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Rivelli A, Lefaiver C, Shields M, Ozoani-Lohrer O, Marek A, Hirschtick J, Fitzpatrick V. A novel approach to assessing disparity in representativeness of clinical trial participants within a large midwestern healthcare system. Contemp Clin Trials Commun 2024; 38:101274. [PMID: 38390273 PMCID: PMC10881410 DOI: 10.1016/j.conctc.2024.101274] [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: 10/02/2023] [Revised: 01/09/2024] [Accepted: 02/13/2024] [Indexed: 02/24/2024] Open
Abstract
Background Representativeness in clinical trials (CT) serves as a metric of access to healthcare and reflects differences that may determine differential efficacy of medical interventions; thus, quantifying representativeness in CT participation is critical. Methods This retrospective, descriptive study utilized patient demographic data extracted from the largest Midwestern non-profit healthcare system. Using data between January 1, 2019 and December 31, 2021, a CT Participant Sample of 4,537 system patients who were active CT participants was compared to a CT Patient Population of 195,726 system patients receiving care by the PI of active CTs, which represented the target population. Chi-square goodness-of-fit tests were used to test differences in distributions of demographic variables between groups, indicating disparity in CT participation. Two metrics adapted from literature - participation incidence disparity (PID) and participation incidence ratio (PIR) - were calculated to quantify absolute and relative disparity in representativeness proportions, respectively. Descriptive approaches to assessing representativeness are also provided. Results Results showed significant differences by race/ethnicity (χ2 = 50.64; p < 0.0001), age categories (χ2 = 56.64; p < 0.0001), and insurance (χ2 = 41.29; p < 0.0001). PID and PIR metrics revealed reduced CT participation among non-White racial/ethnic groups and increased CT participation among White Non-Hispanic patients. Further, CT participants ≥80 or Worker's Compensation were underrepresented while those with Self-Pay insurance were overrepresented as CT participants. Conclusions Despite progress, continued efforts to not only enroll participants into CTs that are representative of the healthcare system and region, but also to better assess representativeness quantitatively are still needed.
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Affiliation(s)
- Anne Rivelli
- Advocate Aurora Research Institute, Milwaukee, WI, USA
- Advocate Health, Milwaukee, WI, USA
| | - Cheryl Lefaiver
- Advocate Aurora Research Institute, Milwaukee, WI, USA
- Center for Child and Family Research, Milwaukee, WI, USA
- Advocate Health, Milwaukee, WI, USA
| | - Maureen Shields
- Advocate Aurora Research Institute, Milwaukee, WI, USA
- Advocate Health, Milwaukee, WI, USA
| | - Osondi Ozoani-Lohrer
- Advocate Aurora Research Institute, Milwaukee, WI, USA
- Center for Child and Family Research, Milwaukee, WI, USA
| | - Andy Marek
- Advocate Aurora Research Institute, Milwaukee, WI, USA
- Advocate Health, Milwaukee, WI, USA
| | - Jana Hirschtick
- Advocate Aurora Research Institute, Milwaukee, WI, USA
- Advocate Health, Milwaukee, WI, USA
| | - Veronica Fitzpatrick
- Advocate Aurora Research Institute, Milwaukee, WI, USA
- Advocate Health, Milwaukee, WI, USA
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Daitch V, Paul M, Daikos GL, Durante-Mangoni E, Yahav D, Carmeli Y, Benattar YD, Skiada A, Andini R, Eliakim-Raz N, Nutman A, Zusman O, Antoniadou A, Cavezza G, Adler A, Dickstein Y, Pavleas I, Zampino R, Bitterman R, Zayyad H, Koppel F, Zak-Doron Y, Levi I, Babich T, Turjeman A, Ben-Zvi H, Friberg LE, Mouton JW, Theuretzbacher U, Leibovici L. Excluded versus included patients in a randomized controlled trial of infections caused by carbapenem-resistant Gram-negative bacteria: relevance to external validity. BMC Infect Dis 2021; 21:309. [PMID: 33789574 PMCID: PMC8010276 DOI: 10.1186/s12879-021-05995-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Accepted: 03/17/2021] [Indexed: 01/19/2023] Open
Abstract
Background Population external validity is the extent to which an experimental study results can be generalized from a specific sample to a defined population. In order to apply the results of a study, we should be able to assess its population external validity. We performed an investigator-initiated randomized controlled trial (RCT) (AIDA study), which compared colistin-meropenem combination therapy to colistin monotherapy in the treatment of patients infected with carbapenem-resistant Gram-negative bacteria. In order to examine the study’s population external validity and to substantiate the use of AIDA study results in clinical practice, we performed a concomitant observational trial. Methods The study was conducted between October 1st, 2013 and January 31st, 2017 (during the RCTs recruitment period) in Greece, Israel and Italy. Patients included in the observational arm of the study have fulfilled clinical and microbiological inclusion criteria but were excluded from the RCT due to receipt of colistin for > 96 h, refusal to participate, or prior inclusion in the RCT. Non-randomized cases were compared to randomized patients. The primary outcome was clinical failure at 14 days of infection onset. Results Analysis included 701 patients. Patients were infected mainly with Acinetobacter baumannii [78.2% (548/701)]. The most common reason for exclusion was refusal to participate [62% (183/295)]. Non-randomized and randomized patients were similar in most of the demographic and background parameters, though randomized patients showed minor differences towards a more severe infection. Combination therapy was less common in non-randomized patients [31.9% (53/166) vs. 51.2% (208/406), p = 0.000]. Randomized patients received longer treatment of colistin [13 days (IQR 10–16) vs. 8.5 days (IQR 0–15), p = 0.000]. Univariate analysis showed that non-randomized patients were more inclined to clinical failure on day 14 from infection onset [82% (242/295) vs. 75.5% (307/406), p = 0.042]. After adjusting for other variables, non-inclusion was not an independent risk factor for clinical failure at day 14. Conclusion The similarity between the observational arm and RCT patients has strengthened our confidence in the population external validity of the AIDA trial. Adding an observational arm to intervention studies can help increase the population external validity and improve implementation of study results in clinical practice. Trial registration The trial was registered with ClinicalTrials.gov, number NCT01732250 on November 22, 2012.
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Affiliation(s)
- Vered Daitch
- Sackler Faculty of Medicine, Tel Aviv University, Ramat-Aviv, Tel Aviv, Israel. .,Department of Medicine E, Rabin Medical Center, Beilinson Hospital, Jebotinski 39, Petah Tikva, Israel.
| | - Mical Paul
- Institute of Infectious Diseases, Rambam Health Care Campus, Haifa, Israel.,The Ruth and Bruce Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Haifa, Israel
| | - George L Daikos
- First Department of Medicine, Laikon General Hospital, Athens, Greece.,National and Kapodistrian University of Athens, Athens, Greece
| | - Emanuele Durante-Mangoni
- Internal Medicine, University of Campania 'L Vanvitelli', and AORN dei Colli-Monaldi Hospital, Naples, Italy
| | - Dafna Yahav
- Sackler Faculty of Medicine, Tel Aviv University, Ramat-Aviv, Tel Aviv, Israel.,Unit of Infectious Diseases, Rabin Medical Center, Beilinson Hospital, Petah Tikva, Israel
| | - Yehuda Carmeli
- Sackler Faculty of Medicine, Tel Aviv University, Ramat-Aviv, Tel Aviv, Israel.,Division of Epidemiology and Preventive Medicine, Tel Aviv Sourasky Medical Centre, Tel Aviv, Israel.,National Institute for Antibiotic Resistance and Infection Control, Ministry of Health, Tel Aviv, Israel
| | - Yael Dishon Benattar
- Internal Medicine, University of Campania 'L Vanvitelli', and AORN dei Colli-Monaldi Hospital, Naples, Italy.,Cheryl Spencer Department of Nursing, University of Haifa, Haifa, Israel
| | - Anna Skiada
- First Department of Medicine, Laikon General Hospital, Athens, Greece.,National and Kapodistrian University of Athens, Athens, Greece
| | - Roberto Andini
- Internal Medicine, University of Campania 'L Vanvitelli', and AORN dei Colli-Monaldi Hospital, Naples, Italy
| | - Noa Eliakim-Raz
- Sackler Faculty of Medicine, Tel Aviv University, Ramat-Aviv, Tel Aviv, Israel.,Department of Medicine E, Rabin Medical Center, Beilinson Hospital, Jebotinski 39, Petah Tikva, Israel
| | - Amir Nutman
- Sackler Faculty of Medicine, Tel Aviv University, Ramat-Aviv, Tel Aviv, Israel.,National Institute for Antibiotic Resistance and Infection Control, Ministry of Health, Tel Aviv, Israel
| | - Oren Zusman
- Sackler Faculty of Medicine, Tel Aviv University, Ramat-Aviv, Tel Aviv, Israel.,Department of Medicine E, Rabin Medical Center, Beilinson Hospital, Jebotinski 39, Petah Tikva, Israel
| | - Anastasia Antoniadou
- National and Kapodistrian University of Athens, Athens, Greece.,Fourth Department of Medicine, Attikon University General Hospital, Athens, Greece
| | - Giusi Cavezza
- Internal Medicine, University of Campania 'L Vanvitelli', and AORN dei Colli-Monaldi Hospital, Naples, Italy
| | - Amos Adler
- Microbiology Laboratory, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel
| | - Yaakov Dickstein
- Institute of Infectious Diseases, Rambam Health Care Campus, Haifa, Israel
| | - Ioannis Pavleas
- Intensive Care Unit, Laikon General Hospital, Athens, Greece
| | - Rosa Zampino
- Internal Medicine, University of Campania 'L Vanvitelli', and AORN dei Colli-Monaldi Hospital, Naples, Italy
| | - Roni Bitterman
- Institute of Infectious Diseases, Rambam Health Care Campus, Haifa, Israel.,The Ruth and Bruce Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Haifa, Israel
| | - Hiba Zayyad
- Institute of Infectious Diseases, Rambam Health Care Campus, Haifa, Israel
| | - Fidi Koppel
- Institute of Infectious Diseases, Rambam Health Care Campus, Haifa, Israel
| | - Yael Zak-Doron
- Institute of Infectious Diseases, Rambam Health Care Campus, Haifa, Israel
| | - Inbar Levi
- Sackler Faculty of Medicine, Tel Aviv University, Ramat-Aviv, Tel Aviv, Israel.,National Institute for Antibiotic Resistance and Infection Control, Ministry of Health, Tel Aviv, Israel
| | - Tanya Babich
- Sackler Faculty of Medicine, Tel Aviv University, Ramat-Aviv, Tel Aviv, Israel.,Department of Medicine E, Rabin Medical Center, Beilinson Hospital, Jebotinski 39, Petah Tikva, Israel
| | - Adi Turjeman
- Sackler Faculty of Medicine, Tel Aviv University, Ramat-Aviv, Tel Aviv, Israel.,Department of Medicine E, Rabin Medical Center, Beilinson Hospital, Jebotinski 39, Petah Tikva, Israel
| | - Haim Ben-Zvi
- Clinical Microbiology Laboratory, Rabin Medical Center, Beilinson Hospital, Petah Tikva, Israel
| | - Lena E Friberg
- Department of Pharmaceutical Biosciences, Uppsala University, Uppsala, Sweden
| | - Johan W Mouton
- Department of Medical Microbiology and Infectious Diseases, Erasmus MC, Rotterdam, The Netherlands
| | | | - Leonard Leibovici
- Sackler Faculty of Medicine, Tel Aviv University, Ramat-Aviv, Tel Aviv, Israel.,Department of Medicine E, Rabin Medical Center, Beilinson Hospital, Jebotinski 39, Petah Tikva, Israel
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Kennedy-Martin T, Curtis S, Faries D, Robinson S, Johnston J. A literature review on the representativeness of randomized controlled trial samples and implications for the external validity of trial results. Trials 2015; 16:495. [PMID: 26530985 PMCID: PMC4632358 DOI: 10.1186/s13063-015-1023-4] [Citation(s) in RCA: 537] [Impact Index Per Article: 59.7] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2015] [Accepted: 10/21/2015] [Indexed: 01/13/2023] Open
Abstract
Randomized controlled trials (RCTs) are conducted under idealized and rigorously controlled conditions that may compromise their external validity. A literature review was conducted of published English language articles that reported the findings of studies assessing external validity by a comparison of the patient sample included in RCTs reporting on pharmaceutical interventions with patients from everyday clinical practice. The review focused on publications in the fields of cardiology, mental health, and oncology. A range of databases were interrogated (MEDLINE; EMBASE; Science Citation Index; Cochrane Methodology Register). Double-abstract review and data extraction were performed as per protocol specifications. Out of 5,456 de-duplicated abstracts, 52 studies met the inclusion criteria (cardiology, n = 20; mental health, n = 17; oncology, n = 15). Studies either performed an analysis of the baseline characteristics (demographic, socioeconomic, and clinical parameters) of RCT-enrolled patients compared with a real-world population, or assessed the proportion of real-world patients who would have been eligible for RCT inclusion following the application of RCT inclusion/exclusion criteria. Many of the included studies concluded that RCT samples are highly selected and have a lower risk profile than real-world populations, with the frequent exclusion of elderly patients and patients with co-morbidities. Calculation of ineligibility rates in individual studies showed that a high proportion of the general disease population was often excluded from trials. The majority of studies (n = 37 [71.2 %]) explicitly concluded that RCT samples were not broadly representative of real-world patients and that this may limit the external validity of the RCT. Authors made a number of recommendations to improve external validity. Findings from this review indicate that there is a need to improve the external validity of RCTs such that physicians treating patients in real-world settings have the appropriate evidence on which to base their clinical decisions. This goal could be achieved by trial design modification to include a more representative patient sample and by supplementing RCT evidence with data generated from observational studies. In general, a thoughtful approach to clinical evidence generation is required in which the trade-offs between internal and external validity are considered in a holistic and balanced manner.
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Affiliation(s)
- Tessa Kennedy-Martin
- Kennedy-Martin Health Outcomes Ltd, 3rd Floor, Queensberry House, 106 Queens Road, Brighton, BN1 3XF, UK.
| | - Sarah Curtis
- Eli Lilly and Company, Indianapolis, Indiana, USA.
| | | | - Susan Robinson
- Kennedy-Martin Health Outcomes Ltd, 3rd Floor, Queensberry House, 106 Queens Road, Brighton, BN1 3XF, UK.
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