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Peters AE, Jones WS, Anderson B, Bramante CT, Broedl U, Hornik CP, Kehoe L, Knowlton KU, Krofah E, Landray M, Locke T, Patel MR, Psotka M, Rockhold FW, Roessig L, Rothman RL, Schofield L, Stockbridge N, Trontell A, Curtis LH, Tenaerts P, Hernandez AF. Framework of the strengths and challenges of clinically integrated trials: An expert panel report. Am Heart J 2024; 275:62-73. [PMID: 38795793 PMCID: PMC11330722 DOI: 10.1016/j.ahj.2024.05.009] [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: 05/13/2024] [Accepted: 05/15/2024] [Indexed: 05/28/2024]
Abstract
The limitations of the explanatory clinical trial framework include the high expense of implementing explanatory trials, restrictive entry criteria for participants, and redundant logistical processes. These limitations can result in slow evidence generation that is not responsive to population health needs, yielding evidence that is not generalizable. Clinically integrated trials, which integrate clinical research into routine care, represent a potential solution to this challenge and an opportunity to support learning health systems. The operational and design features of clinically integrated trials include a focused scope, simplicity in design and requirements, the leveraging of existing data structures, and patient participation in the entire trial process. These features are designed to minimize barriers to participation and trial execution and reduce additional research burdens for participants and clinicians alike. Broad adoption and scalability of clinically integrated trials are dependent, in part, on continuing regulatory, healthcare system, and payer support. This analysis presents a framework of the strengths and challenges of clinically integrated trials and is based on a multidisciplinary expert "Think Tank" panel discussion that included representatives from patient populations, academia, non-profit funding agencies, the U.S. Food and Drug Administration, and industry.
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Affiliation(s)
- Anthony E Peters
- Division of Cardiology, Department of Medicine, Duke University School of Medicine, Durham, NC
| | - W Schuyler Jones
- Division of Cardiology, Department of Medicine, Duke University School of Medicine, Durham, NC; Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | | | - Carolyn T Bramante
- Departmentd of Medicine, University of Minnesota Medical School, Minneapolis, MN
| | | | - Christoph P Hornik
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC; Department of Pediatrics, Duke University School of Medicine, Durham, NC
| | - Lindsay Kehoe
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - Kirk U Knowlton
- Intermountain Medical Center Heart Institute, Salt Lake City, UT
| | | | | | - Trevan Locke
- Margolis Institute for Health Policy, Duke University, Durham, NC
| | - Manesh R Patel
- Division of Cardiology, Department of Medicine, Duke University School of Medicine, Durham, NC; Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | | | - Frank W Rockhold
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC; Department of Biostatistics & Bioinformatics, Duke University School of Medicine, Durham, NC
| | | | | | | | - Norman Stockbridge
- Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, MD
| | - Anne Trontell
- Patient-Centered Outcomes Research Institute (PCORI), Washington, DC
| | - Lesley H Curtis
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | | | - Adrian F Hernandez
- Division of Cardiology, Department of Medicine, Duke University School of Medicine, Durham, NC; Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC.
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Narang M, Saxena A, Kaur R, Gopa HR, West NEJ. Variability in research culture across busy catheterisation labs in the Asia-Pacific region. ASIAINTERVENTION 2024; 10:26-33. [PMID: 38425813 PMCID: PMC10900241 DOI: 10.4244/aij-d-23-00005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 07/11/2023] [Indexed: 03/02/2024]
Abstract
Background Information related to research culture in the busy catheterisation (cath) labs across the Asia-Pacific (APAC) region is sparse. Aims The aims of this study were to examine the variability in research culture in busy cath labs in the APAC region and to propose a roadmap for hospitals to develop in-house research capabilities in conjunction with industry and academia. Methods Data related to research practices in the APAC region were collected from busy cath labs (at least 250 angioplasty/year) and analysed. Results were shared with research experts to understand the challenges in institutional research and create a roadmap for hospitals to develop research capabilities. Results A total of 220 respondents from 62 cath labs (88.6%) across 13 APAC countries participated in the survey. A wide variation was noted in research culture across APAC countries. Well-established infrastructure was reported in Australia, New Zealand, South Korea, Singapore, and Japan. Large multicentre trials were common in South Korea, while routine follow-ups were common in Japan. Linking medical records across hospitals/states was considered challenging. Research exposure and training were limited in the APAC region. The experts suggested a roadmap, including creating a conducive regulatory environment, forming synergistic goals, training programs for the professionals involved in research, and leveraging best practices, for improving the research culture in APAC. Conclusions Clinical research in cardiology has grown significantly in the APAC region, with a huge research potential in China and India. Implementing measures to improve research training and involvement of the industry will boost the research culture in the APAC region.
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Affiliation(s)
- Manish Narang
- Department of Medical Affairs, Abbott Vascular, Abbott Healthcare Pvt Ltd, New Delhi, India
| | - Aseem Saxena
- Department of Medical Affairs, Abbott Vascular, Abbott Healthcare Pvt Ltd, New Delhi, India
| | - Ramneek Kaur
- Department of Medical Affairs, Abbott Vascular, Abbott Healthcare Pvt Ltd, New Delhi, India
| | | | - Nick E J West
- Global Medical Affairs, Abbott Vascular, Santa Clara, CA, USA
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Baasan O, Freihat O, Nagy DU, Lohner S. Change over Five Years in Important Measures of Methodological Quality and Reporting in Randomized Cardiovascular Clinical Trials. J Cardiovasc Dev Dis 2023; 11:2. [PMID: 38276655 PMCID: PMC10816801 DOI: 10.3390/jcdd11010002] [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: 10/29/2023] [Revised: 12/15/2023] [Accepted: 12/18/2023] [Indexed: 01/27/2024] Open
Abstract
OBJECTIVES The aim of our current study was to analyze whether the use of important measures of methodological quality and reporting of randomized clinical trials published in the field of cardiovascular disease research haschanged over time. A furtheraim was to investigate whether there was an improvement over time in the ability of these trials to provide a good estimate of the true intervention effect. METHODS We conducted two searches in the Cochrane Central Register of Controlled Trials (CENTAL) database to identify randomized cardiovascular clinical trials published in either 2012 or 2017. Randomized clinical trials (RCTs) trials in cardiovascular disease research with adult participants were eligible to be included. We randomly selected 250 RCTs for publication years 2012 and 2017. Trial characteristics, data on measures of methodological quality, and reporting were extracted and the risk of bias for each trial was assessed. RESULTS As compared to 2012, in 2017 there were significant improvements in the reporting of the presence of a data monitoring committee (42.0% in 2017 compared to 34.4% in 2012; p < 0.001), and a positive change in registering randomized cardiovascular disease research in clinical trial registries (78.4% in 2017 compared to 68.9% in 2012; p = 0.03). We also observed that significantly more RCTs reported sample size calculation (60.4% in 2017 compared to 49.6% in 2012; p < 0.01) in 2017 as compared to 2012. RCTs in 2017 were more likely to have a low overall risk of bias (RoB) than in 2012 (29.2% in 2017 compared to 21.2% in 2012; p < 0.01). However, fewer 2017 RCTs were rated low (50.8% compared to 65.6%; p < 0.001) risk for blinding of participants and personnel, for blinding of outcome assessors (82.4% compared to 90.8%; p < 0.001), and selective outcome reporting (62.8% compared to 80.0%; <0.001). CONCLUSIONS As compared to 2012, in 2017 there were significant improvements in some, but not all, the important measures of methodological quality. Although more trials in the field of cardiovascular disease research had a lower overall RoB in 2017, the improvement over time was not consistently perceived in all RoB domains.
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Affiliation(s)
- Odgerel Baasan
- Doctoral School of Health Sciences, University of Pécs, 7621 Pécs, Hungary
- Cochrane Hungary, Clinical Centre of the University of Pécs, Medical School, University of Pécs, 7624 Pécs, Hungary
| | - Omar Freihat
- Doctoral School of Health Sciences, University of Pécs, 7621 Pécs, Hungary
| | - Dávid U. Nagy
- Cochrane Hungary, Clinical Centre of the University of Pécs, Medical School, University of Pécs, 7624 Pécs, Hungary
- Institute of Geobotany/Plant Ecology, Martin-Luther-University, 06108 Halle, Germany
| | - Szimonetta Lohner
- Doctoral School of Health Sciences, University of Pécs, 7621 Pécs, Hungary
- Cochrane Hungary, Clinical Centre of the University of Pécs, Medical School, University of Pécs, 7624 Pécs, Hungary
- Department of Public Health Medicine, Medical School, University of Pécs, 7624 Pécs, Hungary
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4
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Avram R, Byrne J, So D, Iturriaga E, Lennon R, Murthy V, Geller N, Goodman S, Rihal C, Rosenberg Y, Bailey K, Farkouh M, Bell M, Cagin C, Chavez I, El-Hajjar M, Ginete W, Lerman A, Levisay J, Marzo K, Nazif T, Tanguay JF, Pletcher M, Marcus GM, Pereira NL, Olgin J. Digital Tool-Assisted Hospitalization Detection in the Tailored Antiplatelet Initiation to Lessen Outcomes due to Decreased Clopidogrel Response After Percutaneous Coronary Intervention Study Compared to Traditional Site-Coordinator Ascertainment: Intervention Study. J Med Internet Res 2023; 25:e47475. [PMID: 37948098 PMCID: PMC10674150 DOI: 10.2196/47475] [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: 03/23/2023] [Revised: 07/12/2023] [Accepted: 09/11/2023] [Indexed: 11/12/2023] Open
Abstract
BACKGROUND Accurate, timely ascertainment of clinical end points, particularly hospitalizations, is crucial for clinical trials. The Tailored Antiplatelet Initiation to Lessen Outcomes Due to Decreased Clopidogrel Response after Percutaneous Coronary Intervention (TAILOR-PCI) Digital Study extended the main TAILOR-PCI trial's follow-up to 2 years, using a smartphone-based research app featuring geofencing-triggered surveys and routine monthly mobile phone surveys to detect cardiovascular (CV) hospitalizations. This pilot study compared these digital tools to conventional site-coordinator ascertainment of CV hospitalizations. OBJECTIVE The objectives were to evaluate geofencing-triggered notifications and routine monthly mobile phone surveys' performance in detecting CV hospitalizations compared to telephone visits and health record reviews by study coordinators at each site. METHODS US and Canadian participants from the TAILOR-PCI Digital Follow-Up Study were invited to download the Eureka Research Platform mobile app, opting in for location tracking using geofencing, triggering a smartphone-based survey if near a hospital for ≥4 hours. Participants were sent monthly notifications for CV hospitalization surveys. RESULTS From 85 participants who consented to the Digital Study, downloaded the mobile app, and had not previously completed their final follow-up visit, 73 (85.8%) initially opted in and consented to geofencing. There were 9 CV hospitalizations ascertained by study coordinators among 5 patients, whereas 8 out of 9 (88.9%) were detected by routine monthly hospitalization surveys. One CV hospitalization went undetected by the survey as it occurred within two weeks of the previous event, and the survey only allowed reporting of a single hospitalization. Among these, 3 were also detected by the geofencing algorithm, but 6 out of 9 (66.7%) were missed by geofencing: 1 occurred in a participant who never consented to geofencing, while 5 hospitalizations occurred among participants who had subsequently turned off geofencing prior to their hospitalization. Geofencing-detected hospitalizations were ascertained within a median of 2 (IQR 1-3) days, monthly surveys within 11 (IQR 6.5-25) days, and site coordinator methods within 38 (IQR 9-105) days. The geofencing algorithm triggered 245 notifications among 39 participants, with 128 (52.2%) from true hospital presence and 117 (47.8%) from nonhospital health care facility visits. Additional geofencing iterative improvements to reduce hospital misidentification were made to the algorithm at months 7 and 12, elevating the rate of true alerts from 35.4% (55 true alerts/155 total alerts before month 7) to 78.7% (59 true alerts/75 total alerts in months 7-12) and ultimately to 93.3% (14 true alerts/5 total alerts in months 13-21), respectively. CONCLUSIONS The monthly digital survey detected most CV hospitalizations, while the geofencing survey enabled earlier detection but did not offer incremental value beyond traditional tools. Digital tools could potentially reduce the burden on study coordinators in ascertaining CV hospitalizations. The advantages of timely reporting via geofencing should be weighed against the issue of false notifications, which can be mitigated through algorithmic refinements.
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Affiliation(s)
- Robert Avram
- University of California San Francisco, San Francisco, CA, United States
- Department of Medicine, Montréal Heart Institute, Université de Montreal, Montréal, QC, Canada
| | - Julia Byrne
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States
| | - Derek So
- University of Ottawa Heart Institute, Ottawa, ON, Canada
| | - Erin Iturriaga
- University of Ottawa Heart Institute, Ottawa, MD, United States
| | - Ryan Lennon
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States
| | - Vishakantha Murthy
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States
| | - Nancy Geller
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, United States
| | - Shaun Goodman
- St Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Charanjit Rihal
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States
| | - Yves Rosenberg
- University of Ottawa Heart Institute, Ottawa, ON, Canada
| | - Kent Bailey
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States
| | | | - Malcolm Bell
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States
| | - Charles Cagin
- Mayo Clinic Health Systems, La Crosse, WI, United States
| | - Ivan Chavez
- Minneapolis Heart Institute, Minneapolis, MN, United States
| | | | - Wilson Ginete
- Essentia Institute of Rural Health, Duluth, MN, United States
| | - Amir Lerman
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States
| | - Justin Levisay
- NorthShore University Health System, Evanston, IL, United States
| | - Kevin Marzo
- Winthrop University Hospital, Mineola, NY, United States
| | - Tamim Nazif
- Columbia University Medical Center, New York, NY, United States
| | | | - Mark Pletcher
- University of California San Francisco, San Francisco, CA, United States
| | - Gregory M Marcus
- University of California San Francisco, San Francisco, CA, United States
| | - Naveen L Pereira
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States
| | - Jeffrey Olgin
- University of California San Francisco, San Francisco, CA, United States
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5
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Cho SMJ, Koyama S, Honigberg MC, Surakka I, Haidermota S, Ganesh S, Patel AP, Bhattacharya R, Lee H, Kim HC, Natarajan P. Genetic, sociodemographic, lifestyle, and clinical risk factors of recurrent coronary artery disease events: a population-based cohort study. Eur Heart J 2023; 44:3456-3465. [PMID: 37350734 PMCID: PMC10516626 DOI: 10.1093/eurheartj/ehad380] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Revised: 05/07/2023] [Accepted: 05/25/2023] [Indexed: 06/24/2023] Open
Abstract
AIMS Complications of coronary artery disease (CAD) represent the leading cause of death among adults globally. This study examined the associations and clinical utilities of genetic, sociodemographic, lifestyle, and clinical risk factors on CAD recurrence. METHODS AND RESULTS Data were from 7024 UK Biobank middle-aged adults with established CAD at enrolment. Cox proportional hazards regressions modelled associations of age at enrolment, age at first CAD diagnosis, sex, cigarette smoking, physical activity, diet, sleep, Townsend Deprivation Index, body mass index, blood pressure, blood lipids, glucose, lipoprotein(a), C reactive protein, estimated glomerular filtration rate (eGFR), statin prescription, and CAD polygenic risk score (PRS) with first post-enrolment CAD recurrence. Over a median [interquartile range] follow-up of 11.6 [7.2-12.7] years, 2003 (28.5%) recurrent CAD events occurred. The hazard ratio (95% confidence interval [CI]) for CAD recurrence was the most pronounced with current smoking (1.35, 1.13-1.61) and per standard deviation increase in age at first CAD (0.74, 0.67-0.82). Additionally, age at enrolment, CAD PRS, C-reactive protein, lipoprotein(a), glucose, low-density lipoprotein cholesterol, deprivation, sleep quality, eGFR, and high-density lipoprotein (HDL) cholesterol also significantly associated with recurrence risk. Based on C indices (95% CI), the strongest predictors were CAD PRS (0.58, 0.57-0.59), HDL cholesterol (0.57, 0.57-0.58), and age at initial CAD event (0.57, 0.56-0.57). In addition to traditional risk factors, a comprehensive model improved the C index from 0.644 (0.632-0.654) to 0.676 (0.667-0.686). CONCLUSION Sociodemographic, clinical, and laboratory factors are each associated with CAD recurrence with genetic risk, age at first CAD event, and HDL cholesterol concentration explaining the most.
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Affiliation(s)
- So Mi Jemma Cho
- Program in Medical and Population Genetics and the Cardiovascular Disease Initiative, Broad Institute of MIT and Harvard, 415 Main St., Cambridge, MA 02142, USA
- Cardiovascular Research Center and Center for Genomic Medicine, Massachusetts General Hospital, 185 Cambridge St., Boston, MA 02114, USA
- Integrative Research Center for Cerebrovascular and Cardiovascular Diseases, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 03722, Republic of Korea
| | - Satoshi Koyama
- Program in Medical and Population Genetics and the Cardiovascular Disease Initiative, Broad Institute of MIT and Harvard, 415 Main St., Cambridge, MA 02142, USA
- Cardiovascular Research Center and Center for Genomic Medicine, Massachusetts General Hospital, 185 Cambridge St., Boston, MA 02114, USA
| | - Michael C Honigberg
- Program in Medical and Population Genetics and the Cardiovascular Disease Initiative, Broad Institute of MIT and Harvard, 415 Main St., Cambridge, MA 02142, USA
- Cardiovascular Research Center and Center for Genomic Medicine, Massachusetts General Hospital, 185 Cambridge St., Boston, MA 02114, USA
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, 55 Fruit St., Boston, MA 02114, USA
- Department of Medicine, Harvard Medical School, 25 Shattuck St., Boston, MA 02114, USA
| | - Ida Surakka
- Program in Medical and Population Genetics and the Cardiovascular Disease Initiative, Broad Institute of MIT and Harvard, 415 Main St., Cambridge, MA 02142, USA
- Division of Cardiology, Department of Internal Medicine, University of Michigan, 1500 E Medical Center Dr., Ann Arbor, MI 48109, USA
| | - Sara Haidermota
- Program in Medical and Population Genetics and the Cardiovascular Disease Initiative, Broad Institute of MIT and Harvard, 415 Main St., Cambridge, MA 02142, USA
- Cardiovascular Research Center and Center for Genomic Medicine, Massachusetts General Hospital, 185 Cambridge St., Boston, MA 02114, USA
| | - Shriienidhie Ganesh
- Program in Medical and Population Genetics and the Cardiovascular Disease Initiative, Broad Institute of MIT and Harvard, 415 Main St., Cambridge, MA 02142, USA
- Cardiovascular Research Center and Center for Genomic Medicine, Massachusetts General Hospital, 185 Cambridge St., Boston, MA 02114, USA
| | - Aniruddh P Patel
- Program in Medical and Population Genetics and the Cardiovascular Disease Initiative, Broad Institute of MIT and Harvard, 415 Main St., Cambridge, MA 02142, USA
- Cardiovascular Research Center and Center for Genomic Medicine, Massachusetts General Hospital, 185 Cambridge St., Boston, MA 02114, USA
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, 55 Fruit St., Boston, MA 02114, USA
- Department of Medicine, Harvard Medical School, 25 Shattuck St., Boston, MA 02114, USA
| | - Romit Bhattacharya
- Program in Medical and Population Genetics and the Cardiovascular Disease Initiative, Broad Institute of MIT and Harvard, 415 Main St., Cambridge, MA 02142, USA
- Cardiovascular Research Center and Center for Genomic Medicine, Massachusetts General Hospital, 185 Cambridge St., Boston, MA 02114, USA
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, 55 Fruit St., Boston, MA 02114, USA
- Department of Medicine, Harvard Medical School, 25 Shattuck St., Boston, MA 02114, USA
| | - Hokyou Lee
- Department of Preventive Medicine, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 03722, Republic of Korea
| | - Hyeon Chang Kim
- Integrative Research Center for Cerebrovascular and Cardiovascular Diseases, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 03722, Republic of Korea
- Department of Preventive Medicine, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 03722, Republic of Korea
- Institute for Innovation in Digital Healthcare, Yonsei University Health System, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 03722, Republic of Korea
| | - Pradeep Natarajan
- Program in Medical and Population Genetics and the Cardiovascular Disease Initiative, Broad Institute of MIT and Harvard, 415 Main St., Cambridge, MA 02142, USA
- Cardiovascular Research Center and Center for Genomic Medicine, Massachusetts General Hospital, 185 Cambridge St., Boston, MA 02114, USA
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, 55 Fruit St., Boston, MA 02114, USA
- Department of Medicine, Harvard Medical School, 25 Shattuck St., Boston, MA 02114, USA
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6
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Greco A, Scilletta S, Faro DC, Agnello F, Mauro MS, Laudani C, Occhipinti G, Spagnolo M, Rochira C, Finocchiaro S, Mazzone PM, Ammirabile N, Landolina D, Imbesi A, Capodanno D. Eligibility to Intensified Antithrombotic Regimens for Secondary Prevention in Patients Who Underwent Percutaneous Coronary Intervention. Am J Cardiol 2023; 199:7-17. [PMID: 37216783 DOI: 10.1016/j.amjcard.2023.04.036] [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: 02/10/2023] [Revised: 04/03/2023] [Accepted: 04/18/2023] [Indexed: 05/24/2023]
Abstract
Single antiplatelet therapy (SAPT) and intensified antithrombotic regimens (prolonged dual antiplatelet therapy [DAPT] or dual pathway inhibition [DPI]) are recommended for secondary prevention in patients who underwent percutaneous coronary intervention (PCI) after initial DAPT. We aimed to characterize eligibility to such strategies and to explore to what extent guidelines are applied in clinical practice. Patients who underwent PCI for acute or chronic coronary syndrome who completed initial DAPT were analyzed from a prospective registry. Patients were categorized into SAPT, prolonged DAPT/DPI, or DPI groups as per guideline indication by using a risk stratification algorithm. Predictors of receiving intensified regimens and the divergency of practice from guidelines were investigated. Between October 2019 and September 2021, a total of 819 patients were included. Based on the guidelines, 83.7% of patients qualified for SAPT, 9.6% for any intensified regimen (i.e., prolonged DAPT or DPI), and 6.7% for DPI only. At multivariable analysis, patients were more likely to receive an intensified regimen if they had diabetes, dyslipidemia, peripheral artery disease, multivessel disease, or previous myocardial infarction. Conversely, they were less likely to receive an intensified regimen if they had atrial fibrillation, chronic kidney disease, or previous stroke. Guidelines were not followed in 18.3% of cases. In particular, only 14.3% of candidates to intensified regimens were treated accordingly. In conclusion, although the majority of patients who underwent PCI after the initial period of DAPT were eligible for SAPT, 1 out of 6 had an indication to intensified regimens. However, such intensified regimens were underused among eligible patients.
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Affiliation(s)
- Antonio Greco
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico - San Marco," University of Catania, Catania, Italy
| | - Sabrina Scilletta
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico - San Marco," University of Catania, Catania, Italy
| | - Denise Cristiana Faro
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico - San Marco," University of Catania, Catania, Italy
| | - Federica Agnello
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico - San Marco," University of Catania, Catania, Italy
| | - Maria Sara Mauro
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico - San Marco," University of Catania, Catania, Italy
| | - Claudio Laudani
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico - San Marco," University of Catania, Catania, Italy
| | - Giovanni Occhipinti
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico - San Marco," University of Catania, Catania, Italy
| | - Marco Spagnolo
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico - San Marco," University of Catania, Catania, Italy
| | - Carla Rochira
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico - San Marco," University of Catania, Catania, Italy
| | - Simone Finocchiaro
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico - San Marco," University of Catania, Catania, Italy
| | - Placido Maria Mazzone
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico - San Marco," University of Catania, Catania, Italy
| | - Nicola Ammirabile
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico - San Marco," University of Catania, Catania, Italy
| | - Davide Landolina
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico - San Marco," University of Catania, Catania, Italy
| | - Antonino Imbesi
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico - San Marco," University of Catania, Catania, Italy
| | - Davide Capodanno
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico - San Marco," University of Catania, Catania, Italy.
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7
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Oh AR, Lee SH, Park J, Min JJ, Lee JH, Yoo SY, Kwon JH, Choi DC, Kim W, Cho HS. Days alive and out of hospital at 30 days and outcomes of off-pump coronary artery bypass grafting. Sci Rep 2023; 13:3359. [PMID: 36849802 PMCID: PMC9971038 DOI: 10.1038/s41598-023-30321-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Accepted: 02/21/2023] [Indexed: 03/01/2023] Open
Abstract
Days alive and out of hospital (DAOH) is a simple estimator based on the number of days not in hospital within a defined period. In cases of mortality within the period, DAOH is regarded as zero. It has not been validated solely in off-pump coronary artery bypass grafting (OPCAB). This study aimed to demonstrate a correlation between DAOH and outcome of OPCAB. We identified 2211 OPCAB performed from January 2010 to August 2016. We calculated DAOH at 30 and 60 days. We generated a receiver-operating curve and compared outcomes. The median duration of hospital stay after OPCAB was 6 days. The median DAOH values at 30 and 60 days were 24 and 54 days. The estimated thresholds for 3-year mortality for DAOH at 30 and 60 days were 20 and 50 days. Three-year mortality was higher for short DAOH (1.2% vs. 5.7% and 1.1% vs. 5.6% DAOH at 30 and 60 days). After adjustment, the short DAOH 30 group showed significantly higher mortality during 3-year follow-up (hazard ratio 3.07; 95% confidence interval 1.45-6.52; p = 0.004). DAOH at 30 days after OPCAB showed a correlation with 3-year outcomes. DAOH 30 might be a reliable long-term outcome measure that can be obtained within 30 days after surgery.
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Affiliation(s)
- Ah Ran Oh
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, Korea.,Department of Anesthesiology and Pain Medicine, Kangwon National University Hospital, Chuncheon, Korea
| | - Seung-Hwa Lee
- Wiltse Memorial Hospital, Suwon, Korea.,Department of Biomedical Engineering, Seoul National University College of Medicine, Seoul, Korea
| | - Jungchan Park
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, Korea. .,Department of Biomedical Sciences, Ajou University Graduate School of Medicine, Suwon, Korea.
| | - Jeong-Jin Min
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, Korea
| | - Jong-Hwan Lee
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, Korea
| | - Seung Yeon Yoo
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, Korea
| | - Ji-Hye Kwon
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, Korea
| | - Dan-Cheong Choi
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, Korea
| | - Wooksung Kim
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hyun Sung Cho
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, Korea
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8
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Spirito A, Sticchi A, Praz F, Gräni C, Messerli F, Siontis GC. Impact of design characteristics among studies comparing coronary computed tomography angiography to noninvasive functional testing in chronic coronary syndromes. Am Heart J 2023; 256:104-116. [PMID: 36400186 DOI: 10.1016/j.ahj.2022.10.087] [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: 03/12/2022] [Revised: 10/11/2022] [Accepted: 10/13/2022] [Indexed: 06/16/2023]
Abstract
BACKGROUND Coronary computed tomography angiography (CCTA) is widely adopted to detect obstructive coronary artery disease (CAD) in patients with chronic coronary syndromes (CCS). However, it is unknown to which extent study-specific characteristics yield different conclusions. METHODS We summarized non-randomized and randomized studies comparing CCTA and noninvasive functional testing for CCS with information on the outcome of myocardial infarction (MI). We evaluated the differential effect according to study characteristics using random-effect meta-analysis with Hartung-Knapp-Sidik-Jonkman adjustments. RESULTS Fifteen studies (8 non-randomized, 7 randomized) were included. CCTA was associated with decrease in relative (odds ratio (OR) 0.54, 95%CI 0.47 to 0.62, P < .001) and absolute MI risk (risk difference (RD) -0.4%, 95%CI -0.6 to -0.1, P = .005). The results remained consistent among the non-randomized (RD -0.4%, 95%CI -0.7 to -0.1, P=.029), but not among the randomized trials where there was no difference in the observed risk (RD 0.2%, 95%CI -0.6 to 0.1, P = .158). CCTA was not associated with MI reduction in studies with clinical outcome definition (OR 0.77, 95%CI 0.41 to 1.44, P = .212), research driven follow-up (OR 0.54, 95%CI 0.24 to 1.21, P = .090), central event assessment (OR 0.63, 95%CI 0.21 to 1.86, P = .207), outcome adjudication (OR 0.74, 95%CI 0.24 to 2.23, P = .178), or at low-risk of bias (OR 0.74, 95%CI 0.24 to 2.23, P = .178). CONCLUSIONS Among studies of any design, CCTA was associated with lower risk of MI in CCS compared to noninvasive functional testing. This benefit was diminished among studies with clinical outcome definition, central outcome assessment/adjudication or at low-risk of bias.
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Affiliation(s)
- Alessandro Spirito
- Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Alessandro Sticchi
- Department of Cardiology, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Fabien Praz
- Department of Cardiology, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Christoph Gräni
- Department of Cardiology, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Franz Messerli
- Department of Cardiology, Bern University Hospital, University of Bern, Bern, Switzerland
| | - George Cm Siontis
- Department of Cardiology, Bern University Hospital, University of Bern, Bern, Switzerland.
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9
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Marquis-Gravel G, Faulkner M, Merritt G, Farrehi P, Zemon N, Robertson HR, Jones WS, Kraschnewski J. Importance of patient engagement in the conduct of pragmatic multicenter randomized controlled trials: The ADAPTABLE experience. Clin Trials 2023; 20:31-35. [PMID: 35999816 DOI: 10.1177/17407745221118559] [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: 11/16/2022]
Abstract
BACKGROUND/AIMS Actively engaging patient partners in the conduct of trials is crucial to ensure the studies answer genuine, patient-centered, unmet clinical needs, and to facilitate participant recruitment and retention. The aim of this article is to demonstrate the feasibility of patient engagement within a large pragmatic multicenter randomized controlled trial, specifically for the purposes of dissemination of study information/updates and to favorize recruitment and retention. METHODS In the patient-centric, pragmatic ADAPTABLE randomized trial, transparent and timely dissemination of information on the study updates to the trial participants was undertaken to create meaningful engagement and to facilitate retention. A national panel of patient partners, the Adaptors, were directly involved in this information dissemination strategy, and study participants were engaged both nationally and locally to design recruitment methods iteratively during the conduct of the trial. All Adaptors had a lived experience with cardiovascular disease. RESULTS Adaptors attended bi-weekly meetings facilitated by the director of the study's patient-powered research network. They drafted and/or edited newsletters and ad hoc educational information written in a lay-friendly manner for study participants, which were regularly distributed to the ADAPTABLE community, in addition to online forums where participants could share their experience of their involvement in ADAPTABLE. To spur recruitment, a patient-driven initiative was to draft letters sharing their story, which were distributed by the local study teams. Patient partners thought that using patients' voice to provide their perspectives on why they believed this project was important would be more engaging for prospective participants than traditional approaches. CONCLUSIONS ADAPTABLE's experience has demonstrated the feasibility of engaging patients as partners in the conduct of a large-scale, multi-center, pragmatic randomized controlled trial. Future trials should embrace and iteratively improve this model by engaging patient partners as early as study protocol development and funding applications, and quantify its impact on the effectiveness and value of the trial.
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Affiliation(s)
| | - Madelaine Faulkner
- Department of Epidemiology and Biostatistics, University of California, San Francisco, CA, USA
| | | | - Peter Farrehi
- University of Michigan Medical School, Ann Arbor, MI, USA
| | | | | | - W Schuyler Jones
- Duke Clinical Research Institute, Durham, NC, USA.,Duke University Medical Center, Durham, NC, USA
| | - Jennifer Kraschnewski
- Departments of Medicine and Public Health Sciences, Penn State College of Medicine, Hershey, PA, USA
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10
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Wilson GJ, Van K, O'Lone E, Tong A, Craig JC, Sautenet B, Budde K, Forfang D, Gill J, Herrington WG, Jafar TH, Johnson DW, Krane V, Levin A, Malyszko J, Rossignol P, Sawinski D, Scholes-Robertons N, Strippoli G, Wang A, Winkelmayer WC, Hawley CM, Viecelli AK. Range and Consistency of Cardiovascular Outcomes Reported by Clinical Trials in Kidney Transplant Recipients: A Systematic Review. Transplant Direct 2023; 9:e1398. [PMID: 36518792 PMCID: PMC9742089 DOI: 10.1097/txd.0000000000001398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 08/28/2022] [Accepted: 09/13/2022] [Indexed: 12/13/2022] Open
Abstract
Cardiovascular disease is a major cause of morbidity and mortality in kidney transplant recipients. Trial evidence to improve cardiovascular outcomes is limited by inconsistent reporting of outcomes, which may also lack patient-relevance. This study aimed to assess the range and consistency of cardiovascular outcomes reported by contemporary trials in kidney transplant recipients. Methods A systematic review of all randomized controlled trials involving adult kidney transplant recipients that reported at least 1 cardiovascular outcome from January 2012 to December 2019 was performed, including Embase, MEDLINE, Cochrane, and ClinicalTrials.gov electronic databases. Trial characteristics were extracted and all levels of specification of the cardiovascular outcome measures reported were analyzed (the measure definition, metric' and method of aggregation). Measures assessing a similar aspect of cardiovascular disease were categorized into outcomes. Results From 93 eligible trials involving 27 609 participants, 490 outcome measures were identified. The outcome measures were grouped into 38 outcomes. A cardiovascular composite was the most common outcome reported (40 trials, 43%) followed by cardiovascular mortality (42%) and acute coronary syndrome (31%). Cardiovascular composite was also the most heterogeneous outcome with 77 measures reported followed by cardiovascular mortality (n = 58) and inflammatory biomarkers (n = 51). The most common cardiovascular composite outcome components reported were major cardiovascular events (18 trials), stroke unspecified (11 trials), and myocardial infarction unspecified (10 trials). Conclusions There is substantial heterogeneity in cardiovascular outcome reporting in kidney transplant trials.
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Affiliation(s)
- Gregory J Wilson
- Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
- Department of Nephrology, Mater Health Services, Brisbane, QLD, Australia
- Department of Nephrology, Princess Alexandra Hospital, Brisbane, QLD, Australia
| | - Kim Van
- Sydney School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Emma O'Lone
- Sydney School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Allison Tong
- Sydney School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Jonathan C Craig
- College of Medicine and Public Health, Flinders University, Bedford Park, SA, Australia
| | - Benedicte Sautenet
- Service de Nephrologie-Hypertension, Dialyses, Transplantation Rénale, Hopital Bretonneau, Université de Tours, Université de Nantes, INSERM SPHERE U 1246, Tours, France
| | | | | | - John Gill
- University of British Columbia, Vancouver, BC, Canada
| | - William G Herrington
- Nuffield Department of Population Health, Medical Research Council Population Health Research Unit at the University of Oxford, Oxford, United Kingdom
| | | | - David W Johnson
- Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
- Department of Nephrology, Princess Alexandra Hospital, Brisbane, QLD, Australia
| | - Vera Krane
- University of Würzburg, Würzburg, Germany
| | - Adeera Levin
- University of British Columbia, Vancouver, BC, Canada
| | - Jolanta Malyszko
- Department of Medicine, Division of Nephrology, University of Wurzburg, Wurzburg, Germany
| | - Patrick Rossignol
- Université de Lorraine & FCRIN INI-CRCT (Cardiovascular and Renal Clinical Trialists) Network, Nancy, France
| | | | | | | | - Angela Wang
- The University of Hong Kong, Pok Fu Lam, Hong Kong
| | | | - Carmel M Hawley
- Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
- Department of Nephrology, Princess Alexandra Hospital, Brisbane, QLD, Australia
| | - Andrea K Viecelli
- Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
- Department of Nephrology, Princess Alexandra Hospital, Brisbane, QLD, Australia
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11
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Matetic A, Mohamed MO, Roberts DJ, Rana JS, Alraies MC, Patel B, Sauer AJ, Diaz-Arocutipa C, Sattar Y, Van Spall HGC, Mamas MA. Real-world management and outcomes of 7 million patients with acute coronary syndrome according to clinical research trial enrolment status: a propensity matched analysis. EUROPEAN HEART JOURNAL. QUALITY OF CARE & CLINICAL OUTCOMES 2022; 8:409-419. [PMID: 34940843 DOI: 10.1093/ehjqcco/qcab098] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Accepted: 12/16/2021] [Indexed: 01/01/2023]
Abstract
AIMS We aimed to determine whether clinical outcomes and invasive care of acute coronary syndrome (ACS) patients participating in trials differed from those of non-participants, particularly including those who were trial eligible. METHODS AND RESULTS We included all hospitalizations with a principal diagnosis of ACS in the US National Inpatient Sample between January 2004 and September 2015, stratified by trial enrolment and eligibility using the International Classification of Diseases, ninth revision. We conducted propensity score matching to investigate the following outcomes: all-cause mortality; major bleeding; stroke; composite of mortality, stroke, and cardiac complications [major adverse cardiovascular and cerebrovascular events (MACCEs)]; coronary angiography (CA); and percutaneous coronary intervention (PCI). A total of 7 091 179 weighted ACS hospitalizations were analysed, including 19 684 (0.3%) trial participants and 7 071 495 non-participants (3 485 514 of whom were trial eligible). Trial participants were more likely to receive CA [Δ% 28.73%, 95% confidence interval (CI) 27.22-30.24, P < 0.001] and PCI (Δ% 27.13%, 95% CI 24.86-29.41, P < 0.001), with decreased mortality (Δ% -3.51%, 95% CI -4.72 to -2.31, P < 0.001), MACCEs (Δ% -3.04%, 95% CI -4.55 to -1.53, P < 0.001), and bleeding (Δ% -0.89%, 95% CI -1.59 to -0.19, P = 0.013) compared with non-participants. After accounting for eligibility, trial participants were more likely to undergo CA (Δ% 22.78%, 95% CI 21.58-23.99, P < 0.001) and PCI (Δ% 23.95%, 95% CI 21.77-26.13, P < 0.001), and had no difference in mortality (Δ% -0.21%, 95% CI -0.65 to 0.24, P = 0.362). CONCLUSION Among ACS patients, trial enrolment was associated with significantly greater invasive care and lower mortality than among matched non-participants. Trial participants were more likely to be invasively managed even when compared with eligible non-participants, even though there was no difference in mortality.
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Affiliation(s)
- Andrija Matetic
- Department of Cardiology, University Hospital of Split, Split, Croatia.,Keele Cardiovascular Research Group, Centre for Prognosis Research, Institute for Primary Care and Health Sciences, Keele University, UK
| | - Mohamed O Mohamed
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Institute for Primary Care and Health Sciences, Keele University, UK
| | - Derek J Roberts
- Division of Vascular and Endovascular Surgery, Department of Surgery, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Jamal S Rana
- Department of Cardiology, Kaiser Permanente Northern California, Oakland, CA, USA
| | - M Chadi Alraies
- Division of Interventional Cardiology, Detroit Medical Center, Detroit, MI, USA
| | - Brijesh Patel
- Division of Cardiology, West Virginia University School of Medicine, Morgantown, WV, USA
| | - Andrew J Sauer
- Department of Cardiovascular Medicine, University of Kansas School of Medicine, Kansas City, KS, USA
| | | | - Yasar Sattar
- Division of Cardiology, West Virginia University School of Medicine, Morgantown, WV, USA
| | - Harriette G C Van Spall
- Department of Medicine, McMaster University, Hamilton, ON, Canada.,Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada.,Division of Cardiology, Department of Medicine, Population Health Research Institute, Hamilton Canada
| | - Mamas A Mamas
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Institute for Primary Care and Health Sciences, Keele University, UK
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12
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Zhao D, Yao C. Pragmatic Clinical Studies: An Emerging Clinical Research Discipline for Improving Evidence-Based Practice of Cardiovascular Diseases in Asia. Korean Circ J 2022; 52:401-413. [PMID: 35656900 PMCID: PMC9160648 DOI: 10.4070/kcj.2022.0100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2022] [Accepted: 04/13/2022] [Indexed: 11/11/2022] Open
Abstract
Pragmatic clinical studies, an emerging clinical research discipline, include a wide range of studies that are largely embedded with routine clinical practice and aim to evaluate the comparative effectiveness and safety of different clinical intervention strategies. Increased availability and quality of electronic medical/health records drives the development of pragmatic clinical studies. In this review, we describe evolution of the conceptual framework of pragmatic clinical studies and share perspectives on the importance of pragmatic clinical studies in evidence-based practice for cardiovascular diseases, as a complement to conventional randomized controlled trials. We also highlight specific needs of pragmatic clinical studies in improving evidence-based practice for cardiovascular disease in Asian countries. The main challenges of pragmatic clinical studies are discussed briefly in this review.
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Affiliation(s)
- Dong Zhao
- Capital Medical University Beijing Anzhen Hospital-Beijing Institute of Heart, Lung & Blood Vessel Diseases, Beijing, China.
| | - Chen Yao
- Peking University Clinical Research Institute. Peking University First Hospital, Beijing, China
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13
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Marquis-Gravel G, Hammill BG, Mulder H, Roe MT, Robertson HR, Wruck LM, Sharlow A, Harris DF, Pohlman FW, Hernandez AF, Jones WS. Validation of Cardiovascular End Points Ascertainment Leveraging Multisource Electronic Health Records Harmonized Into a Common Data Model in the ADAPTABLE Randomized Clinical Trial. Circ Cardiovasc Qual Outcomes 2021; 14:e008190. [PMID: 34886680 DOI: 10.1161/circoutcomes.121.008190] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND The ADAPTABLE trial (Aspirin Dosing: A Patient-Centric Trial Assessing Benefits and Long-Term Effectiveness) is the first randomized trial conducted within the National Patient-Centered Clinical Research Network to use the electronic health record data formatted into a common data model as the primary source of end point ascertainment, without confirmation by standard adjudication. The objective of this prespecified study is to assess the validity of nonfatal end points captured from the National Patient-Centered Clinical Research Network, using traditional blinded adjudication as the gold standard. METHODS A total of 15 076 participants with established atherosclerotic cardiovascular disease were randomized to two doses of aspirin (81 mg and 325 mg once daily). Nonfatal end points (hospitalization for nonfatal myocardial infarction, nonfatal stroke, and major bleeding requiring transfusion of blood products) were captured with the use of programming algorithms applied to National Patient-Centered Clinical Research Network data. A random subset of end points was independently reviewed by a disease-specific expert adjudicator. The positive predictive value of the programming algorithms were calculated separately for end points listed as primary and as nonprimary diagnoses. RESULTS A total of 225 end points were identified (91 myocardial infarction events, 89 stroke events, and 45 bleeding events), including 142 (63%) that were listed as primary diagnoses. Complete source documents were missing for 14% of events. The positive predictive value were 90%, 72%, and 93% for hospitalizations for myocardial infarction, stroke, and major bleeding, respectively, as compared to adjudication. When only primary diagnoses were considered, positive predictive value were 93%, 91%, and 97%, respectively. When only nonprimary diagnoses were considered, positive predictive value were 82%, 36%, and 71%. CONCLUSIONS As compared with blinded adjudication, clinical end point ascertainment from queries of the National Patient-Centered Clinical Research Network distributed harmonized data was valid to identify hospitalizations for myocardial infarction in ADAPTABLE. The proportion of contradicted events was high for hospitalizations for bleeding and strokes when nonprimary diagnoses were analyzed, but not when only primary diagnoses were considered.
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Affiliation(s)
- Guillaume Marquis-Gravel
- Duke Clinical Research Institute, Durham, NC (G.M.-G., B.G.H., H.M., M.T.R., H.R.R., L.M.W., A.S., D.F.H., F.W.P., A.F.H., W.S.J.)
| | - Bradley G Hammill
- Duke Clinical Research Institute, Durham, NC (G.M.-G., B.G.H., H.M., M.T.R., H.R.R., L.M.W., A.S., D.F.H., F.W.P., A.F.H., W.S.J.)
| | - Hillary Mulder
- Duke Clinical Research Institute, Durham, NC (G.M.-G., B.G.H., H.M., M.T.R., H.R.R., L.M.W., A.S., D.F.H., F.W.P., A.F.H., W.S.J.)
| | - Matthew T Roe
- Duke Clinical Research Institute, Durham, NC (G.M.-G., B.G.H., H.M., M.T.R., H.R.R., L.M.W., A.S., D.F.H., F.W.P., A.F.H., W.S.J.).,Duke University Medical Center, Durham, NC (M.T.R., F.W.P., A.F.H., W.S.J.)
| | - Holly R Robertson
- Duke Clinical Research Institute, Durham, NC (G.M.-G., B.G.H., H.M., M.T.R., H.R.R., L.M.W., A.S., D.F.H., F.W.P., A.F.H., W.S.J.)
| | - Lisa M Wruck
- Duke Clinical Research Institute, Durham, NC (G.M.-G., B.G.H., H.M., M.T.R., H.R.R., L.M.W., A.S., D.F.H., F.W.P., A.F.H., W.S.J.)
| | - Amber Sharlow
- Duke Clinical Research Institute, Durham, NC (G.M.-G., B.G.H., H.M., M.T.R., H.R.R., L.M.W., A.S., D.F.H., F.W.P., A.F.H., W.S.J.)
| | - Debra F Harris
- Duke Clinical Research Institute, Durham, NC (G.M.-G., B.G.H., H.M., M.T.R., H.R.R., L.M.W., A.S., D.F.H., F.W.P., A.F.H., W.S.J.)
| | - F Will Pohlman
- Duke Clinical Research Institute, Durham, NC (G.M.-G., B.G.H., H.M., M.T.R., H.R.R., L.M.W., A.S., D.F.H., F.W.P., A.F.H., W.S.J.).,Duke University Medical Center, Durham, NC (M.T.R., F.W.P., A.F.H., W.S.J.)
| | - Adrian F Hernandez
- Duke Clinical Research Institute, Durham, NC (G.M.-G., B.G.H., H.M., M.T.R., H.R.R., L.M.W., A.S., D.F.H., F.W.P., A.F.H., W.S.J.).,Duke University Medical Center, Durham, NC (M.T.R., F.W.P., A.F.H., W.S.J.)
| | - W Schuyler Jones
- Duke Clinical Research Institute, Durham, NC (G.M.-G., B.G.H., H.M., M.T.R., H.R.R., L.M.W., A.S., D.F.H., F.W.P., A.F.H., W.S.J.).,Duke University Medical Center, Durham, NC (M.T.R., F.W.P., A.F.H., W.S.J.)
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14
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Harrington J, Gouda P, Ezekowitz J, Mentz RJ. Exploring the pragmatic-explanatory spectrum across cardiovascular clinical trials. Contemp Clin Trials 2021; 113:106646. [PMID: 34863929 DOI: 10.1016/j.cct.2021.106646] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Revised: 11/01/2021] [Accepted: 11/27/2021] [Indexed: 11/20/2022]
Abstract
Clinical trials are a cornerstone of modern medicine and form the backbone of evidence that is used to create evidence-based guidelines. Contemporary clinical trials have tended to be quite explanatory, assessing an intervention in ideal conditions with highlyprotocolized interventions, strict inclusion/exclusion criteria, high resource utilization and with frequent (and often specialized) follow-up. In conjunction with decreased event-rates due to the improvement of cardiovascular care, this has resulted in increasingly complex, large, clinical trials that are associated with exponentially increasing costs. This has led to a strong push for streamlined trials that more truly represent "real world" settings and conduct. Such pragmatic trials emphasize "real world" conduct, including broader inclusion criteria that lead to more typical and less carefully selected patient populations, and more realistic trial setting and execution elements. We explore the spectrum of pragmatism across cardiovascular clinical trials, highlighting novel innovations and trends over the past decade.
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Affiliation(s)
- Josephine Harrington
- Duke Clinic Research Institute, Durham, NC, United States; VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada
| | - Pishoy Gouda
- Duke Clinic Research Institute, Durham, NC, United States; VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada
| | - Justin Ezekowitz
- Duke Clinic Research Institute, Durham, NC, United States; VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada
| | - Robert J Mentz
- Duke Clinic Research Institute, Durham, NC, United States; VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada.
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15
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Oguntade AS, Oguntade MS. Patent foramen ovale closure review: decades of research and the evolution of the evidence. THE EGYPTIAN JOURNAL OF INTERNAL MEDICINE 2021. [DOI: 10.1186/s43162-021-00059-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
A quarter of the population suffers from patent foramen ovale, a form of interatrial shunt. It has been linked to cryptogenic strokes and is a common cause of paradoxical embolism.
Main text
The benefit of closing the patent foramen ovale in cryptogenic stroke patients aged 18-60 years to prevent recurrent strokes, particularly in those with large shunts or associated atrial septal aneurysms, was recently demonstrated. It is a relatively safe procedure that necessitates post-operative anticoagulation, but it has been linked to new-onset atrial fibrillation of uncertain significance. The effectiveness of patent foramen closure depends on patient selection, and prediction scores such as the Risk of Paradoxical Embolism (RoPE) score should be used. Newer closure devices, such as bioabsorbable devices like the Biostar system and ‘device-less’ devices like the Noble Stitch, are becoming more common due to their lower operative risks. The use of such devices in future trials, as well as careful case selection, could improve the acceptability of patent foramen ovale closure in the general population, removing the need for perioperative anticoagulation.
Conclusion
Individuals aged 18-60 years with cryptogenic stroke who have adverse patent foramen ovale morphology on imaging should be offered patent foramen ovale closure, preferably using the newer closure devices. More studies are needed to determine the significance of periprocedural atrial fibrillation after device closure.
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16
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Goyal A, Schibler T, Alhanti B, Hannan KL, Granger CB, Blazing MA, Lopes RD, Alexander JH, Peterson ED, Rao SV, Green JB, Roe MT, Rorick T, Berdan LG, Reist C, Mahaffey KW, Harrington RA, Califf RM, Patel MR, Hernandez AF, Jones WS. Assessment of North American Clinical Research Site Performance During the Start-up of Large Cardiovascular Clinical Trials. JAMA Netw Open 2021; 4:e2117963. [PMID: 34297072 PMCID: PMC9435961 DOI: 10.1001/jamanetworkopen.2021.17963] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
IMPORTANCE Randomized clinical trials (RCTs) are critical in advancing patient care, yet conducting such large-scale trials requires tremendous resources and coordination. Clinical site start-up performance metrics can provide insight into opportunities for improved trial efficiency but have not been well described. OBJECTIVE To measure the start-up time needed to reach prespecified milestones across sites in large cardiovascular RCTs in North America and to evaluate how these metrics vary by time and type of regulatory review process. DESIGN, SETTING, AND PARTICIPANTS This cohort study evaluated cardiovascular RCTs conducted from July 13, 2004, to February 1, 2017. The RCTs were coordinated by a single academic research organization, the Duke Clinical Research Institute. Nine consecutive trials with completed enrollment and publication of results in their target journal were studied. Data were analyzed from December 4, 2019, to January 11, 2021. EXPOSURES Year of trial enrollment initiation (2004-2007 vs 2008-2012) and use of a central vs local institutional review board (IRB). MAIN OUTCOMES AND MEASURES The primary outcome was the median start-up time (from study protocol delivery to first participant enrollment) as compared by trial year and type of IRB used. The median start-up time for the top 10% of sites was also reported. Secondary outcomes included time to site regulatory approval, time to contract execution, and time to site activation. RESULTS For the 9 RCTs included, the median site start-up time shortened only slightly over time from 267 days (interquartile range [IQR], 185-358 days) for 2004-2007 trials to 237 days (IQR, 162-343 days) for 2008-2012 trials (overall median, 255 days [IQR, 177-350 days]; P < .001). For the top 10% of sites, median start-up time was 107 days (IQR, 95-121 days) for 2004-2007 trials vs 104 days (IQR, 84-118 days) for 2008-2012 trials (overall median, 106 days [IQR, 90-120 days]; P = .04). The median start-up time was shorter among sites using a central IRB (199 days [IQR, 140-292 days]) than those using a local IRB (287 days [IQR, 205-390 days]; P < .001). CONCLUSIONS AND RELEVANCE This cohort study of North American research sites in large cardiovascular RCTs found a duration of nearly 9 months from the time of study protocol delivery to the first participant enrollment; this metric was only slightly shortened during the study period but was reduced to less than 4 months for top-performing sites. These findings suggest that the use of central IRBs has the potential to improve RCT efficiency.
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Affiliation(s)
- Akash Goyal
- The Ohio State University Wexner Medical Center,
Division of Cardiovascular Medicine, Columbus
| | - Tony Schibler
- Duke Clinical Research Institute, Duke
University School of Medicine, Durham, North Carolina
| | - Brooke Alhanti
- Duke Clinical Research Institute, Duke
University School of Medicine, Durham, North Carolina
| | - Karen L. Hannan
- Duke Clinical Research Institute, Duke
University School of Medicine, Durham, North Carolina
| | - Christopher B. Granger
- Duke Clinical Research Institute, Duke
University School of Medicine, Durham, North Carolina
| | - Michael A. Blazing
- Duke Clinical Research Institute, Duke
University School of Medicine, Durham, North Carolina
| | - Renato D. Lopes
- Duke Clinical Research Institute, Duke
University School of Medicine, Durham, North Carolina
| | - John H. Alexander
- Duke Clinical Research Institute, Duke
University School of Medicine, Durham, North Carolina
| | - Eric D. Peterson
- Duke Clinical Research Institute, Duke
University School of Medicine, Durham, North Carolina
| | - Sunil V. Rao
- Duke Clinical Research Institute, Duke
University School of Medicine, Durham, North Carolina
| | - Jennifer B. Green
- Duke Clinical Research Institute, Duke
University School of Medicine, Durham, North Carolina
| | | | - Tyrus Rorick
- Duke Clinical Research Institute, Duke
University School of Medicine, Durham, North Carolina
| | - Lisa G. Berdan
- Duke Clinical Research Institute, Duke
University School of Medicine, Durham, North Carolina
| | | | - Kenneth W. Mahaffey
- Stanford Center for Clinical Research,
Department of Medicine, Stanford University, Stanford, California
| | - Robert A. Harrington
- Stanford Center for Clinical Research,
Department of Medicine, Stanford University, Stanford, California
| | - Robert M. Califf
- Verily Life Sciences and Google Health, San
Francisco, California
| | - Manesh R. Patel
- Duke Clinical Research Institute, Duke
University School of Medicine, Durham, North Carolina
| | - Adrian F. Hernandez
- Duke Clinical Research Institute, Duke
University School of Medicine, Durham, North Carolina
| | - W. Schuyler Jones
- Duke Clinical Research Institute, Duke
University School of Medicine, Durham, North Carolina
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17
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Kochar A, Summers MB, Benziger CP, Marquis-Gravel G, DeWalt DA, Pepine CJ, Gupta K, Bradley SM, Dodson JA, Lampert BC, Robertson H, Polonsky TS, Jones WS, Effron MB. Clinician engagement in the ADAPTABLE (Aspirin Dosing: A Patient-centric Trial Assessing Benefits and Long-Term Effectiveness) trial. Clin Trials 2021; 18:449-456. [PMID: 33541120 DOI: 10.1177/1740774520988838] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND ADAPTABLE (Aspirin Dosing: A Patient-centric Trial Assessing Benefits and Long-Term Effectiveness) is a pragmatic clinical trial examining high-dose versus low-dose aspirin among patients with cardiovascular disease. ADAPTABLE is leveraging novel approaches for clinical trial conduct to expedite study completion and reduce costs. One pivotal aspect of the trial conduct is maximizing clinician engagement. METHODS/RESULTS Clinician engagement can be diminished by barriers including time limitations, insufficient research infrastructure, lack of research training, inadequate compensation for research activities, and clinician beliefs. We used several key approaches to boost clinician engagement such as empowering clinician champions, including a variety of clinicians, nurses and advanced practice providers, periodic newsletters and coordinated team celebrations, and deploying novel technological solutions. Specifically, some centers generated electronic health records-based best practice advisories and research dashboards. Future large pragmatic trials will benefit from standardization of the various clinician engagement strategies especially studies leveraging electronic health records-based approaches like research dashboards. Financial or academic "credit" for clinician engagement in clinical research may boost participation rates in clinical studies. CONCLUSION Maximizing clinician engagement is important for the success of clinical trials; the strategies employed in the ADAPTABLE trial may serve as a template for future pragmatic studies.
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Affiliation(s)
- Ajar Kochar
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Mary B Summers
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
| | | | | | - Darren A DeWalt
- The Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, NC, USA
| | - Carl J Pepine
- Division of Cardiovascular Medicine, University of Florida, Gainesville, FL, USA
| | - Kamal Gupta
- Department of Cardiovascular Medicine, University of Kansas Medical School, Kansas City, KS, USA
| | - Steven M Bradley
- Division of Cardiology, Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Minneapolis, MN, USA
| | - John A Dodson
- Leon H. Charney Division of Cardiology, New York University School of Medicine, New York, NY, USA
| | - Brent C Lampert
- Division of Cardiovascular Medicine, Wexner Medical Center, The Ohio State University, Columbus, OH, USA
| | - Holly Robertson
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
| | - Tamar S Polonsky
- Department of Medicine, The University of Chicago Medicine, Chicago, IL, USA
| | - W Schuyler Jones
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
| | - Mark B Effron
- John Ochsner Heart and Vascular Institute, The University of Queensland Ochsner Clinical School, New Orleans, LA, USA
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18
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Leonardi S, Branca M, Franzone A, McFadden E, Piccolo R, Jüni P, Vranckx P, Steg PG, Serruys PW, Benit E, Liebetrau C, Janssens L, Ferrario M, Zurakowski A, Diletti R, Dominici M, Huber K, Slagboom T, Buszman P, Bolognese L, Tumscitz C, Bryniarski K, Aminian A, Vrolix M, Petrov I, Garg S, Naber C, Prokopczuk J, Hamm C, Heg D, Windecker S, Valgimigli M. Comparison of Investigator-Reported and Clinical Event Committee-Adjudicated Outcome Events in GLASSY. Circ Cardiovasc Qual Outcomes 2021; 14:e006581. [PMID: 33535773 DOI: 10.1161/circoutcomes.120.006581] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Event adjudication by a clinical event committee (CEC) provides a standardized, independent outcome assessment. However, the added value of CEC to investigators reporting remains debated. GLASSY (GLOBAL LEADERS Adjudication Sub-Study) implemented, in a subset of the open-label, investigator-reported (IR) GLOBAL LEADERS trial, an independent adjudication process of reported and unreported potential outcome events (triggers). We describe metrics of GLASSY feasibility and efficiency, diagnostic accuracy of IR events, and their concordance with corresponding CEC-adjudicated events. METHODS We report the proportion of myocardial infarction, bleeding, stroke, and stent thrombosis triggers with sufficient evidence for assessment (feasibility) that were adjudicated as outcome events (efficiency), stratified by source (IR or non-IR). Using CEC-adjudicated events as criterion standard, we describe sensitivity, specificity, positive and negative predictive value, and global diagnostic accuracy of IR events. Using Gwet AC coefficient, we examine the concordance between IR- and corresponding CEC-adjudicated triggers. There was sufficient evidence for assessment for 2592 (98.3%) of 2636 triggers. RESULTS Overall, the adjudicated end point-to-trigger ratio was high and similar between IR- (88%) and non-IR-reported (87%) triggers. The global diagnostic accuracy and concordance between IR-reported and CEC-adjudicated outcome events was 0.70 (95% CI, 0.65-0.74) and 0.54 (95% CI, 0.45-0.62), respectively, for myocardial infarction; 0.77 (95% CI, 0.75-0.79) and 0.71 (95% CI, 0.68-0.74) for bleeding; 0.70 (95% CI, 0.62-0.79) and 0.59 (95% CI, 0.43-0.74) for stroke; 0.59 (95% CI, 0.52-0.66) and 0.39 (95% CI, 0.25-0.53) for stent thrombosis. For IR bleedings, the concordance with the CEC on type of events was generally weak. CONCLUSIONS Implementing CEC adjudication in a pragmatic open-label trial with IR events is feasible and efficient. Our findings of modest global diagnostic accuracy for IR events and generally weak concordance between investigators and CEC support the role for CEC adjudication in such settings. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT03231059.
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Affiliation(s)
- Sergio Leonardi
- Department of Molecular Medicine, Cardiology Unit, University of Pavia, Italy (S.L.).,Coronary Care Unit (S.L.), Fondazione IRCCS Policlinico S. Matteo, Pavia, Italy
| | - Mattia Branca
- Clinical Trials Unit Bern (M.B.), University of Bern, Switzerland
| | - Anna Franzone
- Department of Advanced Biomedical Sciences, Federico II University of Naples, Italy (A.F., R.P.)
| | - Eugene McFadden
- Cardialysis Core Laboratories and Clinical Trial Management, Rotterdam, the Netherlands (E.M.).,Department of Cardiology, Cork University Hospital, Ireland (E.M.)
| | - Raffaele Piccolo
- Department of Advanced Biomedical Sciences, Federico II University of Naples, Italy (A.F., R.P.)
| | - Peter Jüni
- Department of Medicine, Applied Health Research Centre, Li Ka Shing Knowledge Institute of St. Michael's Hospital, University of Toronto, Ontario, Canada (P.J.)
| | - Pascal Vranckx
- Department of Cardiology and Critical Care Medicine, Hartcentrum Hasselt, Jessa Ziekenhuis, Belgium (P.V.)
| | | | - Patrick W Serruys
- Department of Cardiology, Imperial College of London, United Kingdom (P.W.S.)
| | - Edouard Benit
- Department of Cardiology, Jessa Hospital, Hasselt, Belgium (E.B.)
| | - Christoph Liebetrau
- Department of Cardiology, Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany (C.L., C.H.)
| | - Luc Janssens
- German Center for Cardiovascular Research, Partner Site RheinMain, Frankfurt am Main, Germany (C.L., C.H.)
| | - Maurizio Ferrario
- Division of Cardiology (M.F.), Fondazione IRCCS Policlinico S. Matteo, Pavia, Italy
| | - Aleksander Zurakowski
- Department of Interventional Cardiology, American Heart of Poland SA, Chrzanów (A.Z.)
| | - Roberto Diletti
- Thoraxcenter, Erasmus Medical Center, Rotterdam, the Netherlands (R.D.)
| | | | - Kurt Huber
- 3rd Medical Department, Cardiology, Wilhelminen Hospital, Vienna, Austria (K.H.)
| | - Ton Slagboom
- Sigmund Freud University Medical School, Vienna, Austria (K.H.)
| | - Pawel Buszman
- Center for Cardiovascular Research and Development, American Heart of Poland, Ustroń (P.B.).,Department of Epidemiology and Statistics, Medical University of Silesia, Katowice, Poland (P.B.)
| | | | - Carlo Tumscitz
- Cardiology Unit Sant'Anna Hospital, Ferrara, Italy (C.T.)
| | - Krzysztof Bryniarski
- Jagiellonian University Medical College, John Paul II Hospital, Krakow, Poland (K.B.)
| | - Adel Aminian
- Department of Cardiology, Centre Hospitalier Universitaire de Charleroi, Belgium (A.A.)
| | | | - Ivo Petrov
- Acibadem City Clinic Cardiovascular Center, Sofia, Bulgaria (I.P.)
| | - Scot Garg
- East Lancashire Hospitals NHS Trust, Blackburn, United Kingdom (S.G.)
| | - Cristoph Naber
- Contilia Heart and Vascular Centre, Stadtspital Triemli, Zürich, Switzerland (C.N.)
| | | | - Christian Hamm
- Department of Cardiology, Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany (C.L., C.H.).,German Center for Cardiovascular Research, Partner Site RheinMain, Frankfurt am Main, Germany (C.L., C.H.)
| | - Dik Heg
- Institute of Social and Preventive Medicine and Clinical Trials Unit (D.H.), University of Bern, Switzerland
| | - Stephan Windecker
- Department of Cardiology, Inselspital (S.W.), University of Bern, Switzerland
| | - Marco Valgimigli
- Department of Cardiology, Cardiocentro Ticino, Lugano, Switzerland (M. Valgimigli)
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19
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Hernandez-Boussard T, Monda KL, Crespo BC, Riskin D. Real world evidence in cardiovascular medicine: ensuring data validity in electronic health record-based studies. J Am Med Inform Assoc 2021; 26:1189-1194. [PMID: 31414700 PMCID: PMC6798570 DOI: 10.1093/jamia/ocz119] [Citation(s) in RCA: 43] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Revised: 05/17/2019] [Accepted: 06/19/2019] [Indexed: 01/11/2023] Open
Abstract
Objective With growing availability of digital health data and technology, health-related studies are increasingly augmented or implemented using real world data (RWD). Recent federal initiatives promote the use of RWD to make clinical assertions that influence regulatory decision-making. Our objective was to determine whether traditional real world evidence (RWE) techniques in cardiovascular medicine achieve accuracy sufficient for credible clinical assertions, also known as “regulatory-grade” RWE. Design Retrospective observational study using electronic health records (EHR), 2010–2016. Methods A predefined set of clinical concepts was extracted from EHR structured (EHR-S) and unstructured (EHR-U) data using traditional query techniques and artificial intelligence (AI) technologies, respectively. Performance was evaluated against manually annotated cohorts using standard metrics. Accuracy was compared to pre-defined criteria for regulatory-grade. Differences in accuracy were compared using Chi-square test. Results The dataset included 10 840 clinical notes. Individual concept occurrence ranged from 194 for coronary artery bypass graft to 4502 for diabetes mellitus. In EHR-S, average recall and precision were 51.7% and 98.3%, respectively and 95.5% and 95.3% in EHR-U, respectively. For each clinical concept, EHR-S accuracy was below regulatory-grade, while EHR-U met or exceeded criteria, with the exception of medications. Conclusions Identifying an appropriate RWE approach is dependent on cohorts studied and accuracy required. In this study, recall varied greatly between EHR-S and EHR-U. Overall, EHR-S did not meet regulatory grade criteria, while EHR-U did. These results suggest that recall should be routinely measured in EHR-based studes intended for regulatory use. Furthermore, advanced data and technologies may be required to achieve regulatory grade results.
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Affiliation(s)
- Tina Hernandez-Boussard
- Department of Medicine, Stanford University, Stanford, California, USA.,Department of Biomedical Data Science, Stanford University, Stanford, California, USA.,Department of Surgery, Stanford University School of Medicine, Stanford, California, USA
| | - Keri L Monda
- The Center for Observational Research and Medical Affairs, Amgen, Inc., Thousand Oaks, California, USA.,Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Blai Coll Crespo
- The Center for Observational Research and Medical Affairs, Amgen, Inc., Thousand Oaks, California, USA
| | - Dan Riskin
- Department of Medicine, Stanford University, Stanford, California, USA.,Department of Surgery, Stanford University School of Medicine, Stanford, California, USA.,Verantos Inc, Menlo Park, California, USA
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20
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Marquis-Gravel G, Robertson H, Jones WS, Riley D, Ford DE, Crenshaw D, Joosten YA, Rudov L, Hernandez AF, Hess R. Streamlining the institutional review board process in pragmatic randomized clinical trials: challenges and lessons learned from the Aspirin Dosing: A Patient-centric Trial Assessing Benefits and Long-Term Effectiveness (ADAPTABLE) trial. Trials 2021; 22:90. [PMID: 33494785 PMCID: PMC7831187 DOI: 10.1186/s13063-021-05026-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Accepted: 01/06/2021] [Indexed: 11/10/2022] Open
Abstract
Background New considerations during the ethical review processes may emerge from innovative, yet unfamiliar operational methods enabled in pragmatic randomized controlled trials (RCT), potentially making institutional review board (IRB) evaluation more complex. In this manuscript, key components of the pragmatic “Aspirin Dosing: A Patient-Centric Trial Assessing Benefits and Long-term Effectiveness (ADAPTABLE)” randomized trial that required a reappraisal of the IRB submission, review, and approval processes are discussed. Main text ADAPTABLE is a pragmatic, multicenter, open-label RCT evaluating the comparative effectiveness of two doses of aspirin widely used for secondary prevention (81 mg and 325 mg) in 15,000 patients with an established history of atherosclerotic cardiovascular disease. The electronic informed consent form is completed online by the participants at the time of enrollment, and endpoint ascertainment is conducted through queries of electronic health records. IRB challenges encountered regarding centralized IRB evaluation, electronic informed consent, patient engagement, and risk determination in ADAPTABLE are described in this manuscript. The experience of ADAPTABLE encapsulates how pragmatic protocol components intended to facilitate the study conduct have been tempered by unexpected, yet justified concerns raised by local IRBs. How the lessons learned can be applied to future similar pragmatic trials is delineated. Conclusion Development of engaging communication channels between IRB and study personnel in pragmatic randomized trials as early as at the time of protocol design allows to reduce issues with IRB approval. Integrations of the lessons learned in ADAPTABLE regarding the IRB process for centralized IRBs, informed consent, patient engagement, and risk determination can be emulated and will be instrumental in future pragmatic studies. Supplementary Information The online version contains supplementary material available at 10.1186/s13063-021-05026-w.
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Affiliation(s)
| | - Holly Robertson
- Duke Clinical Research Institute, 200 Morris St, Durham, NC, 27701, USA
| | - W Schuyler Jones
- Duke Clinical Research Institute, 200 Morris St, Durham, NC, 27701, USA.,Duke University Medical Center, 2301 Erwin Road, Durham, NC, 27710, USA
| | - Danielle Riley
- University of Iowa College of Public Health, 145 N Riverside Dr, Iowa City, IA, 52242, USA
| | - Daniel E Ford
- Institute for Clinical and Translational Research, Johns Hopkins School of Medicine, 750 E. Pratt Street, Baltimore, MD, 21202, USA
| | - David Crenshaw
- Institute for Medicine and Public Health, Vanderbilt University Medical Center, 2525 West End Avenue, Suite 1200, Nashville, TN, 37203, USA
| | - Yvonne A Joosten
- Institute for Medicine and Public Health, Vanderbilt University Medical Center, 2525 West End Avenue, Suite 1200, Nashville, TN, 37203, USA
| | - Lindsey Rudov
- Louisiana Public Health Institute, 1515 Poydras St #1200, New Orleans, LA, 70112, USA
| | - Adrian F Hernandez
- Duke Clinical Research Institute, 200 Morris St, Durham, NC, 27701, USA.,Duke University Medical Center, 2301 Erwin Road, Durham, NC, 27710, USA
| | - Rachel Hess
- Departments of Population Health Sciences and Internal Medicine, University of Utah School of Medicine, 295 Chipeta Way Williams Building Room 1N492, Salt Lake City, UT, 84108, USA.
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21
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Marquis-Gravel G, Roe MT, Robertson HR, Harrington RA, Pencina MJ, Berdan LG, Hammill BG, Faulkner M, Muñoz D, Fonarow GC, Nallamothu BK, Fintel DJ, Ford DE, Zhou L, Daugherty SE, Nauman E, Kraschnewski J, Ahmad FS, Benziger CP, Haynes K, Merritt JG, Metkus T, Kripalani S, Gupta K, Shah RC, McClay JC, Re RN, Geary C, Lampert BC, Bradley SM, Jain SK, Seifein H, Whittle J, Roger VL, Effron MB, Alvarado G, Goldberg YH, VanWormer JL, Girotra S, Farrehi P, McTigue KM, Rothman R, Hernandez AF, Jones WS. Rationale and Design of the Aspirin Dosing-A Patient-Centric Trial Assessing Benefits and Long-term Effectiveness (ADAPTABLE) Trial. JAMA Cardiol 2021; 5:598-607. [PMID: 32186653 DOI: 10.1001/jamacardio.2020.0116] [Citation(s) in RCA: 59] [Impact Index Per Article: 19.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Importance Determining the right dosage of aspirin for the secondary prevention treatment of atherosclerotic cardiovascular disease (ASCVD) remains an unanswered and critical question. Objective To report the rationale and design for a randomized clinical trial to determine the optimal dosage of aspirin to be used for secondary prevention of ASCVD, using an innovative research method. Design, Setting, and Participants This pragmatic, open-label, patient-centered, randomized clinical trial is being conducted in 15 000 patients within the National Patient-Centered Clinical Research Network (PCORnet), a distributed research network of partners including clinical research networks, health plan research networks, and patient-powered research networks across the United States. Patients with established ASCVD treated in routine clinical practice within the network are eligible. Patient recruitment began in April 2016. Enrollment was completed in June 2019. Final follow-up is expected to be completed by June 2020. Interventions Participants are randomized on a web platform in a 1:1 fashion to either 81 mg or 325 mg of aspirin daily. Main Outcomes and Measures The primary efficacy end point is the composite of all-cause mortality, hospitalization for nonfatal myocardial infarction, or hospitalization for a nonfatal stroke. The primary safety end point is hospitalization for major bleeding associated with a blood-product transfusion. End points are captured through regular queries of the health systems' common data model within the structure of PCORnet's distributed data environment. Conclusions and Relevance As a pragmatic study and the first interventional trial conducted within the PCORnet electronic data infrastructure, this trial is testing several unique and innovative operational approaches that have the potential to disrupt and transform the conduct of future patient-centered randomized clinical trials by evaluating treatments integrated in clinical practice while at the same time determining the optimal dosage of aspirin for secondary prevention of ASCVD. Trial Registration ClinicalTrials.gov Identifier: NCT02697916.
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Affiliation(s)
| | - Matthew T Roe
- Duke Clinical Research Institute, Durham, North Carolina.,Duke University Medical Center, Durham, North Carolina
| | | | | | - Michael J Pencina
- Department of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina
| | - Lisa G Berdan
- Duke Clinical Research Institute, Durham, North Carolina
| | | | - Madelaine Faulkner
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco
| | - Daniel Muñoz
- Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Gregg C Fonarow
- Department of Medicine, University of California, Los Angeles, Los Angeles.,Associate Editor
| | - Brahmajee K Nallamothu
- Michigan Integrated Center of Health Analytics and Medical Prediction, Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan School of Medicine, Ann Arbor
| | - Dan J Fintel
- Feinberg School of Medicine, Division of Cardiology, Department of Medicine, Northwestern University, Chicago, Illinois
| | - Daniel E Ford
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Li Zhou
- Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | | | | | - Jennifer Kraschnewski
- Department of Medicine, Department of Public Health Sciences, Penn State College of Medicine, Hershey, Pennsylvania
| | - Faraz S Ahmad
- Center for Health Information Partnerships, Feinberg School of Medicine, Institute of Public Health and Medicine, Division of Cardiology, Department of Medicine, Northwestern University, Chicago, Illinois
| | | | | | - J Greg Merritt
- Patient-Centered Network of Learning Health Systems (LHSNet), Ann Arbor, Michigan
| | - Thomas Metkus
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland.,Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Sunil Kripalani
- Division of General Internal Medicine and Public Health, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Kamal Gupta
- Division of Cardiovascular Medicine, Department of Medicine, University of Kansas Medical Center, Kansas City
| | - Raj C Shah
- Rush Alzheimer's Disease Center, Department of Family Medicine, Rush University Medical Center, Chicago, Illinois
| | - James C McClay
- Department of Emergency Medicine, University of Nebraska Medical Center College of Medicine, Omaha
| | | | - Carol Geary
- University of Nebraska Medical Center, Omaha
| | - Brent C Lampert
- Wexner Medical Center, Division of Cardiovascular Medicine, The Ohio State University, Columbus
| | - Steven M Bradley
- Minneapolis Heart Institute, Minneapolis Heart Institute Foundation, Minneapolis
| | - Sandeep K Jain
- UPMC Heart and Vascular Institute, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Hani Seifein
- AdventHealth Medical Group Cardiology, Oviedo, Florida
| | - Jeff Whittle
- Department of Medicine, Division of General Internal Medicine, Medical College of Wisconsin, Milwaukee
| | | | - Mark B Effron
- Ochsner Clinical School, John Ochsner Heart and Vascular Institute, University of Queensland School of Medicine, New Orleans, Louisiana
| | - Giselle Alvarado
- Herbert H. Lehman College, Department of Biological Sciences, City University of New York, Bronx
| | | | | | - Saket Girotra
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City
| | | | | | - Russell Rothman
- Center for Health Services Research, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Adrian F Hernandez
- Duke Clinical Research Institute, Durham, North Carolina.,Duke University Medical Center, Durham, North Carolina
| | - W Schuyler Jones
- Duke Clinical Research Institute, Durham, North Carolina.,Duke University Medical Center, Durham, North Carolina
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22
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Rist PM, Sesso HD, Manson JE. Innovation in the design of large-scale hybrid randomized clinical trials. Contemp Clin Trials 2020; 99:106178. [PMID: 33086158 PMCID: PMC7568770 DOI: 10.1016/j.cct.2020.106178] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Revised: 10/11/2020] [Accepted: 10/15/2020] [Indexed: 02/07/2023]
Affiliation(s)
- Pamela M Rist
- Division of Preventive Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA; Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA.
| | - Howard D Sesso
- Division of Preventive Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA; Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - JoAnn E Manson
- Division of Preventive Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA; Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA
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23
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Zhao C, Li S, Zhang J, Huang Y, Zhang L, Zhao F, Du X, Hou J, Zhang T, Shi C, Wang P, Huo R, Woodman OL, Qin CX, Xu H, Huang L. Current state and future perspective of cardiovascular medicines derived from natural products. Pharmacol Ther 2020; 216:107698. [PMID: 33039419 DOI: 10.1016/j.pharmthera.2020.107698] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Revised: 09/25/2020] [Accepted: 09/28/2020] [Indexed: 02/06/2023]
Abstract
The contribution of natural products (NPs) to cardiovascular medicine has been extensively documented, and many have been used for centuries. Cardiovascular disease (CVD) is the leading cause of morbidity and mortality worldwide. Over the past 40 years, approximately 50% of newly developed cardiovascular drugs were based on NPs, suggesting that NPs provide essential skeletal structures for the discovery of novel medicines. After a period of lower productivity since the 1990s, NPs have recently regained scientific and commercial attention, leveraging the wealth of knowledge provided by multi-omics, combinatorial biosynthesis, synthetic biology, integrative pharmacology, analytical and computational technologies. In addition, as a crucial part of complementary and alternative medicine, Traditional Chinese Medicine has increasingly drawn attention as an important source of NPs for cardiovascular drug discovery. Given their structural diversity and biological activity NPs are one of the most valuable sources of drugs and drug leads. In this review, we briefly described the characteristics and classification of NPs in CVDs. Then, we provide an up to date summary on the therapeutic potential and the underlying mechanisms of action of NPs in CVDs, and the current view and future prospect of developing safer and more effective cardiovascular drugs based on NPs.
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Affiliation(s)
- Chunhui Zhao
- Institute of Chinese Materia Medica, China Academy of Chinese Medical Sciences, Beijing 100700, China
| | - Sen Li
- National Resource Center for Chinese Materia Medica, China Academy of Chinese Medical Sciences, Beijing 100700, China; College of Chinese Medicinal Materials, Jilin Agricultural University, Changchun 130118, China
| | - Junhong Zhang
- Institute of Chinese Materia Medica, China Academy of Chinese Medical Sciences, Beijing 100700, China
| | - Yuanyun Huang
- Biology Department, Cornell University, Ithaca, NY 14850, United States of America
| | - Luoqi Zhang
- National Resource Center for Chinese Materia Medica, China Academy of Chinese Medical Sciences, Beijing 100700, China; College of Chinese Medicinal Materials, Jilin Agricultural University, Changchun 130118, China
| | - Feng Zhao
- Institute of Chinese Materia Medica, China Academy of Chinese Medical Sciences, Beijing 100700, China
| | - Xia Du
- Institute of Chinese Materia Medica, China Academy of Chinese Medical Sciences, Beijing 100700, China; Shaanxi Academy of Traditional Chinese Medicine, Xi'an 710003, China
| | - Jinli Hou
- Institute of Chinese Materia Medica, China Academy of Chinese Medical Sciences, Beijing 100700, China
| | - Tong Zhang
- Institute of Chinese Materia Medica, China Academy of Chinese Medical Sciences, Beijing 100700, China
| | - Chenjing Shi
- Institute of Chinese Materia Medica, China Academy of Chinese Medical Sciences, Beijing 100700, China
| | - Ping Wang
- Institute of Chinese Materia Medica, China Academy of Chinese Medical Sciences, Beijing 100700, China
| | - Ruili Huo
- China Academy of Chinese Medical Sciences, Beijing 100700, China
| | - Owen L Woodman
- Drug Discovery Biology, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, VIC 3800, Australia
| | - Cheng Xue Qin
- Drug Discovery Biology, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, VIC 3800, Australia; School of Pharmaceutical Science, Shandong University, Shandong 250100, China; Qilu Hospital, Cheeloo College of Medicine, Shandong University, Shandong 250100, China.
| | - Haiyu Xu
- Institute of Chinese Materia Medica, China Academy of Chinese Medical Sciences, Beijing 100700, China.
| | - Luqi Huang
- National Resource Center for Chinese Materia Medica, China Academy of Chinese Medical Sciences, Beijing 100700, China; China Academy of Chinese Medical Sciences, Beijing 100700, China.
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24
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Marquis-Gravel G, Moliterno DJ, Francis DP, Jüni P, Rosenberg YD, Claessen BE, Mentz RJ, Mehran R, Cutlip DE, Chauhan C, Quella S, Zannad F, Goodman SG. Improving the Design of Future PCI Trials for Stable Coronary Artery Disease: JACC State-of-the-Art Review. J Am Coll Cardiol 2020; 76:435-450. [PMID: 32703515 PMCID: PMC10018282 DOI: 10.1016/j.jacc.2020.05.060] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Revised: 05/07/2020] [Accepted: 05/15/2020] [Indexed: 01/09/2023]
Abstract
The role of percutaneous coronary interventions in addition to medical therapy for patients with stable coronary artery disease continues to be debated in routine clinical practice, despite more than 2 decades of randomized controlled trials. The residual uncertainty arises from particular challenges facing revascularization trials. Which endpoint do doctors care about, and which do patients care about? Which participants should be enrolled? What background medical therapy should we use? When is placebo control relevant? In this paper, we discuss how these questions can be approached and examine the merits and disadvantages of possible options. Engaging multiple stakeholders, including patients, researchers, regulators, and funders, to ensure the design elements are methodologically valid and clinically meaningful should be an aspirational goal in the development of future trials.
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Affiliation(s)
| | - David J Moliterno
- Gill Heart Institute and Division of Cardiovascular Medicine, University of Kentucky, Lexington, Kentucky
| | - Darrel P Francis
- Department of Cardiology, Hammersmith Hospital, Imperial College Healthcare National Health Service Trust, London, United Kingdom
| | - Peter Jüni
- Department of Medicine and Institute of Health Policy, Management and Evaluation, Applied Health Research Centre, Li Ka Shing Knowledge Institute of St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Yves D Rosenberg
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - Bimmer E Claessen
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Robert J Mentz
- Duke Clinical Research Institute, Durham, North Carolina; Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
| | - Roxana Mehran
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York; Clinical Trials Center, Cardiovascular Research Foundation, New York, New York
| | | | | | | | - Faiez Zannad
- Clinical Investigation Center 1433, French Clinical Research Infrastructure Network, Investigation Network Initiative-Cardiovascular and Renal Clinical Trialists, Centre Hospitalier Regional et Universitaire de Nancy, Vandoeuvre les Nancy, France
| | - Shaun G Goodman
- Terrence Donnelly Heart Centre, St. Michael's Hospital, University of Toronto and Canadian Heart Research Centre, Toronto, Ontario, Canada; Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada.
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25
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Precision Medicine in TAVR: How to Select the Right Device for the Right Patient. Can J Cardiol 2020; 37:4-6. [PMID: 32619447 DOI: 10.1016/j.cjca.2020.03.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Revised: 03/28/2020] [Accepted: 03/29/2020] [Indexed: 11/22/2022] Open
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26
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Karanatsios B, Prang KH, Verbunt E, Yeung JM, Kelaher M, Gibbs P. Defining key design elements of registry-based randomised controlled trials: a scoping review. Trials 2020; 21:552. [PMID: 32571382 PMCID: PMC7310018 DOI: 10.1186/s13063-020-04459-z] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Accepted: 05/26/2020] [Indexed: 01/09/2023] Open
Abstract
Background Traditional randomised controlled trials remain the gold standard for improving clinical care but they do have their limitations, including their associated high costs, high failure rate and limited external validity. An alternative methodology is the newly defined, prospective, registry-based randomised controlled trial (RRCT), where treatment and outcome data is collected in an existing registry. This scoping review explores the current literature regarding RRCTs to help identify the key design elements of RRCTs and the characteristics of clinical registries on which they are reliant on. Methods A scoping review methodology conducted in accordance with the Joanna Briggs Institute guidelines was performed. Four databases were searched for articles published from inception to June 2018: Medline; Embase; the Cumulative Index to Nursing and Allied Health Literature and; Scopus. The search strategy included MeSH and text words related to RRCT. Results We identified 2369 articles of which 75 were selected for full-text screening. Of these, only 17 articles satisfied our inclusion criteria. All studies were published between 1996 and 2017 and all were investigator-initiated. Study designs were mainly multi-site comparative/effectiveness studies incorporating the use of disease registries (n = 8), procedure registries (n = 8) and a health services registry (n = 1). The low cost, reduced administrative burden and enhanced external validity of RRCTs make them an attractive research methodology which can be used to address questions of public health importance. We identified that that there are variable definitions of what constituted a RRCT and that issues related to ethical conduct and data integrity, completeness, timeliness, validation and endpoint adjudication need to be carefully addressed. Conclusion RRCTs potentially have an important role to play in informing best clinical practice and health policy. There are a number of issues that need to be addressed to optimise the utility of this approach, including establishing universally accepted criteria for the definition of a RRCT.
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Affiliation(s)
- Bill Karanatsios
- Department of Surgery, The University of Melbourne, Parkville, VIC, Australia. .,Western Health Chronic Disease Alliance, Western Health, St Albans, VIC, Australia.
| | - Khic-Houy Prang
- Centre for Health Policy, The University of Melbourne, Parkville, VIC, Australia
| | - Ebony Verbunt
- Centre for Health Policy, The University of Melbourne, Parkville, VIC, Australia
| | - Justin M Yeung
- Department of Surgery, The University of Melbourne, Parkville, VIC, Australia.,Western Health Chronic Disease Alliance, Western Health, St Albans, VIC, Australia
| | - Margaret Kelaher
- Centre for Health Policy, The University of Melbourne, Parkville, VIC, Australia
| | - Peter Gibbs
- Systems Biology and Personalised Medicine Division, The Walter and Eliza Hall Institute of Medical Research, Parkville, VIC, Australia.,Department of Medical Biology, The University of Melbourne, Parkville, VIC, Australia.,Department of Medical Oncology, Peter MacCallum Cancer Center, Parkville, VIC, Australia
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27
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Yoon YH, Ahn JM, Kang DY, Park H, Cho SC, Lee PH, Hur SH, Kim WJ, Park CS, Lee BK, Suh JW, Yoon JH, Choi JW, Kim KS, Choi SW, Lee SN, Park SJ, Park DW. Pragmatic trial comparing routine versus no routine functional testing in high-risk patients who underwent percutaneous coronary intervention: Rationale and design of POST-PCI trial. Am Heart J 2020; 224:156-165. [PMID: 32402702 DOI: 10.1016/j.ahj.2020.03.019] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Accepted: 03/20/2020] [Indexed: 01/21/2023]
Abstract
BACKGROUND Although the need to detect restenosis has diminished in the contemporary practice of percutaneous coronary intervention (PCI) with drug-eluting stents (DES), the surveillance of ischemia owing to restenosis or disease progression deserves attention in high-risk PCI settings. It is unknown whether follow-up strategy of routine noninvasive functional testing potentially reduces the risk of major cardiovascular events in high-risk PCI patients. METHODS The POST-PCI study is an investigator-initiated, multicenter, prospective randomized trial comparing the effectiveness of two follow-up strategies in patients with high-risk anatomic or clinical characteristics who underwent PCI. Study participants were randomly assigned to either (1) the routine noninvasive stress testing (exercise electrocardiography, nuclear stress imaging, or stress echocardiography) at 12 months post-PCI or (2) the standard-care without routine testing. In the routine stress testing group, depending on the testing results, all clinical decisions regarding subsequent diagnostic or therapeutic procedures were at the treating physician's discretion. The primary endpoint was a composite outcome of death from any causes, myocardial infarction, or hospitalization for unstable angina at 2 years post-PCI. RESULTS More than 1700 high-risk PCI patients have been randomized over 2.0 years at 11 major cardiac centers in Korea. CONCLUSION This pragmatic POST-PCI trial will provide valuable clinical evidence on the effectiveness of follow-up strategy of routine noninvasive stress testing in high-risk PCI patients.
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28
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Ahmad FS, Ricket IM, Hammill BG, Eskenazi L, Robertson HR, Curtis LH, Dobi CD, Girotra S, Haynes K, Kizer JR, Kripalani S, Roe MT, Roumie CL, Waitman R, Jones WS, Weiner MG. Computable Phenotype Implementation for a National, Multicenter Pragmatic Clinical Trial: Lessons Learned From ADAPTABLE. Circ Cardiovasc Qual Outcomes 2020; 13:e006292. [PMID: 32466729 DOI: 10.1161/circoutcomes.119.006292] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Many large-scale cardiovascular clinical trials are plagued with escalating costs and low enrollment. Implementing a computable phenotype, which is a set of executable algorithms, to identify a group of clinical characteristics derivable from electronic health records or administrative claims records, is essential to successful recruitment in large-scale pragmatic clinical trials. This methods paper provides an overview of the development and implementation of a computable phenotype in ADAPTABLE (Aspirin Dosing: a Patient-Centric Trial Assessing Benefits and Long-Term Effectiveness)-a pragmatic, randomized, open-label clinical trial testing the optimal dose of aspirin for secondary prevention of atherosclerotic cardiovascular disease events. METHODS AND RESULTS A multidisciplinary team developed and tested the computable phenotype to identify adults ≥18 years of age with a history of atherosclerotic cardiovascular disease without safety concerns around using aspirin and meeting trial eligibility criteria. Using the computable phenotype, investigators identified over 650 000 potentially eligible patients from the 40 participating sites from Patient-Centered Outcomes Research Network-a network of Clinical Data Research Networks, Patient-Powered Research Networks, and Health Plan Research Networks. Leveraging diverse recruitment methods, sites enrolled 15 076 participants from April 2016 to June 2019. During the process of developing and implementing the ADAPTABLE computable phenotype, several key lessons were learned. The accuracy and utility of a computable phenotype are dependent on the quality of the source data, which can be variable even with a common data model. Local validation and modification were required based on site factors, such as recruitment strategies, data quality, and local coding patterns. Sustained collaboration among a diverse team of researchers is needed during computable phenotype development and implementation. CONCLUSIONS The ADAPTABLE computable phenotype served as an efficient method to recruit patients in a multisite pragmatic clinical trial. This process of development and implementation will be informative for future large-scale, pragmatic clinical trials. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT02697916.
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Affiliation(s)
- Faraz S Ahmad
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL (F.S.A.)
| | - Iben M Ricket
- Louisiana Public Health Institute, New Orleans (I.M.R.)
| | - Bradley G Hammill
- Duke University School of Medicine, Durham, NC (B.G.H., M.T.R., W.S.J.).,Duke Clinical Research Institute, Durham, NC (B.G.H., L.E., H.R., L.H.C., M.T.R., W.S.J.)
| | - Lisa Eskenazi
- Duke Clinical Research Institute, Durham, NC (B.G.H., L.E., H.R., L.H.C., M.T.R., W.S.J.)
| | - Holly R Robertson
- Duke Clinical Research Institute, Durham, NC (B.G.H., L.E., H.R., L.H.C., M.T.R., W.S.J.)
| | - Lesley H Curtis
- Duke Clinical Research Institute, Durham, NC (B.G.H., L.E., H.R., L.H.C., M.T.R., W.S.J.)
| | - Cecilia D Dobi
- Department of Clinical Sciences, Lewis Katz School of Medicine at Temple University, Philadelphia, PA (C.D.D.)
| | - Saket Girotra
- University of Iowa Carver College of Medicine, Iowa City (S.G.).,Iowa City Veteran Affairs Medical Center (S.G.)
| | - Kevin Haynes
- Scientific Affairs, HealthCore, Inc., Wilmington, DE (K.H.)
| | - Jorge R Kizer
- Cardiology Section, San Francisco Veterans Affairs Health Care System, CA (J.R.K.).,Department of Medicine and Department of Epidemiology and Biostatistics, University of California San Francisco (J.R.K.)
| | - Sunil Kripalani
- Department of Medicine, Vanderbilt University Medical Center, Veterans Health Administration-Tennessee Valley Healthcare System Geriatric Research Education Clinical Center, Health Services Research and Development Center, Nashville, TN (S.K., C.L.R.)
| | - Mathew T Roe
- Duke University School of Medicine, Durham, NC (B.G.H., M.T.R., W.S.J.).,Duke Clinical Research Institute, Durham, NC (B.G.H., L.E., H.R., L.H.C., M.T.R., W.S.J.)
| | - Christianne L Roumie
- Department of Medicine, Vanderbilt University Medical Center, Veterans Health Administration-Tennessee Valley Healthcare System Geriatric Research Education Clinical Center, Health Services Research and Development Center, Nashville, TN (S.K., C.L.R.)
| | - Russ Waitman
- Department of Internal Medicine, University of Kansas Medical Center, Kansas City, KS (R.W.)
| | - W Schuyler Jones
- Duke University School of Medicine, Durham, NC (B.G.H., M.T.R., W.S.J.).,Duke Clinical Research Institute, Durham, NC (B.G.H., L.E., H.R., L.H.C., M.T.R., W.S.J.)
| | - Mark G Weiner
- Department of Population Health Sciences, Weill Cornell Medicine, New York Presbyterian-Weill Cornell Campus, New York (M.G.W.)
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29
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Fanaroff AC, Haque G, Thomas B, Stone AE, Perkins LM, Wilson M, Jones WS, Melloni C, Mahaffey KW, Alexander KP, Lopes RD. Methods for safety and endpoint ascertainment: identification of adverse events through scrutiny of negatively adjudicated events. Trials 2020; 21:323. [PMID: 32272961 PMCID: PMC7147037 DOI: 10.1186/s13063-020-04254-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Accepted: 03/14/2020] [Indexed: 11/10/2022] Open
Abstract
Background The primary goal of phase 2 and 3 clinical trials is to evaluate the safety and effectiveness of therapeutic interventions, and efficient and reproducible ascertainment of important clinical events, either as clinical outcome events (COEs) or adverse events (AEs), is critical. Clinical outcomes require consistency and clinical judgment, so these events are often adjudicated centrally by clinical events classification (CEC) physician reviewers using standardized definitions. In contrast, AEs are reported by sites to the trial coordinating center based on common reporting criteria set by regulatory authorities and trial sponsors. These different requirements have led to the development of separate tracks for COE and AE review. Main body Potential COEs that fail to meet standardized definitions for CEC adjudication – i.e. negatively adjudicated events (NAE) – may meet criteria for AEs. Trial oversight practices require the sponsor to process AEs regardless of how the AEs are submitted; therefore, review of NAEs may be necessary to ensure that important AEs do not go unreported. The Duke Clinical Research Institute (DCRI) developed and implemented a process for scrutinizing NAEs to detect potential missed serious AEs. Initial experience with this process across two trials suggests that approximately 0.2% of NAEs are serious unexpected AEs that were not otherwise reported and another 1.5% are serious expected AEs. Conclusions Given their infrequent concealment of serious AEs in two large trials assessing cardiovascular outcomes, routine scrutiny of NAEs to identify AEs is not recommended at this time, though it may be useful in some trials and should be carefully considered by the trial team. Closer integration of data across safety surveillance and endpoint adjudication systems may enable scrutiny of NAEs when indicated while limiting complexity associated with this process.
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Affiliation(s)
- Alexander C Fanaroff
- Cardiovascular Medicine Division, Penn Cardiovascular Outcomes, Quality and Evaluative Research Center, Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
| | - Ghazala Haque
- Duke Clinical Research Institute, Duke University, 200 Morris Street, Durham, NC, USA
| | - Betsy Thomas
- Duke Clinical Research Institute, Duke University, 200 Morris Street, Durham, NC, USA
| | - Allegra E Stone
- Duke Clinical Research Institute, Duke University, 200 Morris Street, Durham, NC, USA
| | - Lynn M Perkins
- Duke Clinical Research Institute, Duke University, 200 Morris Street, Durham, NC, USA
| | - Matthew Wilson
- Duke Clinical Research Institute, Duke University, 200 Morris Street, Durham, NC, USA
| | - W Schuyler Jones
- Duke Clinical Research Institute, Duke University, 200 Morris Street, Durham, NC, USA.,Division of Cardiology, Duke University, Durham, NC, USA
| | - Chiara Melloni
- Duke Clinical Research Institute, Duke University, 200 Morris Street, Durham, NC, USA.,Division of Cardiology, Duke University, Durham, NC, USA
| | - Kenneth W Mahaffey
- Stanford Center for Clinical Research, Department of Medicine, Stanford Univeristy School of Medicine, Stanford, CA, USA
| | - Karen P Alexander
- Duke Clinical Research Institute, Duke University, 200 Morris Street, Durham, NC, USA.,Division of Cardiology, Duke University, Durham, NC, USA
| | - Renato D Lopes
- Duke Clinical Research Institute, Duke University, 200 Morris Street, Durham, NC, USA. .,Division of Cardiology, Duke University, Durham, NC, USA.
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30
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Design and rationale of a multi-center, pragmatic, open-label randomized trial of antimicrobial therapy - the study of clinical efficacy of antimicrobial therapy strategy using pragmatic design in Idiopathic Pulmonary Fibrosis (CleanUP-IPF) clinical trial. Respir Res 2020; 21:68. [PMID: 32164673 PMCID: PMC7069004 DOI: 10.1186/s12931-020-1326-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Accepted: 02/19/2020] [Indexed: 01/20/2023] Open
Abstract
Abstract Compelling data have linked disease progression in patients with idiopathic pulmonary fibrosis (IPF) with lung dysbiosis and the resulting dysregulated local and systemic immune response. Moreover, prior therapeutic trials have suggested improved outcomes in these patients treated with either sulfamethoxazole/ trimethoprim or doxycycline. These trials have been limited by methodological concerns. This trial addresses the primary hypothesis that long-term treatment with antimicrobial therapy increases the time-to-event endpoint of respiratory hospitalization or all-cause mortality compared to usual care treatment in patients with IPF. We invoke numerous innovative features to achieve this goal, including: 1) utilizing a pragmatic randomized trial design; 2) collecting targeted biological samples to allow future exploration of ‘personalized’ therapy; and 3) developing a strong partnership between the NHLBI, a broad range of investigators, industry, and philanthropic organizations. The trial will randomize approximately 500 individuals in a 1:1 ratio to either antimicrobial therapy or usual care. The site principal investigator will declare their preferred initial antimicrobial treatment strategy (trimethoprim 160 mg/ sulfamethoxazole 800 mg twice a day plus folic acid 5 mg daily or doxycycline 100 mg once daily if body weight is < 50 kg or 100 mg twice daily if ≥50 kg) for the participant prior to randomization. Participants randomized to antimicrobial therapy will receive a voucher to help cover the additional prescription drug costs. Additionally, those participants will have 4–5 scheduled blood draws over the initial 24 months of therapy for safety monitoring. Blood sampling for DNA sequencing and genome wide transcriptomics will be collected before therapy. Blood sampling for transcriptomics and oral and fecal swabs for determination of the microbiome communities will be collected before and after study completion. As a pragmatic study, participants in both treatment arms will have limited in-person visits with the enrolling clinical center. Visits are limited to assessments of lung function and other clinical parameters at time points prior to randomization and at months 12, 24, and 36. All participants will be followed until the study completion for the assessment of clinical endpoints related to hospitalization and mortality events. Trial Registration ClinicalTrials.gov identifier NCT02759120.
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31
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Dhruva SS, Parzynski CS, Gamble GM, Curtis JP, Desai NR, Yeh RW, Masoudi FA, Kuntz R, Shaw RE, Marinac‐Dabic D, Sedrakyan A, Normand ST, Krumholz HM, Ross JS. Attribution of Adverse Events Following Coronary Stent Placement Identified Using Administrative Claims Data. J Am Heart Assoc 2020; 9:e013606. [PMID: 32063087 PMCID: PMC7070203 DOI: 10.1161/jaha.119.013606] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Accepted: 01/13/2020] [Indexed: 11/22/2022]
Abstract
Background More than 600 000 coronary stents are implanted during percutaneous coronary interventions (PCIs) annually in the United States. Because no real-world surveillance system exists to monitor their long-term safety, claims data are often used for this purpose. The extent to which adverse events identified with claims data can be reasonably attributed to a specific medical device is uncertain. Methods and Results We used deterministic matching to link the NCDR (National Cardiovascular Data Registry) CathPCI Registry to Medicare fee-for-service claims for patients aged ≥65 years who underwent PCI with drug-eluting stents (DESs) between July 1, 2009 and December 31, 2013. We identified subsequent PCIs within 1 year of the index procedure in Medicare claims as potential safety events. We linked these subsequent PCIs back to the NCDR CathPCI Registry to ascertain how often the revascularization could be reasonably attributed to the same coronary artery as the index PCI (ie, target vessel revascularization). Of 415 306 DES placements in 368 194 patients, 33 174 repeat PCIs were identified in Medicare claims within 1 year. Of these, 28 632 (86.3%) could be linked back to the NCDR CathPCI Registry; 16 942 (51.1% of repeat PCIs) were target vessel revascularizations. Of these, 8544 (50.4%) were within a previously placed DES: 7652 for in-stent restenosis and 1341 for stent thrombosis. Of 16 176 patients with a claim for acute myocardial infarction in the follow-up period, 4446 (27.5%) were attributed to the same coronary artery in which the DES was implanted during the index PCI (ie, target vessel myocardial infarction). Of 24 288 patients whose death was identified in claims data, 278 (1.1%) were attributed to the same coronary artery in which the DES was implanted during the index PCI. Conclusions Most repeat PCIs following DES stent implantation identified in longitudinal claims data could be linked to real-world registry data, but only half could be reasonably attributed to the same coronary artery as the index procedure. Attribution among those with acute myocardial infarction or who died was even less frequent. Safety signals identified using claims data alone will require more in-depth examination to accurately assess stent safety.
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Affiliation(s)
- Sanket S. Dhruva
- University of California, San Francisco, School of Medicine and San Francisco Veterans Affairs Healthcare SystemSan FranciscoCA
- National Clinician Scholars ProgramYale School of MedicineNew HavenCT
- Center for Outcomes Research and EvaluationYale–New Haven HospitalNew HavenCT
| | - Craig S. Parzynski
- Center for Outcomes Research and EvaluationYale–New Haven HospitalNew HavenCT
| | - Ginger M. Gamble
- Center for Outcomes Research and EvaluationYale–New Haven HospitalNew HavenCT
| | - Jeptha P. Curtis
- Center for Outcomes Research and EvaluationYale–New Haven HospitalNew HavenCT
- Section of Cardiovascular MedicineDepartment of Medicine, and National Clinician Scholars ProgramYale School of MedicineNew HavenCT
| | - Nihar R. Desai
- Center for Outcomes Research and EvaluationYale–New Haven HospitalNew HavenCT
- Section of Cardiovascular MedicineDepartment of Medicine, and National Clinician Scholars ProgramYale School of MedicineNew HavenCT
| | - Robert W. Yeh
- Richard A. and Susan F. Smith Center for Outcomes Research in CardiologyBostonMA
- Division of Cardiovascular MedicineBeth Israel Deaconess Medical CenterBostonMA
- Harvard Medical SchoolBostonMA
- Baim Institute for Clinical ResearchBostonMA
| | - Frederick A. Masoudi
- Division of CardiologyDepartment of MedicineUniversity of Colorado Anschutz Medical CampusAuroraCO
| | | | - Richard E. Shaw
- Department of Clinical InformaticsCalifornia Pacific Medical CenterSan FranciscoCA
| | - Danica Marinac‐Dabic
- Office of Clinical Evidence and AnalysisCenter for Devices and Radiological HealthU.S. Food and Drug AdministrationSilver SpringMD
| | - Art Sedrakyan
- Department of Health Policy and ResearchWeill Cornell MedicineNew York Presbyterian HospitalNew YorkNY
| | - Sharon‐Lise T. Normand
- Department of Health Care PolicyHarvard Medical SchoolBostonMA
- Department of BiostatisticsHarvard T.H. Chan School of Public HealthHarvard UniversityBostonMA
| | - Harlan M. Krumholz
- National Clinician Scholars ProgramYale School of MedicineNew HavenCT
- Center for Outcomes Research and EvaluationYale–New Haven HospitalNew HavenCT
- Section of Cardiovascular MedicineDepartment of Medicine, and National Clinician Scholars ProgramYale School of MedicineNew HavenCT
- Department of Health Policy and ManagementYale School of Public HealthNew HavenCT
| | - Joseph S. Ross
- National Clinician Scholars ProgramYale School of MedicineNew HavenCT
- Center for Outcomes Research and EvaluationYale–New Haven HospitalNew HavenCT
- Department of Health Policy and ManagementYale School of Public HealthNew HavenCT
- Section of General MedicineDepartment of Medicine, and National Clinician Scholars ProgramYale School of MedicineNew HavenCT
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32
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Lee P, Chin K, Liew D, Stub D, Brennan AL, Lefkovits J, Zomer E. Economic evaluation of clinical quality registries: a systematic review. BMJ Open 2019; 9:e030984. [PMID: 31843824 PMCID: PMC6924778 DOI: 10.1136/bmjopen-2019-030984] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
OBJECTIVES The objective of this systematic review was to examine the existing evidence base for the cost-effectiveness or cost-benefit of clinical quality registries (CQRs). DESIGN Systematic review and narrative synthesis. DATA SOURCES Nine electronic bibliographic databases, including MEDLINE, EMBASE and CENTRAL, in the period from January 2000 to August 2019. ELIGIBILITY CRITERIA Any peer-reviewed published study or grey literature in English which had reported on an economic evaluation of one or more CQRs. DATA EXTRACTION AND SYNTHESIS Data were screened, extracted and appraised by two independent reviewers. A narrative synthesis was performed around key attributes of each CQR and on key patient outcomes or changes to healthcare processes or utilisation. A narrative synthesis of the cost-effectiveness associated with CQRs was also conducted. The primary outcome was cost-effectiveness, in terms of the estimated incremental cost-effectiveness ratio (ICER), cost savings or return-on-investment (ROI) attributed to CQR implementation. RESULTS Three studies and one government report met the inclusion criteria for the review. A study of the National Surgical Quality Improvement Programme (NSQIP) in the USA found that the cost-effectiveness of this registry improved over time, based on an ICER of US$8312 per postoperative event avoided. A separate study in Canada estimated the ROI to be US$3.43 per US$1.00 invested in the NSQIP. An evaluation of a post-splenectomy CQR in Australia estimated that registry cost-effectiveness improved from US$234 329 to US$18 358 per life year gained when considering the benefits accrued over the lifetime of the population. The government report evaluating five Australian CQRs estimated an overall return of 1.6-5.5 times the cost of investment. CONCLUSIONS Available data indicate that CQRs can be cost-effective and can lead to significant returns on investment. It is clear that further studies that evaluate the economic and clinical impacts of CQRs are necessary. PROSPERO REGISTRATION NUMBER CRD42018116807.
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Affiliation(s)
- Peter Lee
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Ken Chin
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Melbourne Medical School, The University of Melbourne, Melbourne, Victoria, Australia
| | - Danny Liew
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Dion Stub
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Departrment of Cardiology, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Angela L Brennan
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Jeffrey Lefkovits
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Department of Cardiology, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Ella Zomer
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
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Fanaroff AC, Clare R, Pieper KS, Mahaffey KW, Melloni C, Green JB, Alexander JH, Jones WS, Harrison RW, Mehta RH, Povsic TJ, Moreira HG, Al-Khatib SM, Roe MT, Kong DF, Mathews R, Tricoci P, Holman RR, Wallentin L, Held C, Califf RM, Alexander KP, Lopes RD. Frequency, Regional Variation, and Predictors of Undetermined Cause of Death in Cardiometabolic Clinical Trials: A Pooled Analysis of 9259 Deaths in 9 Trials. Circulation 2019; 139:863-873. [PMID: 30586739 DOI: 10.1161/circulationaha.118.037202] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Modern cardiometabolic clinical trials often include cardiovascular death as a component of a composite primary outcome, requiring central adjudication by a clinical events committee to classify cause of death. However, sometimes the cause of death cannot be determined from available data. The US Food and Drug Administration has indicated that this circumstance should occur only rarely, but its prevalence has not been formally assessed. METHODS Data from 9 global clinical trials (2009-2017) with long-term follow-up and blinded, centrally adjudicated cause of death were used to calculate the proportion of deaths attributed to cardiovascular, noncardiovascular, or undetermined causes by therapeutic area (diabetes mellitus/pre-diabetes mellitus, stable atherosclerosis, atrial fibrillation, and acute coronary syndrome), region of patient enrollment, and year of trial manuscript publication. Patient- and trial-level variables associated with undetermined cause of death were identified using a logistic model. RESULTS Across 127 049 enrolled participants from 9 trials, there were 9259 centrally adjudicated deaths: 5012 (54.1%) attributable to cardiovascular causes, 2800 (30.2%) attributable to noncardiovascular causes, and 1447 (15.6%) attributable to undetermined causes. There was variability in the proportion of deaths ascribed to undetermined causes by trial therapeutic area, region of enrollment, and year of trial manuscript publication. On multivariable analysis, acute coronary syndrome or atrial fibrillation trial (versus atherosclerotic vascular disease or diabetes mellitus/pre-diabetes mellitus), longer time from enrollment to death, more recent trial manuscript publication year, enrollment in North America (versus Western Europe), female sex, and older age were associated with greater likelihood of death of undetermined cause. CONCLUSIONS In 9 cardiometabolic clinical trials with long-term follow-up, approximately 16% of deaths had undetermined causes. This provides a baseline for quality assessment of clinical trials and informs operational efforts to potentially reduce the frequency of undetermined deaths in future clinical research.
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Affiliation(s)
- Alexander C Fanaroff
- Division of Cardiology (A.C.F., C.M., J.H.A., W.S.J., R.W.H., T.J.P., S.M.A-K., M.T.R., D.F.K., R.M., R.M.C., K.P.A., R.D.L.), Duke University School of Medicine, Durham, NC.,Duke Clinical Research Institute (A.C.F. R.C., K.S.P., C.M., J.B.G., J.H.A., W.S.J., R.W.H., R.H.M., T.J.P., S.M.A-K., M.T.R., D.F.K., R.M., R.M.C., K.P.A., R.D.L.), Duke University School of Medicine, Durham, NC
| | - Robert Clare
- Duke Clinical Research Institute (A.C.F. R.C., K.S.P., C.M., J.B.G., J.H.A., W.S.J., R.W.H., R.H.M., T.J.P., S.M.A-K., M.T.R., D.F.K., R.M., R.M.C., K.P.A., R.D.L.), Duke University School of Medicine, Durham, NC
| | - Karen S Pieper
- Duke Clinical Research Institute (A.C.F. R.C., K.S.P., C.M., J.B.G., J.H.A., W.S.J., R.W.H., R.H.M., T.J.P., S.M.A-K., M.T.R., D.F.K., R.M., R.M.C., K.P.A., R.D.L.), Duke University School of Medicine, Durham, NC
| | - Kenneth W Mahaffey
- Stanford Center for Clinical Research, Stanford University School of Medicine, CA (K.W.M.)
| | - Chiara Melloni
- Division of Cardiology (A.C.F., C.M., J.H.A., W.S.J., R.W.H., T.J.P., S.M.A-K., M.T.R., D.F.K., R.M., R.M.C., K.P.A., R.D.L.), Duke University School of Medicine, Durham, NC.,Duke Clinical Research Institute (A.C.F. R.C., K.S.P., C.M., J.B.G., J.H.A., W.S.J., R.W.H., R.H.M., T.J.P., S.M.A-K., M.T.R., D.F.K., R.M., R.M.C., K.P.A., R.D.L.), Duke University School of Medicine, Durham, NC
| | - Jennifer B Green
- Duke Clinical Research Institute (A.C.F. R.C., K.S.P., C.M., J.B.G., J.H.A., W.S.J., R.W.H., R.H.M., T.J.P., S.M.A-K., M.T.R., D.F.K., R.M., R.M.C., K.P.A., R.D.L.), Duke University School of Medicine, Durham, NC.,Division of Endocrinology (J.B.G.), Duke University School of Medicine, Durham, NC
| | - John H Alexander
- Division of Cardiology (A.C.F., C.M., J.H.A., W.S.J., R.W.H., T.J.P., S.M.A-K., M.T.R., D.F.K., R.M., R.M.C., K.P.A., R.D.L.), Duke University School of Medicine, Durham, NC.,Duke Clinical Research Institute (A.C.F. R.C., K.S.P., C.M., J.B.G., J.H.A., W.S.J., R.W.H., R.H.M., T.J.P., S.M.A-K., M.T.R., D.F.K., R.M., R.M.C., K.P.A., R.D.L.), Duke University School of Medicine, Durham, NC
| | - W Schuyler Jones
- Division of Cardiology (A.C.F., C.M., J.H.A., W.S.J., R.W.H., T.J.P., S.M.A-K., M.T.R., D.F.K., R.M., R.M.C., K.P.A., R.D.L.), Duke University School of Medicine, Durham, NC.,Duke Clinical Research Institute (A.C.F. R.C., K.S.P., C.M., J.B.G., J.H.A., W.S.J., R.W.H., R.H.M., T.J.P., S.M.A-K., M.T.R., D.F.K., R.M., R.M.C., K.P.A., R.D.L.), Duke University School of Medicine, Durham, NC
| | - Robert W Harrison
- Division of Cardiology (A.C.F., C.M., J.H.A., W.S.J., R.W.H., T.J.P., S.M.A-K., M.T.R., D.F.K., R.M., R.M.C., K.P.A., R.D.L.), Duke University School of Medicine, Durham, NC.,Duke Clinical Research Institute (A.C.F. R.C., K.S.P., C.M., J.B.G., J.H.A., W.S.J., R.W.H., R.H.M., T.J.P., S.M.A-K., M.T.R., D.F.K., R.M., R.M.C., K.P.A., R.D.L.), Duke University School of Medicine, Durham, NC
| | - Rajendra H Mehta
- Duke Clinical Research Institute (A.C.F. R.C., K.S.P., C.M., J.B.G., J.H.A., W.S.J., R.W.H., R.H.M., T.J.P., S.M.A-K., M.T.R., D.F.K., R.M., R.M.C., K.P.A., R.D.L.), Duke University School of Medicine, Durham, NC
| | - Thomas J Povsic
- Division of Cardiology (A.C.F., C.M., J.H.A., W.S.J., R.W.H., T.J.P., S.M.A-K., M.T.R., D.F.K., R.M., R.M.C., K.P.A., R.D.L.), Duke University School of Medicine, Durham, NC.,Duke Clinical Research Institute (A.C.F. R.C., K.S.P., C.M., J.B.G., J.H.A., W.S.J., R.W.H., R.H.M., T.J.P., S.M.A-K., M.T.R., D.F.K., R.M., R.M.C., K.P.A., R.D.L.), Duke University School of Medicine, Durham, NC
| | - Humberto G Moreira
- Heart Institute (InCor), University of São Paulo Medical School, Brazil (H.G.M.)
| | - Sana M Al-Khatib
- Division of Cardiology (A.C.F., C.M., J.H.A., W.S.J., R.W.H., T.J.P., S.M.A-K., M.T.R., D.F.K., R.M., R.M.C., K.P.A., R.D.L.), Duke University School of Medicine, Durham, NC.,Duke Clinical Research Institute (A.C.F. R.C., K.S.P., C.M., J.B.G., J.H.A., W.S.J., R.W.H., R.H.M., T.J.P., S.M.A-K., M.T.R., D.F.K., R.M., R.M.C., K.P.A., R.D.L.), Duke University School of Medicine, Durham, NC
| | - Matthew T Roe
- Division of Cardiology (A.C.F., C.M., J.H.A., W.S.J., R.W.H., T.J.P., S.M.A-K., M.T.R., D.F.K., R.M., R.M.C., K.P.A., R.D.L.), Duke University School of Medicine, Durham, NC.,Duke Clinical Research Institute (A.C.F. R.C., K.S.P., C.M., J.B.G., J.H.A., W.S.J., R.W.H., R.H.M., T.J.P., S.M.A-K., M.T.R., D.F.K., R.M., R.M.C., K.P.A., R.D.L.), Duke University School of Medicine, Durham, NC
| | - David F Kong
- Division of Cardiology (A.C.F., C.M., J.H.A., W.S.J., R.W.H., T.J.P., S.M.A-K., M.T.R., D.F.K., R.M., R.M.C., K.P.A., R.D.L.), Duke University School of Medicine, Durham, NC.,Duke Clinical Research Institute (A.C.F. R.C., K.S.P., C.M., J.B.G., J.H.A., W.S.J., R.W.H., R.H.M., T.J.P., S.M.A-K., M.T.R., D.F.K., R.M., R.M.C., K.P.A., R.D.L.), Duke University School of Medicine, Durham, NC
| | - Robin Mathews
- Division of Cardiology (A.C.F., C.M., J.H.A., W.S.J., R.W.H., T.J.P., S.M.A-K., M.T.R., D.F.K., R.M., R.M.C., K.P.A., R.D.L.), Duke University School of Medicine, Durham, NC.,Duke Clinical Research Institute (A.C.F. R.C., K.S.P., C.M., J.B.G., J.H.A., W.S.J., R.W.H., R.H.M., T.J.P., S.M.A-K., M.T.R., D.F.K., R.M., R.M.C., K.P.A., R.D.L.), Duke University School of Medicine, Durham, NC
| | | | - Rury R Holman
- Diabetes Trials Unit, Oxford Centre for Diabetes, Endocrinology and Metabolism, University of Oxford, United Kingdom (R.R.H)
| | - Lars Wallentin
- Department of Medical Sciences, Cardiology, and Uppsala Clinical Research Institute, Uppsala University, Sweden (L.W., C.H.)
| | - Claes Held
- Department of Medical Sciences, Cardiology, and Uppsala Clinical Research Institute, Uppsala University, Sweden (L.W., C.H.)
| | - Robert M Califf
- Division of Cardiology (A.C.F., C.M., J.H.A., W.S.J., R.W.H., T.J.P., S.M.A-K., M.T.R., D.F.K., R.M., R.M.C., K.P.A., R.D.L.), Duke University School of Medicine, Durham, NC.,Duke Clinical Research Institute (A.C.F. R.C., K.S.P., C.M., J.B.G., J.H.A., W.S.J., R.W.H., R.H.M., T.J.P., S.M.A-K., M.T.R., D.F.K., R.M., R.M.C., K.P.A., R.D.L.), Duke University School of Medicine, Durham, NC.,Verily Life Sciences, South San Francisco, CA (R.M.C.)
| | - Karen P Alexander
- Division of Cardiology (A.C.F., C.M., J.H.A., W.S.J., R.W.H., T.J.P., S.M.A-K., M.T.R., D.F.K., R.M., R.M.C., K.P.A., R.D.L.), Duke University School of Medicine, Durham, NC.,Duke Clinical Research Institute (A.C.F. R.C., K.S.P., C.M., J.B.G., J.H.A., W.S.J., R.W.H., R.H.M., T.J.P., S.M.A-K., M.T.R., D.F.K., R.M., R.M.C., K.P.A., R.D.L.), Duke University School of Medicine, Durham, NC
| | - Renato D Lopes
- Division of Cardiology (A.C.F., C.M., J.H.A., W.S.J., R.W.H., T.J.P., S.M.A-K., M.T.R., D.F.K., R.M., R.M.C., K.P.A., R.D.L.), Duke University School of Medicine, Durham, NC.,Duke Clinical Research Institute (A.C.F. R.C., K.S.P., C.M., J.B.G., J.H.A., W.S.J., R.W.H., R.H.M., T.J.P., S.M.A-K., M.T.R., D.F.K., R.M., R.M.C., K.P.A., R.D.L.), Duke University School of Medicine, Durham, NC
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Fanaroff AC, Cyr D, Neely ML, Bakal J, White HD, Fox KAA, Armstrong PW, Lopes RD, Ohman EM, Roe MT. Days Alive and Out of Hospital: Exploring a Patient-Centered, Pragmatic Outcome in a Clinical Trial of Patients With Acute Coronary Syndromes. Circ Cardiovasc Qual Outcomes 2019; 11:e004755. [PMID: 30562068 DOI: 10.1161/circoutcomes.118.004755] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Cardiovascular clinical trials have traditionally incorporated separate time-to-first-event analyses for their primary efficacy and safety comparisons, but this framework has a number of limitations, including limited patient-centeredness and a traditional requirement for central adjudication. Days alive and out of the hospital (DAOH) has the potential to provide additional insight. Methods and Results TRILOGY ACS (Targeted Platelet Inhibition to Clarify the Optimal Strategy to Medically Manage Acute Coronary Syndromes) was a randomized, multinational clinical trial that compared the effect of prasugrel versus clopidogrel in patients stabilized after non-ST segment elevation acute coronary syndrome treated without revascularization; the trial had a neutral result. DAOH was calculated for each patient using site-submitted adverse event reporting data. We described patterns of DAOH overall, and among younger adults (<75 years old), older adults (≥75 years old), and frail/prefrail patients over 12 months follow-up and used Poisson regression to compare DAOH for patients randomized to prasugrel versus clopidogrel. Of 9249 patients in the overall trial population, 500 (5.4%) died, and 2504 (27.1%) were hospitalized 4150 times over 12 months' follow-up; the mean±SD DAOH was 317±86. The distribution of DAOH over 12 months was left-skewed, with median DAOH 363 days. Among younger adults, older adults, and frail/prefrail patients, mean DAOH were 323, 293, and 304 days, respectively. There were no differences in DAOH by treatment arm in the overall population (rate ratio, 1.00; 95% CI, 0.99-1.01) or any subgroup. Conclusions These results support the feasibility of determining DAOH, a patient-centered outcome that can potentially overcome many of the disadvantages of the traditional time-to-composite-event framework in the clinical trial setting. Clinical Trial Registration URL: https://www.clinicaltrials.gov. Unique identifier: NCT00699998.
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Affiliation(s)
- Alexander C Fanaroff
- Division of Cardiology (A.C.F., R.D.L., E.M.O., M.T.R.), Duke University, Durham, NC.,Duke Clinical Research Institute (A.C.F., D.C., M.L.N., R.D.L., E.M.O., M.T.R.), Duke University, Durham, NC
| | - Derek Cyr
- Duke Clinical Research Institute (A.C.F., D.C., M.L.N., R.D.L., E.M.O., M.T.R.), Duke University, Durham, NC
| | - Megan L Neely
- Duke Clinical Research Institute (A.C.F., D.C., M.L.N., R.D.L., E.M.O., M.T.R.), Duke University, Durham, NC
| | - Jeffery Bakal
- Division of Cardiology, University of Alberta and the Canadian VIGOUR Centre, Edmonton (J.B., P.W.A.)
| | - Harvey D White
- Green Lane Cardiovascular Service, Auckland City Hospital and University of Auckland, New Zealand (H.D.W.)
| | - Keith A A Fox
- Centre for Cardiovascular Science, University of Edinburgh, United Kingdom (K.A.A.F.)
| | - Paul W Armstrong
- Division of Cardiology, University of Alberta and the Canadian VIGOUR Centre, Edmonton (J.B., P.W.A.)
| | - Renato D Lopes
- Division of Cardiology (A.C.F., R.D.L., E.M.O., M.T.R.), Duke University, Durham, NC.,Duke Clinical Research Institute (A.C.F., D.C., M.L.N., R.D.L., E.M.O., M.T.R.), Duke University, Durham, NC
| | - E Magnus Ohman
- Division of Cardiology (A.C.F., R.D.L., E.M.O., M.T.R.), Duke University, Durham, NC.,Duke Clinical Research Institute (A.C.F., D.C., M.L.N., R.D.L., E.M.O., M.T.R.), Duke University, Durham, NC
| | - Matthew T Roe
- Division of Cardiology (A.C.F., R.D.L., E.M.O., M.T.R.), Duke University, Durham, NC.,Duke Clinical Research Institute (A.C.F., D.C., M.L.N., R.D.L., E.M.O., M.T.R.), Duke University, Durham, NC
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Marquis-Gravel G, Roe MT, Turakhia MP, Boden W, Temple R, Sharma A, Hirshberg B, Slater P, Craft N, Stockbridge N, McDowell B, Waldstreicher J, Bourla A, Bansilal S, Wong JL, Meunier C, Kassahun H, Coran P, Bataille L, Patrick-Lake B, Hirsch B, Reites J, Mehta R, Muse ED, Chandross KJ, Silverstein JC, Silcox C, Overhage JM, Califf RM, Peterson ED. Technology-Enabled Clinical Trials. Circulation 2019; 140:1426-1436. [DOI: 10.1161/circulationaha.119.040798] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
The complexity and costs associated with traditional randomized, controlled trials have increased exponentially over time, and now threaten to stifle the development of new drugs and devices. Nevertheless, the growing use of electronic health records, mobile applications, and wearable devices offers significant promise for transforming clinical trials, making them more pragmatic and efficient. However, many challenges must be overcome before these innovations can be implemented routinely in randomized, controlled trial operations. In October of 2018, a diverse stakeholder group convened in Washington, DC, to examine how electronic health record, mobile, and wearable technologies could be applied to clinical trials. The group specifically examined how these technologies might streamline the execution of clinical trial components, delineated innovative trial designs facilitated by technological developments, identified barriers to implementation, and determined the optimal frameworks needed for regulatory oversight. The group concluded that the application of novel technologies to clinical trials provided enormous potential, yet these changes needed to be iterative and facilitated by continuous learning and pilot studies.
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Affiliation(s)
| | - Matthew T. Roe
- Duke Clinical Research Institute, Durham, NC (G.M.-G., M.T.R., B.P.-L., E.D.P.)
| | - Mintu P. Turakhia
- Center for Digital Health (M.P.T.), Stanford University, CA
- VA Palo Alto Health Care System, CA (M.P.T.)
| | - William Boden
- Boston University and VA New England Health Care System, MA (W.B.)
| | - Robert Temple
- U.S. Food and Drug Administration, Silver Spring, MD (R.T., N.S.)
| | - Abhinav Sharma
- Division of Cardiology (A.S.), Stanford University, CA
- Division of Cardiology, McGill University Health Centre, Montreal, QC, Canada (A.S.)
| | | | - Paul Slater
- Life Sciences Innovation, Microsoft, Seattle, WA (P.S.)
| | | | | | | | | | | | | | | | | | | | | | - Lauren Bataille
- The Michael J. Fox Foundation for Parkinson’s Research, New York (L.B.)
| | - Bray Patrick-Lake
- Duke Clinical Research Institute, Durham, NC (G.M.-G., M.T.R., B.P.-L., E.D.P.)
| | | | | | | | - Evan D. Muse
- Scripps Research Translational Institute; Division of Cardiovascular Disease, Scripps Clinic, Scripps Health, La Jolla, CA (E.D.M.)
| | | | | | | | | | - Robert M. Califf
- Department of Medicine (R.M.C.), Stanford University, CA
- Duke Forge, Duke University School of Medicine, Durham, NC (R.M.C.)
- Verily Life Sciences (Alphabet), South San Francisco, CA (R.M.C.)
| | - Eric D. Peterson
- Duke Clinical Research Institute, Durham, NC (G.M.-G., M.T.R., B.P.-L., E.D.P.)
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Fanaroff AC, Morrow V, Krucoff MW, Seltzer JH, Perin EC, Taylor DA, Miller LW, Zeiher AM, Fernández-Avilés F, Losordo DW, Henry TD, Povsic TJ. A Path Forward for Regenerative Medicine. Circ Res 2019; 123:495-505. [PMID: 30355250 DOI: 10.1161/circresaha.118.313261] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Although clinical trials of cell-based approaches to cardiovascular disease have yielded some promising results, no cell-based therapy has achieved regulatory approval for a cardiovascular indication. To broadly assess the challenges to regulatory approval and identify strategies to facilitate this goal, the Cardiac Safety Research Consortium sponsored a session during the Texas Heart Institute International Symposium on Cardiovascular Regenerative Medicine in September 2017. This session convened leaders in cardiovascular regenerative medicine, including participants from academia, the pharmaceutical industry, the US Food and Drug Administration, and the Cardiac Safety Research Consortium, with particular focus on treatments closest to regulatory approval. A goal of the session was to identify barriers to regulatory approval and potential pathways to overcome them. Barriers identified include manufacturing and therapeutic complexity, difficulties identifying an optimal comparator group, limited industry capacity for funding pivotal clinical trials, and challenges to demonstrating efficacy on clinical end points required for regulatory decisions. Strategies to overcome these barriers include precompetitive development of a cell therapy registry network to enable dual-purposing of clinical data as part of pragmatic clinical trial design, development of standardized terminology for product activity and end points to facilitate this registry, use of innovative statistical methods and quality of life or functional end points to supplement outcomes such as death or heart failure hospitalization and reduce sample size, involvement of patients in determining the research agenda, and use of the Food and Drug Administration's new Regenerative Medicine Advanced Therapy designation to facilitate early discussion with regulatory authorities when planning development pathways.
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Affiliation(s)
- Alexander C Fanaroff
- From the Division of Cardiology (A.C.F., M.W.K., T.J.P.).,Duke Clinical Research Institute (A.C.F., V.M., M.W.K., T.J.P.)
| | - Valarie Morrow
- Duke Clinical Research Institute (A.C.F., V.M., M.W.K., T.J.P.)
| | - Mitchell W Krucoff
- From the Division of Cardiology (A.C.F., M.W.K., T.J.P.).,Duke Clinical Research Institute (A.C.F., V.M., M.W.K., T.J.P.)
| | - Jonathan H Seltzer
- Duke University School of Medicine, Durham, NC; ACI Clinical, Bala Cynwyd, PA (J.H.S.)
| | - Emerson C Perin
- Stem Cell Center and Regenerative Medicine Research, Texas Heart Institute, Houston (E.C.P., D.A.T., L.W.M.)
| | - Doris A Taylor
- Stem Cell Center and Regenerative Medicine Research, Texas Heart Institute, Houston (E.C.P., D.A.T., L.W.M.)
| | - Leslie W Miller
- Stem Cell Center and Regenerative Medicine Research, Texas Heart Institute, Houston (E.C.P., D.A.T., L.W.M.)
| | - Andreas M Zeiher
- Department of Cardiology, University of Frankfurt, Germany (A.M.Z.)
| | - Francisco Fernández-Avilés
- Department of Cardiology, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón, Universidad Complutense, CIBERCV, Madrid, Spain (F.F.-A.)
| | - Douglas W Losordo
- Feinberg Cardiovascular Research Institute, Northwestern University, Chicago, IL (D.W.L.).,Caladrius Biosciences Inc, Basking Ridge, NJ (D.W.L.)
| | - Timothy D Henry
- Cedars-Sinai Smidt Heart Institute, Los Angeles, CA (T.D.H.)
| | - Thomas J Povsic
- From the Division of Cardiology (A.C.F., M.W.K., T.J.P.).,Duke Clinical Research Institute (A.C.F., V.M., M.W.K., T.J.P.)
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37
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Greene SJ, O'Brien EC, Mentz RJ, Luo N, Hardy NC, Laskey WK, Heidenreich PA, Chang CL, Turner SJ, Yancy CW, Hernandez AF, Curtis LH, Peterson PN, Fonarow GC, Hammill BG. Home-Time After Discharge Among Patients Hospitalized With Heart Failure. J Am Coll Cardiol 2019; 71:2643-2652. [PMID: 29880124 DOI: 10.1016/j.jacc.2018.03.517] [Citation(s) in RCA: 69] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Revised: 03/05/2018] [Accepted: 03/07/2018] [Indexed: 10/14/2022]
Abstract
BACKGROUND Surveys of patients with cardiovascular disease have suggested that "home-time"-being alive and out of any health care institution-is a prioritized outcome. This novel measure has not been studied among patients with heart failure (HF). OBJECTIVES This study sought to characterize home-time following hospitalization for HF and assess its relationship with patient characteristics and traditionally reported clinical outcomes. METHODS Using GWTG-HF (Get With The Guidelines-Heart Failure) registry data, patients discharged alive from an HF hospitalization between 2011 and 2014 and ≥65 years of age were identified. Using Medicare claims, post-discharge home-time over 30-day and 1-year follow-up was calculated for each patient as the number of days alive and spent outside of a hospital, skilled nursing facility (SNF), or rehabilitation facility. RESULTS Among 59,736 patients, 57,992 (97.1%) and 42,153 (70.6%) had complete follow-up for home-time calculation through 30 days and 1 year, respectively. The mean home-time was 21.6 ± 11.7 days at 30 days and 243.9 ± 137.6 days at 1 year. Contributions to reduced home-time varied by follow-up period, with days spent in SNF being the largest contributor though 30 days and death being the largest contributor through 1 year. Over 1 year, 2,044 (4.8%) patients had no home-time following index hospitalization discharge, whereas 8,194 (19.4%) had 365 days of home-time. In regression models, several conditions were associated with substantially reduced home-time, including chronic obstructive pulmonary disease, renal insufficiency, and dementia. Through 1 year, home-time was highly correlated with time-to-event endpoints of death (tau = 0.72) and the composite of death or HF readmission (tau = 0.59). CONCLUSIONS Home-time, which can be readily calculated from administrative claims data, is substantially reduced for many patients following hospitalization for HF and is highly correlated with traditional time-to-event mortality and hospitalization outcomes. Home-time represents a novel, easily measured, patient-centered endpoint that may reflect effectiveness of interventions in future HF studies.
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Affiliation(s)
- Stephen J Greene
- Duke Clinical Research Institute, Durham, North Carolina; Division of Cardiology, Duke University School of Medicine, Durham, North Carolina
| | - Emily C O'Brien
- Duke Clinical Research Institute, Durham, North Carolina; Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
| | - Robert J Mentz
- Duke Clinical Research Institute, Durham, North Carolina; Division of Cardiology, Duke University School of Medicine, Durham, North Carolina
| | - Nancy Luo
- Duke Clinical Research Institute, Durham, North Carolina; Division of Cardiology, Duke University School of Medicine, Durham, North Carolina
| | - N Chantelle Hardy
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
| | - Warren K Laskey
- Division of Cardiology, University of New Mexico School of Medicine, Albuquerque, New Mexico
| | - Paul A Heidenreich
- Department of Medicine, Veterans Affairs Palo Alto Health Care System, Palo Alto, California
| | - Chun-Lan Chang
- Novartis Pharmaceuticals Corporation, East Hanover, New Jersey
| | - Stuart J Turner
- Novartis Pharmaceuticals Corporation, East Hanover, New Jersey
| | - Clyde W Yancy
- Division of Cardiology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Adrian F Hernandez
- Duke Clinical Research Institute, Durham, North Carolina; Division of Cardiology, Duke University School of Medicine, Durham, North Carolina
| | - Lesley H Curtis
- Duke Clinical Research Institute, Durham, North Carolina; Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
| | - Pamela N Peterson
- Division of Cardiology, Anschutz Medical Campus, University of Colorado Denver, Aurora, Colorado; Division of Cardiology, Denver Health Medical Center, Denver, Colorado
| | - Gregg C Fonarow
- Ahmanson-UCLA Cardiomyopathy Center, David Geffen School of Medicine, University of California-Los Angeles, Los Angeles, California
| | - Bradley G Hammill
- Duke Clinical Research Institute, Durham, North Carolina; Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina.
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38
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Prospero CJ, Trachtenberg FL, Pemberton VL, Pasquali SK, Anderson BR, Ash KE, Bainton J, Dunbar-Masterson C, Graham EM, Hamstra MS, Hollenbeck-Pringle D, Jacobs JP, Jacobs ML, John R, Lambert LM, Oster ME, Swan E, Waldron A, Nathan M. Lessons learned in the use of clinical registry data in a multi-centre prospective study: the Pediatric Heart Network Residual Lesion Score Study. Cardiol Young 2019; 29:930-938. [PMID: 31204627 PMCID: PMC6715515 DOI: 10.1017/s1047951119001148] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Using existing data from clinical registries to support clinical trials and other prospective studies has the potential to improve research efficiency. However, little has been reported about staff experiences and lessons learned from implementation of this method in pediatric cardiology. OBJECTIVES We describe the process of using existing registry data in the Pediatric Heart Network Residual Lesion Score Study, report stakeholders' perspectives, and provide recommendations to guide future studies using this methodology. METHODS The Residual Lesion Score Study, a 17-site prospective, observational study, piloted the use of existing local surgical registry data (collected for submission to the Society of Thoracic Surgeons-Congenital Heart Surgery Database) to supplement manual data collection. A survey regarding processes and perceptions was administered to study site and data coordinating center staff. RESULTS Survey response rate was 98% (54/55). Overall, 57% perceived that using registry data saved research staff time in the current study, and 74% perceived that it would save time in future studies; 55% noted significant upfront time in developing a methodology for extracting registry data. Survey recommendations included simplifying data extraction processes and tailoring to the needs of the study, understanding registry characteristics to maximise data quality and security, and involving all stakeholders in design and implementation processes. CONCLUSIONS Use of existing registry data was perceived to save time and promote efficiency. Consideration must be given to the upfront investment of time and resources needed. Ongoing efforts focussed on automating and centralising data management may aid in further optimising this methodology for future studies.
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Affiliation(s)
- Carol J. Prospero
- Nemours Cardiac Center, Alfred I. duPont Hospital for
Children, Wilmington, DE USA
| | | | | | - Sara K. Pasquali
- Division of Pediatric Cardiology, Department of Pediatrics,
University of Michigan C.S. Mott Children’s Hospital, Ann Arbor, MI USA
| | - Brett R. Anderson
- Division of Pediatric Cardiology, New York
Presbyterian/Morgan Stanley Children’s Hospital, New York, NY USA
| | - Kathleen E. Ash
- Division of Pediatric Cardiology, Cincinnati
Children’s Hospital Medical Center, Cincinnati, OH USA
| | - Jessica Bainton
- Division of Pediatric Cardiology, The Hospital for Sick
Children, Toronto, ON Canada
| | | | - Eric M. Graham
- Division of Pediatric Cardiology, Medical University of
South Carolina, Charleston, SC USA
| | - Michelle S. Hamstra
- Division of Pediatric Cardiology, Cincinnati
Children’s Hospital Medical Center, Cincinnati, OH USA
| | | | - Jeffrey P. Jacobs
- Department of Surgery, Johns Hopkins All
Children’s Hospital, Saint Petersburg, FL USA
| | - Marshall L. Jacobs
- Division of Cardiac Surgery, Johns Hopkins Heart and
Vascular Institute, Baltimore, MD USA
| | - Rija John
- Division of Congenital Heart Surgery, Texas
Children’s Hospital, Houston, TX USA
| | - Linda M. Lambert
- Division of Pediatric Cardiothoracic Surgery, University
of Utah, Salt Lake City, UT USA
| | - Matthew E. Oster
- Division of Pediatric Cardiology, Emory University School
of Medicine, Children’s Healthcare of Atlanta, Atlanta, GA USA
| | - Elizabeth Swan
- Division of Pediatric Cardiology, Riley Hospital for
Children, Indianapolis, IN USA
| | - Abigail Waldron
- Division of Cardiology,
Children’s Hospital Philadelphia, Philadelphia, PA USA
| | - Meena Nathan
- Department of Cardiac Surgery, Boston Children’s
Hospital, Boston, MA USA
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Mathioudakis AG, Moberg M, Janner J, Alonso-Coello P, Vestbo J. Outcomes reported on the management of COPD exacerbations: a systematic survey of randomised controlled trials. ERJ Open Res 2019; 5:00072-2019. [PMID: 31111041 PMCID: PMC6513037 DOI: 10.1183/23120541.00072-2019] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2019] [Accepted: 04/01/2019] [Indexed: 01/10/2023] Open
Abstract
Randomised controlled trials (RCTs) evaluating the management of acute exacerbations of chronic obstructive pulmonary disease (COPD) report heterogeneous outcome measures, thus rendering their results incomparable, complicating their translation into clinical practice. As a first step in the development of a core outcome set that will aim to homogenise outcome measures in future RCTs, we assessed the outcomes reported in recent relevant RCTs and systematic reviews. We conducted a methodological systematic review (https://www.crd.york.ac.uk/prospero/ registration number CRD42016052437) of RCTs and systematic reviews on COPD exacerbation management indexed on Medline and PubMed during the last decade. We evaluated their methodology, specifically focusing on the reported outcome measures. Based on 123 RCTs and 38 systematic reviews, we found significant variability in the outcomes reported and in their definition. Mortality, which was assessed in 82% of the included trials, was the most frequently assessed outcome, followed by the rate of treatment success or failure (63%), adverse events (59%), health status, symptoms and quality of life (59%), lung function (47%), and duration of exacerbations (42%). The significant heterogeneity in the selection and definition of outcome measures in RCTs and systematic reviews limits the interpretability and comparability of their results, and warrants the development of a core outcome set for COPD exacerbations management.
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Affiliation(s)
- Alexander G Mathioudakis
- Division of Infection, Immunity and Respiratory Medicine, School of Biological Sciences, The University of Manchester, Manchester Academic Health Science Centre, Manchester, UK.,North West Lung Centre, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - Mia Moberg
- Dept of Respiratory Medicine, Hvidovre University Hospital, Hvidovre, Denmark
| | - Julie Janner
- Dept of Respiratory Medicine, Hvidovre University Hospital, Hvidovre, Denmark
| | - Pablo Alonso-Coello
- Cochrane Iberoamérica, Biomedical Research Institute Sant Pau (IIB Sant Pau-CIBERESP), Barcelona, Spain
| | - Jørgen Vestbo
- Division of Infection, Immunity and Respiratory Medicine, School of Biological Sciences, The University of Manchester, Manchester Academic Health Science Centre, Manchester, UK.,North West Lung Centre, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK
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40
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Beskow LM, Weinfurt KP. Exploring Understanding of "Understanding": The Paradigm Case of Biobank Consent Comprehension. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2019; 19:6-18. [PMID: 31068107 PMCID: PMC6824537 DOI: 10.1080/15265161.2019.1587031] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/06/2023]
Abstract
Data documenting poor understanding among research participants and real-time efforts to assess comprehension in large-scale studies are focusing new attention on informed consent comprehension. Within the context of biobanking consent, we previously convened a multidisciplinary panel to reach consensus about what information must be understood for a prospective participant's consent to be considered valid. Subsequently, we presented them with data from another study showing that many U.S. adults would fail to comprehend the information the panel had deemed essential. When asked to evaluate the importance of the information again, panelists' opinions shifted dramatically in the direction of requiring that less information be understood. Follow-up interviews indicated significant uncertainty about defining a threshold of understanding and what should happen when prospective participants are unable to grasp key information. These findings have important implications for urgently needed discussion of whether consent comprehension is an ethical requirement or an ethical aspiration.
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Affiliation(s)
- Laura M. Beskow
- Center for Biomedical Ethics and Society and Department of Health Policy, Vanderbilt University Medical Center, Nashville, TN USA
| | - Kevin P. Weinfurt
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC USA
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41
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Butala AA, Pontone GM. Absence of Evidence Versus Evidence of Absence-SAPS-PD. Am J Geriatr Psychiatry 2018; 26:1012-1013. [PMID: 30077588 DOI: 10.1016/j.jagp.2018.06.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Revised: 06/18/2018] [Accepted: 06/18/2018] [Indexed: 11/24/2022]
Affiliation(s)
- Ankur A Butala
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD; Department of Psychiatry, Johns Hopkins University School of Medicine, Baltimore, MD.
| | - Gregory M Pontone
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD; Department of Psychiatry, Johns Hopkins University School of Medicine, Baltimore, MD
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42
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Non-vitamin K antagonist oral anticoagulants (NOACs) in cardioversions: The past, the present and the future. Int J Cardiol 2018; 268:149-150. [DOI: 10.1016/j.ijcard.2018.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Accepted: 05/04/2018] [Indexed: 10/28/2022]
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43
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Pencina MJ, Rockhold FW, D'Agostino RB. Deriving Real-World Insights From Real-World Data: Biostatistics to the Rescue. Ann Intern Med 2018; 169:401-402. [PMID: 30039173 DOI: 10.7326/m18-1093] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
| | - Frank W Rockhold
- Duke Clinical Research Institute, Durham, North Carolina (F.W.R.)
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44
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Welsh J, Lu Y, Dhruva SS, Bikdeli B, Desai NR, Benchetrit L, Zimmerman CO, Mu L, Ross JS, Krumholz HM. Age of Data at the Time of Publication of Contemporary Clinical Trials. JAMA Netw Open 2018; 1:e181065. [PMID: 30646100 PMCID: PMC6324269 DOI: 10.1001/jamanetworkopen.2018.1065] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE As medical knowledge and clinical practice rapidly evolve over time, there is an imperative to publish results of clinical trials in a timely way and reduce unnecessary delays. OBJECTIVES To characterize the age of clinical trial data at the time of publication in journals with a high impact factor and highlight the time from final data collection to publication. DESIGN AND SETTING A cross-sectional analysis was conducted of all randomized clinical trials published from January 1 through December 31, 2015, in the Annals of Internal Medicine, BMJ, JAMA, JAMA Internal Medicine, Lancet, and New England Journal of Medicine. Multivariable linear regression analyses were conducted to assess whether data age (adjusted for follow-up duration) and publication time were associated with trial characteristics. MAIN OUTCOMES AND MEASURES The outcome measures were the midpoint of data collection until publication (data age), the time from first participant enrollment to last participant enrollment (enrollment time), and the time from final data collection to publication (publication time). RESULTS There were 341 clinical trials published in 2015 by the 6 journals. For assessment of the primary end point, 37 trials (10.9%) had a follow-up period of less than 1 month, 172 trials (50.4%) had a follow-up period of 1 month to 1 year, and 132 trials (38.7%) had a follow-up period of more than 1 year. For all trials, the median data age at publication was 33.9 months (interquartile range, 23.5-46.3 months). Among trials with a follow-up period of 1 month or less, the median data age was 30.6 months (interquartile range, 18.6-39.0 months). A total of 68 trials (19.9%) required more than 4 years to complete enrollment. The median time from the completion of data collection to publication was 14.8 months (interquartile range, 7.4-22.2 months); publication time was 2 or more years in 63 trials (18.5%). In multivariable regression analyses adjusted for follow-up time, inconclusive or unfavorable trial results were significantly associated with older data age (>235 days). Compared with trials funded only by private industry, trials funded by government were associated with a significantly longer time to publication (>180 days). CONCLUSIONS AND RELEVANCE Clinical trials in journals with a high impact factor were published with a median data age of nearly 3 years. For a substantial proportion of studies, time for enrollment and time from completion of data collection to publication were quite long, indicating marked opportunities for improvement in clinical trials to reduce data age.
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Affiliation(s)
- John Welsh
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut
| | - Yuan Lu
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Sanket S. Dhruva
- National Clinician Scholars Program, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
- Veterans Affairs Connecticut Healthcare System, West Haven
| | - Behnood Bikdeli
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut
- Cardiovascular Research Foundation, New York, New York
- Division of Cardiology, Department of Medicine, Columbia University Medical Center/New York-Presbyterian Hospital, New York
| | - Nihar R. Desai
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Liliya Benchetrit
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Chloe O. Zimmerman
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Lin Mu
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Joseph S. Ross
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut
- National Clinician Scholars Program, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
- Section of General Internal Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
- Department of Health Policy and Management, Yale School of Public Health, New Haven, Connecticut
| | - Harlan M. Krumholz
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
- Department of Health Policy and Management, Yale School of Public Health, New Haven, Connecticut
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45
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Effect of renin-angiotensin system inhibitors on mortality in heart failure with preserved ejection fraction: a meta-analysis of observational cohort and randomized controlled studies. Heart Fail Rev 2018; 22:775-782. [PMID: 28702858 DOI: 10.1007/s10741-017-9637-0] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Despite the high mortality rate, there is no therapy to improve survival in heart failure with preserved ejection fraction (HFpEF). Large randomized controlled trials (RCTs) did not show clear mortality benefit of renin-angiotensin system (RAS) inhibitors (angiotensin-converting enzyme inhibitors or angiotensin receptor blockers) in HFpEF. However, because of the strict enrollment criteria, the patients who participated in these trials might represent a selected group of patients that is poorly representative of patients treated in routine clinical practice. In contrast, clinical characteristics of real-world patients are similar to those of patients enrolled in observational cohort studies (OCSs). Although many OCSs have examined the prognostic effect of RAS inhibitors in HFpEF, the results are inconsistent due to limited power with small sample sizes and/or inadequate adjustment for known prognostic factors. We aimed to conduct a meta-analysis of OCSs with and those without propensity score (PS) analysis and RCTs on the effect of RAS inhibitors on mortality in HFpEF patients. The search of electronic databases identified 4 OCSs with PS analysis (10,164 patients), 8 OCSs without PS analysis (16,393 patients), and 3 RCTs (8001 patients). Use of RAS inhibitors was associated with reduced mortality in the pooled analysis of OCSs with PS analysis (RR [95% CI] = 0.90 [0.81-1.00]) and in that of OCSs without PS analysis (0.81 [0.68-0.96]) but not in that of RCTs (0.99 [0.87-1.12]). In conclusion, the present meta-analysis suggests the potential mortality benefit of RAS inhibitors in HFpEF, emphasizing the importance of conducting new well-designed RCTs.
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46
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Peterson ED, Harrington RA. Evaluating Health Technology Through Pragmatic Trials: Novel Approaches to Generate High-Quality Evidence. JAMA 2018; 320:137-138. [PMID: 29998322 DOI: 10.1001/jama.2018.8512] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Affiliation(s)
- Eric D Peterson
- Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
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47
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Vemulapalli S, Patel MR. Odyssey of Patent Foramen Ovale: Closure in Cryptogenic Stroke: The Canary in the Coal Mine of Clinical Trials? J Am Heart Assoc 2018; 7:e009558. [PMID: 29910194 PMCID: PMC6220532 DOI: 10.1161/jaha.118.009558] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Sreekanth Vemulapalli
- Duke Clinical Research Institute and Division of Cardiology, Duke University Medical Center, Durham, NC
| | - Manesh R Patel
- Duke Clinical Research Institute and Division of Cardiology, Duke University Medical Center, Durham, NC
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48
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Krause JH, Saver RS. Real-World Evidence in the Real World: Beyond the FDA. AMERICAN JOURNAL OF LAW & MEDICINE 2018; 44:161-179. [PMID: 30106647 DOI: 10.1177/0098858818789423] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
The 21st Century Cures Act ("Cures Act") 1 relies on the concept of real-world evidence ("RWE") 2 to improve the Food and Drug Administration ("FDA") approval process. This has amplified interest and furthered momentum in applying RWE more broadly, beyond FDA regulation. In this article, we discuss the understandable appeal of RWE's pragmatic application and its many potential benefits. But we also caution that claims about RWE's wide-ranging, ameliorative impact on the health care system are likely overstated. The real world of RWE is messy and uncertain. Successfully incorporating RWE into regular health care system decision-making, beyond the FDA, faces considerable obstacles and limitations. We review the reasons to be wary about RWE as a game-changer. These concerns including data reliability, insufficient incentives for stakeholders to generate and engage with high-quality RWE, and lack of comprehensive regulatory oversight. In addition, the push for RWE may impact the enforcement of the health care fraud and abuse laws, perhaps not in necessarily positive ways. Increased reliance on RWE may have significant implications for off-label fraud enforcement, further conflating the distinction between claims that are false for reimbursement rather than for scientific purposes.
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Affiliation(s)
- Joan H Krause
- Dan K. Moore Distinguished Professor, UNC School of Law; Professor (Secondary Appointment), Social Medicine, UNC School of Medicine; Adjunct Professor, Health Policy & Management, UNC Gillings School of Global Public Health. I thank Lenore R. Livingston for her research assistance
| | - Richard S Saver
- Arch T. Allen Distinguished Professor, UNC School of Law; Professor (Secondary Appointment), Social Medicine, UNC School of Medicine, Adjunct Professor, Health Policy & Management, UNC Gillings School of Global Public Health. I thank MacKenzie D. Dickerman for her research assistance
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49
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Fanaroff AC, Steffel J, Alexander JH, Lip GYH, Califf RM, Lopes RD. Stroke prevention in atrial fibrillation: re-defining ‘real-world data’ within the broader data universe. Eur Heart J 2018; 39:2932-2941. [DOI: 10.1093/eurheartj/ehy236] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2017] [Accepted: 04/06/2018] [Indexed: 02/07/2023] Open
Affiliation(s)
- Alexander C Fanaroff
- Division of Cardiology, Duke Clinical Research Institute, Duke University, 2400 Pratt Street, Durham, NC USA
| | - Jan Steffel
- Division of Cardiology, University Heart Center Zürich, Rämistrasse 100, Zürich, Switzerland
| | - John H Alexander
- Division of Cardiology, Duke Clinical Research Institute, Duke University, 2400 Pratt Street, Durham, NC USA
| | - Gregory Y H Lip
- Institute of Cardiovascular Sciences, University of Birmingham, Edgbaston, Birmingham, UK
- Division of Clinical Medicine, Aalborg Thrombosis Research Unit, Aalborg University, Søndre Skovvej 15, Forskningens Hus, Aalborg, Denmark
| | - Robert M Califf
- Division of Cardiology, Duke Clinical Research Institute, Duke University, 2400 Pratt Street, Durham, NC USA
- Verily Life Sciences, 269 E Grand Ave, South San Francisco, CA, USA
| | - Renato D Lopes
- Division of Cardiology, Duke Clinical Research Institute, Duke University, 2400 Pratt Street, Durham, NC USA
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50
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Fanaroff AC, Li S, Webb LE, Miller V, Navar AM, Peterson ED, Wang TY. An Observational Study of the Association of Video- Versus Text-Based Informed Consent With Multicenter Trial Enrollment: Lessons From the PALM Study (Patient and Provider Assessment of Lipid Management). Circ Cardiovasc Qual Outcomes 2018; 11:e004675. [PMID: 29625993 PMCID: PMC5891825 DOI: 10.1161/circoutcomes.118.004675] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND Patient participation in clinical research is low, in part because of the length and complexity of the informed consent process. Video informed consent may enhance the appeal of research and help break down barriers to participation. METHODS AND RESULTS The PALM study (Patient and Provider Assessment of Lipid Management) enrolled 7904 patients at cardiology, endocrinology, and primary care clinics across the United States to evaluate cholesterol management practices. Of 153 participating clinics, 67 (43.8%) secured institutional review board approval to use a tablet-based video informed consent tool that patients could select to navigate through the informed consent process instead of traditional text-based informed consent. At sites without institutional review board approval of video consent, all patients read a text-based informed consent document. Site activation times and enrollment volumes, as well as characteristics of enrolled patients, were compared between sites with and without video consent capability. Sites with video consent capability more often used a central institutional review board (89.6% versus 73.3%), were more often rural (16.7% versus 3.8%), and tended to have fewer providers. Compared with sites without video consent capability, sites with video consent capability had shorter times from site approach to first patient enrollment (median 178 versus 207 days; P=0.02). Sites with video consent capability enrolled similar numbers of patients as sites without video consent capability (P=0.48) but enrolled a greater proportion of patients who were ≥75 years old (27.5% versus 23.6%; P<0.001) and nonwhite (17.7% versus 14.2%; P<0.001). CONCLUSIONS In this observational study of recruitment in a multicenter registry, sites approved for video consent use enrolled the same number of patients as sites with only traditional text-based informed consent but had faster speed to first patient enrolled and more often enrolled older and nonwhite patients. Future randomized trials are needed to assess the impact of video consent on enrollment mechanics and demographics. CLINICAL TRIAL REGISTRATION URL: https://www.clinicaltrials.gov. Unique identifier: NCT02341664.
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Affiliation(s)
- Alexander C Fanaroff
- Department of Medicine (A.C.F., A.M.N., E.D.P., T.Y.W.) and Duke Clinical Research Institute (A.C.F., A.M.N., E.D.P., T.Y.W., S.L., L.E.W., V.M.,), Duke University Medical Center, Durham, NC.
| | - Shuang Li
- Department of Medicine (A.C.F., A.M.N., E.D.P., T.Y.W.) and Duke Clinical Research Institute (A.C.F., A.M.N., E.D.P., T.Y.W., S.L., L.E.W., V.M.,), Duke University Medical Center, Durham, NC
| | - Laura E Webb
- Department of Medicine (A.C.F., A.M.N., E.D.P., T.Y.W.) and Duke Clinical Research Institute (A.C.F., A.M.N., E.D.P., T.Y.W., S.L., L.E.W., V.M.,), Duke University Medical Center, Durham, NC
| | - Vincent Miller
- Department of Medicine (A.C.F., A.M.N., E.D.P., T.Y.W.) and Duke Clinical Research Institute (A.C.F., A.M.N., E.D.P., T.Y.W., S.L., L.E.W., V.M.,), Duke University Medical Center, Durham, NC
| | - Ann Marie Navar
- Department of Medicine (A.C.F., A.M.N., E.D.P., T.Y.W.) and Duke Clinical Research Institute (A.C.F., A.M.N., E.D.P., T.Y.W., S.L., L.E.W., V.M.,), Duke University Medical Center, Durham, NC
| | - Eric D Peterson
- Department of Medicine (A.C.F., A.M.N., E.D.P., T.Y.W.) and Duke Clinical Research Institute (A.C.F., A.M.N., E.D.P., T.Y.W., S.L., L.E.W., V.M.,), Duke University Medical Center, Durham, NC
| | - Tracy Y Wang
- Department of Medicine (A.C.F., A.M.N., E.D.P., T.Y.W.) and Duke Clinical Research Institute (A.C.F., A.M.N., E.D.P., T.Y.W., S.L., L.E.W., V.M.,), Duke University Medical Center, Durham, NC
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