIHR), Birmingham Biomedical Research Centre, United Kingdom.
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Zhang J, Peng M, Li J, Li L, Bai X, Thabane L, Yh Lip G, Van Spall HG, Li G. Enrollment of Black, Indigenous and People of Color (BIPOC) and female participants in the US diabetes trials spanning 2000 to 2020: A chronological survey. Diabetes Metab Syndr 2024; 18:103074. [PMID: 39033649 DOI: 10.1016/j.dsx.2024.103074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Revised: 07/11/2024] [Accepted: 07/14/2024] [Indexed: 07/23/2024]
Abstract
AIMS Little is known about the enrollment practice of both Black, Indigenous and People of Color (BIPOC) and females in the US diabetes trials. We aimed to perform a chronological survey to evaluate the enrollment of BIPOC and female participants in the US diabetes randomized controlled trials (RCTs) over the past two decades. METHODS We searched databases to systematically include the US diabetes RCTs from 2000 January 1st to 2020 December 31st. Primary outcome was the adequate enrollment of both BIPOC and females, defined by the participation to prevalence ratio (PPR) > 0.8. We tested the temporal trend in adequate enrollment over time and used logistic regression analysis to explore the relationship between adequate enrollment and trial characteristics. RESULTS A total of 69 US diabetes trials were included for analyses, with a median BIPOC and female enrollment percentage of 29.0 % and 45.4 % respectively. There were 22 (31.9 %) trials with adequate enrollment of both BIPOC and females. No significant trend of adequate enrollment percentage of BIPOC and females over time was observed (P = 0.16). Of trial types, those with medication interventions were significantly related to decreased odds of adequate enrollment, when compared to trials with non-drug interventions (odds ratio = 0.29, 95 % confidence interval: 0.11-0.84). CONCLUSIONS Less than one third of the US diabetes trials adequately enrolled both BIPOC and females over the past two decades, and no temporal improvement in BIPOC and female participant enrollment was observed. These results highlight the need for more endeavors to mitigate inadequate representation regarding BIPOC and female enrollment in diabetes trials.
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Affiliation(s)
- Jingyi Zhang
- Center for Clinical Epidemiology and Methodology (CCEM), The Affiliated Guangdong Second Provincial General Hospital of Jinan University, Guangzhou, China
| | - Miaoguan Peng
- Department of Endocrinology, Guangdong Provincial Key Laboratory of Major Obstetric Diseases, Guangdong Provincial Clinical Research Center for Obstetrics and Gynecology, Guangdong-Hong Kong-Macao Greater Bay Area Higher Education Joint Laboratory of Maternal-Fetal Medicine, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510150, China
| | - Jianfeng Li
- Department of Epidemiology and Health Statistics, School of Public Health, Guangdong Medical University, Dongguan, China
| | - Likang Li
- Center for Clinical Epidemiology and Methodology (CCEM), The Affiliated Guangdong Second Provincial General Hospital of Jinan University, Guangzhou, China
| | - Xuerui Bai
- Department of Public Health and Preventive Medicine, School of Medicine, Jinan University, Guangzhou, China
| | - Lehana Thabane
- Father Sean O'Sullivan Research Centre, St Joseph's Healthcare Hamilton, Hamilton, ON, Canada; Faculty of Health Sciences, University of Johannesburg, Johannesburg, South Africa; Department of Health Research Methods, Evidence, and Impact (HEI), McMaster University, Hamilton, ON, Canada
| | - Gregory Yh Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom; Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Harriette Gc Van Spall
- Department of Health Research Methods, Evidence, and Impact (HEI), McMaster University, Hamilton, ON, Canada; Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Guowei Li
- Center for Clinical Epidemiology and Methodology (CCEM), The Affiliated Guangdong Second Provincial General Hospital of Jinan University, Guangzhou, China; Father Sean O'Sullivan Research Centre, St Joseph's Healthcare Hamilton, Hamilton, ON, Canada.
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Li G, Zhang J, Van Spall HGC, Douglas PS, Wang Y, Sun X, Thabane L. Exploring ethnic representativeness in diabetes clinical trial enrolment from 2000 to 2020: a chronological survey. Diabetologia 2022; 65:1461-1472. [PMID: 35705796 PMCID: PMC9200441 DOI: 10.1007/s00125-022-05736-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Accepted: 04/07/2022] [Indexed: 02/05/2023]
Abstract
AIMS/HYPOTHESIS Ethnic representativeness of participant enrolment in diabetes RCTs involving multiple ethnicities remains unknown. The aims of this study were to evaluate the status and temporal trend of ethnic representativeness in enrolment to diabetes RCTs, and to assess under-enrolment of non-white ethnic groups and explore trial characteristics associated with under-enrolment. METHODS We conducted a chronological survey by systematically searching the literature to include eligible RCTs published between January 2000 and December 2020. We assessed temporal trends in enrolment of ethnic groups in the included trials. Univariable logistic regression was used to explore the association between trial characteristics and under-enrolment of non-white groups, using a participant to prevalence ratio of <0.8 to define under-enrolment. This study was registered in PROSPERO (CRD42021229100). RESULTS We included 405 RCTs for analysis (327 multi-country trials, 69 conducted in the USA and nine conducted in the UK). The median enrolment rate of all non-white groups was 24.0% in the overall RCTs. Trials conducted in the USA and the UK had median enrolment rates of 29.0% and 12.0% for all non-white groups, respectively. There was a temporal trend towards increased participation of non-white ethnic groups in the overall RCTs; however, no significant improvement over time was found in the US or UK trials. Non-white groups were under-enrolled in most included trials: 62.3% (43/69) in US trials and 77.8% (7/9) in UK trials. The US trials with a high female proportion were associated with lower odds of under-enrolment of all non-white groups (OR 0.22; 95% CI 0.07, 0.65), while trials receiving funding from industry showed increased odds of under-enrolment (OR 4.64; 95% CI 1.50, 14.35). Outpatient enrolment and intervention duration were significantly associated with under-enrolment of Black participants. Only a small proportion of trials reported subgroup results or explored the effect modification by ethnicity. CONCLUSIONS/INTERPRETATION A temporal trend towards increased non-white ethnic enrolment was found in diabetes RCTs globally, but not in the USA or the UK. Non-white ethnic groups were under-represented in the majority of diabetes trials conducted in the USA and the UK. Some trial characteristics may be associated with non-white under-enrolment in diabetes trials. These findings provide some evidence for non-white ethnic representativeness in diabetes trials over the past two decades, and highlight the need for more effective strategies and endeavours to alleviate under-enrolment of non-white ethnic groups.
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Affiliation(s)
- Guowei Li
- Center for Clinical Epidemiology and Methodology, Guangdong Second Provincial General Hospital, Guangzhou, China.
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada.
| | - Jingyi Zhang
- Center for Clinical Epidemiology and Methodology, Guangdong Second Provincial General Hospital, Guangzhou, China
| | - Harriette G C Van Spall
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Pamela S Douglas
- Duke University Clinical Research Institute, Duke University, Durham, NC, USA
| | - Yaoyao Wang
- Department of Epidemiology, School of Medicine, Jinan University, Guangzhou, China
| | - Xin Sun
- Chinese Evidence-Based Medicine Center and Cochrane China Center, West China Hospital, Sichuan University, Chengdu, China.
| | - Lehana Thabane
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
- St Joseph's Healthcare Hamilton, Hamilton, ON, Canada
- Faculty of Health Sciences, University of Johannesburg, Johannesburg, South Africa
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Matetic A, Mohamed MO, Roberts DJ, Rana JS, Alraies MC, Patel B, Sauer AJ, Diaz-Arocutipa C, Sattar Y, Van Spall HGC, Mamas MA. Real-world management and outcomes of 7 million patients with acute coronary syndrome according to clinical research trial enrolment status: a propensity matched analysis. EUROPEAN HEART JOURNAL. QUALITY OF CARE & CLINICAL OUTCOMES 2022; 8:409-419. [PMID: 34940843 DOI: 10.1093/ehjqcco/qcab098] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Accepted: 12/16/2021] [Indexed: 01/01/2023]
Abstract
AIMS We aimed to determine whether clinical outcomes and invasive care of acute coronary syndrome (ACS) patients participating in trials differed from those of non-participants, particularly including those who were trial eligible. METHODS AND RESULTS We included all hospitalizations with a principal diagnosis of ACS in the US National Inpatient Sample between January 2004 and September 2015, stratified by trial enrolment and eligibility using the International Classification of Diseases, ninth revision. We conducted propensity score matching to investigate the following outcomes: all-cause mortality; major bleeding; stroke; composite of mortality, stroke, and cardiac complications [major adverse cardiovascular and cerebrovascular events (MACCEs)]; coronary angiography (CA); and percutaneous coronary intervention (PCI). A total of 7 091 179 weighted ACS hospitalizations were analysed, including 19 684 (0.3%) trial participants and 7 071 495 non-participants (3 485 514 of whom were trial eligible). Trial participants were more likely to receive CA [Δ% 28.73%, 95% confidence interval (CI) 27.22-30.24, P < 0.001] and PCI (Δ% 27.13%, 95% CI 24.86-29.41, P < 0.001), with decreased mortality (Δ% -3.51%, 95% CI -4.72 to -2.31, P < 0.001), MACCEs (Δ% -3.04%, 95% CI -4.55 to -1.53, P < 0.001), and bleeding (Δ% -0.89%, 95% CI -1.59 to -0.19, P = 0.013) compared with non-participants. After accounting for eligibility, trial participants were more likely to undergo CA (Δ% 22.78%, 95% CI 21.58-23.99, P < 0.001) and PCI (Δ% 23.95%, 95% CI 21.77-26.13, P < 0.001), and had no difference in mortality (Δ% -0.21%, 95% CI -0.65 to 0.24, P = 0.362). CONCLUSION Among ACS patients, trial enrolment was associated with significantly greater invasive care and lower mortality than among matched non-participants. Trial participants were more likely to be invasively managed even when compared with eligible non-participants, even though there was no difference in mortality.
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Affiliation(s)
- Andrija Matetic
- Department of Cardiology, University Hospital of Split, Split, Croatia.,Keele Cardiovascular Research Group, Centre for Prognosis Research, Institute for Primary Care and Health Sciences, Keele University, UK
| | - Mohamed O Mohamed
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Institute for Primary Care and Health Sciences, Keele University, UK
| | - Derek J Roberts
- Division of Vascular and Endovascular Surgery, Department of Surgery, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Jamal S Rana
- Department of Cardiology, Kaiser Permanente Northern California, Oakland, CA, USA
| | - M Chadi Alraies
- Division of Interventional Cardiology, Detroit Medical Center, Detroit, MI, USA
| | - Brijesh Patel
- Division of Cardiology, West Virginia University School of Medicine, Morgantown, WV, USA
| | - Andrew J Sauer
- Department of Cardiovascular Medicine, University of Kansas School of Medicine, Kansas City, KS, USA
| | | | - Yasar Sattar
- Division of Cardiology, West Virginia University School of Medicine, Morgantown, WV, USA
| | - Harriette G C Van Spall
- Department of Medicine, McMaster University, Hamilton, ON, Canada.,Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada.,Division of Cardiology, Department of Medicine, Population Health Research Institute, Hamilton Canada
| | - Mamas A Mamas
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Institute for Primary Care and Health Sciences, Keele University, UK
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Ohm J, Jernberg T, Johansson D, Warnqvist A, Leosdottir M, Hambraeus K, Svensson P. Association of clinical trial participation after myocardial infarction with socioeconomic status, clinical characteristics, and outcomes. EUROPEAN HEART JOURNAL OPEN 2021; 1:oeab020. [PMID: 35919264 PMCID: PMC9241569 DOI: 10.1093/ehjopen/oeab020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Revised: 07/17/2021] [Accepted: 08/10/2021] [Indexed: 02/01/2023]
Abstract
Abstract
Aims
To investigate whether participants in clinical trials after myocardial infarction (MI) are representable for the post-MI population concerning characteristics, secondary prevention, and prognosis.
Methods and results
Cohort study on 31 792 attendants to 1-year revisits after MI throughout Sweden (n = 2941 clinical trial participants) between 2008 and 2013 identified in the Swedish Web-System for Enhancement and Development of Evidence-Based Care in Heart Disease Evaluated According to Recommended Therapies (SWEDEHEART). Individual-level data on socioeconomic status (SES) (disposable income, educational level, and marital status) and outcomes (first recurrent non-fatal MI, coronary heart disease death, fatal or non-fatal stroke until study end 2018) were linked from other national registries. Trial participants were more likely to be men [risk ratio 1.09; 95% confidence interval (CI) 1.07–1.11], and married (1.07; 1.04–1.10), have a highest-quintile income (1.42; 1.36–1.48), and post-secondary education (1.25; 1.18–1.33), while less likely to have a history of MI (0.88; 0.80–0.97), be persistent smokers (0.83; 0.75–0.92) and have left ventricular dysfunction (0.59; 0.44–0.79) compared to non-participants. During a mean 6.7-year follow-up, 5206 outcome events occurred. Risk was lower in trial participants (hazard ratio 0.80; 95% CI 0.72–0.89), also after adjusting for clinical characteristics and post-MI therapies (0.85; 0.77–0.94) and additionally for SES (0.88; 0.79–0.97).
Conclusions
Clinical trial participants post-MI are more often male, have higher SES, a more advantageous risk profile, and better prognosis. Additional unmeasured participation bias was implied. Questionable external validity of post-MI trials highlights the importance of complementary studies using real-world data.
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Affiliation(s)
- Joel Ohm
- Department of Emergency Medicine, Solna, Karolinska University Hospital , Anna Steckséns gata 33 , Stockholm SE-171 76, Sweden
- Department of Medicine, Solna, Karolinska Institutet , Stockholm SE-17177, Sweden
| | - Tomas Jernberg
- Department of Clinical Sciences, Danderyd University Hospital, Karolinska Institutet , Stockholm SE-18288, Sweden
| | - David Johansson
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet , Stockholm SE-11883, Sweden
| | - Anna Warnqvist
- Division of Biostatistics, Institute of Environmental Medicine, Nobels väg 13, Karolinska Institutet , Stockholm SE-17177, Sweden
| | - Margrét Leosdottir
- Department of Cardiology, Skåne University Hospital , Jan Waldenströms gata 15, Malmö SE-20502, Sweden
- Department of Clinical Sciences Malmö, Lund University , Box 50332, Malmö SE-20213, Sweden
| | - Kristina Hambraeus
- Department of Cardiology, Falu Hospital , Lasarettsvägen, Falun SE-79182, Sweden
| | - Per Svensson
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet , Stockholm SE-11883, Sweden
- Department of Cardiology, Södersjukhuset , Sjukhusbacken 10, Stockholm SE-11883, Sweden
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Fanaroff AC, Califf RM, Harrington RA, Granger CB, McMurray JJV, Patel MR, Bhatt DL, Windecker S, Hernandez AF, Gibson CM, Alexander JH, Lopes RD. Randomized Trials Versus Common Sense and Clinical Observation: JACC Review Topic of the Week. J Am Coll Cardiol 2021; 76:580-589. [PMID: 32731936 PMCID: PMC7384793 DOI: 10.1016/j.jacc.2020.05.069] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Revised: 04/30/2020] [Accepted: 05/04/2020] [Indexed: 12/11/2022]
Abstract
Concerns about the external validity of traditional randomized clinical trials (RCTs), together with the widespread availability of real-world data and advanced data analytic tools, have led to claims that common sense and clinical observation, rather than RCTs, should be the preferred method to generate evidence to support clinical decision-making. However, over the past 4 decades, results from well-done RCTs have repeatedly contradicted practices supported by common sense and clinical observation. Common sense and clinical observation fail for several reasons: incomplete understanding of pathophysiology, biases and unmeasured confounding in observational research, and failure to understand risks and benefits of treatments within complex systems. Concerns about traditional RCT models are legitimate, but randomization remains a critical tool to understand the causal relationship between treatments and outcomes. Instead, development and promulgation of tools to apply randomization to real-world data are needed to build the best evidence base in cardiovascular medicine. Well-conducted RCTs have repeatedly contradicted practices supported by common sense and clinical observation. Common sense and clinical observation fail because of the inability to fully understand complex biopsychosocial systems. RCTs must be integrated into clinical practice to improve the evidence base in cardiology.
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Affiliation(s)
- Alexander C Fanaroff
- Penn Cardiovascular Outcomes, Quality and Evaluative Research Center, Leonard Davis Institute, and Cardiovascular Medicine Division, University of Pennsylvania, Philadelphia, Pennsylvania. https://twitter.com/ACFanaroff
| | - Robert M Califf
- Verily Life Sciences (Alphabet), South San Francisco, California
| | | | - Christopher B Granger
- Division of Cardiology and Duke Clinical Research Institute, Duke University, Durham, North Carolina
| | - John J V McMurray
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, Scotland
| | - Manesh R Patel
- Division of Cardiology and Duke Clinical Research Institute, Duke University, Durham, North Carolina
| | - Deepak L Bhatt
- Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, Massachusetts
| | - Stephan Windecker
- Department of Cardiology, Bern University Hospital, Inselspital, University of Bern, Bern, Switzerland
| | - Adrian F Hernandez
- Division of Cardiology and Duke Clinical Research Institute, Duke University, Durham, North Carolina
| | - C Michael Gibson
- Cardiovascular Division, Beth Israel Deaconess Medical, Harvard Medical School, Boston, Massachusetts
| | - John H Alexander
- Division of Cardiology and Duke Clinical Research Institute, Duke University, Durham, North Carolina
| | - Renato D Lopes
- Division of Cardiology and Duke Clinical Research Institute, Duke University, Durham, North Carolina.
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Whitelaw S, Sullivan K, Eliya Y, Alruwayeh M, Thabane L, Yancy CW, Mehran R, Mamas MA, Van Spall HGC. Trial characteristics associated with under-enrolment of females in randomized controlled trials of heart failure with reduced ejection fraction: a systematic review. Eur J Heart Fail 2020; 23:15-24. [PMID: 33118664 DOI: 10.1002/ejhf.2034] [Citation(s) in RCA: 72] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2020] [Revised: 10/20/2020] [Accepted: 10/24/2020] [Indexed: 12/11/2022] Open
Abstract
AIMS To evaluate temporal trends in the enrolment of females in randomized controlled trials (RCTs) of heart failure with reduced ejection fraction (HFrEF) published in high-impact journals, and assess RCT characteristics associated with under-enrolment. METHODS AND RESULTS We searched MEDLINE, EMBASE and CINAHL for studies published from January 2000 to May 2019 in journals with impact factor ≥10. We included RCTs that recruited adults with HFrEF. We used a 20% threshold below the sex distribution of HFrEF to define under-enrolment. We used multivariable logistic regression to assess trial characteristics independently associated with under-enrolment. We included 317 RCTs. Among the 183 097 participants, mean (standard deviation) age was 63.0 (7.0) years and 25.5% were female. Females were under-enrolled in 71.6% [95% confidence interval (CI) 66.6-76.6%] of the RCTs; enrolment did not increase significantly between 2000-2019. Sex-related eligibility criteria [odds ratio (OR) 2.05, 95% CI 1.01-4.16; P = 0.046]; recruitment in ambulatory settings (OR 2.56, 95% CI 1.37-4.81; P = 0.003); trial coordination in North America (OR 4.44, 95% CI 1.09-18.07; P = 0.037), Europe (OR 6.79, 95% CI 1.63-27.39; P = 0.018) and Asia (OR 9.33, 95% CI 1.40-12.40; P = 0.033); drug (OR 1.76, 95% CI 1.96-7.36; P < 0.001) and device/surgical interventions (OR 1.69, 95% CI 1.16-9.43; P = 0.002); and men in first and last authorship position (OR 1.32, 95% CI 1.12-3.54; P = 0.047) were associated with under-enrolment of females. CONCLUSIONS Females were under-enrolled relative to disease distribution in a majority of high-impact HFrEF RCTs, with no change in temporal trends between 2000 and 2019. Trial characteristics and gender of trial leaders were associated with under-enrolment.
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Affiliation(s)
- Sera Whitelaw
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
| | | | - Yousif Eliya
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
| | | | - Lehana Thabane
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
| | - Clyde W Yancy
- Department of Medicine, Northwestern University, Chicago, IL, USA
| | - Roxana Mehran
- Ican School of Medicine, Mount Sinai Hospital, NY, New York, USA
| | - Mamas A Mamas
- Institute of Population Health, University of Manchester, Manchester, UK.,Keele Cardiac Research Group, Centre for Prognosis Research, Keele University, Stoke-on-Trent, UK
| | - Harriette G C Van Spall
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada.,Department of Medicine, McMaster University, Hamilton, Canada.,Population Health Research Institute, Hamilton, Canada.,ICES, McMaster University, Hamilton, Canada
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Fanaroff AC, Fudim M, Califf RM, Windecker S, Smith SC, Lopes RD. Levels of evidence supporting drug, device, and other recommendations in the American Heart Association/American College of Cardiology guidelines. Am Heart J 2020; 226:4-12. [PMID: 32502881 DOI: 10.1016/j.ahj.2020.05.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Accepted: 05/02/2020] [Indexed: 12/11/2022]
Abstract
Clinical guideline documents reflect the evidence supporting clinical practice, but few recommendations in cardiovascular guidelines are supported by evidence from randomized controlled trials (RCTs), the highest level of evidence. Incentives for generating evidence from RCTs differ by topic of guideline recommendation, and it is uncertain whether evidence supporting guideline recommendations differs based on the topic of the recommendation. METHODS We abstracted recommendation statements from current ACC/AHA guideline documents (2008-2019). Two reviewers independently characterized each statement into categories based on its primary topic: pharmaceutical, device, non-invasive or minimally invasive therapeutic procedure, surgery, diagnostic invasive procedure or non-invasive imaging, laboratory, care strategies, health services or policy, history/physical examination, lifestyle or counseling. We determined the number and proportion of recommendations in each category characterized as level of evidence (LOE) A (supported by multiple RCTs), B (supported by a single RCT or observational data), and C (supported by expert opinion or limited data). RESULTS Of 2934 recommendations from 29 clinical guideline documents, 784 (26.7%) were primarily about pharmaceuticals, 503 (17.1%) diagnostic invasive procedure or non-invasive imaging, 366 (12.5%) devices, 349 (11.9%) care strategies, 274 (9.3%) surgery, 216 (7.4%) therapeutic procedures, 162 (5.5%) lifestyle interventions or counseling, 160 (5.5%) health services, care delivery, or policy, 83 (2.8%) laboratory, and 37 (1.3%) elements of the history and physical. Across all recommendations, 257 (8.8%) were characterized as LOE A, with considerable variability by topic. 25.9% of lifestyle/counseling recommendations, 16.9% of lab recommendations, and 14.7% of drug recommendations were classified as LOE A, but <8% of recommendations in all other categories, including 5.5% of device recommendations, 6.0% of therapeutic procedure recommendations, 2.6% of surgery recommendations, and 5.0% of health services or policy recommendations. CONCLUSION Less than 10% of current ACC/AHA guideline recommendations are supported by high quality evidence from RCTs, with substantial variability by topic and multiple areas with very few recommendations supported by high-quality evidence. Development and implementation of inexpensive methods for generating a higher volume of RCT evidence to support clinical practice are needed, especially in areas where there are not strong incentives to conduct RCTs.
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Affiliation(s)
- Alexander C Fanaroff
- Penn Cardiovascular Outcomes, Quality and Evaluative Research Center, Leonard Davis Institute, and Cardiovascular Medicine Division, University of Pennsylvania, Philadelphia, PA.
| | - Marat Fudim
- Division of Cardiology and Duke Clinical Research Institute, Duke University, Durham, NC, USA
| | - Robert M Califf
- Verily Life Sciences (Alphabet), South San Francisco, CA, USA
| | - Stephan Windecker
- Department of Cardiology, Inselspital, University of Bern, Bern, Switzerland
| | - Sidney C Smith
- Division of Cardiology, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Renato D Lopes
- Division of Cardiology and Duke Clinical Research Institute, Duke University, Durham, NC, USA
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Warner JJ, Crook HL, Whelan KM, Bleser WK, Roiland RA, Hamilton Lopez M, Saunders RS, Wang TY, Hernandez AF, McClellan MB, Califf RM, Brown N. Improving Cardiovascular Drug and Device Development and Evidence Through Patient-Centered Research and Clinical Trials. Circ Cardiovasc Qual Outcomes 2020; 13:e006606. [DOI: 10.1161/circoutcomes.120.006606] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
The pipeline of new cardiovascular drugs is relatively limited compared with many other clinical areas. Challenges causing lagging drug innovation include the duration and expense of cardiovascular clinical trials needed for regulatory evaluation and approvals, which generally must demonstrate noninferiority to existing standards of care and measure longer-term outcomes. By comparison, there has been substantial progress in cardiovascular device innovation. There has also been progress in cardiovascular trial participation equity in recent years, especially among women, due in part to important efforts by Food and Drug Administration, National Institutes of Health, American Heart Association, and others. Yet women and especially racial and ethnic minority populations remain underrepresented in cardiovascular trials, indicating much work ahead to continue recent success. Given these challenges and opportunities, the multistakeholder Partnering with Regulators Learning Collaborative of the Value in Healthcare Initiative, a collaboration of the American Heart Association and the Robert J. Margolis, MD, Center for Health Policy at Duke University, identified how to improve the evidence generation process for cardiovascular drugs and devices. Drawing on a series of meetings, literature reviews, and analyses of regulatory options, the Collaborative makes recommendations across four identified areas for improvement. First, we offer strategies to enhance patient engagement in trial design, convenient participation, and meaningful end points and outcomes to improve patient recruitment and retention (major expenses in clinical trials). Second, new digital technologies expand the potential for real-world evidence to streamline data collection and reduce cost and time of trials. However, technical challenges must be overcome to routinely leverage real-world data, including standardizing data, managing data quality, understanding data comparability, and ensuring real-world evidence does not worsen inequities. Third, as trials are driven by evidence needs of regulators and payers, we recommend ways to improve their collaboration in trial design to streamline and standardize efficient and innovative trials, reducing costs and delays. Finally, we discuss creative ways to expand the minuscule proportion of sites involved in cardiovascular evidence generation and medical product development. These actions, paired with continued policy research into better ways to pay for and equitably develop therapies, will help reduce the cost and complexity of drug and device research, development, and trials.
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Affiliation(s)
- John J. Warner
- University of Texas Southwestern Medical Center, Dallas (J.J.W.)
| | - Hannah L. Crook
- Robert J. Margolis, MD, Center for Health Policy, Duke University, Washington, DC and Durham, NC (H.L.C., K.M.W., W.K.B., R.A.R., M.H.L., R.S.S., M.B.M.)
| | - Karley M. Whelan
- Robert J. Margolis, MD, Center for Health Policy, Duke University, Washington, DC and Durham, NC (H.L.C., K.M.W., W.K.B., R.A.R., M.H.L., R.S.S., M.B.M.)
| | - William K. Bleser
- Robert J. Margolis, MD, Center for Health Policy, Duke University, Washington, DC and Durham, NC (H.L.C., K.M.W., W.K.B., R.A.R., M.H.L., R.S.S., M.B.M.)
| | - Rachel A. Roiland
- Robert J. Margolis, MD, Center for Health Policy, Duke University, Washington, DC and Durham, NC (H.L.C., K.M.W., W.K.B., R.A.R., M.H.L., R.S.S., M.B.M.)
| | - Marianne Hamilton Lopez
- Robert J. Margolis, MD, Center for Health Policy, Duke University, Washington, DC and Durham, NC (H.L.C., K.M.W., W.K.B., R.A.R., M.H.L., R.S.S., M.B.M.)
| | - Robert S. Saunders
- Robert J. Margolis, MD, Center for Health Policy, Duke University, Washington, DC and Durham, NC (H.L.C., K.M.W., W.K.B., R.A.R., M.H.L., R.S.S., M.B.M.)
| | - Tracy Y. Wang
- Duke University School of Medicine, Duke University, Durham, NC (T.Y.W., A.F.H.)
| | - Adrian F. Hernandez
- Duke University School of Medicine, Duke University, Durham, NC (T.Y.W., A.F.H.)
| | - Mark B. McClellan
- Robert J. Margolis, MD, Center for Health Policy, Duke University, Washington, DC and Durham, NC (H.L.C., K.M.W., W.K.B., R.A.R., M.H.L., R.S.S., M.B.M.)
| | - Robert M. Califf
- Verily Life Sciences, South San Francisco, CA (R.M.C.)
- Google Life Sciences, Palo Alto, CA (R.M.C.)
| | - Nancy Brown
- American Heart Association, Dallas, TX (N.B.)
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11
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Fanaroff AC, Califf RM, Lopes RD. New Approaches to Conducting Randomized Controlled Trials. J Am Coll Cardiol 2020; 75:556-559. [DOI: 10.1016/j.jacc.2019.11.043] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Revised: 11/17/2019] [Accepted: 11/19/2019] [Indexed: 01/08/2023]
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