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Gallagher H, Methven S, Casula A, Rayner H, Lenguerrand E, Thomas N, Dawnay A, Kennedy D, Woolnough L, Nation M, Caskey FJ. A stepped wedge cluster randomized trial of graphical surveillance of kidney function data to reduce late presentation for kidney replacement therapy. Kidney Int 2024; 106:522-531. [PMID: 38797327 DOI: 10.1016/j.kint.2024.04.020] [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: 10/30/2023] [Revised: 04/07/2024] [Accepted: 04/30/2024] [Indexed: 05/29/2024]
Abstract
Late presentation for kidney replacement therapy (KRT) is an important cause of avoidable morbidity and mortality. Here, we evaluated the effect of a complex intervention of graphical estimated glomerular filtration rate (eGFR) surveillance across 15% of the United Kingdom population on the rate of late presentation using data routinely collected by the United Kingdom Renal Registry. A stepped wedge cluster randomized trial was established across 19 sites with eGFR graphs generated from all routine blood tests (community and hospital) across the population served by each site. Graphs were reviewed by trained laboratory or clinical staff and high-risk graphs reported to family doctors. Due to delays outside the control of clinicians and researchers few laboratories activated the intervention in their randomly assigned time period, so the trial was converted to a quasi-experimental design. We studied 6,100 kidney failure events at 20 laboratories served by 17 main kidney units. A total of 63,981 graphs were sent out. After adjustment for calendar time there was no significant reduction in the rate of presentation during the intervention period. Therefore, implementation of eGFR graph surveillance did not reduce the rate of late presentation for KRT after adjustment for secular trends. Thus, graphical surveillance is an intervention aimed at reducing late presentation, but more evidence is required before adoption of this strategy can be recommended.
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Affiliation(s)
- Hugh Gallagher
- SW Thames Renal Unit, Epsom and St Helier National Health Service Trust, Carshalton, Surrey, UK.
| | - Shona Methven
- Renal Unit, Aberdeen Royal Infirmary, Foresterhill, Aberdeen, UK
| | - Anna Casula
- UK Renal Registry, Brandon House, Bristol, UK
| | - Hugh Rayner
- Retired Consultant Nephrologist, Birmingham, UK
| | - Erik Lenguerrand
- Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Nicola Thomas
- Institute of Health and Social Care, London South Bank University, London, UK
| | - Anne Dawnay
- Clinical Biochemistry, Barts Health National Health Service Trust, The Royal Hospital, London, UK
| | - David Kennedy
- Gateshead Health National Health Service Foundation Trust, QE Hospital, Tyne and Wear, UK
| | | | - Michael Nation
- Kidney Research UK, Stuart House, Peterborough, Cambridgeshire, UK
| | - Fergus J Caskey
- Population Health Science, Bristol Medical School, University of Bristol, Bristol, UK
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Mullhall P, Taggart L, McDermott G, Slater P, Fitzpatrick B, Murphy MH, Hassiotis A, Johnston A. 'Walk Buds': A walking intervention to increase physical activity, physical fitness, and emotional wellbeing, in 9-13 year old children with intellectual disabilities. Results of a clustered randomised feasibility trial. JOURNAL OF APPLIED RESEARCH IN INTELLECTUAL DISABILITIES 2024; 37:e13260. [PMID: 38937072 DOI: 10.1111/jar.13260] [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: 11/21/2023] [Revised: 04/30/2024] [Accepted: 05/26/2024] [Indexed: 06/29/2024]
Abstract
BACKGROUND Children with intellectual disability are less physically active and more sedentary than typically developing peers. To date no studies have tested the feasibility of a school-based walking intervention for children with Intellectual Disability. METHOD A clustered randomised controlled trial (cRCT), with an embedded process evaluation, was used to test the feasibility of a school-based walking intervention. Eight schools (n = 161 pupils aged 9-13 years) were randomised into either an intervention arm or an 'exercise as usual' arm. Measures included physical activity, physical fitness and emotional wellbeing. Baseline and 3-month follow-up data were collected. RESULTS The 'Walk Buds' intervention was found to be acceptable to teaching staff and pupils, with an uptake rate of the walking sessions offered of 84%. CONCLUSION A number of challenges were experienced, relating to the COVID-19 pandemic, and difficulties collecting accelerometer data. Barriers, facilitators and required changes identified through the mixed methods process evaluation are discussed.
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Affiliation(s)
- Peter Mullhall
- Institute of Nursing and Paramedic Science, Ulster University, Belfast, Northern Ireland
| | - Laurence Taggart
- Institute of Nursing and Paramedic Science, Ulster University, Belfast, Northern Ireland
| | - Gary McDermott
- Institute of Nursing and Paramedic Science, Ulster University, Belfast, Northern Ireland
| | - Paul Slater
- Institute of Nursing and Paramedic Science, Ulster University, Belfast, Northern Ireland
| | - Ben Fitzpatrick
- Institute of Nursing and Paramedic Science, Ulster University, Belfast, Northern Ireland
| | - Marie H Murphy
- The School of Sport, Ulster University, Belfast, Northern Ireland
| | - Angela Hassiotis
- Division of Psychiatry, University College London, Belfast, Northern Ireland
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Stalter L, Hanlon BM, Bushaw KJ, Kwekkeboom KL, Zelenski A, Fritz M, Buffington A, Stein DM, Cocanour CS, Robles AJ, Jansen J, Brasel K, O'Connell KM, Cipolle MD, Ayoung-Chee P, Morris R, Gelbard RB, Kozar RA, Lueckel S, Schwarze M. Best Case/Worst Case-ICU: protocol for a multisite, stepped-wedge, randomised clinical trial of scenario planning to improve communication in the ICU in US trauma centres for older adults with serious injury. BMJ Open 2024; 14:e083603. [PMID: 39209498 PMCID: PMC11367315 DOI: 10.1136/bmjopen-2023-083603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Accepted: 08/02/2024] [Indexed: 09/04/2024] Open
Abstract
INTRODUCTION Poor communication about serious injury in older adults can lead to treatment that is inconsistent with patient preferences, create conflict and strain healthcare resources. We developed a communication intervention called Best Case/Worst Case-intensive care unit (ICU) that uses daily scenario planning, that is, a narrative description of plausible futures, to support prognostication and facilitate dialogue among patients, their families and the trauma ICU team. This article describes a protocol for a multisite, randomised, stepped-wedge study to test the effectiveness of the intervention on the quality of communication (QOC) in the ICU. METHODS AND ANALYSIS We will follow all patients aged 50 and older admitted to the trauma ICU for 3 or more days after a serious injury at eight high-volume level 1 trauma centres. We aim to survey one family or 'like family' member per eligible patient 5-7 days following their loved ones' admission and clinicians providing care in the trauma ICU. Using a stepped-wedge design, we will use permuted block randomisation to assign the timing for each site to begin implementation of the intervention and routine use of the Best Case/Worst Case-ICU tool. We will use a linear mixed-effects model to test the effect of the tool on family-reported QOC (using the QOC scale) as compared with usual care. Secondary outcomes include the effect of the tool on reducing clinician moral distress (using the Measure of Moral Distress for Healthcare Professionals scale) and patients' length of stay in the ICU. ETHICS AND DISSEMINATION Institutional review board (IRB) approval was granted at the University of Wisconsin, and all study sites ceded review to the primary IRB. We plan to report results in peer-reviewed publications and national meetings. TRIAL REGISTRATION NUMBER NCT05780918.
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Affiliation(s)
- Lily Stalter
- Department of Surgery, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Bret M Hanlon
- Department of Surgery, University of Wisconsin-Madison, Madison, Wisconsin, USA
- Department of Biostatistics & Medical Informatics, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Kyle J Bushaw
- Department of Surgery, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | | | - Amy Zelenski
- Department of Medicine, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Melanie Fritz
- Department of Surgery, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Anne Buffington
- Department of Surgery, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Deborah M Stein
- Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | | | - Anamaria J Robles
- Department of Surgery, University of California Davis, Davis, California, USA
| | - Jan Jansen
- Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Karen Brasel
- School of Medicine, Oregon Health and Science University, Portland, Oregon, USA
| | | | - Mark D Cipolle
- Division of Trauma-Surgical Critical Care, Lehigh Valley Health Network, Allentown, Pennsylvania, USA
| | - Patricia Ayoung-Chee
- Department of Surgery, Morehouse School of Medicine, Morehouse School of Medicine, Atlanta, Georgia, USA
| | - Rachel Morris
- Department of Surgery, Division of Trauma and Acute Care Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Rondi B Gelbard
- Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Rosemary A Kozar
- Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Stephanie Lueckel
- Division of Acute Care Surgery and Surgical Critical Care, Brown University, Providence, Rhode Island, USA
| | - Margaret Schwarze
- Department of Surgery, University of Wisconsin-Madison, Madison, Wisconsin, USA
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Vrachnis N, Antonakopoulos N, von Dadelszen P, Vidler M, Maroudias G, Bone J, Sandhu A, Loukas N, Magee L, Roussos N, Kassaris S, Fotiou A, Zygouris D, Adonakis G, Akrivis C, Antsaklis A, Athanasiadis A, Bontis N, Daniilidis A, Daponte A, Daskalakis G, Deligeoroglou E, Dinas K, Drakakis P, Gerede A, Grimbizis G, Iacovidou N, Kambas N, Katasos T, Katsetos C, Katsikis I, Makrigiannakis A, Matalliotakis M, Messini C, Mikos T, Nikolettos N, Pados G, Paschopoulos M, Patsouras K, Siahanidou S, Sioulas V, Skentou C, Stavros S, Temmerman M, Tsikouras P, Tsitsis V, Vlahos N, Rodolakis A, Papageorghiou A, Loutradis D. ENhancinG vAGinal dElivery in Greece through educational and behavioral interventions among maternity care providers regarding labor management: the ENGAGE stepped-wedge randomized prospective trial protocol. Trials 2024; 25:548. [PMID: 39155367 PMCID: PMC11331648 DOI: 10.1186/s13063-024-08263-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Accepted: 06/18/2024] [Indexed: 08/20/2024] Open
Abstract
BACKGROUND There is an emerging need to systematically investigate the causes for the increased cesarean section rates in Greece and undertake interventions so as to substantially reduce its rates. To this end, the ability of the participating Greek obstetricians to follow evidence-based guidelines and respond to other educational and behavioral interventions while managing labor will be explored, along with barriers and enablers. Herein discussed is the protocol of a stepped-wedge designed intervention trial in Greek maternity units with the aforementioned goals in mind, named ENGAGE (ENhancinG vAGinal dElivery in Greece). METHODS Twenty-two selected maternity units in Greece will participate in a multicenter stepped-wedge randomized prospective trial involving 20,000 to 25,000 births, with two of them entering the intervention period of the study each month (stepped randomization). The maternity care units entering the study will apply the suggested interventions for a period of 8-18 months depending on the time they enter the intervention stage of the study. There will also be an initial phase of the study lasting from 8 to 18 months including observation and recording of the routine practice (cesarean section, vaginal birth, and maternal and perinatal morbidity and mortality) in the participating units. The second phase, the intervention period, will include such interventions as the application of the HSOG (the Hellenic Society of Obstetrics and Gynecology) Guidelines on labor management, training on the correct interpretation of cardiotocography, and dealing with emergencies in vaginal deliveries, while the steering committee members will be available to discuss and implement organizational and behavioral changes, answer questions, clarify relevant issues, and provide practical instructions to the participating healthcare professionals during regular visits or video conferences. Furthermore, during the study, the results will be available for the participating units in order for them to monitor their own performance while also receiving feedback regarding their rates. Τhe final 2-month phase of the study will be devoted to completing follow-up questionnaires with data concerning maternal and neonatal morbidities that occurred after the completion of the intervention period. The total duration of the study is estimated at 28 months. The primary outcome assessed will be the cesarean section rate change and the secondary outcomes will be maternal and neonatal morbidity and mortality. DISCUSSION The study is expected to yield new information on the effects, advantages, possibilities, and challenges of consistent clinical engagement and implementation of behavioral, educational, and organizational interventions described in detail in the protocol on cesarean section practice in Greece. The results may lead to new insights into means of improving the quality of maternal and neonatal care, particularly since this represents a shared effort to reduce the high cesarean section rates in Greece and, moreover, points the way to their reduction in other countries. TRIAL REGISTRATION NCT04504500 (ClinicalTrials.gov). The trial was prospectively registered. Ethics Reference No: 320/23.6.2020, Bioethics and Conduct Committee, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece.
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Affiliation(s)
- Nikolaos Vrachnis
- 3rd Department of Obstetrics and Gynecology of the University of Athens, Attikon Hospital, Athens, Greece.
- St George's University Hospital NHS Foundation trust, London, UK.
| | - Nikolaos Antonakopoulos
- Department of Obstetrics and Gynecology of the University of Patras, University Hospital of Patras, Patras, Greece
| | - Peter von Dadelszen
- Department of Women and Children's Health, School of Life Course Sciences, Institute of Women and Children's Health, King's Health Partners Academic Health Science Centre, King's College London, London, UK
| | - Marianne Vidler
- Women's Health Research Institute/Medicine, Department of Maternal and Fetal Medicine & Pediatric Anesthesia, University of British Columbia, Vancouver, Canada
| | - Georgios Maroudias
- Department of Obstetrics and Gynecology, Tzaneio General Hospital of Piraeus, Piraeus, Greece
| | - Jeffrey Bone
- B.C. Women's and Children's Hospital, University of British Columbia, Vancouver, Canada
| | - Ash Sandhu
- Women's Health Research Institute/Medicine, Department of Maternal and Fetal Medicine & Pediatric Anesthesia, University of British Columbia, Vancouver, Canada
| | - Nikolaos Loukas
- Department of Obstetrics and Gynecology, Tzaneio General Hospital of Piraeus, Piraeus, Greece
| | | | - Nikolaos Roussos
- 1st Department of Obstetrics and Gynecology of the University of Thessaloniki, Papageorgiou Hospital, Thessaloniki, Greece
| | - Stefania Kassaris
- Faculty of Medicine, University of British Columbia, Vancouver, Canada
| | - Alexandros Fotiou
- 3rd Department of Obstetrics and Gynecology of the University of Athens, Attikon Hospital, Athens, Greece
| | | | - Georgios Adonakis
- Department of Obstetrics and Gynecology of the University of Patras, University Hospital of Patras, Patras, Greece
| | | | - Aris Antsaklis
- Department of Obstetrics and Gynecology, Iaso Hospital, Athens, Greece
| | - Apostolos Athanasiadis
- 3rd Department of Obstetrics and Gynecology of the University of Thessaloniki, Ippokratio Hospital, Thessaloniki, Greece
| | | | - Angelos Daniilidis
- 2nd Department of Obstetrics and Gynecology of the University of Thessaloniki, Ippokratio Hospital, Thessaloniki, Greece
| | - Alexandros Daponte
- Department of Obstetrics and Gynecology of the University of Larissa, University Hospital of Larissa, Larissa, Greece
| | - Georgios Daskalakis
- 1st Department of Obstetrics and Gynecology of the University of Athens, Alexandra Hospital, Athens, Greece
| | - Efthimios Deligeoroglou
- 2nd Department of Obstetrics and Gynecology of the University of Athens, Aretaieion Hospital, Athens, Greece
| | - Konstantinos Dinas
- 2nd Department of Obstetrics and Gynecology of the University of Thessaloniki, Ippokratio Hospital, Thessaloniki, Greece
| | - Peter Drakakis
- 3rd Department of Obstetrics and Gynecology of the University of Athens, Attikon Hospital, Athens, Greece
| | - Angeliki Gerede
- Department of Obstetrics and Gynecology of the University of Thrace, University Hospital of Alexandroupolis, Alexandroupolis, Greece
| | - Grigorios Grimbizis
- 1st Department of Obstetrics and Gynecology of the University of Thessaloniki, Papageorgiou Hospital, Thessaloniki, Greece
| | - Nicoletta Iacovidou
- Department of Neonatology of the University of Athens, Aretaieion Hospital, Athens, Greece
| | - Nikolaos Kambas
- Department of Obstetrics and Gynecology, Hospital of Corinth, Corinth, Greece
| | - Theodoros Katasos
- Department of Obstetrics and Gynecology, Hospital of Agios Nikolaos, Agios Nikolaos, Greece
| | - Christos Katsetos
- Department of Obstetrics and Gynecology, Tzaneio General Hospital of Piraeus, Piraeus, Greece
| | - Ilias Katsikis
- Department of Obstetrics and Gynecology, Viokliniki Hospital, Thessaloniki, Greece
| | - Antonios Makrigiannakis
- Department of Obstetrics and Gynecology of the University of Crete, University Hospital of Heraklion, Heraklion, Greece
| | - Michail Matalliotakis
- Department of Obstetrics and Gynecology, Venizeleio General Hospital of Heraklion, Heraklion, Greece
| | - Christina Messini
- Department of Obstetrics and Gynecology of the University of Larissa, University Hospital of Larissa, Larissa, Greece
| | - Themis Mikos
- 1st Department of Obstetrics and Gynecology of the University of Thessaloniki, Papageorgiou Hospital, Thessaloniki, Greece
| | - Nikolaos Nikolettos
- Department of Obstetrics and Gynecology of the University of Thrace, University Hospital of Alexandroupolis, Alexandroupolis, Greece
| | - Georgios Pados
- Department of Obstetrics and Gynecology, Diavalkanikon Hospital, Thessaloniki, Greece
| | - Minas Paschopoulos
- Department of Obstetrics and Gynecology of the University of Ioannina, University Hospital of Ioannina, Ioannina, Greece
| | - Konstantinos Patsouras
- Department of Obstetrics and Gynecology, Tzaneio General Hospital of Piraeus, Piraeus, Greece
| | - Soultana Siahanidou
- Neonatal Unit, First Department of Pediatrics, Athens University Medical School, Athens, Greece
| | - Vasileios Sioulas
- Department of Obstetrics and Gynecology, Mitera Hospital, Athens, Greece
| | - Chara Skentou
- Department of Obstetrics and Gynecology of the University of Ioannina, University Hospital of Ioannina, Ioannina, Greece
| | - Sofoklis Stavros
- 3rd Department of Obstetrics and Gynecology of the University of Athens, Attikon Hospital, Athens, Greece
| | - Marleen Temmerman
- Department of Obstetrics & Gynaecology, Aga Khan University Hospital, Nairobi, Kenya
| | - Panagiotis Tsikouras
- Department of Obstetrics and Gynecology of the University of Thrace, University Hospital of Alexandroupolis, Alexandroupolis, Greece
| | - Vasilios Tsitsis
- Department of Obstetrics and Gynecology, Hospital of Pyrgos, Pyrgos, Greece
| | - Nikolaos Vlahos
- 2nd Department of Obstetrics and Gynecology of the University of Athens, Aretaieion Hospital, Athens, Greece
| | - Alexandros Rodolakis
- 1st Department of Obstetrics and Gynecology of the University of Athens, Alexandra Hospital, Athens, Greece
| | - Aris Papageorghiou
- St George's University Hospital NHS Foundation trust, London, UK
- Nuffield Department of Women's & Reproductive Health, University of Oxford, Oxford, UK
| | - Dimitrios Loutradis
- 1st Department of Obstetrics and Gynecology of the University of Athens, Alexandra Hospital, Athens, Greece
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Van Houtven CH, Coffman CJ, Decosimo K, Grubber JM, Dadolf J, Sullivan C, Tucker M, Bruening R, Sperber NR, Stechuchak KM, Shepherd-Banigan M, Boucher N, Ma JE, Kaufman BG, Colón-Emeric CS, Jackson GL, Damush TM, Christensen L, Wang V, Allen KD, Hastings SN. A stepped wedge cluster randomized trial to evaluate the effectiveness of a multisite family caregiver skills training program. Health Serv Res 2024. [PMID: 39137974 DOI: 10.1111/1475-6773.14326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/15/2024] Open
Abstract
OBJECTIVE To assess the effects of an evidence-based family caregiver training program (implementation of Helping Invested Families Improve Veteran Experiences Study [iHI-FIVES]) in the Veterans Affairs healthcare system on Veteran days not at home and family caregiver well-being. DATA SOURCES AND STUDY SETTING Participants included Veterans referred to home- and community-based services with an identified caregiver across 8 medical centers and confirmed family caregivers of eligible Veterans. STUDY DESIGN In a stepped wedge cluster randomized trial, sites were randomized to a 6-month time interval for starting iHI-FIVES and received standardized implementation support. The primary outcome, number of Veteran "days not at home," and secondary outcomes, changes over 3 months in measures of caregiver well-being, were compared between pre- and post-iHI-FIVES intervals using generalized linear models including covariates. DATA COLLECTION/EXTRACTION METHODS Patient data were extracted from the electronic health record. Caregiver data were collected from 2 telephone-based surveys. PRINCIPAL FINDINGS Overall, n = 898 eligible Veterans were identified across pre-iHI-FIVES (n = 327) and post-iHI-FIVES intervals (n = 571). Just under one fifth (17%) of Veterans in post-iHI-FIVES intervals had a caregiver enroll in iHI-FIVES. Veteran and caregiver demographics in pre-iHI-FIVES intervals were similar to those in post-iHI-FIVES intervals. In adjusted models, the estimated rate of days not at home over 6-months was 42% lower (rate ratio = 0.58 [95% confidence interval: 0.31-1.09; p = 0.09]) post-iHI-FIVES compared with pre-iHI-FIVES. The estimated mean days not at home over a 6-month period was 13.0 days pre-iHI-FIVES and 7.5 post-iHI-FIVES. There were no differences between pre- and post-iHI-FIVES in change over 3 months in caregiver well-being measures. CONCLUSIONS Reducing days not at home is consistent with effectiveness because more time at home increases quality of life. In this study, after adjusting for Veteran characteristics, we did not find evidence that implementation of a caregiver training program yielded a reduction in Veteran's days not at home.
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Affiliation(s)
- Courtney Harold Van Houtven
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, North Carolina, USA
- Department of Population Health Sciences, Duke University, Durham, North Carolina, USA
- Margolis Institute for Health Policy, Duke University, Durham, North Carolina, USA
| | - Cynthia J Coffman
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, North Carolina, USA
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina, USA
| | - Kasey Decosimo
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, North Carolina, USA
| | - Janet M Grubber
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, North Carolina, USA
- Cooperative Studies Program Coordinating Center, VHA Boston Health Care System, Boston, Massachusetts, USA
| | - Joshua Dadolf
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, North Carolina, USA
| | - Caitlin Sullivan
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, North Carolina, USA
| | - Matthew Tucker
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, North Carolina, USA
| | - Rebecca Bruening
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, North Carolina, USA
| | - Nina R Sperber
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, North Carolina, USA
- Department of Population Health Sciences, Duke University, Durham, North Carolina, USA
| | - Karen M Stechuchak
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, North Carolina, USA
| | - Megan Shepherd-Banigan
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, North Carolina, USA
- Department of Population Health Sciences, Duke University, Durham, North Carolina, USA
- Margolis Institute for Health Policy, Duke University, Durham, North Carolina, USA
| | - Nathan Boucher
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, North Carolina, USA
- Department of Population Health Sciences, Duke University, Durham, North Carolina, USA
- Margolis Institute for Health Policy, Duke University, Durham, North Carolina, USA
- Sanford School of Public Policy, Duke University, Durham, North Carolina, USA
- Center for the Study of Aging, Duke University School of Medicine, Durham, North Carolina, USA
| | - Jessica E Ma
- Peter O'Donnell Jr. School of Public Health, University of Texas Southwestern Medical Center, Dallas, Texas, USA
- Geriatric Research, Education, and Clinical Center, Durham VA Health Care System, Durham, North Carolina, USA
| | - Brystana G Kaufman
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, North Carolina, USA
- Department of Population Health Sciences, Duke University, Durham, North Carolina, USA
- Margolis Institute for Health Policy, Duke University, Durham, North Carolina, USA
| | - Cathleen S Colón-Emeric
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, North Carolina, USA
- Center for the Study of Aging, Duke University School of Medicine, Durham, North Carolina, USA
- Peter O'Donnell Jr. School of Public Health, University of Texas Southwestern Medical Center, Dallas, Texas, USA
- Geriatric Research, Education, and Clinical Center, Durham VA Health Care System, Durham, North Carolina, USA
| | - George L Jackson
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, North Carolina, USA
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Teresa M Damush
- Health Services Research and Development Center for Health Information and Communication, Richard L. Roudebush VA Medical Center, Indianapolis, Indiana, USA
- Department of General Internal Medicine and Geriatrics, Indiana University School of Medicine, Indianapolis, Indiana, USA
- Regenstrief Institute, Inc, Indianapolis, Indiana, USA
| | - Leah Christensen
- Veteran's Health Administration Central Office, Washington, DC, USA
| | - Virginia Wang
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, North Carolina, USA
- Department of Population Health Sciences, Duke University, Durham, North Carolina, USA
- Margolis Institute for Health Policy, Duke University, Durham, North Carolina, USA
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Kelli D Allen
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, North Carolina, USA
- Division of Rheumatology, Allergy, and Immunology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Susan N Hastings
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, North Carolina, USA
- Department of Population Health Sciences, Duke University, Durham, North Carolina, USA
- Center for the Study of Aging, Duke University School of Medicine, Durham, North Carolina, USA
- Peter O'Donnell Jr. School of Public Health, University of Texas Southwestern Medical Center, Dallas, Texas, USA
- Geriatric Research, Education, and Clinical Center, Durham VA Health Care System, Durham, North Carolina, USA
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6
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Salway R, Jago R, de Vocht F, House D, Porter A, Walker R, Kipping R, Owen CG, Hudda MT, Northstone K, van Sluijs E. School-level intra-cluster correlation coefficients and autocorrelations for children's accelerometer-measured physical activity in England by age and gender. BMC Med Res Methodol 2024; 24:179. [PMID: 39123109 PMCID: PMC11313128 DOI: 10.1186/s12874-024-02290-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Accepted: 07/17/2024] [Indexed: 08/12/2024] Open
Abstract
BACKGROUND Randomised, cluster-based study designs in schools are commonly used to evaluate children's physical activity interventions. Sample size estimation relies on accurate estimation of the intra-cluster correlation coefficient (ICC), but published estimates, especially using accelerometry-measured physical activity, are few and vary depending on physical activity outcome and participant age. Less commonly-used cluster-based designs, such as stepped wedge designs, also need to account for correlations over time, e.g. cluster autocorrelation (CAC) and individual autocorrelation (IAC), but no estimates are currently available. This paper estimates the school-level ICC, CAC and IAC for England children's accelerometer-measured physical activity outcomes by age group and gender, to inform the design of future school-based cluster trials. METHODS Data were pooled from seven large English datasets of accelerometer-measured physical activity data between 2002-18 (> 13,500 pupils, 540 primary and secondary schools). Linear mixed effect models estimated ICCs for weekday and whole week for minutes spent in moderate-to-vigorous physical activity (MVPA) and being sedentary for different age groups, stratified by gender. The CAC (1,252 schools) and IAC (34,923 pupils) were estimated by length of follow-up from pooled longitudinal data. RESULTS School-level ICCs for weekday MVPA were higher in primary schools (from 0.07 (95% CI: 0.05, 0.10) to 0.08 (95% CI: 0.06, 0.11)) compared to secondary (from 0.04 (95% CI: 0.03, 0.07) to (95% CI: 0.04, 0.10)). Girls' ICCs were similar for primary and secondary schools, but boys' were lower in secondary. For all ages, combined the CAC was 0.60 (95% CI: 0.44-0.72), and the IAC was 0.46 (95% CI: 0.42-0.49), irrespective of follow-up time. Estimates were higher for MVPA vs sedentary time, and for weekdays vs the whole week. CONCLUSIONS Adequately powered studies are important to evidence effective physical activity strategies. Our estimates of the ICC, CAC and IAC may be used to plan future school-based physical activity evaluations and were fairly consistent across a range of ages and settings, suggesting that results may be applied to other high income countries with similar school physical activity provision. It is important to use estimates appropriate to the study design, and that match the intended study population as closely as possible.
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Affiliation(s)
- Ruth Salway
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK.
| | - Russell Jago
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- The National Institute for Health Research, Applied Research Collaboration West (NIHR ARC West), University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
- NIHR Bristol Biomedical Research Centre, University Hospitals Bristol and Weston NHS Foundation Trust and University of Bristol, Bristol, UK
| | - Frank de Vocht
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- The National Institute for Health Research, Applied Research Collaboration West (NIHR ARC West), University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Danielle House
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Alice Porter
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- NIHR Bristol Biomedical Research Centre, University Hospitals Bristol and Weston NHS Foundation Trust and University of Bristol, Bristol, UK
| | - Robert Walker
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Ruth Kipping
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Christopher G Owen
- Population Health Research Institute, St George's, University of London, London, UK
| | - Mohammed T Hudda
- Department of Population Health, Dasman Diabetes Institute, Kuwait City, Kuwait
| | - Kate Northstone
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Esther van Sluijs
- MRC Epidemiology Unit, School of Clinical Medicine, University of Cambridge, Cambridge, UK
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Haider S, Ott E, Moore A, Rankin K, Campbell R, Mohanty N, Gemkow JW, Caskey R. Linking inter-professional newborn and contraception care (LINCC) trial: Protocol for a stepped wedge cluster randomized trial to link postpartum contraception care with routine well-baby visits. Contemp Clin Trials 2024; 145:107659. [PMID: 39121991 DOI: 10.1016/j.cct.2024.107659] [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: 03/25/2024] [Revised: 07/24/2024] [Accepted: 08/06/2024] [Indexed: 08/12/2024]
Abstract
BACKGROUND Pregnancies conceived within 18 months of a prior delivery (termed short inter-pregnancy interval [IPI]) place mothers and infants at high risk for poor health outcomes. Despite this, nearly one third of U.S. women experience a short IPI. OBJECTIVE To address the gap in the current model of postpartum (PP) contraception care by developing and implementing a novel approach to link (co-schedule) PP contraception care with newborn well-baby care to improve access to timely PP contraception. METHODS The LINCC Trial will take place in seven clinical locations across five community health centers within the U.S. PP patients (planned n = 3150) who are attending a Well-Baby Visit between 0 and 6 months will be enrolled. The LINCC Trial aims to leverage the Electronic Health Record to prompt providers to ask PP patients attending a Well-Baby Visit about their PP contraception needs and facilitate co-scheduling of PP contraception care with routine newborn care visits. The study includes a cluster randomized, cross-sectional stepped wedge design to roll out the intervention across the seven sites. The outcomes of the study include receipt of most or moderately effective methods of contraception by two and six months PP; and rate of short IPI pregnancies. Implementation outcomes will be assessed at baseline and 6 months after site enters intervention period. CONCLUSIONS The LINCC Trial seeks to evaluate the effectiveness and feasibility of a linked care model in comparison to usual care.
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Affiliation(s)
- Sadia Haider
- Rush University Medical Center, 1653 W Congress Parkway, Chicago, IL, 60612, United States.
| | - Emily Ott
- Rush University Medical Center, 1653 W Congress Parkway, Chicago, IL, 60612, United States
| | - Amy Moore
- The University of Chicago, 5841 S. Maryland Ave., MC 2050, Chicago, IL, 60637, United States
| | - Kristin Rankin
- The University of Illinois at Chicago, 820 S. Wood Street, MC 808, Chicago, IL, 60612, United States
| | - Rebecca Campbell
- The University of Illinois at Chicago, 820 S. Wood Street, MC 808, Chicago, IL, 60612, United States
| | - Nivedita Mohanty
- AllianceChicago, 225 W. Illinois Street, 5(th) Floor, Chicago, IL, 60654, United States
| | - Jena Wallander Gemkow
- AllianceChicago, 225 W. Illinois Street, 5(th) Floor, Chicago, IL, 60654, United States
| | - Rachel Caskey
- The University of Illinois at Chicago, 820 S. Wood Street, MC 808, Chicago, IL, 60612, United States
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8
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Bowden RA, Kasza J, Forbes AB. A simple and effective method for simulating nested exchangeable correlated binary data for longitudinal cluster randomised trials. BMC Med Res Methodol 2024; 24:174. [PMID: 39118054 PMCID: PMC11308151 DOI: 10.1186/s12874-024-02285-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 07/15/2024] [Indexed: 08/10/2024] Open
Abstract
BACKGROUND Simulation is an important tool for assessing the performance of statistical methods for the analysis of data and for the planning of studies. While methods are available for the simulation of correlated binary random variables, all have significant practical limitations for simulating outcomes from longitudinal cluster randomised trial designs, such as the cluster randomised crossover and the stepped wedge trial designs. For these trial designs as the number of observations in each cluster increases these methods either become computationally infeasible or their range of allowable correlations rapidly shrinks to zero. METHODS In this paper we present a simple method for simulating binary random variables with a specified vector of prevalences and correlation matrix. This method allows for the outcome prevalence to change due to treatment or over time, and for a 'nested exchangeable' correlation structure, in which observations in the same cluster are more highly correlated if they are measured in the same time period than in different time periods, and where different individuals are measured in each time period. This means that our method is also applicable to more general hierarchical clustered data contexts, such as students within classrooms within schools. The method is demonstrated by simulating 1000 datasets with parameters matching those derived from data from a cluster randomised crossover trial assessing two variants of stress ulcer prophylaxis. RESULTS Our method is orders of magnitude faster than the most well known general simulation method while also allowing a much wider range of correlations than alternative methods. An implementation of our method is available in an R package NestBin. CONCLUSIONS This simulation method is the first to allow for practical and efficient simulation of large datasets of binary outcomes with the commonly used nested exchangeable correlation structure. This will allow for much more effective testing of designs and inference methods for longitudinal cluster randomised trials with binary outcomes.
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Affiliation(s)
- Rhys A Bowden
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia.
| | - Jessica Kasza
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Andrew B Forbes
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
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9
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Wang J, Cao J, Ahn C, Zhang S. A Bayesian adaptive design approach for stepped-wedge cluster randomized trials. Clin Trials 2024; 21:440-450. [PMID: 38240270 PMCID: PMC11261240 DOI: 10.1177/17407745231221438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/24/2024]
Abstract
BACKGROUND The Bayesian group sequential design has been applied widely in clinical studies, especially in Phase II and III studies. It allows early termination based on accumulating interim data. However, to date, there lacks development in its application to stepped-wedge cluster randomized trials, which are gaining popularity in pragmatic trials conducted by clinical and health care delivery researchers. METHODS We propose a Bayesian adaptive design approach for stepped-wedge cluster randomized trials, which makes adaptive decisions based on the predictive probability of declaring the intervention effective at the end of study given interim data. The Bayesian models and the algorithms for posterior inference and trial conduct are presented. RESULTS We present how to determine design parameters through extensive simulations to achieve desired operational characteristics. We further evaluate how various design factors, such as the number of steps, cluster size, random variability in cluster size, and correlation structures, impact trial properties, including power, type I error, and the probability of early stopping. An application example is presented. CONCLUSION This study presents the incorporation of Bayesian adaptive strategies into stepped-wedge cluster randomized trials design. The proposed approach provides the flexibility to stop the trial early if substantial evidence of efficacy or futility is observed, improving the flexibility and efficiency of stepped-wedge cluster randomized trials.
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Affiliation(s)
- Jijia Wang
- Department of Applied Clinical Research, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Jing Cao
- Department of Statistics and Data Science, Southern Methodist University, Dallas, TX, USA
| | - Chul Ahn
- Peter O’Donnell Jr. School of Public Health, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Song Zhang
- Peter O’Donnell Jr. School of Public Health, University of Texas Southwestern Medical Center, Dallas, TX, USA
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10
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Voldal EC, Kenny A, Xia F, Heagerty P, Hughes JP. Robust analysis of stepped wedge trials using composite likelihood models. Stat Med 2024; 43:3326-3352. [PMID: 38837431 PMCID: PMC11257102 DOI: 10.1002/sim.10120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Revised: 05/02/2024] [Accepted: 05/09/2024] [Indexed: 06/07/2024]
Abstract
Stepped wedge trials (SWTs) are a type of cluster randomized trial that involve repeated measures on clusters and design-induced confounding between time and treatment. Although mixed models are commonly used to analyze SWTs, they are susceptible to misspecification particularly for cluster-longitudinal designs such as SWTs. Mixed model estimation leverages both "horizontal" or within-cluster information and "vertical" or between-cluster information. To use horizontal information in a mixed model, both the mean model and correlation structure must be correctly specified or accounted for, since time is confounded with treatment and measurements are likely correlated within clusters. Alternative non-parametric methods have been proposed that use only vertical information; these are more robust because between-cluster comparisons in a SWT preserve randomization, but these non-parametric methods are not very efficient. We propose a composite likelihood method that focuses on vertical information, but has the flexibility to recover efficiency by using additional horizontal information. We compare the properties and performance of various methods, using simulations based on COVID-19 data and a demonstration of application to the LIRE trial. We found that a vertical composite likelihood model that leverages baseline data is more robust than traditional methods, and more efficient than methods that use only vertical information. We hope that these results demonstrate the potential value of model-based vertical methods for SWTs with a large number of clusters, and that these new tools are useful to researchers who are concerned about misspecification of traditional models.
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Affiliation(s)
| | - Avi Kenny
- Department of Biostatistics & Bioinformatics, Duke University, North Carolina, US
- Global Health Institute, Duke University, North Carolina, US
| | - Fan Xia
- Department of Epidemiology & Biostatistics, University of California San Francisco, California, US
| | - Patrick Heagerty
- Department of Biostatistics, University of Washington, Washington, US
| | - James P. Hughes
- Department of Biostatistics, University of Washington, Washington, US
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11
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Kennedy KA, Snow AL, Mills WL, Haigh S, Mochel A, Curyto K, Bishop T, Hartmann CW, Camp CJ, Hilgeman MM. Implementing Montessori approaches after training: A mixed methods study to examine staff understanding and movement toward action. DEMENTIA 2024:14713012241263712. [PMID: 39039035 DOI: 10.1177/14713012241263712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/24/2024]
Abstract
Background: This paper uses Normalization Process Theory (NPT) to examine staff impressions of Montessori-based program training and implementation at Veterans Affairs Community Living Centers (VA CLCs; nursing homes). Methods: We conducted a mixed-methods evaluation of Montessori Approaches to Person-Centered Care (MAP-VA) at eight VA CLCs. Trainings were conducted as either a live virtual course or a pre-recorded asynchronous class. Two NPT constructs, coherence building and cognitive participation, informed qualitative interview questions, surveys, and analyses focused on staff movement from knowledge to action during initial implementation. Data collection included staff-completed standardized post-training exams (N = 906), post-training evaluations (N = 761), and optional validated surveys on perceptions of Montessori training (N = 307). Champions (peer-leaders) from each CLC completed semi-structured qualitative interviews post-training (N = 22). Findings: The majority of staff (83%-90%) passed all courses. Staff evaluated the training highly (80%+ agreement) on learning relevant new knowledge and confidence applying new skills. On average, staff felt MAP-VA would become a normal part of their work (7.68/10 scale), and reported increased familiarity with Montessori approaches after training (p = .002). Qualitative interview data from staff trained in Montessori supported three themes concordant with the NPT dimensions of coherence building and cognitive participation. (1) Coherence regarding Montessori: staff demonstrated an understanding of the program and mentioned the benefits of Montessori compared to their previous usual routines. Cognitive participation or engagement with Montessori: (2) staff had positive feelings about Montessori principles/applications and demonstrated a willingness to try the Montessori approach, and (3) staff made sense of the new intervention through early rehearsal of Montessori principles/practices and recognized opportunities for using Montessori in future interactions. Conclusions: Montessori virtual training resulted in high levels of coherence and cognitive participation among multidisciplinary staff, evidenced by high knowledge, self-efficacy, and readiness to act. The asynchronous and synchronous trainings were accessible, relevant, and supported diverse learners.
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Affiliation(s)
- Katherine A Kennedy
- Center for Innovation in Long-Term Services and Supports, Providence VA Medical Center, USA
| | - A Lynn Snow
- Research & Development Service, Tuscaloosa VA Medical Center, USA; Department of Psychology & Alabama Research Institute on Aging, The University of Alabama, USA
| | - Whitney L Mills
- Center for Innovation in Long-Term Services and Supports, Providence VA Medical Center, USA; Department of Health Services, Policy & Practice, Brown University School of Public Health, USA
| | - Sylvia Haigh
- Center for Innovation in Long-Term Services and Supports, Providence VA Medical Center, USA
| | - Amy Mochel
- Center for Innovation in Long-Term Services and Supports, Providence VA Medical Center, USA
| | - Kimberly Curyto
- Center for Integrated Healthcare, VA Western NY Healthcare System, USA
| | - Teddy Bishop
- Research & Development Service, Tuscaloosa VA Medical Center, USA
| | - Christine W Hartmann
- Center for Healthcare Organization and Implementation Research, VA Edith Nourse Rogers Memorial Veterans Hospital, USA; Department of Public Health, Zuckerberg College of Health Sciences, University of Massachusetts Lowell, USA
| | | | - Michelle M Hilgeman
- Research & Development Service, Tuscaloosa VA Medical Center, USA; Department of Psychology & Alabama Research Institute on Aging, The University of Alabama, USA; Division of Gerontology, Geriatrics, & Palliative Care, Department of Medicine, The University of Alabama at Birmingham, USA
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12
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Montoya SM, Olaore P, Bastardo-Acosta J, Abdulla R, Schell MJ, Hidalgo A, Turner B, Rider M, Kishun-Jit N, Joshua A, Pollard J, Friedman M, Christy SM, Meade CD, Gwede CK. Protocol paper for an implementation science approach to promoting colorectal cancer screening in Federally Qualified Health Center clinics: A stepped-wedge, multilevel intervention trial. RESEARCH SQUARE 2024:rs.3.rs-4558718. [PMID: 39070625 PMCID: PMC11275978 DOI: 10.21203/rs.3.rs-4558718/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/30/2024]
Abstract
Background Colorectal cancer is the third leading cause of cancer-related deaths in the United States. Despite the Healthy People 2030 goal of 70.5%, colorectal cancer (CRC) screening rates in Federally Qualified Health Centers (FQHCs) are suboptimal at about 40%. The Colorectal Cancer Awareness, Research, Education and Screening-Rural Expansion, Access, and Capacity for Health (CARES-REACH) study seeks to address this disparity and accelerate the adoption and utilization of effective, evidence-based CRC screening practices. This paper describes the CARES-REACH study design and implementation methods. Methods Informed by a community-based participatory research (CBPR) framework and enriched by implementation science approaches, CARES-REACH features a stepped wedge design with extension for maintenance to support an implementation strategy focused on multiple levels: organizational, provider, and patient levels that entail processes to boost initial and repeat screening among average risk and age-eligible adults. This multilevel study entails the implementation of a core set of evidence-based interventions (EBIs) that include low literacy patient education (English, Spanish, and Haitian Creole language); provider education, system-wide electronic medical record (EMR) tools including provider prompts and patient reminders, FIT (fecal immunochemical test) kit distribution, plus an organization-wide cancer control champion who motivates providers, coaches and navigates patients, and monitors system-wide CRC screening activities. Trial registration NCT04464668.
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13
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Lemon SC, LeClair AM, Christenson E, Amburgey D, FitzGerald M, Cabral H, Lloyd-Travaglini C, Clark CR, Wang FQ, Ross J, Ohrenberger E, Haas JS, Freund KN, Battaglia TA. Implementation of social needs screening for minoritized patients newly diagnosed with breast cancer: a mixed methods evaluation in a pragmatic patient navigation trial. BMC Health Serv Res 2024; 24:783. [PMID: 38982469 PMCID: PMC11234663 DOI: 10.1186/s12913-024-11213-7] [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: 09/27/2023] [Accepted: 06/17/2024] [Indexed: 07/11/2024] Open
Abstract
BACKGROUND Social needs inhibit receipt of timely medical care. Social needs screening is a vital part of comprehensive cancer care, and patient navigators are well-positioned to screen for and address social needs. This mixed methods project describes social needs screening implementation in a prospective pragmatic patient navigation intervention trial for minoritized women newly diagnosed with breast cancer. METHODS Translating Research Into Practice (TRIP) was conducted at five cancer care sites in Boston, MA from 2018 to 2022. The patient navigation intervention protocol included completion of a social needs screening survey covering 9 domains (e.g., food, transportation) within 90 days of intake. We estimated the proportion of patients who received a social needs screening within 90 days of navigation intake. A multivariable log binomial regression model estimated the adjusted rate ratios (aRR) and 95% confidence intervals (CI) of patient socio-demographic characteristics and screening delivery. Key informant interviews with navigators (n = 8) and patients (n = 21) assessed screening acceptability and factors that facilitate and impede implementation. Using a convergent, parallel mixed methods approach, findings from each data source were integrated to interpret study results. RESULTS Patients' (n = 588) mean age was 59 (SD = 13); 45% were non-Hispanic Black and 27% were Hispanic. Sixty-nine percent of patients in the navigators' caseloads received social needs screening. Patients of non-Hispanic Black race/ethnicity (aRR = 1.25; 95% CI = 1.06-1.48) and those with Medicare insurance (aRR = 1.13; 95% CI = 1.04-1.23) were more likely to be screened. Screening was universally acceptable to navigators and generally acceptable to patients. Systems-based supports for improving implementation were identified. CONCLUSIONS Social needs screening was acceptable, yet with modest implementation. Continued systems-based efforts to integrate social needs screening in medical care are needed.
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Affiliation(s)
- Stephenie C Lemon
- Division of Preventive and Behavioral Medicine, UMass Chan Medical School, 55 Lake Avenue North, Worcester, MA, 01655, USA.
| | | | | | | | | | - Howard Cabral
- Boston University School of Public Health, Boston, MA, USA
| | | | | | | | - Joellen Ross
- Beth Israel Deaconess Medical Center, Boston, MA, USA
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Strechen I, Wilson P, Eltalhi T, Piche K, Tschida-Reuter D, Howard D, Sutor B, Tiong I, Herasevich S, Pickering B, Barwise A. Harnessing health information technology to promote equitable care for patients with limited English proficiency and complex care needs. Trials 2024; 25:450. [PMID: 38961501 PMCID: PMC11223355 DOI: 10.1186/s13063-024-08254-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2024] [Accepted: 06/18/2024] [Indexed: 07/05/2024] Open
Abstract
BACKGROUND Patients with language barriers encounter healthcare disparities, which may be alleviated by leveraging interpreter skills to reduce cultural, language, and literacy barriers through improved bidirectional communication. Evidence supports the use of in-person interpreters, especially for interactions involving patients with complex care needs. Unfortunately, due to interpreter shortages and clinician underuse of interpreters, patients with language barriers frequently do not get the language services they need or are entitled to. Health information technologies (HIT), including artificial intelligence (AI), have the potential to streamline processes, prompt clinicians to utilize in-person interpreters, and support prioritization. METHODS From May 1, 2023, to June 21, 2024, a single-center stepped wedge cluster randomized trial will be conducted within 35 units of Saint Marys Hospital & Methodist Hospital at Mayo Clinic in Rochester, Minnesota. The units include medical, surgical, trauma, and mixed ICUs and hospital floors that admit acute medical and surgical care patients as well as the emergency department (ED). The transitions between study phases will be initiated at 60-day intervals resulting in a 12-month study period. Units in the control group will receive standard care and rely on clinician initiative to request interpreter services. In the intervention group, the study team will generate a daily list of adult inpatients with language barriers, order the list based on their complexity scores (from highest to lowest), and share it with interpreter services, who will send a secure chat message to the bedside nurse. This engagement will be triggered by a predictive machine-learning algorithm based on a palliative care score, supplemented by other predictors of complexity including length of stay and level of care as well as procedures, events, and clinical notes. DISCUSSION This pragmatic clinical trial approach will integrate a predictive machine-learning algorithm into a workflow process and evaluate the effectiveness of the intervention. We will compare the use of in-person interpreters and time to first interpreter use between the control and intervention groups. TRIAL REGISTRATION NCT05860777. May 16, 2023.
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Affiliation(s)
- Inna Strechen
- Department of Anesthesiology and Perioperative Medicine, Division of Critical Care, Mayo Clinic, Rochester, MN, USA.
| | - Patrick Wilson
- Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - Targ Eltalhi
- Language Services, Mayo Clinic, Rochester, MN, USA
| | | | | | - Diane Howard
- Language Services Operations Administrator, Mayo Clinic, Rochester, MN, USA
| | - Bruce Sutor
- Department of Psychiatry and Psychology and Medical Director of Language Services, Mayo Clinic, Rochester, MN, USA
| | - Ing Tiong
- Information Technology, Mayo Clinic, Rochester, MN, USA
| | - Svetlana Herasevich
- Department of Anesthesiology and Perioperative Medicine, Division of Critical Care, Mayo Clinic, Rochester, MN, USA
| | - Brian Pickering
- Department of Anesthesiology and Perioperative Medicine, Division of Critical Care, Mayo Clinic, Rochester, MN, USA
| | - Amelia Barwise
- Biomedical Ethics Research Program and Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
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15
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Andersen SK, Chang CCH, Arnold RM, Pidro C, Darby JM, Angus DC, White DB. Impact of a family support intervention on hospitalization costs and hospital readmissions among ICU patients at high risk of death or severe functional impairment. Ann Intensive Care 2024; 14:103. [PMID: 38954149 PMCID: PMC11219699 DOI: 10.1186/s13613-024-01344-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2024] [Accepted: 06/21/2024] [Indexed: 07/04/2024] Open
Abstract
BACKGROUND Patients with advanced critical illness often receive more intensive treatment than they would choose for themselves, which contributes to high health care costs near the end of life. The purpose of this study was to determine whether a family support intervention delivered by the interprofessional ICU team decreases hospitalization costs and hospital readmissions among critically ill patients at high risk of death or severe functional impairment. RESULTS We examined index hospitalization costs as well as post-discharge utilization of acute care hospitals, rehabilitation and skilled nursing facilities, and hospice services for the PARTNER trial, a multicenter, stepped-wedge, cluster randomized trial of an interprofessional ICU family support intervention. We determined patients' total controllable and direct variable costs using a computerized accounting system. We determined post-discharge resource utilization (as defined above) by structured telephone interview at 6-month follow-up. We used multiple variable regression modelling to compare outcomes between groups. Compared to usual care, the PARTNER intervention resulted in significantly lower total controllable costs (geometric mean: $26,529 vs $32,105; log-linear coefficient: - 0.30; 95% CI - 0.49, - 0.11) and direct variable costs ($3912 vs $6034; - 0.33; 95% CI - 0.56, - 0.10). A larger cost reduction occurred for decedents ($20,304 vs. $26,610; - 0.66; 95% CI - 1.01, - 0.31) compared to survivors ($31,353 vs. $35,015; - 0.15; 95% CI - 0.35,0.05). A lower proportion in the intervention arm were re-admitted to an acute care hospital (34.9% vs 45.1%; 0.66; 95% CI 0.56, 0.77) or skilled nursing facility (25.3% vs 31.6%; 0.63; 95% CI 0.47, 0.84). CONCLUSIONS A family support intervention delivered by the interprofessional ICU team significantly decreased index hospitalization costs and readmission rates over 6-month follow-up. Trial registration Trial registration number: NCT01844492.
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Affiliation(s)
- Sarah K Andersen
- Program on Ethics and Decision Making, Department of Critical Care Medicine, The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, University of Pittsburgh School of Medicine, 3550 Terrace St, Scaife Hall, Room 608, Pittsburgh, PA, 15261, USA
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Chung-Chou H Chang
- Department of Critical Care Medicine, The CRISMA Center, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Robert M Arnold
- Section of Palliative Care and Medical Ethics, Department of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Palliative and Supportive Institute, UPMC Health System, Pittsburgh, PA, USA
| | - Caroline Pidro
- Department of Critical Care Medicine, The CRISMA Center, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Joseph M Darby
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Derek C Angus
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Douglas B White
- Program on Ethics and Decision Making, Department of Critical Care Medicine, The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, University of Pittsburgh School of Medicine, 3550 Terrace St, Scaife Hall, Room 608, Pittsburgh, PA, 15261, USA.
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Ambasta A, Holroyd-Leduc JM, Pokharel S, Mathura P, Shih AWY, Stelfox HT, Ma I, Harrison M, Manns B, Faris P, Williamson T, Shukalek C, Santana M, Omodon O, McCaughey D, Kassam N, Naugler C. Re-Purposing the Ordering of Routine Laboratory Tests in Hospitalized Medical Patients (RePORT): protocol for a multicenter stepped-wedge cluster randomised trial to evaluate the impact of a multicomponent intervention bundle to reduce laboratory test over-utilization. Implement Sci 2024; 19:45. [PMID: 38956637 PMCID: PMC11221016 DOI: 10.1186/s13012-024-01376-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2024] [Accepted: 06/23/2024] [Indexed: 07/04/2024] Open
Abstract
BACKGROUND Laboratory test overuse in hospitals is a form of healthcare waste that also harms patients. Developing and evaluating interventions to reduce this form of healthcare waste is critical. We detail the protocol for our study which aims to implement and evaluate the impact of an evidence-based, multicomponent intervention bundle on repetitive use of routine laboratory testing in hospitalized medical patients across adult hospitals in the province of British Columbia, Canada. METHODS We have designed a stepped-wedge cluster randomized trial to assess the impact of a multicomponent intervention bundle across 16 hospitals in the province of British Columbia in Canada. We will use the Knowledge to Action cycle to guide implementation and the RE-AIM framework to guide evaluation of the intervention bundle. The primary outcome will be the number of routine laboratory tests ordered per patient-day in the intervention versus control periods. Secondary outcome measures will assess implementation fidelity, number of all common laboratory tests used, impact on healthcare costs, and safety outcomes. The study will include patients admitted to adult medical wards (internal medicine or family medicine) and healthcare providers working in these wards within the participating hospitals. After a baseline period of 24 weeks, we will conduct a 16-week pilot at one hospital site. A new cluster (containing approximately 2-3 hospitals) will receive the intervention every 12 weeks. We will evaluate the sustainability of implementation at 24 weeks post implementation of the final cluster. Using intention to treat, we will use generalized linear mixed models for analysis to evaluate the impact of the intervention on outcomes. DISCUSSION The study builds upon a multicomponent intervention bundle that has previously demonstrated effectiveness. The elements of the intervention bundle are easily adaptable to other settings, facilitating future adoption in wider contexts. The study outputs are expected to have a positive impact as they will reduce usage of repetitive laboratory tests and provide empirically supported measures and tools for accomplishing this work. TRIAL REGISTRATION This study was prospectively registered on April 8, 2024, via ClinicalTrials.gov Protocols Registration and Results System (NCT06359587). https://classic. CLINICALTRIALS gov/ct2/show/NCT06359587?term=NCT06359587&recrs=ab&draw=2&rank=1.
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Affiliation(s)
- Anshula Ambasta
- Department of Medicine, Cumming School of Medicine, University of Calgary, 3330 Hospital Dr NW, Calgary, AB, T2N 4N1, Canada.
- Department of Anesthesia, Pharmacology and Therapeutics, Therapeutics Initiative, University of British Columbia, Vancouver, V6T 1Z4, Canada.
| | - Jayna M Holroyd-Leduc
- Department of Medicine, Cumming School of Medicine, University of Calgary, 3330 Hospital Dr NW, Calgary, AB, T2N 4N1, Canada
| | - Surakshya Pokharel
- Department of Medicine, Cumming School of Medicine, University of Calgary, 3330 Hospital Dr NW, Calgary, AB, T2N 4N1, Canada
- Ward of the 21st Century, University of Calgary, GD01, CWPH,Building 3280 Hospital Drive NW, Calgary, AB, T2N 4Z6, Canada
| | - Pamela Mathura
- Department of Medicine, University of Alberta, 116 St & 85 Ave, Edmonton, AB, T6G 2R3, Canada
| | - Andrew Wei-Yeh Shih
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, V6T 1Z4, Canada
| | - Henry T Stelfox
- Faculty of Medicine and Dentistry, University of Alberta, 116 St & 85 Ave, Edmonton, AB, T6G 2R3, Canada
| | - Irene Ma
- Department of Medicine, Cumming School of Medicine, University of Calgary, 3330 Hospital Dr NW, Calgary, AB, T2N 4N1, Canada
| | - Mark Harrison
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, V6T 1Z4, Canada
| | - Braden Manns
- Department of Medicine, Cumming School of Medicine, University of Calgary, 3330 Hospital Dr NW, Calgary, AB, T2N 4N1, Canada
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, 3330 Hospital Dr NW, Calgary, AB, T2N 4N1, Canada
| | - Peter Faris
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, 3330 Hospital Dr NW, Calgary, AB, T2N 4N1, Canada
| | - Tyler Williamson
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, 3330 Hospital Dr NW, Calgary, AB, T2N 4N1, Canada
| | - Caley Shukalek
- Department of Medicine, Cumming School of Medicine, University of Calgary, 3330 Hospital Dr NW, Calgary, AB, T2N 4N1, Canada
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, 3330 Hospital Dr NW, Calgary, AB, T2N 4N1, Canada
| | - Maria Santana
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, 3330 Hospital Dr NW, Calgary, AB, T2N 4N1, Canada
- Department of Pediatrics, Cumming School of Medicine, University of Calgary, 3330 Hospital Dr NW, Calgary, AB, T2N 4N1, Canada
| | - Onyebuchi Omodon
- Department of Medicine, Cumming School of Medicine, University of Calgary, 3330 Hospital Dr NW, Calgary, AB, T2N 4N1, Canada
- Ward of the 21st Century, University of Calgary, GD01, CWPH,Building 3280 Hospital Drive NW, Calgary, AB, T2N 4Z6, Canada
| | - Deirdre McCaughey
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, 3330 Hospital Dr NW, Calgary, AB, T2N 4N1, Canada
| | - Narmin Kassam
- Department of Medicine, University of Alberta, 116 St & 85 Ave, Edmonton, AB, T6G 2R3, Canada
| | - Chris Naugler
- Department of Pathology and Laboratory Medicine, Cumming School of Medicine, University of Calgary, 3330 Hospital Dr NW, Calgary, AB, T2N 4N1, Canada
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Murray DM, Goodman MS. Design and Analytic Methods to Evaluate Multilevel Interventions to Reduce Health Disparities: Rigorous Methods Are Available. PREVENTION SCIENCE : THE OFFICIAL JOURNAL OF THE SOCIETY FOR PREVENTION RESEARCH 2024; 25:343-347. [PMID: 38951424 PMCID: PMC11239746 DOI: 10.1007/s11121-024-01676-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/09/2024] [Indexed: 07/03/2024]
Abstract
In June 2022, the NIH Office of Disease Prevention (ODP) issued a Call for Papers for a Supplemental Issue to Prevention Science on Design and Analytic Methods to Evaluate Multilevel Interventions to Reduce Health Disparities. ODP sought to bring together current thinking and new ideas about design and analytic methods for studies aimed at reducing health disparities, including strategies for balancing methodological rigor with design feasibility, acceptability, and ethical considerations. ODP was particularly interested in papers on design and analytic methods for parallel group- or cluster-randomized trials (GRTs), stepped-wedge GRTs, group-level regression discontinuity trials, and other methods appropriate for evaluating multilevel interventions. In this issue, we include 12 papers that report new methods, provide examples of strong applications of existing methods, or provide guidance on developing multilevel interventions to reduce health disparities. These papers provide examples showing that rigorous methods are available for the design and analysis of multilevel interventions to reduce health disparities.
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Affiliation(s)
- David M Murray
- Office of Disease Prevention, National Institutes of Health, Bethesda, MD, USA.
| | - Melody S Goodman
- School of Global Public Health, New York University, New York City, NY, USA
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18
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Hughes JP, Lee WY, Troxel AB, Heagerty PJ. Sample Size Calculations for Stepped Wedge Designs with Treatment Effects that May Change with the Duration of Time under Intervention. PREVENTION SCIENCE : THE OFFICIAL JOURNAL OF THE SOCIETY FOR PREVENTION RESEARCH 2024; 25:348-355. [PMID: 37728810 PMCID: PMC10950842 DOI: 10.1007/s11121-023-01587-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/11/2023] [Indexed: 09/21/2023]
Abstract
The stepped wedge design is often used to evaluate interventions as they are rolled out across schools, health clinics, communities, or other clusters. Most models used in the design and analysis of stepped wedge trials assume that the intervention effect is immediate and constant over time following implementation of the intervention (the "exposure time"). This is known as the IT (immediate treatment effect) assumption. However, recent research has shown that using methods based on the IT assumption when the treatment effect varies over exposure time can give extremely misleading results. In this manuscript, we discuss the need to carefully specify an appropriate measure of the treatment effect when the IT assumption is violated and we show how a stepped wedge trial can be powered when it is anticipated that the treatment effect will vary as a function of the exposure time. Specifically, we describe how to power a trial when the exposure time indicator (ETI) model of Kenny et al. (Statistics in Medicine, 41, 4311-4339, 2022) is used and the estimand of interest is a weighted average of the time-varying treatment effects. We apply these methods to the ADDRESS-BP trial, a type 3 hybrid implementation study designed to address racial disparities in health care by evaluating a practice-based implementation strategy to reduce hypertension in African American communities.
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Affiliation(s)
- James P Hughes
- Department of Biostatistics, University of Washington, Seattle, WA, 98195, USA.
| | - Wen-Yu Lee
- Department of Population Health, Division of Biostatistics, New York University, New York, NY, USA
| | - Andrea B Troxel
- Department of Population Health, Division of Biostatistics, New York University, New York, NY, USA
| | - Patrick J Heagerty
- Department of Biostatistics, University of Washington, Seattle, WA, 98195, USA
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19
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Sperger J, Kosorok MR, Linnan L, Kneipp SM. Multilevel Intervention Stepped Wedge Designs (MLI-SWDs). PREVENTION SCIENCE : THE OFFICIAL JOURNAL OF THE SOCIETY FOR PREVENTION RESEARCH 2024; 25:371-383. [PMID: 38748315 PMCID: PMC11239753 DOI: 10.1007/s11121-024-01657-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/20/2024] [Indexed: 07/12/2024]
Abstract
Multilevel interventions (MLIs) hold promise for reducing health inequities by intervening at multiple types of social determinants of health consistent with the socioecological model of health. In spite of their potential, methodological challenges related to study design compounded by a lack of tools for sample size calculation inhibit their development. We help address this gap by proposing the Multilevel Intervention Stepped Wedge Design (MLI-SWD), a hybrid experimental design which combines cluster-level (CL) randomization using a Stepped Wedge design (SWD) with independent individual-level (IL) randomization. The MLI-SWD is suitable for MLIs where the IL intervention has a low risk of interference between individuals in the same cluster, and it enables estimation of the component IL and CL treatment effects, their interaction, and the combined intervention effect. The MLI-SWD accommodates cross-sectional and cohort designs as well as both incomplete (clusters are not observed in every study period) and complete observation patterns. We adapt recent work using generalized estimating equations for SWD sample size calculation to the multilevel setting and provide an R package for power and sample size calculation. Furthermore, motivated by our experiences with the ongoing NC Works 4 Health study, we consider how to apply the MLI-SWD when individuals join clusters over the course of the study. This situation arises when unemployment MLIs include IL interventions that are delivered while the individual is unemployed. This extension requires carefully considering whether the study interventions will satisfy additional causal assumptions but could permit randomization in new settings.
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Affiliation(s)
- John Sperger
- Department of Biostatistics, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, USA.
| | - Michael R Kosorok
- Department of Biostatistics, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, USA
| | - Laura Linnan
- Department of Health Behavior, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, USA
| | - Shawn M Kneipp
- School of Nursing, The University of North Carolina at Chapel Hill, Chapel Hill, USA
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20
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Rink E, Stotz SA, Johnson-Jennings M, Huyser K, Collins K, Manson SM, Berkowitz SA, Hebert L, Byker Shanks C, Begay K, Hicks T, Dennison M, Jiang L, Firemoon P, Johnson O, Anastario M, Ricker A, GrowingThunder R, Baldwin J. "We don't separate out these things. Everything is related": Partnerships with Indigenous Communities to Design, Implement, and Evaluate Multilevel Interventions to Reduce Health Disparities. PREVENTION SCIENCE : THE OFFICIAL JOURNAL OF THE SOCIETY FOR PREVENTION RESEARCH 2024; 25:474-485. [PMID: 38598040 PMCID: PMC11239303 DOI: 10.1007/s11121-024-01668-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/11/2024] [Indexed: 04/11/2024]
Abstract
Multilevel interventions (MLIs) are appropriate to reduce health disparities among Indigenous peoples because of their ability to address these communities' diverse histories, dynamics, cultures, politics, and environments. Intervention science has highlighted the importance of context-sensitive MLIs in Indigenous communities that can prioritize Indigenous and local knowledge systems and emphasize the collective versus the individual. This paradigm shift away from individual-level focus interventions to community-level focus interventions underscores the need for community engagement and diverse partnerships in MLI design, implementation, and evaluation. In this paper, we discuss three case studies addressing how Indigenous partners collaborated with researchers in each stage of the design, implementation, and evaluation of MLIs to reduce health disparities impacting their communities. We highlight the following: (1) collaborations with multiple, diverse tribal partners to carry out MLIs which require iterative, consistent conversations over time; (2) inclusion of qualitative and Indigenous research methods in MLIs as a way to honor Indigenous and local knowledge systems as well as a way to understand a health disparity phenomenon in a community; and (3) relationship building, maintenance, and mutual respect among MLI partners to reconcile past research abuses, prevent extractive research practices, decolonize research processes, and generate co-created knowledge between Indigenous and academic communities.
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Affiliation(s)
- Elizabeth Rink
- Department of Health and Human Development, Montana State University, 312 Herrick Hall, Bozeman, MT, 59715, USA.
| | - Sarah A Stotz
- Department of Food Science and Human Nutrition, Colorado State University, 502 West Lake Street, Fort Collins, CO, 80526, USA
| | - Michelle Johnson-Jennings
- Division of Indigenous Environmental Health and Land-Based Healing, Indigenous Wellness Research Institute, University of Washington, Gergerding Hall GBO, Box 351202, Seattle, WA, USA
| | - Kimberly Huyser
- Department of Sociology, Research, and Development/CIEDAR Center, COVID-19 Indigenous Engagement, University of British Columbia, 310-6251 Cecil Green Park Road, Vancouver, BC, V6T 1Z1, Canada
| | - Katie Collins
- CIEDAR co-Lead. Department of Psychology, University of Saskatchewan, 9 Campus Drive, 154 Arts, Saskatoon, SK, S7N 5A5, Canada
| | - Spero M Manson
- Colorado School of Public Health, Centers for American Indian and Alaska Native Health, University of Colorado Anschutz Medical Campus, 13055 East 17th Avenue, Aurora, CO, 80045, USA
| | - Seth A Berkowitz
- Division of General Medicine and Clinical Epidemiology, Department of Medicine, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC; Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, 725 M.L.K. Jr Blvd, Chapel Hill, NC, 27516, USA
| | - Luciana Hebert
- Institute for Research and Education to Advance Community Health (IREACH), Elson S. Floyd College of Medicine, Washington State University, 1100 Olive Way #1200, Seattle, WA, 98101, USA
| | - Carmen Byker Shanks
- Gretchen Swanson Center for Nutrition, 14301 FNB Pkwy #100, Omaha, NE, 68154, USA
| | - Kelli Begay
- Maven Collective Consulting, LLC, 15712 N Pennsylvania Avenue Cube 5, Edmond, OK, 73013, USA
| | - Teresa Hicks
- Teresa Hicks Consulting, 1107 East Babcock Street, Bozeman, MT, 59715, USA
| | - Michelle Dennison
- Oklahoma City Indian Clinic, 4913 W Reno Ave, 856 Health Sciences Quad, Suite 3400, Oklahoma City, OK, 73127, USA
| | - Luohua Jiang
- Department of Epidemiology and Biostatistics; UCI Health Sciences Complex, University of California Irvine, Program in Public Health, 856 Health Sciences Quad, Suite 3400, Irvine, CA, 92617, USA
| | - Paula Firemoon
- Fort Peck Community College, 605 Indian Ave.,, Poplar, MT, 59255, USA
| | - Olivia Johnson
- Fort Peck Community College, 605 Indian Ave.,, Poplar, MT, 59255, USA
| | - Mike Anastario
- Center for Health Equity Research, Northern Arizona University, P.O. Box 4065, Suite 120, Flagstaff, AZ, 86011-4065, USA
| | - Adriann Ricker
- Fort Peck Tribal Health Department, 501 Medicine Bear Road, Poplar, MT, 59255, USA
| | - Ramey GrowingThunder
- Fort Peck Tribes Language and Culture Department, 603 Court Ave., Poplar, MT, 59255, USA
| | - Julie Baldwin
- Center for Health Equity Research, Northern Arizona University, P.O. Box 4065, Suite 120, Flagstaff, AZ, 86011-4065, USA
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Kwizera A, Kabatoro D, Owachi D, Kansiime J, Kateregga G, Nanyunja D, Sendagire C, Nyakato D, Olaro C, Audureau E, Mekontso Dessap A. Respiratory support with standard low-flow oxygen therapy, high-flow oxygen therapy or continuous positive airway pressure in adults with acute hypoxaemic respiratory failure in a resource-limited setting: protocol for a randomised, open-label, clinical trial - the Acute Respiratory Intervention StudiEs in Africa (ARISE-AFRICA) study. BMJ Open 2024; 14:e082223. [PMID: 38951007 PMCID: PMC11218023 DOI: 10.1136/bmjopen-2023-082223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Accepted: 05/19/2024] [Indexed: 07/03/2024] Open
Abstract
RATIONALE Acute hypoxaemic respiratory failure (AHRF) is associated with high mortality in sub-Saharan Africa. This is at least in part due to critical care-related resource constraints including limited access to invasive mechanical ventilation and/or highly skilled acute care workers. Continuous positive airway pressure (CPAP) and high-flow oxygen by nasal cannula (HFNC) may prove useful to reduce intubation, and therefore, improve survival outcomes among critically ill patients, particularly in resource-limited settings, but data in such settings are lacking. The aim of this study is to determine whether CPAP or HFNC as compared with standard oxygen therapy, could reduce mortality among adults presenting with AHRF in a resource-limited setting. METHODS This is a prospective, multicentre, randomised, controlled, stepped wedge trial, in which patients presenting with AHRF in Uganda will be randomly assigned to standard oxygen therapy delivered through a face mask, HFNC oxygen or CPAP. The primary outcome is all-cause mortality at 28 days. Secondary outcomes include the number of patients with criteria for intubation at day 7, the number of patients intubated at day 28, ventilator-free days at day 28 and tolerance of each respiratory support. ETHICS AND DISSEMINATION The study has obtained ethical approval from the Research and Ethics Committee, School of Biomedical Sciences, College of Health Sciences, Makerere University as well as the Uganda National Council for Science and Technology. Patients will be included after informed consent. The results will be submitted for publication in peer-reviewed journals. TRIAL REGISTRATION NUMBER NCT04693403. PROTOCOL VERSION 8 September 2023; version 5.
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Affiliation(s)
- Arthur Kwizera
- Department of Anaesthesia and Critical Care, Makerere University College of Health Sciences, Kampala, Uganda
| | - Daphne Kabatoro
- Department of Anaesthesia and Critical Care, Makerere University College of Health Sciences, Kampala, Uganda
| | - Darius Owachi
- Department of Emergency Medicine, Kiruddu National Referral Hospital, Kampala, Uganda
| | - Jackson Kansiime
- Department of Internal Medicine, St Mary's Hospital, Gulu, Uganda
| | - George Kateregga
- Department of Anaesthesia and Intensive Care, Mbarara Regional Referral Hospital, Mbarara, Uganda
| | - Doreen Nanyunja
- Department of Internal Medicine, China-Uganda Friendship Hospital Naguru, Kampala, Uganda
| | | | | | | | - Etienne Audureau
- CEPIA EA7376, Universite Paris-Est Creteil Val de Marne, Creteil, France
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Wong DCW, Bonnici T, Gerry S, Birks J, Watkinson PJ. Effect of Digital Early Warning Scores on Hospital Vital Sign Observation Protocol Adherence: Stepped-Wedge Evaluation. J Med Internet Res 2024; 26:e46691. [PMID: 38900529 PMCID: PMC11224703 DOI: 10.2196/46691] [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: 02/21/2023] [Revised: 11/17/2023] [Accepted: 04/08/2024] [Indexed: 06/21/2024] Open
Abstract
BACKGROUND Early warning scores (EWS) are routinely used in hospitals to assess a patient's risk of deterioration. EWS are traditionally recorded on paper observation charts but are increasingly recorded digitally. In either case, evidence for the clinical effectiveness of such scores is mixed, and previous studies have not considered whether EWS leads to changes in how deteriorating patients are managed. OBJECTIVE This study aims to examine whether the introduction of a digital EWS system was associated with more frequent observation of patients with abnormal vital signs, a precursor to earlier clinical intervention. METHODS We conducted a 2-armed stepped-wedge study from February 2015 to December 2016, over 4 hospitals in 1 UK hospital trust. In the control arm, vital signs were recorded using paper observation charts. In the intervention arm, a digital EWS system was used. The primary outcome measure was time to next observation (TTNO), defined as the time between a patient's first elevated EWS (EWS ≥3) and subsequent observations set. Secondary outcomes were time to death in the hospital, length of stay, and time to unplanned intensive care unit admission. Differences between the 2 arms were analyzed using a mixed-effects Cox model. The usability of the system was assessed using the system usability score survey. RESULTS We included 12,802 admissions, 1084 in the paper (control) arm and 11,718 in the digital EWS (intervention) arm. The system usability score was 77.6, indicating good usability. The median TTNO in the control and intervention arms were 128 (IQR 73-218) minutes and 131 (IQR 73-223) minutes, respectively. The corresponding hazard ratio for TTNO was 0.99 (95% CI 0.91-1.07; P=.73). CONCLUSIONS We demonstrated strong clinical engagement with the system. We found no difference in any of the predefined patient outcomes, suggesting that the introduction of a highly usable electronic system can be achieved without impacting clinical care. Our findings contrast with previous claims that digital EWS systems are associated with improvement in clinical outcomes. Future research should investigate how digital EWS systems can be integrated with new clinical pathways adjusting staff behaviors to improve patient outcomes.
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Affiliation(s)
- David Chi-Wai Wong
- Leeds Institute of Health Sciences, School of Medicine, University of Leeds, Leeds, United Kingdom
| | - Timothy Bonnici
- Critical Care Division, University College Hospital London NHS Foundation Trust, London, United Kingdom
| | - Stephen Gerry
- Centre for Statistics in Medicine, University of Oxford, Oxford, United Kingdom
| | - Jacqueline Birks
- Centre for Statistics in Medicine, University of Oxford, Oxford, United Kingdom
| | - Peter J Watkinson
- Oxford University Hospitals NHS Trust, Oxford, United Kingdom
- NIHR Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
- Nuffield Department of Clinical Neurosciences, Kadoorie Centre for Critical Care Research and Education, University of Oxford, Oxford, United Kingdom
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Ryan EG, Gao CX, Grantham KL, Thao LTP, Charles-Nelson A, Bowden R, Herschtal A, Lee KJ, Forbes AB, Heritier S, Phillipou A, Wolfe R. Advancing randomized controlled trial methodologies: The place of innovative trial design in eating disorders research. Int J Eat Disord 2024; 57:1337-1349. [PMID: 38469971 DOI: 10.1002/eat.24187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Revised: 02/26/2024] [Accepted: 02/26/2024] [Indexed: 03/13/2024]
Abstract
Randomized controlled trials can be used to generate evidence on the efficacy and safety of new treatments in eating disorders research. Many of the trials previously conducted in this area have been deemed to be of low quality, in part due to a number of practical constraints. This article provides an overview of established and more innovative clinical trial designs, accompanied by pertinent examples, to highlight how design choices can enhance flexibility and improve efficiency of both resource allocation and participant involvement. Trial designs include individually randomized, cluster randomized, and designs with randomizations at multiple time points and/or addressing several research questions (master protocol studies). Design features include the use of adaptations and considerations for pragmatic or registry-based trials. The appropriate choice of trial design, together with rigorous trial conduct, reporting and analysis, can establish high-quality evidence to advance knowledge in the field. It is anticipated that this article will provide a broad and contemporary introduction to trial designs and will help researchers make informed trial design choices for improved testing of new interventions in eating disorders. PUBLIC SIGNIFICANCE: There is a paucity of high quality randomized controlled trials that have been conducted in eating disorders, highlighting the need to identify where efficiency gains in trial design may be possible to advance the eating disorder research field. We provide an overview of some key trial designs and features which may offer solutions to practical constraints and increase trial efficiency.
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Affiliation(s)
- Elizabeth G Ryan
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Caroline X Gao
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Centre for Youth Mental Health, University of Melbourne, Melbourne, Victoria, Australia
- Orygen, Melbourne, Victoria, Australia
| | - Kelsey L Grantham
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Le Thi Phuong Thao
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Anaïs Charles-Nelson
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Rhys Bowden
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Alan Herschtal
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Katherine J Lee
- Clinical Epidemiology and Biostatistics Unit, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
- Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia
| | - Andrew B Forbes
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Stephane Heritier
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Andrea Phillipou
- Centre for Youth Mental Health, University of Melbourne, Melbourne, Victoria, Australia
- Orygen, Melbourne, Victoria, Australia
- Department of Psychological Sciences, Swinburne University of Technology, Melbourne, Victoria, Australia
- Department of Mental Health, Austin Health, Melbourne, Victoria, Australia
- Department of Mental Health, St Vincent's Hospital, Melbourne, Victoria, Australia
| | - Rory Wolfe
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
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Loeffler M, Maas R, Neumann D, Scherag A. [INTERPOLAR-prospective, interventional studies as part of the Medical Informatics Initiative to improve medication therapy safety in healthcare]. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2024; 67:676-684. [PMID: 38750238 PMCID: PMC11166858 DOI: 10.1007/s00103-024-03890-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Accepted: 04/29/2024] [Indexed: 06/12/2024]
Abstract
Medication analyses by ward pharmacists are an important measure of drug therapy safety (DTS). Medication-related problems (MRPs) are identified and resolved with the attending clinicians. However, staff resources for extended medication analyses and complete documentation are often limited. Until now, data required for the identification of risk patients and for an extended medication analysis often had to be collected from various parts of the institution's internal electronic medical record (EMR). This error-prone and time-consuming process is to be improved in the INTERPOLAR (INTERventional POLypharmacy-Drug interActions-Risks) project using an IT tool provided by the data integration centers (DIC).INTERPOLAR is a use case of the Medical Informatics Initiative (MII) that focuses on the topic of DTS. The planning phase took place in 2023, with routine implementation planned from 2024. DTS-relevant data from the EMR is to be presented and the documentation of MRPs in routine care is to be facilitated. The prospective multicenter, cluster-randomized INTERPOLAR‑1 study serves to evaluate the benefits of IT support in routine care. The aim is to show that more MRPs can be detected and resolved with the help of IT support. For this purpose, six normal wards will be selected at each of eight university hospitals, so that 48 clusters (with a total of at least 70,000 cases) are available for randomization.
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Affiliation(s)
- Markus Loeffler
- Institut für Medizinische Informatik, Statistik und Epidemiologie (IMISE), Universität Leipzig, Härtelstraße 16-18, 04103, Leipzig, Deutschland
| | - Renke Maas
- Institut für Experimentelle und Klinische Pharmakologie und Toxikologie, Pharmakologie, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Deutschland
| | - Daniel Neumann
- Institut für Medizinische Informatik, Statistik und Epidemiologie (IMISE), Universität Leipzig, Härtelstraße 16-18, 04103, Leipzig, Deutschland.
| | - André Scherag
- Institut für Medizinische Statistik, Informatik und Datenwissenschaften, Universitätsklinikum Jena, Jena, Deutschland
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Liu J, Li F. Optimal designs using generalized estimating equations in cluster randomized crossover and stepped wedge trials. Stat Methods Med Res 2024:9622802241247717. [PMID: 38813761 DOI: 10.1177/09622802241247717] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2024]
Abstract
Cluster randomized crossover and stepped wedge cluster randomized trials are two types of longitudinal cluster randomized trials that leverage both the within- and between-cluster comparisons to estimate the treatment effect and are increasingly used in healthcare delivery and implementation science research. While the variance expressions of estimated treatment effect have been previously developed from the method of generalized estimating equations for analyzing cluster randomized crossover trials and stepped wedge cluster randomized trials, little guidance has been provided for optimal designs to ensure maximum efficiency. Here, an optimal design refers to the combination of optimal cluster-period size and optimal number of clusters that provide the smallest variance of the treatment effect estimator or maximum efficiency under a fixed total budget. In this work, we develop optimal designs for multiple-period cluster randomized crossover trials and stepped wedge cluster randomized trials with continuous outcomes, including both closed-cohort and repeated cross-sectional sampling schemes. Local optimal design algorithms are proposed when the correlation parameters in the working correlation structure are known. MaxiMin optimal design algorithms are proposed when the exact values are unavailable, but investigators may specify a range of correlation values. The closed-form formulae of local optimal design and MaxiMin optimal design are derived for multiple-period cluster randomized crossover trials, where the cluster-period size and number of clusters are decimal. The decimal estimates from closed-form formulae can then be used to investigate the performances of integer estimates from local optimal design and MaxiMin optimal design algorithms. One unique contribution from this work, compared to the previous optimal design research, is that we adopt constrained optimization techniques to obtain integer estimates under the MaxiMin optimal design. To assist practical implementation, we also develop four SAS macros to find local optimal designs and MaxiMin optimal designs.
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Affiliation(s)
- Jingxia Liu
- Division of Public Health Sciences, Department of Surgery and Division of Biostatistics, Washington University School of Medicine, St. Louis, MO, USA
| | - Fan Li
- Department of Biostatistics, Yale University, New Haven, CT, USA
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Ouyang Y, Taljaard M, Forbes AB, Li F. Maintaining the validity of inference from linear mixed models in stepped-wedge cluster randomized trials under misspecified random-effects structures. Stat Methods Med Res 2024:9622802241248382. [PMID: 38807552 DOI: 10.1177/09622802241248382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2024]
Abstract
Linear mixed models are commonly used in analyzing stepped-wedge cluster randomized trials. A key consideration for analyzing a stepped-wedge cluster randomized trial is accounting for the potentially complex correlation structure, which can be achieved by specifying random-effects. The simplest random effects structure is random intercept but more complex structures such as random cluster-by-period, discrete-time decay, and more recently, the random intervention structure, have been proposed. Specifying appropriate random effects in practice can be challenging: assuming more complex correlation structures may be reasonable but they are vulnerable to computational challenges. To circumvent these challenges, robust variance estimators may be applied to linear mixed models to provide consistent estimators of standard errors of fixed effect parameters in the presence of random-effects misspecification. However, there has been no empirical investigation of robust variance estimators for stepped-wedge cluster randomized trials. In this article, we review six robust variance estimators (both standard and small-sample bias-corrected robust variance estimators) that are available for linear mixed models in R, and then describe a comprehensive simulation study to examine the performance of these robust variance estimators for stepped-wedge cluster randomized trials with a continuous outcome under different data generators. For each data generator, we investigate whether the use of a robust variance estimator with either the random intercept model or the random cluster-by-period model is sufficient to provide valid statistical inference for fixed effect parameters, when these working models are subject to random-effect misspecification. Our results indicate that the random intercept and random cluster-by-period models with robust variance estimators performed adequately. The CR3 robust variance estimator (approximate jackknife) estimator, coupled with the number of clusters minus two degrees of freedom correction, consistently gave the best coverage results, but could be slightly conservative when the number of clusters was below 16. We summarize the implications of our results for the linear mixed model analysis of stepped-wedge cluster randomized trials and offer some practical recommendations on the choice of the analytic model.
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Affiliation(s)
- Yongdong Ouyang
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
| | - Monica Taljaard
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
| | - Andrew B Forbes
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Fan Li
- Department of Biostatistics, Yale School of Public Health, New Haven, CT, USA
- Center for Methods in Implementation and Prevention Science, Yale School of Public Health, New Haven, CT, USA
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Hooper R, Quintin O, Kasza J. Efficient designs for three-sequence stepped wedge trials with continuous recruitment. Clin Trials 2024:17407745241251780. [PMID: 38773924 DOI: 10.1177/17407745241251780] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/24/2024]
Abstract
BACKGROUND/AIMS The standard approach to designing stepped wedge trials that recruit participants in a continuous stream is to divide time into periods of equal length. But the choice of design in such cases is infinitely more flexible: each cluster could cross from the control to the intervention at any point on the continuous time-scale. We consider the case of a stepped wedge design with clusters randomised to just three sequences (designs with small numbers of sequences may be preferred for their simplicity and practicality) and investigate the choice of design that minimises the variance of the treatment effect estimator under different assumptions about the intra-cluster correlation. METHODS We make some simplifying assumptions in order to calculate the variance: in particular that we recruit the same number of participants, m , from each cluster over the course of the trial, and that participants present at regularly spaced intervals. We consider an intra-cluster correlation that decays exponentially with separation in time between the presentation of two individuals from the same cluster, from a value of ρ for two individuals who present at the same time, to a value of ρ τ for individuals presenting at the start and end of the trial recruitment interval. We restrict attention to three-sequence designs with centrosymmetry - the property that if we reverse time and swap the intervention and control conditions then the design looks the same. We obtain an expression for the variance of the treatment effect estimator adjusted for effects of time, using methods for generalised least squares estimation, and we evaluate this expression numerically for different designs, and for different parameter values. RESULTS There is a two-dimensional space of possible three-sequence, centrosymmetric stepped wedge designs with continuous recruitment. The variance of the treatment effect estimator for given ρ and τ can be plotted as a contour map over this space. The shape of this variance surface depends on τ and on the parameter m ρ / ( 1 - ρ ) , but typically indicates a broad, flat region of close-to-optimal designs. The 'standard' design with equally spaced periods and 1:1:1 allocation rarely performs well, however. CONCLUSIONS In many different settings, a relatively simple design can be found (e.g. one based on simple fractions) that offers close-to-optimal efficiency in that setting. There may also be designs that are robustly efficient over a wide range of settings. Contour maps of the kind we illustrate can help guide this choice. If efficiency is offered as one of the justifications for using a stepped wedge design, then it is worth designing with optimal efficiency in mind.
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Affiliation(s)
- Richard Hooper
- Wolfson Institute of Population Health, Queen Mary University of London, London, UK
| | - Olivier Quintin
- Wolfson Institute of Population Health, Queen Mary University of London, London, UK
| | - Jessica Kasza
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
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Bada F, Mansfield ME, Okui L, Montebatsi M, DiClemente C, Tapera R, Ikgopoleng K, Mokonopi S, Magidson JF, Onukwugha E, Ndwapi N, Himelhoch S, Mbongwe B, Charurat M. Design and rationale of the Botswana Smoking Abstinence Reinforcement Trial: a protocol for a stepped-wedge cluster randomized trial. Implement Sci Commun 2024; 5:53. [PMID: 38720363 PMCID: PMC11077839 DOI: 10.1186/s43058-024-00588-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Accepted: 04/25/2024] [Indexed: 05/12/2024] Open
Abstract
BACKGROUND With expanded and sustained availability of HIV treatment resulting in substantial improvements in life expectancy, the need to address modifiable risk factors associated with leading causes of death among people living with HIV/AIDS (PLWH), such as tobacco smoking, has increased. Tobacco use is highly prevalent among PLWH, especially in southern Africa, where HIV is heavily concentrated, and many people who smoke would like to quit but are unable to do so without assistance. SBIRT (Screening, Brief Intervention and Referral to Treatment) is a well-established evidence-based approach successful at supporting smoking cessation in a variety of settings. Varenicline is efficacious in supporting smoking cessation. We intend to assess the effectiveness of SBIRT and varenicline on smoking cessation among PLWH in Botswana and the effectiveness of our implementation. METHODS BSMART (Botswana Smoking Abstinence Reinforcement Trial) is a stepped-wedge, cluster randomized, hybrid Type 2 effectiveness-implementation study guided by the RE-AIM framework, to evaluate the effectiveness and implementation of an SBIRT intervention consisting of the 5As compared to an enhanced standard of care. SBIRT will be delivered by trained lay health workers (LHWs), followed by referral to treatment with varenicline prescribed and monitored by trained nurse prescribers in a network of outpatient HIV care facilities. Seven hundred and fifty people living with HIV who smoke daily and have been receiving HIV care and treatment at one of 15 health facilities will be recruited if they are up to 18 years of age and willing to provide informed consent to participate in the study. DISCUSSION BSMART tests a scalable approach to achieve and sustain smoking abstinence implemented in a sustainable way. Integrating an evidence-based approach such as SBIRT, into an HIV care system presents an important opportunity to establish and evaluate a modifiable cancer prevention strategy in a middle-income country (MIC) setting where both LHW and non-physician clinicians are widely used. The findings, including the preliminary cost-effectiveness, will provide evidence to guide the Botswanan government and similar countries as they strive to provide affordable smoking cessation support at scale. CLINICAL TRIAL REGISTRATION NCT05694637 Registered on 7 December 2022 on clinicaltrials.gov, https://clinicaltrials.gov/search?locStr=Botswana&country=Botswana&cond=Smoking%20Cessation&intr=SBIRT.
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Affiliation(s)
- Florence Bada
- Division of Epidemiology and Prevention, Institute of Human Virology, University of Maryland School of Medicine, Baltimore, MD, USA.
| | - Megan E Mansfield
- Division of Epidemiology and Prevention, Institute of Human Virology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Lillian Okui
- Botswana University of Maryland Medicine Health Initiative, Gaborone, Botswana
| | - Milton Montebatsi
- Botswana University of Maryland Medicine Health Initiative, Gaborone, Botswana
| | - Carlo DiClemente
- Department of Psychology, University of Maryland Baltimore County, Baltimore, MD, USA
| | - Roy Tapera
- School of Public Health, University of Botswana, Gaborone, Botswana
- Anti-Tobacco Network, University of Botswana, Gaborone, Botswana
| | - Kaizer Ikgopoleng
- Botswana University of Maryland Medicine Health Initiative, Gaborone, Botswana
| | - Selebaleng Mokonopi
- Botswana University of Maryland Medicine Health Initiative, Gaborone, Botswana
| | - Jessica F Magidson
- Department of Psychology and the Center for Substance Use, Addiction & Health Research (CESAR), University of Maryland, College Park, Maryland, USA
| | - Eberechukwu Onukwugha
- Department of Practice, Sciences, and Health Outcomes Research, University of Maryland School of Pharmacy, Baltimore, MD, USA
| | - Ndwapi Ndwapi
- Botswana University of Maryland Medicine Health Initiative, Gaborone, Botswana
| | - Seth Himelhoch
- Department of Psychiatry, University of Kentucky School of Medicine, Lexington, KY, USA
| | - Bontle Mbongwe
- School of Public Health, University of Botswana, Gaborone, Botswana
- Anti-Tobacco Network, University of Botswana, Gaborone, Botswana
| | - Man Charurat
- Division of Epidemiology and Prevention, Institute of Human Virology, University of Maryland School of Medicine, Baltimore, MD, USA
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, USA
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Gago C, De Leon E, Mandal S, de la Calle F, Garcia M, Colella D, Dapkins I, Schoenthaler A. "Hypertension is such a difficult disease to manage": federally qualified health center staff- and leadership-perceived readiness to implement a technology-facilitated team-based hypertension model. Implement Sci Commun 2024; 5:49. [PMID: 38698497 PMCID: PMC11067286 DOI: 10.1186/s43058-024-00587-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Accepted: 04/25/2024] [Indexed: 05/05/2024] Open
Abstract
BACKGROUND Despite decades of evidence demonstrating the efficacy of hypertension care delivery in reducing morbidity and mortality, a majority of hypertension cases remain uncontrolled. There is an urgent need to elucidate and address multilevel facilitators and barriers clinical staff face in delivering evidence-based hypertension care, patients face in accessing it, and clinical systems face in sustaining it. Through a rigorous pre-implementation evaluation, we aimed to identify facilitators and barriers bearing the potential to affect the planned implementation of a multilevel technology-facilitated hypertension management trial across six primary care sites in a large federally qualified health center (FQHC) in New York City. METHODS During a dedicated pre-implementation period (3-9 months/site, 2021-2022), a capacity assessment was conducted by trained practice facilitators, including (1) online anonymous surveys (n = 124; 70.5% of eligible), (2) hypertension training analytics (n = 69; 94.5% of assigned), and (3) audio-recorded semi-structured interviews (n = 67; 48.6% of eligible) with FQHC leadership and staff. Surveys measured staff sociodemographic characteristics, adaptive reserve, evidence-based practice attitudes, and implementation leadership scores via validated scales. Training analytics, derived from end-of-course quizzes, included mean score and number attempts needed to pass. Interviews assessed staff-reported facilitators and barriers to current hypertension care delivery and uptake; following audio transcription, trained qualitative researchers employed a deductive coding approach, informed by the Consolidated Framework for Implementation Research (CFIR). RESULTS Most survey respondents reported moderate adaptive reserve (mean = 0.7, range = 0-1), evidence-based practice attitudes (mean = 2.7, range = 0-4), and implementation leadership (mean = 2.5, range = 0-4). Most staff passed training courses on first attempt and demonstrated high scores (means > 80%). Findings from interviews identified potential facilitators and barriers to implementation; specifically, staff reported that complex barriers to hypertension care, control, and clinical communication exist; there is a recognized need to improve hypertension care; in-clinic challenges with digital tool access imposes workflow delays; and despite high patient loads, staff are motivated to provide high-quality cares. CONCLUSIONS This study serves as one of the first to apply the CFIR to a rigorous pre-implementation evaluation within the understudied context of a FQHC and can serve as a model for similar trials seeking to identify and address contextual factors known to impact implementation success. TRIAL REGISTRATION ClinicalTrials.gov NCT03713515 , date of registration: October 19, 2018.
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Affiliation(s)
- Cristina Gago
- Institute for Excellence in Health Equity, NYU Langone Health, 180 Madison Avenue, 7th Floor, New York, NY, 10016, USA.
| | - Elaine De Leon
- Institute for Excellence in Health Equity, NYU Langone Health, 180 Madison Avenue, 7th Floor, New York, NY, 10016, USA
| | - Soumik Mandal
- Institute for Excellence in Health Equity, NYU Langone Health, 180 Madison Avenue, 7th Floor, New York, NY, 10016, USA
| | - Franze de la Calle
- Institute for Excellence in Health Equity, NYU Langone Health, 180 Madison Avenue, 7th Floor, New York, NY, 10016, USA
| | - Masiel Garcia
- Family Health Centers at NYU Langone, Brooklyn, NY, USA
| | | | - Isaac Dapkins
- Family Health Centers at NYU Langone, Brooklyn, NY, USA
| | - Antoinette Schoenthaler
- Institute for Excellence in Health Equity, NYU Langone Health, 180 Madison Avenue, 7th Floor, New York, NY, 10016, USA
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Shulman M, Greiner MG, Tafessu HM, Opara O, Ohrtman K, Potter K, Hefner K, Jelstrom E, Rosenthal RN, Wenzel K, Fishman M, Rotrosen J, Ghitza UE, Nunes EV, Bisaga A. Rapid Initiation of Injection Naltrexone for Opioid Use Disorder: A Stepped-Wedge Cluster Randomized Clinical Trial. JAMA Netw Open 2024; 7:e249744. [PMID: 38717773 PMCID: PMC11079685 DOI: 10.1001/jamanetworkopen.2024.9744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Accepted: 03/05/2024] [Indexed: 05/12/2024] Open
Abstract
Importance Injectable extended-release (XR)-naltrexone is an effective treatment option for opioid use disorder (OUD), but the need to withdraw patients from opioid treatment prior to initiation is a barrier to implementation. Objective To compare the effectiveness of the standard procedure (SP) with the rapid procedure (RP) for XR-naltrexone initiation. Design, Setting, and Participants The Surmounting Withdrawal to Initiate Fast Treatment with Naltrexone study was an optimized stepped-wedge cluster randomized trial conducted at 6 community-based inpatient addiction treatment units. Units using the SP were randomly assigned at 14-week intervals to implement the RP. Participants admitted with OUD received the procedure the unit was delivering at the time of their admission. Participant recruitment took place between March 16, 2021, and July 18, 2022. The last visit was September 21, 2022. Interventions Standard procedure, based on the XR-naltrexone package insert (approximately 5-day buprenorphine taper followed by a 7- to 10-day opioid-free period and RP, defined as 1 day of buprenorphine at minimum necessary dose, 1 opioid-free day, and ascending low doses of oral naltrexone and adjunctive medications (eg, clonidine, clonazepam, antiemetics) for opioid withdrawal. Main Outcomes and Measures Receipt of XR-naltrexone injection prior to inpatient discharge (primary outcome). Secondary outcomes included opioid withdrawal scores and targeted safety events and serious adverse events. All analyses were intention-to-treat. Results A total of 415 participants with OUD were enrolled (mean [SD] age, 33.6 [8.48] years; 205 [49.4%] identified sex as male); 54 [13.0%] individuals identified as Black, 91 [21.9%] as Hispanic, 290 [69.9%] as White, and 22 [5.3%] as multiracial. Rates of successful initiation of XR-naltrexone among the RP group (141 of 225 [62.7%]) were noninferior to those of the SP group (68 of 190 [35.8%]) (odds ratio [OR], 3.60; 95% CI, 2.12-6.10). Withdrawal did not differ significantly between conditions (proportion of days with a moderate or greater maximum Clinical Opiate Withdrawal Scale score (>12) for RP vs SP: OR, 1.25; 95% CI, 0.62-2.50). Targeted safety events (RP: 12 [5.3%]; SP: 4 [2.1%]) and serious adverse events (RP: 15 [6.7%]; SP: 3 [1.6%]) were infrequent but occurred more often with RP than SP. Conclusions and Relevance In this trial, the RP of XR-naltrexone initiation was noninferior to the standard approach and saved time, although it required more intensive medical management and safety monitoring. The results of this trial suggest that rapid initiation could make XR-naltrexone a more viable treatment for patients with OUD. Trial Registration ClinicalTrials.gov Identifier: NCT04762537.
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Affiliation(s)
- Matisyahu Shulman
- Department of Psychiatry, New York State Psychiatric Institute and Columbia University Irving Medical Center, New York, New York
| | - Miranda G. Greiner
- Department of Psychiatry, New York State Psychiatric Institute and Columbia University Irving Medical Center, New York, New York
| | | | - Onumara Opara
- Department of Psychiatry, New York State Psychiatric Institute and Columbia University Irving Medical Center, New York, New York
| | - Kaitlyn Ohrtman
- Department of Psychiatry, New York State Psychiatric Institute and Columbia University Irving Medical Center, New York, New York
| | - Kenzie Potter
- Department of Psychiatry, New York State Psychiatric Institute and Columbia University Irving Medical Center, New York, New York
| | | | | | | | - Kevin Wenzel
- Department of Psychiatry, Johns Hopkins University School of Medicine and Maryland Treatment Centers, Baltimore, Maryland
| | - Marc Fishman
- Department of Psychiatry, Johns Hopkins University School of Medicine and Maryland Treatment Centers, Baltimore, Maryland
| | - John Rotrosen
- Department of Psychiatry, New York University Grossman School of Medicine, New York, New York
| | - Udi E. Ghitza
- National Institute on Drug Abuse, Bethesda, Maryland
| | - Edward V. Nunes
- Department of Psychiatry, New York State Psychiatric Institute and Columbia University Irving Medical Center, New York, New York
| | - Adam Bisaga
- Department of Psychiatry, New York State Psychiatric Institute and Columbia University Irving Medical Center, New York, New York
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Brown GK, Wolk CB, Green KL, Nezir F, Mowery DL, Gallop R, Reilly ME, Stanley B, Mandell DS, Oquendo MA, Jager-Hyman S. Safety planning intervention and follow-up: A telehealth service model for suicidal individuals in emergency department settings: Study design and protocol. Contemp Clin Trials 2024; 140:107492. [PMID: 38484793 PMCID: PMC11071175 DOI: 10.1016/j.cct.2024.107492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2023] [Revised: 02/29/2024] [Accepted: 03/05/2024] [Indexed: 03/26/2024]
Abstract
BACKGROUND The Safety Planning Intervention with follow-up services (SPI+) is a promising suicide prevention intervention, yet many Emergency Departments (EDs) lack the resources for adequate implementation. Comprehensive strategies addressing structural and organizational barriers are needed to optimize SPI+ implementation and scale-up. This protocol describes a test of one strategy in which ED staff connect at-risk patients to expert clinicians from a Suicide Prevention Consultation Center (SPCC) via telehealth. METHOD This stepped wedge, cluster-randomized trial compares the effectiveness, implementation, cost, and cost offsets of SPI+ delivered by SPCC clinicians versus ED-based clinicians (enhanced usual care; EUC). Eight EDs will start with EUC and cross over to the SPCC phase. Blocks of two EDs will be randomly assigned to start dates 3 months apart. Approximately 13,320 adults discharged following a suicide-related ED visit will be included; EUC and SPCC samples will comprise patients from before and after SPCC crossover, respectively. Effectiveness data sources are electronic health records, administrative claims, and the National Death Index. Primary effectiveness outcomes are presence of suicidal behavior and number/type of mental healthcare visits and secondary outcomes include number/type of suicide-related acute services 6-months post-discharge. We will use the same data sources to assess cost offsets to gauge SPCC scalability and sustainability. We will examine preliminary implementation outcomes (reach, adoption, fidelity, acceptability, and feasibility) through patient, clinician, and health-system leader interviews and surveys. CONCLUSION If the SPCC demonstrates clinical effectiveness and health system cost reduction, it may be a scalable model for evidence-based suicide prevention in the ED.
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Affiliation(s)
- Gregory K Brown
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
| | - Courtney Benjamin Wolk
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Kelly L Green
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Freya Nezir
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Danielle L Mowery
- Department of Biostatistics, Epidemiology, & Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Robert Gallop
- Department of Biostatistics, Epidemiology, & Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Department of Mathematics, West Chester University of Pennsylvania, West Chester, PA, USA
| | - Megan E Reilly
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Barbara Stanley
- Department of Psychiatry, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - David S Mandell
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Maria A Oquendo
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Shari Jager-Hyman
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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Birnbaum ML, Garrett C, Baumel A, Germano NT, Sosa D, Ngo H, John M, Dixon L, Kane JM. Examining the Effectiveness of a Digital Media Campaign at Reducing the Duration of Untreated Psychosis in New York State: Results From a Stepped-wedge Randomized Controlled Trial. Schizophr Bull 2024; 50:705-716. [PMID: 38408135 PMCID: PMC11059796 DOI: 10.1093/schbul/sbae018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/28/2024]
Abstract
BACKGROUND AND HYPOTHESIS Longer duration of untreated psychosis (DUP) predicts worse outcomes in First Episode Psychosis (FEP). Searching online represents one of the first proactive step toward treatment initiation for many, yet few studies have informed how best to support FEP youth as they engage in early online help-seeking steps to care. STUDY DESIGN Using a stepped-wedge randomized design, this project evaluated the effectiveness of a digital marketing campaign at reducing DUP and raising rates of referrals to FEP services by proactively targeting and engaging prospective patients and their adult allies online. STUDY RESULTS Throughout the 18-month campaign, 41 372 individuals visited our website, and 371 advanced to remote clinical assessment (median age = 24.4), including 53 allies and 318 youth. Among those assessed (n = 371), 53 individuals (14.3%) reported symptoms consistent with psychotic spectrum disorders (62.2% female, mean age 20.7 years) including 39 (10.5%) reporting symptoms consistent with either Clinical High Risk (ie, attenuated psychotic symptoms; n = 26) or FEP (n = 13). Among those with either suspected CHR or FEP (n = 39), 20 (51.3%) successfully connected with care. The campaign did not result in significant differences in DUP. CONCLUSION This study highlights the potential to leverage digital media to help identify and engage youth with early psychosis online. However, despite its potential, online education and professional support alone are not yet sufficient to expedite treatment initiation and reduce DUP.
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Affiliation(s)
- Michael L Birnbaum
- The Zucker Hillside Hospital, Department of Psychiatry, Northwell Health, Glen Oaks, NY, USA
- The Feinstein Institute for Medical Research, Manhasset, NY, USA
- The Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | | | - Amit Baumel
- Department of Community Mental Health, University of Haifa, Haifa, Israel
| | - Nicole T Germano
- The Zucker Hillside Hospital, Department of Psychiatry, Northwell Health, Glen Oaks, NY, USA
| | - Danny Sosa
- The Zucker Hillside Hospital, Department of Psychiatry, Northwell Health, Glen Oaks, NY, USA
| | - Hong Ngo
- Department of Psychiatry, New York State Psychiatric Institute, New York, NY, USA
| | - Majnu John
- The Zucker Hillside Hospital, Department of Psychiatry, Northwell Health, Glen Oaks, NY, USA
- The Feinstein Institute for Medical Research, Manhasset, NY, USA
| | - Lisa Dixon
- Department of Psychiatry, New York State Psychiatric Institute, New York, NY, USA
| | - John M Kane
- The Zucker Hillside Hospital, Department of Psychiatry, Northwell Health, Glen Oaks, NY, USA
- The Feinstein Institute for Medical Research, Manhasset, NY, USA
- The Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
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Xiao Y, Fulda KG, Young RA, Hendrix ZN, Daniel KM, Chen KY, Zhou Y, Roye JL, Kosmari L, Wilson J, Espinoza AM, Sutcliffe KM, Pitts SI, Arbaje AI, Chui MA, Blair S, Sloan D, Jackson M, Gurses AP. Patient Partnership Tools to Support Medication Safety in Community-Dwelling Older Adults: Protocol for a Nonrandomized Stepped Wedge Clinical Trial. JMIR Res Protoc 2024; 13:e57878. [PMID: 38684080 PMCID: PMC11091807 DOI: 10.2196/57878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2024] [Revised: 03/20/2024] [Accepted: 03/23/2024] [Indexed: 05/02/2024] Open
Abstract
BACKGROUND Preventable harms from medications are significant threats to patient safety in community settings, especially among ambulatory older adults on multiple prescription medications. Patients may partner with primary care professionals by taking on active roles in decisions, learning the basics of medication self-management, and working with community resources. OBJECTIVE This study aims to assess the impact of a set of patient partnership tools that redesign primary care encounters to encourage and empower patients to make more effective use of those encounters to improve medication safety. METHODS The study is a nonrandomized, cross-sectional stepped wedge cluster-controlled trial with 1 private family medicine clinic and 2 public safety-net primary care clinics each composing their own cluster. There are 2 intervention sequences with 1 cluster per sequence and 1 control sequence with 1 cluster. Cross-sectional surveys will be taken immediately at the conclusion of visits to the clinics during 6 time periods of 6 weeks each, with a transition period of no data collection during intervention implementation. The number of visits to be surveyed will vary by period and cluster. We plan to recruit patients and professionals for surveys during 405 visits. In the experimental periods, visits will be conducted with two partnership tools and associated clinic process changes: (1) a 1-page visit preparation guide given to relevant patients by clinic staff before seeing the provider, with the intention to improve communication and shared decision-making, and (2) a library of short educational videos that clinic staff encourage patients to watch on medication safety. In the control periods, visits will be conducted with usual care. The primary outcome will be patients' self-efficacy in medication use. The secondary outcomes are medication-related issues such as duplicate therapies identified by primary care providers and assessment of collaborative work during visits. RESULTS The study was funded in September 2019. Data collection started in April 2023 and ended in December 2023. Data was collected for 405 primary care encounters during that period. As of February 15, 2024, initial descriptive statistics were calculated. Full data analysis is expected to be completed and published in the summer of 2024. CONCLUSIONS This study will assess the impact of patient partnership tools and associated process changes in primary care on medication use self-efficacy and medication-related issues. The study is powered to identify types of patients who may benefit most from patient engagement tools in primary care visits. TRIAL REGISTRATION ClinicalTrials.gov NCT05880368; https://clinicaltrials.gov/study/NCT05880368. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/57878.
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Affiliation(s)
- Yan Xiao
- College of Nursing and Health Innovation, University of Texas at Arlington, Arlington, TX, United States
- College of Engineering, University of Texas at Arlington, Arlington, TX, United States
| | - Kimberley G Fulda
- Department of Family Medicine and Osteopathic Manipulative Medicine and North Texas Primary Care Practice-Based Research Network (NorTex), University of North Texas Health Science Center, Fort Worth, TX, United States
| | - Richard A Young
- Family Medicine Residency Program, John Peter Smith Health Network, Fort Worth, TX, United States
| | - Z Noah Hendrix
- College of Nursing and Health Innovation, University of Texas at Arlington, Arlington, TX, United States
| | - Kathryn M Daniel
- College of Nursing and Health Innovation, University of Texas at Arlington, Arlington, TX, United States
| | - Kay Yut Chen
- College of Business, University of Texas at Arlington, Arlington, TX, United States
| | - Yuan Zhou
- College of Engineering, University of Texas at Arlington, Arlington, TX, United States
| | - Jennifer L Roye
- College of Nursing and Health Innovation, University of Texas at Arlington, Arlington, TX, United States
| | - Ludmila Kosmari
- College of Nursing and Health Innovation, University of Texas at Arlington, Arlington, TX, United States
| | - Joshua Wilson
- College of Liberal Arts, University of Texas at Arlington, Arlington, TX, United States
| | - Anna M Espinoza
- Department of Family Medicine and Osteopathic Manipulative Medicine and North Texas Primary Care Practice-Based Research Network (NorTex), University of North Texas Health Science Center, Fort Worth, TX, United States
| | - Kathleen M Sutcliffe
- Carey Business School, Johns Hopkins University, Baltimore, MD, United States
- School of Medicine, Johns Hopkins University, Baltimore, MD, United States
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, United States
- School of Nursing, Johns Hopkins University, Baltimore, MD, United States
| | - Samantha I Pitts
- School of Medicine, Johns Hopkins University, Baltimore, MD, United States
| | - Alicia I Arbaje
- School of Medicine, Johns Hopkins University, Baltimore, MD, United States
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, United States
| | - Michelle A Chui
- School of Pharmacy, University of Wisconsin-Madison, Madison, WI, United States
| | - Somer Blair
- Office of Clinical Research, John Peter Smith Health Network, Fort Worth, TX, United States
| | - Dawn Sloan
- Family Medicine Residency Program, John Peter Smith Health Network, Fort Worth, TX, United States
| | - Masheika Jackson
- Family Medicine Residency Program, John Peter Smith Health Network, Fort Worth, TX, United States
| | - Ayse P Gurses
- School of Medicine, Johns Hopkins University, Baltimore, MD, United States
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, United States
- Whiting School of Engineering, Johns Hopkins University, Baltimore, MD, United States
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Talal AH, Markatou M, Liu A, Perumalswami PV, Dinani AM, Tobin JN, Brown LS. Integrated Hepatitis C-Opioid Use Disorder Care Through Facilitated Telemedicine: A Randomized Trial. JAMA 2024; 331:1369-1378. [PMID: 38568601 PMCID: PMC10993166 DOI: 10.1001/jama.2024.2452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Accepted: 02/13/2024] [Indexed: 04/06/2024]
Abstract
Importance Facilitated telemedicine may promote hepatitis C virus elimination by mitigating geographic and temporal barriers. Objective To compare sustained virologic responses for hepatitis C virus among persons with opioid use disorder treated through facilitated telemedicine integrated into opioid treatment programs compared with off-site hepatitis specialist referral. Design, Setting, and Participants Prospective, cluster randomized clinical trial using a stepped wedge design. Twelve programs throughout New York State included hepatitis C-infected participants (n = 602) enrolled between March 1, 2017, and February 29, 2020. Data were analyzed from December 1, 2022, through September 1, 2023. Intervention Hepatitis C treatment with direct-acting antivirals through comanagement with a hepatitis specialist either through facilitated telemedicine integrated into opioid treatment programs (n = 290) or standard-of-care off-site referral (n = 312). Main Outcomes and Measures The primary outcome was hepatitis C virus cure. Twelve programs began with off-site referral, and every 9 months, 4 randomly selected sites transitioned to facilitated telemedicine during 3 steps without participant crossover. Participants completed 2-year follow-up for reinfection assessment. Inclusion criteria required 6-month enrollment in opioid treatment and insurance coverage of hepatitis C medications. Generalized linear mixed-effects models were used to test for the intervention effect, adjusted for time, clustering, and effect modification in individual-based intention-to-treat analysis. Results Among 602 participants, 369 were male (61.3%); 296 (49.2%) were American Indian or Alaska Native, Asian, Black or African American, multiracial, or other (ie, no race category was selected, with race data collected according to the 5 standard National Institutes of Health categories); and 306 (50.8%) were White. The mean (SD) age of the enrolled participants in the telemedicine group was 47.1 (13.1) years; that of the referral group was 48.9 (12.8) years. In telemedicine, 268 of 290 participants (92.4%) initiated treatment compared with 126 of 312 participants (40.4%) in referral. Intention-to-treat cure percentages were 90.3% (262 of 290) in telemedicine and 39.4% (123 of 312) in referral, with an estimated logarithmic odds ratio of the study group effect of 2.9 (95% CI, 2.0-3.5; P < .001) with no effect modification. Observed cure percentages were 246 of 290 participants (84.8%) in telemedicine vs 106 of 312 participants (34.0%) in referral. Subgroup effects were not significant, including fibrosis stage, urban or rural participant residence location, or mental health (anxiety or depression) comorbid conditions. Illicit drug use decreased significantly (referral: 95% CI, 1.2-4.8; P = .001; telemedicine: 95% CI, 0.3-1.0; P < .001) among cured participants. Minimal reinfections (n = 13) occurred, with hepatitis C virus reinfection incidence of 2.5 per 100 person-years. Participants in both groups rated health care delivery satisfaction as high or very high. Conclusions and Relevance Opioid treatment program-integrated facilitated telemedicine resulted in significantly higher hepatitis C virus cure rates compared with off-site referral, with high participant satisfaction. Illicit drug use declined significantly among cured participants with minimal reinfections. Trial Registration ClinicalTrials.gov Identifier: NCT02933970.
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Affiliation(s)
- Andrew H. Talal
- Division of Gastroenterology, Hepatology, and Nutrition, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York
| | | | - Anran Liu
- Department of Biostatistics, University at Buffalo, Buffalo, New York
| | - Ponni V. Perumalswami
- Division of Liver Diseases, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor
| | - Amreen M. Dinani
- Division of Liver Diseases, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Jonathan N. Tobin
- Clinical Directors Network, Inc (CDN), New York, New York
- The Rockefeller University Center for Clinical and Translational Science, New York, New York
| | - Lawrence S. Brown
- START Treatment & Recovery Centers, Brooklyn, New York
- Weill Cornell Medicine, New York, New York
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Søjbjerg A, Mygind A, Rasmussen SE, Christensen B, Pedersen AF, Maindal HT, Burau V, Christensen KS. Improving mental health in chronic care in general practice: study protocol for a cluster-randomised controlled trial of the Healthy Mind intervention. Trials 2024; 25:277. [PMID: 38654329 PMCID: PMC11036681 DOI: 10.1186/s13063-024-08115-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Accepted: 04/12/2024] [Indexed: 04/25/2024] Open
Abstract
BACKGROUND Mental health issues are common among patients with chronic physical conditions, affecting approximately one in five patients. Poor mental health is associated with worse disease outcomes and increased mortality. Problem-solving therapy (PST) may be a suitable treatment for targeting poor mental health in these patients. This study protocol describes a randomised controlled trial of the Healthy Mind intervention, a general practice-based intervention offering PST to patients with type 2 diabetes and/or ischaemic heart disease and poor mental well-being. METHODS A stepped-wedge cluster-randomised controlled trial with 1-year follow-up will be conducted in Danish general practice. At the annual chronic care consultation, patients with type 2 diabetes and/or chronic ischaemic heart disease will be screened for poor mental well-being. Patients in the control group will be offered usual care while patients in the intervention group will be offered treatment with PST provided by general practitioners (GPs) or general practice staff, such as nurses, who will undergo a 2-day PST course before transitioning from the control to the intervention group. The primary outcome is change in depressive symptoms after 6 and 12 months. Secondary outcomes include change in mental well-being, anxiety, and diabetes distress (patients with type 2 diabetes) after 6 and 12 months as well as change in total cholesterol levels, low-density lipoprotein (LDL) levels, and blood glucose levels (patients with diabetes) after 12 months. Process outcomes include measures of implementation and mechanisms of impact. We aim to include a total of 188 patients, corresponding to approximately 14 average-sized general practices. DISCUSSION The Healthy Mind trial investigates the impact of PST treatment for patients with chronic disease and poor mental well-being in general practice. This will be the first randomised controlled trial determining the effect of PST treatment for patients with chronic diseases in general practice. The results of this study will provide relevant insights to aid GPs, and general practice staff manage patients with poor mental well-being. TRIAL REGISTRATION ClinicalTrials.gov NCT05611112. Registered on October 28, 2022.
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Affiliation(s)
- Anne Søjbjerg
- Research Unit for General Practice, Bartholins Allé 2, 8000, Aarhus C, Denmark.
- Department of Public Health, Aarhus University, Bartholins Allé 2, 8000, Aarhus C, Denmark.
| | - Anna Mygind
- Research Unit for General Practice, Bartholins Allé 2, 8000, Aarhus C, Denmark
| | - Stinne Eika Rasmussen
- Research Unit for General Practice, Bartholins Allé 2, 8000, Aarhus C, Denmark
- Department of Public Health, Aarhus University, Bartholins Allé 2, 8000, Aarhus C, Denmark
| | - Bo Christensen
- Research Unit for General Practice, Bartholins Allé 2, 8000, Aarhus C, Denmark
- Department of Public Health, Aarhus University, Bartholins Allé 2, 8000, Aarhus C, Denmark
| | - Anette Fischer Pedersen
- Research Unit for General Practice, Bartholins Allé 2, 8000, Aarhus C, Denmark
- Department of Clinical Medicine, Aarhus University, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N, Denmark
| | | | - Viola Burau
- Department of Public Health, Aarhus University, Bartholins Allé 2, 8000, Aarhus C, Denmark
| | - Kaj Sparle Christensen
- Research Unit for General Practice, Bartholins Allé 2, 8000, Aarhus C, Denmark
- Department of Public Health, Aarhus University, Bartholins Allé 2, 8000, Aarhus C, Denmark
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Westgate PM, Nigam SR, Shoben AB. Reconsidering stepped wedge cluster randomized trial designs with implementation periods: Fewer sequences or the parallel-group design with baseline and implementation periods are potentially more efficient. Clin Trials 2024:17407745241244790. [PMID: 38650332 DOI: 10.1177/17407745241244790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/25/2024]
Abstract
BACKGROUND/AIMS When designing a cluster randomized trial, advantages and disadvantages of tentative designs must be weighed. The stepped wedge design is popular for multiple reasons, including its potential to increase power via improved efficiency relative to a parallel-group design. In many realistic settings, it will take time for clusters to fully implement the intervention. When designing the HEALing (Helping to End Addiction Long-termSM) Communities Study, implementation time was a major consideration, and we examined the efficiency and practicality of three designs. Specifically, a three-sequence stepped wedge design with implementation periods, a corresponding two-sequence modified design that is created by removing the middle sequence, and a parallel-group design with baseline and implementation periods. In this article, we study the relative efficiencies of these specific designs. More generally, we study the relative efficiencies of modified designs when the stepped wedge design with implementation periods has three or more sequences. We also consider different correlation structures. METHODS We compare efficiencies of stepped wedge designs with implementation periods consisting of three to nine sequences with a variety of corresponding designs. The three-sequence design is compared to the two-sequence modified design and to the parallel-group design with baseline and implementation periods analysed via analysis of covariance. Stepped wedge designs with implementation periods consisting of four or more sequences are compared to modified designs that remove all or a subset of 'middle' sequences. Efficiencies are based on the use of linear mixed effects models. RESULTS In the studied settings, the modified design is more efficient than the three-sequence stepped wedge design with implementation periods. The parallel-group design with baseline and implementation periods with analysis of covariance-based analysis is often more efficient than the three-sequence design. With respect to stepped wedge designs with implementation periods that are comprised of more sequences, there are often corresponding modified designs that improve efficiency. However, use of only the first and last sequences has the potential to be either relatively efficient or inefficient. Relative efficiency is impacted by the strength of the statistical correlation among outcomes from the same cluster; for example, the relative efficiencies of modified designs tend to be greater for smaller cluster auto-correlation values. CONCLUSION If a three-sequence stepped wedge design with implementation periods is being considered for a future cluster randomized trial, then a corresponding modified design using only the first and last sequences should be considered if sole focus is on efficiency. However, a parallel-group design with baseline and implementation periods and analysis of covariance-based analysis can be a practical, efficient alternative. For stepped wedge designs with implementation periods and a larger number of sequences, modified versions that remove 'middle' sequences should be considered. Due to the potential sensitivity of design efficiencies, statistical correlation should be carefully considered.
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Affiliation(s)
- Philip M Westgate
- Department of Biostatistics, College of Public Health, University of Kentucky, Lexington, KY, USA
| | - Shawn R Nigam
- Department of Biostatistics, College of Public Health, University of Kentucky, Lexington, KY, USA
| | - Abigail B Shoben
- Division of Biostatistics, College of Public Health, The Ohio State University, Columbus, OH, USA
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Brünn R, Basten J, Lemke D, Piotrowski A, Söling S, Surmann B, Greiner W, Grandt D, Kellermann-Mühlhoff P, Harder S, Glasziou P, Perera R, Köberlein-Neu J, Ihle P, van den Akker M, Timmesfeld N, Muth C. Digital Medication Management in Polypharmacy. DEUTSCHES ARZTEBLATT INTERNATIONAL 2024; 121:243-250. [PMID: 38377330 DOI: 10.3238/arztebl.m2024.0007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Revised: 01/11/2024] [Accepted: 01/11/2024] [Indexed: 02/22/2024]
Abstract
BACKGROUND Inappropriate drug prescriptions for patients with polypharmacy can have avoidable adverse consequences. We studied the effects of a clinical decision-support system (CDSS) for medication management on hospitalizations and mortality. METHODS This stepped-wedge, cluster-randomized, controlled trial involved an open cohort of adult patients with polypharmacy in primary care practices (=clusters) in Westphalia-Lippe, Germany. During the period of the intervention, their medication lists were checked annually using the CDSS. The CDSS warns against inappropriate prescriptions on the basis of patient-related health insurance data. The combined primary endpoint consisted of overall mortality and hospitalization for any reason. The secondary endpoints were mortality, hospitalizations, and high-risk prescription. We analyzed the quarterly health insurance data of the intention- to-treat population with a mixed logistic model taking account of clustering and repeated measurements. Sensitivity analyses addressed effects of the COVID-19 pandemic and other effects. RESULTS 688 primary care practices were randomized, and data were obtained on 42 700 patients over 391 994 quarter years. No significant reduction was found in either the primary endpoint (odds ratio [OR] 1.00; 95% confidence interval [0.95; 1.04]; p = 0.8716) or the secondary endpoints (hospitalizations: OR 1.00 [0.95; 1.05]; mortality: OR 1.04 [0.92; 1.17]; high-risk prescription: OR 0.98 [0.92; 1.04]). CONCLUSION The planned analyses did not reveal any significant effect of the intervention. Pandemicadjusted analyses yielded evidence that the mortality of adult patients with polypharmacy might potentially be lowered by the CDSS. Controlled trials with appropriate follow-up are needed to prove that a CDSS has significant effects on mortality in patients with polypharmacy.
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Affiliation(s)
- Robin Brünn
- Institute of General Practice, Goethe University Frankfurt am Main; Pharmacy of University Hospital Frankfurt; Department of Medical Informatics, Biometry and Epidemiology, Ruhr University Bochum; Department of Medical Informatics, Biometry and Epidemiology, Ruhr University Bochum; Institute of General Practice, Goethe University Frankfurt am Main; Working Group General and Family Medicine, Medical Faculty East Westphalia-Lippe, University of Bielefeld; Institute of General Practice, Goethe University Frankfurt am Main; Bergisch Competence Center for Health Economics and Health Services Research, Bergische University Wuppertal; Chair of General Medicine II and Patient Orientation in Primary Care, Institute of General Medicine and Ambulatory Health Care (iamag), University Witten/Herdecke; Working Group for Health Economics and Health Management, Faculty of ; Health Sciences, Bielefeld University; Chairman of the Drug Therapy Management and Drug Therapy Safety Commission, German Society for Internal Medicine (DGIM); Barmer, Wuppertal; Institute of Clinical Pharmacology, University Hospital and Faculty of Medicine, Goethe University Frankfurt, Frankfurt am Main; Institute for Evidence-Based Healthcare, Faculty of Health Sciences & Medicine, Bond University, Gold Coast, Queensland, 4229, Australia; Nuffield Department of Primary Care Health Sciences, University of Oxford, UK; PMV Research Group, Faculty of Medicine, University Hospital Cologne, University of Cologne; Institute of General Practice, Goethe-University Frankfurt am Main; Department of Family Medicine, Care and Public Health Research Institute, Maastricht University; Department of Public Health and Primary Care, Academic Centre of General Practice, KU Leuven
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Gonçalves Tasca B, Bousmah MAQ, Coulibaly K, Gosselin A, Ravalihasy A, Desgrées du Loû A, Melchior M. Depression and loneliness among Sub-Saharan immigrants living in the greater Paris area: results from the MAKASI empowerment stepped wedge cluster randomised controlled trial. Soc Psychiatry Psychiatr Epidemiol 2024:10.1007/s00127-024-02665-7. [PMID: 38584200 DOI: 10.1007/s00127-024-02665-7] [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: 03/19/2023] [Accepted: 03/19/2024] [Indexed: 04/09/2024]
Abstract
PURPOSE The MAKASI intervention aimed to empower Sub-Saharan African immigrants living in precarious situations in the Paris metropolitan area. Because there are factors specifically related to immigration that may increase the risk for common mental disorders, the present study aimed to examine participants' levels of depression and loneliness and analyze the effect of the intervention on depression and loneliness. METHODS The MAKASI study was designed as a stepped wedge cluster randomized trial. Study participants were recruited through an outreach program led by a nongovernmental organization and randomly assigned to two clusters, with an intervention delay of 3 months between them. Participants were assessed for 6 months after inclusion and the effect of the intervention on depression and loneliness was assessed using generalized linear mixed models. The study was conducted from 2018 to 2021 and took in consideration whether being interviewed during one of the Covid-19 confinement had an effect on the results. RESULTS Between 2018 and 2021 a total of 821 subjects participated in the Makasi study. High levels of depression and loneliness were found in the study population. We found no effect of the intervention on depression [95% CI 0.77 to 2.40]. Similarly, no effect of the intervention was found on loneliness [95% CI 0.87 to 2.54]. CONCLUSIONS The intervention tested did not appear to improve the level of depression and loneliness among participants. However, the high prevalence of mental and emotional problems in the study population suggests a public health crisis among immigrants in the greater Paris area. CLINICAL TRIAL REGISTRATION NUMBER Trial registration Clinicaltrials.gov, NCT04468724 (July 13, 2020).
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Affiliation(s)
- Bianca Gonçalves Tasca
- Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie Et de Santé Publique (IPLESP), Équipe de Recherche en Épidémiologie Sociale (ERES), Paris, France.
| | - Marwân-Al-Qays Bousmah
- Université Paris Cité, IRD, Inserm, Ceped, 75006, Paris, France
- CNRS, French Collaborative Institute On Migrations, Aubervilliers, France
- IRD, UMR LEDa-DIAL, PSL, Université Paris-Dauphine, CNRS, Paris, France
| | - Karna Coulibaly
- Université Paris Cité, IRD, Inserm, Ceped, 75006, Paris, France
- CNRS, French Collaborative Institute On Migrations, Aubervilliers, France
| | - Anne Gosselin
- Université Paris Cité, IRD, Inserm, Ceped, 75006, Paris, France
- CNRS, French Collaborative Institute On Migrations, Aubervilliers, France
- Ined, National Institute for Demographic Studies, Aubervilliers, France
| | - Andrainolo Ravalihasy
- Université Paris Cité, IRD, Inserm, Ceped, 75006, Paris, France
- CNRS, French Collaborative Institute On Migrations, Aubervilliers, France
| | - Annabel Desgrées du Loû
- Université Paris Cité, IRD, Inserm, Ceped, 75006, Paris, France
- CNRS, French Collaborative Institute On Migrations, Aubervilliers, France
| | - Maria Melchior
- Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie Et de Santé Publique (IPLESP), Équipe de Recherche en Épidémiologie Sociale (ERES), Paris, France
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Daly JB, Doherty E, Tully B, Wiggers J, Hollis J, Licata M, Foster M, Tzelepis F, Lecathelinais C, Kingsland M. Effect of implementation strategies on the routine provision of antenatal care addressing smoking in pregnancy: study protocol for a non-randomised stepped-wedge cluster controlled trial. BMJ Open 2024; 14:e076725. [PMID: 38580367 PMCID: PMC11002428 DOI: 10.1136/bmjopen-2023-076725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Accepted: 02/21/2024] [Indexed: 04/07/2024] Open
Abstract
INTRODUCTION Globally, guideline-recommended antenatal care for smoking cessation is not routinely delivered by antenatal care providers. Implementation strategies have been shown to improve the delivery of clinical practices across a variety of clinical services but there is an absence of evidence in applying such strategies to support improvements to antenatal care for smoking cessation in pregnancy. This study aims to determine the effectiveness and cost effectiveness of implementation strategies in increasing the routine provision of recommended antenatal care for smoking cessation in public maternity services. METHODS AND ANALYSIS A non-randomised stepped-wedge cluster-controlled trial will be conducted in maternity services across three health sectors in New South Wales, Australia. Implementation strategies including guidelines and procedures, reminders and prompts, leadership support, champions, training and monitoring and feedback will be delivered sequentially to each sector over 4 months. Primary outcome measures will be the proportion of: (1) pregnant women who report receiving a carbon monoxide breath test; (2) smokers or recent quitters who report receiving quit/relapse advice; and (3) smokers who report offer of help to quit smoking (Quitline referral or nicotine replacement therapy). Outcomes will be measured via cross-sectional telephone surveys with a random sample of women who attend antenatal appointments each week. Economic analyses will be undertaken to assess the cost effectiveness of the implementation intervention. Process measures including acceptability, adoption, fidelity and reach will be reported. ETHICS AND DISSEMINATION Ethics approval was obtained through the Hunter New England Human Research Ethics Committee (16/11/16/4.07; 16/10/19/5.15) and the Aboriginal Health and Medical Research Council (1236/16). Trial findings will be disseminated to health policy-makers and health services to inform best practice processes for effective guideline implementation. Findings will also be disseminated at scientific conferences and in peer-reviewed journals. TRIAL REGISTRATION NUMBER Australian New Zealand Clinical Trials Registry-ACTRN12622001010785.
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Affiliation(s)
- Justine B Daly
- Hunter New England Population Health, Hunter New England Local Health District, Wallsend, New South Wales, Australia
- School of Medicine and Public Health, College of Health, Medicine and Wellbeing, The University of Newcastle, Callaghan, New South Wales, Australia
- Population Health Research Program, Hunter Medical Research Institute, New Lambton Heights, New South Wales, Australia
| | - Emma Doherty
- Hunter New England Population Health, Hunter New England Local Health District, Wallsend, New South Wales, Australia
- School of Medicine and Public Health, College of Health, Medicine and Wellbeing, The University of Newcastle, Callaghan, New South Wales, Australia
- Population Health Research Program, Hunter Medical Research Institute, New Lambton Heights, New South Wales, Australia
| | - Belinda Tully
- Hunter New England Population Health, Hunter New England Local Health District, Wallsend, New South Wales, Australia
- Armajun Aboriginal Health Service, Inverell, New South Wales, Australia
- Gomeroi Nation, New South Wales, Australia
| | - John Wiggers
- Hunter New England Population Health, Hunter New England Local Health District, Wallsend, New South Wales, Australia
- School of Medicine and Public Health, College of Health, Medicine and Wellbeing, The University of Newcastle, Callaghan, New South Wales, Australia
- Population Health Research Program, Hunter Medical Research Institute, New Lambton Heights, New South Wales, Australia
| | - Jenna Hollis
- Hunter New England Population Health, Hunter New England Local Health District, Wallsend, New South Wales, Australia
- School of Medicine and Public Health, College of Health, Medicine and Wellbeing, The University of Newcastle, Callaghan, New South Wales, Australia
- Population Health Research Program, Hunter Medical Research Institute, New Lambton Heights, New South Wales, Australia
| | - Milly Licata
- Hunter New England Population Health, Hunter New England Local Health District, Wallsend, New South Wales, Australia
| | - Michelle Foster
- Nursing and Midwifery Services, Hunter New England Local Health District, New Lambton, New South Wales, Australia
| | - Flora Tzelepis
- Hunter New England Population Health, Hunter New England Local Health District, Wallsend, New South Wales, Australia
- School of Medicine and Public Health, College of Health, Medicine and Wellbeing, The University of Newcastle, Callaghan, New South Wales, Australia
- Population Health Research Program, Hunter Medical Research Institute, New Lambton Heights, New South Wales, Australia
| | - Christophe Lecathelinais
- Hunter New England Population Health, Hunter New England Local Health District, Wallsend, New South Wales, Australia
| | - Melanie Kingsland
- Hunter New England Population Health, Hunter New England Local Health District, Wallsend, New South Wales, Australia
- School of Medicine and Public Health, College of Health, Medicine and Wellbeing, The University of Newcastle, Callaghan, New South Wales, Australia
- Population Health Research Program, Hunter Medical Research Institute, New Lambton Heights, New South Wales, Australia
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Oyler DR, Westgate PM, Walsh SL, Dolly Prothro J, Miller CS, Roberts MF, Freeman PR, Knudsen HK, Lang M, Dominguez-Fernandez E, Rojas-Ramirez MV. Alternatives to dental opioid prescribing after tooth extraction (ADOPT): protocol for a stepped wedge cluster randomized trial. BMC Oral Health 2024; 24:414. [PMID: 38575929 PMCID: PMC10996080 DOI: 10.1186/s12903-024-04201-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Accepted: 03/28/2024] [Indexed: 04/06/2024] Open
Abstract
BACKGROUND Dentists and oral surgeons are leading prescribers of opioids to adolescents and young adults (AYA), who are at high risk for developing problematic opioid use after an initial exposure. Most opioids are prescribed after tooth extraction, but non-opioid analgesics provide similar analgesia and are recommended by multiple professional organizations. METHODS This multi-site stepped wedge cluster-randomized trial will assess whether a multicomponent behavioral intervention can influence opioid prescribing behavior among dentists and oral surgeons compared to usual practice. Across up to 12 clinical practices (clusters), up to 33 dentists/oral surgeons (provider participants) who perform tooth extractions for individuals 12-25 years old will be enrolled. After enrollment, all provider participants will receive the intervention at a time based on the sequence to which their cluster is randomized. The intervention consists of prescriber education via academic detailing plus provision of standardized patient post-extraction instructions and blister packs of acetaminophen and ibuprofen. Provider participants will dispense the blister packs and distribute the patient instructions at their discretion to AYA undergoing tooth extraction, with or without additional analgesics. The primary outcome is a binary, patient-level indicator of electronic post-extraction opioid prescription. Data for the primary outcome will be collected from the provider participant's electronic health records quarterly throughout the study. Provider participants will complete a survey before and approximately 3 months after transitioning into the intervention condition to assess implementation outcomes. AYA patients undergoing tooth extraction will be offered a survey to assess pain control and satisfaction with pain management in the week after their extraction. Primary analyses will use generalized estimating equations to compare the binary patient-level indicator of being prescribed a post-extraction opioid in the intervention condition compared to usual practice. Secondary analyses will assess provider participants' perceptions of feasibility and appropriateness of the intervention, and patient-reported pain control and satisfaction with pain management. Analyses will adjust for patient-level factors (e.g., sex, number of teeth extracted, etc.). DISCUSSION This real-world study will address an important need, providing information on the effectiveness of a multicomponent intervention at modifying dental prescribing behavior and reducing opioid prescriptions to AYA. CLINICALTRIALS GOV: NCT06275191.
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Affiliation(s)
- Douglas R Oyler
- Department of Pharmacy Practice and Science, College of Pharmacy, University of Kentucky, 760 Press Avenue, Ste. 260, Lexington, KY, 40536, USA.
| | - Philip M Westgate
- Department of Biostatistics, College of Public Health, University of Kentucky, Lexington, KY, USA
| | - Sharon L Walsh
- Department of Behavioral Science and Center on Drug and Alcohol Research, College of Medicine, University of Kentucky, Lexington, KY, USA
| | - Jennifer Dolly Prothro
- Department of Pharmacy Practice and Science, College of Pharmacy, University of Kentucky, 760 Press Avenue, Ste. 260, Lexington, KY, 40536, USA
| | - Craig S Miller
- Department of Oral Diagnosis, Medicine, and Radiology, College of Dentistry, University of Kentucky, Lexington, KY, USA
| | - Monica F Roberts
- Substance Use Priority Research Area, University of Kentucky, Lexington, KY, USA
| | - Patricia R Freeman
- Department of Pharmacy Practice and Science, College of Pharmacy, University of Kentucky, 760 Press Avenue, Ste. 260, Lexington, KY, 40536, USA
| | - Hannah K Knudsen
- Department of Behavioral Science and Center on Drug and Alcohol Research, College of Medicine, University of Kentucky, Lexington, KY, USA
| | - Maggie Lang
- Department of Biostatistics, College of Public Health, University of Kentucky, Lexington, KY, USA
| | - Enif Dominguez-Fernandez
- Department of Oral Health Science, College of Dentistry, University of Kentucky, Lexington, KY, USA
| | - Marcia V Rojas-Ramirez
- Department of Oral Diagnosis, Medicine, and Radiology, College of Dentistry, University of Kentucky, Lexington, KY, USA
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Xu DR, Samu GC, Chen J. Advancing mental health service delivery in low-resource settings. Lancet Glob Health 2024; 12:e543-e545. [PMID: 38408460 DOI: 10.1016/s2214-109x(24)00031-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Accepted: 01/12/2024] [Indexed: 02/28/2024]
Affiliation(s)
- Dong Roman Xu
- Acacia Lab for Implementation Science, SMU Institute for Global Health and Center for World Health Organization Studies, School of Health Management and Dermatology Hospital, Southern Medical University, Guangzhou 510515, China
| | | | - Jiangyun Chen
- Acacia Lab for Implementation Science, SMU Institute for Global Health and Center for World Health Organization Studies, School of Health Management and Dermatology Hospital, Southern Medical University, Guangzhou 510515, China.
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Wang R. Choosing the Unit of Randomization - Individual or Cluster? NEJM EVIDENCE 2024; 3:EVIDe2400037. [PMID: 38805608 DOI: 10.1056/evide2400037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/30/2024]
Affiliation(s)
- Rui Wang
- Department of Population Medicine, Harvard Pilgrim Health Care Institute and Harvard Medical School, Boston
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston
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Najafpour Z, Arab M, Rashidian A, Shayanfard K, Yaseri M, Biparva-Haghighi S. A Stepped-Wedge Cluster-Randomized Controlled Trial of a Multi-interventional Approach for Fall Prevention. Qual Manag Health Care 2024; 33:77-85. [PMID: 38031258 DOI: 10.1097/qmh.0000000000000435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2023]
Abstract
BACKGROUND AND OBJECTIVES Falls are one of the most common adverse events at hospitals that may result in injury and even death. They are also associated with raised length of stay (LOS) and hospitalization costs. This experiment aimed to examine the effectiveness of multiple interventions in reducing inpatient fall rates and the consequent injuries. METHODS The present study was a stepped-wedge cluster-randomized controlled trial. It was done in 18 units in a public university hospital over 36 weeks. Patients included in this research were at risk of falls. Overall, 33 856 patients were admitted, of whom 4766 were considered high-risk patients. During the intervention phases, a series of preventive and control measures were considered, namely staff training; patient education; placement of nursing call bells; adequate lighting; supervision of high-risk patients during transmission and handovers; mobility device allocation; placement of call bell and safe guard in bathrooms; placing "fall alert" signs above patients' beds; nurses informing physicians timely about complications such as delirium and hypoxia; encouraging appropriate use of eyeglasses, hearing aids and footwear; keeping side rails up; and reassessing patients after each fall. The primary outcome was participant falls per 1000 patient-days. Secondary outcomes were fall-related injuries and LOS. RESULTS The results revealed a decrease in fall rate (n = 4 per 1000 patient-days vs 1.34 per 1000 patient-days, incidence rate ratio (IRR) = 0.19 [95% confidence interval (CI), 0.14-0.26]; P = .001) and injuries (n = 2.4 per 1000 patient-days vs 0.79 per 1000 patient-days, IRR = 0.22 [95% CI, 0.15-0.32]; P = .001) in exposed compared with unexposed phases. There was not a significant difference in LOS (exposed mean 10.63 days [95% CI, 10.26-10.97], unexposed mean 10.84 days [95% CI, 10.59-11.09], mean difference = -0.13 [95% CI, -0.53 to 0.27], P = .52). CONCLUSIONS This multi-interventional trial showed a reduction in falls and fall rates with injury but without an overall effect on LOS. Further research is needed to understand the sustainability of multiple fall prevention strategies in hospitals and their long-term impacts.
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Affiliation(s)
- Zhila Najafpour
- Author Affiliations: Department of Health Care Management, School of Public Health, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran (Dr Najafpour); School of Public Health, Tehran University of Medical Sciences, Tehran, Iran (Drs Arab and Rashidian); University of Luxembourg, Luxembourg (Dr Shayanfard); Department of Epidemiology and Biostatistics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran (Dr Yaseri); and Faculty of Medicine, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran (Dr Biparva-Haghighi)
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Nevins P, Ryan M, Davis-Plourde K, Ouyang Y, Macedo JAP, Meng C, Tong G, Wang X, Ortiz-Reyes L, Caille A, Li F, Taljaard M. Adherence to key recommendations for design and analysis of stepped-wedge cluster randomized trials: A review of trials published 2016-2022. Clin Trials 2024; 21:199-210. [PMID: 37990575 PMCID: PMC11003836 DOI: 10.1177/17407745231208397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2023]
Abstract
BACKGROUND/AIMS The stepped-wedge cluster randomized trial (SW-CRT), in which clusters are randomized to a time at which they will transition to the intervention condition - rather than a trial arm - is a relatively new design. SW-CRTs have additional design and analytical considerations compared to conventional parallel arm trials. To inform future methodological development, including guidance for trialists and the selection of parameters for statistical simulation studies, we conducted a review of recently published SW-CRTs. Specific objectives were to describe (1) the types of designs used in practice, (2) adherence to key requirements for statistical analysis, and (3) practices around covariate adjustment. We also examined changes in adherence over time and by journal impact factor. METHODS We used electronic searches to identify primary reports of SW-CRTs published 2016-2022. Two reviewers extracted information from each trial report and its protocol, if available, and resolved disagreements through discussion. RESULTS We identified 160 eligible trials, randomizing a median (Q1-Q3) of 11 (8-18) clusters to 5 (4-7) sequences. The majority (122, 76%) were cross-sectional (almost all with continuous recruitment), 23 (14%) were closed cohorts and 15 (9%) open cohorts. Many trials had complex design features such as multiple or multivariate primary outcomes (50, 31%) or time-dependent repeated measures (27, 22%). The most common type of primary outcome was binary (51%); continuous outcomes were less common (26%). The most frequently used method of analysis was a generalized linear mixed model (112, 70%); generalized estimating equations were used less frequently (12, 8%). Among 142 trials with fewer than 40 clusters, only 9 (6%) reported using methods appropriate for a small number of clusters. Statistical analyses clearly adjusted for time effects in 119 (74%), for within-cluster correlations in 132 (83%), and for distinct between-period correlations in 13 (8%). Covariates were included in the primary analysis of the primary outcome in 82 (51%) and were most often individual-level covariates; however, clear and complete pre-specification of covariates was uncommon. Adherence to some key methodological requirements (adjusting for time effects, accounting for within-period correlation) was higher among trials published in higher versus lower impact factor journals. Substantial improvements over time were not observed although a slight improvement was observed in the proportion accounting for a distinct between-period correlation. CONCLUSIONS Future methods development should prioritize methods for SW-CRTs with binary or time-to-event outcomes, small numbers of clusters, continuous recruitment designs, multivariate outcomes, or time-dependent repeated measures. Trialists, journal editors, and peer reviewers should be aware that SW-CRTs have additional methodological requirements over parallel arm designs including the need to account for period effects as well as complex intracluster correlations.
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Affiliation(s)
- Pascale Nevins
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Mary Ryan
- Department of Biostatistics, Yale School of Public Health, New Haven, CT, USA
| | - Kendra Davis-Plourde
- Department of Biostatistics, Yale School of Public Health, New Haven, CT, USA
- Yale Center for Analytical Sciences, Yale School of Public Health, New Haven, CT, USA
| | - Yongdong Ouyang
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | | | - Can Meng
- Yale Center for Analytical Sciences, Yale School of Public Health, New Haven, CT, USA
| | - Guangyu Tong
- Department of Biostatistics, Yale School of Public Health, New Haven, CT, USA
- Center for Methods in Implementation and Prevention Science, Yale University, New Haven, CT, USA
| | - Xueqi Wang
- Department of Biostatistics, Yale School of Public Health, New Haven, CT, USA
- Section of Geriatrics, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Luis Ortiz-Reyes
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Agnès Caille
- Université de Tours, Université de Nantes, INSERM, SPHERE U1246, Tours, France
- INSERM CIC 1415, CHRU de Tours, Tours, France
| | - Fan Li
- Department of Biostatistics, Yale School of Public Health, New Haven, CT, USA
- Center for Methods in Implementation and Prevention Science, Yale University, New Haven, CT, USA
| | - Monica Taljaard
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
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McCoy RG, Swarna KS, Jiang DH, Van Houten HK, Chen J, Davis EM, Herrin J. Enrollment in High-Deductible Health Plans and Incident Diabetes Complications. JAMA Netw Open 2024; 7:e243394. [PMID: 38517436 PMCID: PMC10960199 DOI: 10.1001/jamanetworkopen.2024.3394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2023] [Accepted: 01/25/2024] [Indexed: 03/23/2024] Open
Abstract
Importance Preventing diabetes complications requires monitoring and control of hyperglycemia and cardiovascular risk factors. Switching to high-deductible health plans (HDHPs) has been shown to hinder aspects of diabetes care; however, the association of HDHP enrollment with microvascular and macrovascular diabetes complications is unknown. Objective To examine the association between an employer-required switch to an HDHP and incident complications of diabetes. Design, Setting, and Participants This retrospective cohort study used deidentified administrative claims data for US adults with diabetes enrolled in employer-sponsored health plans between January 1, 2010, and December 31, 2019. Data analysis was performed from May 26, 2022, to January 2, 2024. Exposures Adults with a baseline year of non-HDHP enrollment who had to switch to an HDHP because their employer offered no non-HDHP alternative in that year were compared with adults who were continuously enrolled in a non-HDHP. Main Outcomes and Measures Mixed-effects logistic regression models examined the association between switching to an HDHP and, individually, the odds of myocardial infarction, stroke, hospitalization for heart failure, lower-extremity complication, end-stage kidney disease, proliferative retinopathy, treatment for retinopathy, and blindness. Models were adjusted for demographics, comorbidities, and medications, with inverse propensity score weighting used to account for potential selection bias. Results The study included 42 326 adults who switched to an HDHP (mean [SD] age, 52 [10] years; 19 752 [46.7%] female) and 202 729 adults who did not switch (mean [SD] age, 53 [10] years; 89 828 [44.3%] female). Those who switched to an HDHP had greater odds of experiencing all diabetes complications (odds ratio [OR], 1.11; 95% CI, 1.06-1.16 for myocardial infarction; OR, 1.15; 95% CI, 1.09-1.21 for stroke; OR, 1.35; 95% CI, 1.30-1.41 for hospitalization for heart failure; OR, 2.53; 95% CI, 2.38-2.70 for end-stage kidney disease; OR, 2.23; 95% CI, 2.17-2.29 for lower-extremity complication; OR, 1.17; 95% CI, 1.13-1.21 for proliferative retinopathy; OR, 2.35; 95% CI, 2.18-2.54 for blindness; and OR, 2.28; 95% CI, 2.15-2.41 for retinopathy treatment). Conclusions and Relevance This study found that an employer-driven switch to an HDHP was associated with increased odds of experiencing all diabetes complications. These findings reinforce the potential harm associated with HDHPs for people with diabetes and the importance of affordable and accessible chronic disease management, which is hindered by high out-of-pocket costs incurred by HDHPs.
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Affiliation(s)
- Rozalina G. McCoy
- Division of Endocrinology, Diabetes, and Nutrition, Department of Medicine, University of Maryland School of Medicine, Baltimore
- University of Maryland Institute for Health Computing, Bethesda
- Division of Gerontology, Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore
- Department of Health Policy and Management, University of Maryland School of Public Health, College Park
- OptumLabs, Eden Prairie, Minnesota
| | - Kavya S. Swarna
- OptumLabs, Eden Prairie, Minnesota
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
| | | | - Holly K. Van Houten
- OptumLabs, Eden Prairie, Minnesota
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
| | - Jie Chen
- Department of Health Policy and Management, University of Maryland School of Public Health, College Park
| | - Esa M. Davis
- University of Maryland Institute for Health Computing, Bethesda
- Department of Family and Community Medicine, University of Maryland School of Medicine, Baltimore
| | - Jeph Herrin
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
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Krauss MJ, Somerville E, Bollinger RM, Chen SW, Kehrer-Dunlap AL, Haxton M, Yan Y, Stark SL. Removing home hazards for older adults living in affordable housing: A stepped-wedge cluster-randomized trial. J Am Geriatr Soc 2024; 72:670-681. [PMID: 38103187 PMCID: PMC10947940 DOI: 10.1111/jgs.18706] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Revised: 11/06/2023] [Accepted: 11/15/2023] [Indexed: 12/18/2023]
Abstract
BACKGROUND Falls are the leading cause of injury, disability, premature institutionalization, and injury-related mortality among older adults. Home hazard removal can effectively reduce falls in this population but is not implemented as standard practice. This study translated an evidence-based home hazard removal program (HARP) for delivery in low-income senior apartments to test whether the intervention would work in the "real world." METHODS From May 1, 2019 to December 31, 2020, a stepped-wedge cluster-randomized trial was used to implement the evidence-based HARP among residents with high fall risk in 11 low-income senior apartment buildings. Five clusters of buildings were randomly assigned an intervention allocation sequence. Three-level negative-binomial models (repeated measures nested within individuals, individuals nested within buildings) were used to compare fall rates between treatment and control conditions (excluding a crossover period), controlling for demographic characteristics, fall risk, and time period. RESULTS Among 656 residents, 548 agreed to screening, 435 were eligible (high fall risk), and 291 agreed to participate and received HARP. Participants were, on average, 72 years, 67% female, and 76% Black. Approximately 95.4% of fall prevention strategies and modifications implemented were still used 3 months later. The fall rate (per 1000 participant-days) was 4.87 during the control period and 4.31 during the posttreatment period. After adjusting for covariates and secular trend, there was no significant difference in fall rate (incidence rate ratio [IRR] 0.97, 95% CI 0.66-1.42). After excluding data collected during a hiatus in the intervention due to COVID-19, the reduction in fall rate was not significant (IRR 0.93, 95% CI 0.62-1.40). CONCLUSIONS Although HARP did not significantly reduce the rate of falls, this pragmatic study showed that the program was feasible to deliver in low-income senior housing and was acceptable among residents. There was effective collaboration between researchers and community agency staff.
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Affiliation(s)
- Melissa J Krauss
- Program in Occupational Therapy, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA
| | - Emily Somerville
- Program in Occupational Therapy, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA
| | - Rebecca M Bollinger
- Program in Occupational Therapy, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA
| | - Szu-Wei Chen
- Program in Occupational Therapy, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA
| | - Abigail L Kehrer-Dunlap
- Program in Occupational Therapy, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA
| | - Meghan Haxton
- Program in Occupational Therapy, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA
| | - Yan Yan
- Department of Surgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA
| | - Susan L Stark
- Program in Occupational Therapy, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA
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Wieland ML, Molina L, Goodson M, Capetillo GP, Osman A, Ahmed Y, Elmi H, Nur O, Iteghete SO, Torres-Herbeck G, Dirie H, Clark MM, Lohr AM, Smith K, Zeratsky K, Rieck T, Herrin J, Valente TW, Sia IG. Healthy immigrant community study protocol: A randomized controlled trial of a social network intervention for cardiovascular risk reduction among Hispanic and Somali adults. Contemp Clin Trials 2024; 138:107465. [PMID: 38309526 PMCID: PMC10923143 DOI: 10.1016/j.cct.2024.107465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Revised: 12/18/2023] [Accepted: 01/28/2024] [Indexed: 02/05/2024]
Abstract
BACKGROUND Immigrants to the United States face structural barriers that contribute to rising cardiovascular risk factors and obesity after immigration. This manuscript describes the development of the Healthy Immigrant Community protocol and baseline measures for a stepped wedge cluster randomized trial to test the effectiveness of a social network intervention for cardiovascular risk reduction among two immigrant populations. METHODS We developed a social network-informed, community-based, participatory research-derived health promotion intervention with Hispanic and Somali immigrant communities in Minnesota consisting of mentoring, educational and motivational sessions, group activities, and a community toolkit for healthy weight loss delivered by culturally concordant health promoters (HPs) to their social networks. Using a stepped wedge cluster randomized design, social network-based groups were randomly assigned to receive the intervention either immediately or after a delay of one year. Outcomes, measured at baseline, 6 months, 12 months, and 24 months, were derived from the American Heart Association's "Life's Simple 7": BMI and waist circumference, blood pressure, fasting blood glucose, total cholesterol, physical activity level, and dietary quality. RESULTS A total of 51 HPs were enrolled and randomized (29 Hispanic; 22 Somali). There were 475 participants enrolled in the study, representing a mean social network group size of 8 (range, 5-12). The mean BMI of the sample (32.2) was in the "obese" range. CONCLUSION Processes and products from this Healthy Immigrant Community protocol are relevant to other communities seeking to reduce cardiovascular risk factors and negative health behaviors among immigrant populations by leveraging the influence of their social networks.
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Affiliation(s)
- Mark L Wieland
- Division of Community Internal Medicine, Geriatrics, and Palliative Care, Mayo Clinic, Rochester, MN, USA; Rochester Healthy Community Partnership.
| | | | - Miriam Goodson
- Rochester Healthy Community Partnership; Alliance for Chicanos, Hispanics, and Latin Americans, Rochester, MN, USA
| | - Graciela Porraz Capetillo
- Rochester Healthy Community Partnership; Department of Language Services, Mayo Clinic, Rochester, MN, USA
| | - Ahmed Osman
- Rochester Healthy Community Partnership; Intercultural Mutual Assistance Association, Rochester, MN, USA
| | - Yahye Ahmed
- Rochester Healthy Community Partnership; Somali American Social Service Association, Rochester, MN, USA
| | - Hindi Elmi
- Rochester Healthy Community Partnership; Intercultural Mutual Assistance Association, Rochester, MN, USA
| | - Omar Nur
- Rochester Healthy Community Partnership; Somali American Social Service Association, Rochester, MN, USA
| | | | - Gloria Torres-Herbeck
- Rochester Healthy Community Partnership; Alliance for Chicanos, Hispanics, and Latin Americans, Rochester, MN, USA
| | | | - Matthew M Clark
- Rochester Healthy Community Partnership; Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN, USA
| | - Abby M Lohr
- Division of Community Internal Medicine, Geriatrics, and Palliative Care, Mayo Clinic, Rochester, MN, USA; Rochester Healthy Community Partnership
| | | | - Katherine Zeratsky
- Rochester Healthy Community Partnership; Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN, USA
| | - Thomas Rieck
- Rochester Healthy Community Partnership; Department of Integrative Medicine and Health, Mayo Clinic, Rochester, MN, USA
| | - Jeph Herrin
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Thomas W Valente
- Department of Preventive Medicine, University of Southern California, Los Angeles, CA, USA
| | - Irene G Sia
- Rochester Healthy Community Partnership; Division of Public Health, Infectious Diseases, and Occupational Medicine, Mayo Clinic, Rochester, MN, USA
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Tian Z, Li F. Information content of stepped wedge designs under the working independence assumption. J Stat Plan Inference 2024; 229:106097. [PMID: 37954217 PMCID: PMC10634667 DOI: 10.1016/j.jspi.2023.106097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2023]
Abstract
The stepped wedge design is increasingly popular in pragmatic trials and implementation science research studies for evaluating system-level interventions that are perceived to be beneficial to patient populations. An important step in planning a stepped wedge design is to understand the efficiency of the treatment effect estimator and hence the power of the study. We develop several novel analytical results for designing stepped wedge cluster randomized trials analyzed through generalized estimating equations under a misspecified working independence correlation structure. We first contribute a general variance expression of the treatment effect estimator when data collection is scheduled for each cluster-period. Because resource and patient-centered considerations may intentionally call for an incomplete design with outcome data being omitted for certain cluster-periods, we further derive the information content based on the robust sandwich variance to identify data elements that may be preferentially omitted with minimum loss of precision in estimating the treatment effect. We prove that centrosymmetric pairs of cluster-periods, treatment sequences and periods have identical information content and thus contribute equally to the treatment effect estimation, as long as the true covariance structure for the cluster-period means remains centrosymmetric. Finally, we provide an example of how to obtain an incomplete stepped wedge design that admits a more efficient independence GEE estimator but requires less data collection effort. Our results elegantly extend existing ones from linear mixed models coupled with model-based variances to accommodate a misspecified independence working correlation structure through the robust sandwich variances.
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Affiliation(s)
- Zibo Tian
- Department of Biostatistics, University of Florida, Gainesville, FL, USA
| | - Fan Li
- Department of Biostatistics, Yale School of Public Health, New Haven, CT, USA
- Center for Methods in Implementation and Prevention Science, Yale University, New Haven, CT, USA
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Dijkstra BM, Rood PJT, Teerenstra S, Rutten AMF, Leerentveld C, Burgers-Bonthuis DC, Festen-Spanjer B, Klarenbeek T, Van Den Boogaard M, Ewalds E, Schoonhoven L, Van Der Hoeven JG, Vloet LCM. Effect of a Standardized Family Participation Program in the ICU: A Multicenter Stepped-Wedge Cluster Randomized Controlled Trial. Crit Care Med 2024; 52:420-431. [PMID: 37934138 PMCID: PMC10876177 DOI: 10.1097/ccm.0000000000006093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2023]
Abstract
OBJECTIVES To determine the effect of a standardized program for family participation in essential care activities in the ICU on symptoms of anxiety, depression, posttraumatic stress and satisfaction among relatives, and perceptions and experiences of ICU healthcare providers (HCPs). DESIGN Multicenter stepped-wedge cluster randomized controlled trial. SETTING Seven adult ICUs, one university, and six general teaching hospitals. PARTICIPANTS Three hundred six relatives and 235 ICU HCPs. INTERVENTIONS A standardized program to facilitate family participation inpatient communication, amusement/distraction, comfort, personal care, breathing, mobilization, and nutrition. MEASUREMENTS AND MAIN RESULTS Data were collected through surveys among relatives and ICU HCPs. There were no significant differences in symptoms of anxiety in relatives in the intervention period compared with the control period (median Hospital Anxiety and Depression Scale [HADS] 5 [interquartile range (IQR) 2-10] vs 6 [IQR 3-9]; median ratio [MR] 0.72; 95% CI, 0.46-1.13; p = 0.15), depression (median HADS 4 [IQR 2-6] vs 3 [IQR 1-6]; MR 0.85; 95% CI, 0.55-1.32; p = 0.47) or posttraumatic stress (median Impact of Event Scale-Revised score 0.45 [IQR 0.27-0.82] vs 0.41 [IQR 0.14-1]; MR 0.94; 95% CI, 0.78-1.14; p = 0.54). Reported satisfaction was slightly lower in the intervention period (mean 8.90 [ sd 1.10] vs mean 9.06 [ sd 1.10], difference -0.60; 95% CI, -1.07 to -0.12; p = 0.01). ICU HCPs perceived that more relatives knew how to participate: 47% in the intervention period versus 22% in the control period (odds ratio [OR] 3.15; 95% CI, 1.64-6.05; p < 0.01). They also reported relatives having sufficient knowledge (41% vs 16%; OR 3.56; 95% CI, 1.75-7.25; p < 0.01) and skills (44% vs 25%; OR 2.38; 95% CI, 1.22-4.63; p = 0.01) to apply family participation. CONCLUSIONS Application of a standardized program to facilitate family participation did not change mental health symptoms in relatives of ICU patients 3 months after discharge. ICU HCPs reported increased clarity, knowledge, and skills among relatives and ICU HCPs.
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Affiliation(s)
- Boukje M Dijkstra
- Research Department Emergency and Critical Care, School of Health Studies Nijmegen, HAN University of Applied Sciences, Nijmegen, The Netherlands
- Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Paul J T Rood
- Research Department Emergency and Critical Care, School of Health Studies Nijmegen, HAN University of Applied Sciences, Nijmegen, The Netherlands
- Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Steven Teerenstra
- Department for Health Evidence, Section Biostatistics, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Anne M F Rutten
- Department of Intensive Care Medicine, Elisabeth Tweesteden Hospital, Tilburg, The Netherlands
| | - Crista Leerentveld
- Department of Intensive Care Medicine, ISALA Hospital, Zwolle, The Netherlands
| | | | | | - Toine Klarenbeek
- Department of Intensive Care Medicine, Máxima Medical Center, Veldhoven, The Netherlands
| | - Mark Van Den Boogaard
- Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Esther Ewalds
- Department of Intensive Care Medicine, Bernhoven, Uden, The Netherlands
| | - Lisette Schoonhoven
- Nursing Science, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
- School of Health Sciences, Faculty of Environmental and Life Sciences, University of Southampton, Southampton, United Kingdom
| | | | - Lilian C M Vloet
- Research Department Emergency and Critical Care, School of Health Studies Nijmegen, HAN University of Applied Sciences, Nijmegen, The Netherlands
- IQ Healthcare, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
- Foundation for Family and Patient Centered Intensive Care, Alkmaar, The Netherlands
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Li F, Chen X, Tian Z, Wang R, Heagerty PJ. Planning stepped wedge cluster randomized trials to detect treatment effect heterogeneity. Stat Med 2024; 43:890-911. [PMID: 38115805 DOI: 10.1002/sim.9990] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2022] [Revised: 09/22/2023] [Accepted: 11/30/2023] [Indexed: 12/21/2023]
Abstract
Stepped wedge design is a popular research design that enables a rigorous evaluation of candidate interventions by using a staggered cluster randomization strategy. While analytical methods were developed for designing stepped wedge trials, the prior focus has been solely on testing for the average treatment effect. With a growing interest on formal evaluation of the heterogeneity of treatment effects across patient subpopulations, trial planning efforts need appropriate methods to accurately identify sample sizes or design configurations that can generate evidence for both the average treatment effect and variations in subgroup treatment effects. To fill in that important gap, this article derives novel variance formulas for confirmatory analyses of treatment effect heterogeneity, that are applicable to both cross-sectional and closed-cohort stepped wedge designs. We additionally point out that the same framework can be used for more efficient average treatment effect analyses via covariate adjustment, and allows the use of familiar power formulas for average treatment effect analyses to proceed. Our results further sheds light on optimal design allocations of clusters to maximize the weighted precision for assessing both the average and heterogeneous treatment effects. We apply the new methods to the Lumbar Imaging with Reporting of Epidemiology Trial, and carry out a simulation study to validate our new methods.
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Affiliation(s)
- Fan Li
- Department of Biostatistics, Yale University School of Public Health, New Haven, Connecticut, USA
- Center for Methods in Implementation and Prevention Science, Yale University School of Public Health, New Haven, Connecticut, USA
| | - Xinyuan Chen
- Department of Mathematics and Statistics, Mississippi State University, Mississippi State, Mississippi, USA
| | - Zizhong Tian
- Department of Public Health Sciences, Pennsylvania State University College of Medicine, Hershey, Pennsylvania, USA
| | - Rui Wang
- Department of Population Medicine, Harvard Pilgrim Health Care Institute and Harvard Medical School, Boston, Massachusetts, USA
- Department of Biostatistics, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Patrick J Heagerty
- Department of Biostatistics, University of Washington, Seattle, Washington, USA
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