1
|
Boateng D, Kumke T, Vernooij R, Goetz I, Meinecke AK, Steenhuis C, Grobbee D, Zuidgeest MGP. Validation of the GetReal Trial Tool - Facilitating discussion and understanding more pragmatic design choices and their implications. Contemp Clin Trials 2023; 125:107054. [PMID: 36529438 DOI: 10.1016/j.cct.2022.107054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Revised: 12/12/2022] [Accepted: 12/13/2022] [Indexed: 12/23/2022]
Abstract
BACKGROUND The GetReal Trial Tool is a decision support tool to assess the impact of design choices on generalizability of clinical trials to routine clinical practice, while taking into account the risk of bias, precision, acceptability and operational feasibility. This study describes the validation of the GetReal Trial Tool. METHODS Twelve experts took part in the GetReal Trial tool validation using the protocols of 6 trials conducted with pragmatic elements. The tool entails 7 domains with a total of 43 questions. A pooled Kappa statistic (95% CI) using random effects model was estimated using Open Meta (analyst) software. The possible operational challenges were collated and discussed with the trialists that conducted the trials. RESULTS Agreement in the design choices made for the trial protocols was >50% for all the trials and all teams reached consensus during discussion. The pooled Kappa statistic (95% CI) was 0.236 (0.154-0.318). The GetReal Trial tool highlighted several operational challenges, of which almost half had been experienced previously by the trialists. Out of 25 additional operational challenges mentioned by the trialists, 76% were already highlighted by the tool. The tool was considered helpful to optimize trials right from the design stage. CONCLUSION The GetReal Trial Tool helps to scrutinize the choice of study design in the light of Real World Evidence generation. The tool identifies most of the operational challenges experienced by trialists to date. The tool serves the intended purpose of facilitating discussion and understanding more pragmatic design choices and their implications.
Collapse
Affiliation(s)
- Daniel Boateng
- Julius Global Health, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands.
| | | | - Robin Vernooij
- Division Internal Medicine and Dermatology, Nephrology & Hypertension, University Medical Center Utrecht, the Netherlands
| | - Iris Goetz
- Department of Value, Evidence and Outcomes (VEO), Eli Lilly & Co. Ltd, Bracknell, UK
| | - Anna-Katharina Meinecke
- Partnerships and IEG Office, Integrated Evidence Generation & Business Innovation, Medical Affairs & Pharmacovigilance, Bayer AG
| | | | - Diederick Grobbee
- Julius Global Health, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Mira G P Zuidgeest
- Julius Global Health, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
| | | |
Collapse
|
2
|
Castor D, Saidu R, Boa R, Mbatani N, Mutsvangwa TEM, Moodley J, Denny L, Kuhn L. Assessment of the implementation context in preparation for a clinical study of machine-learning algorithms to automate the classification of digital cervical images for cervical cancer screening in resource-constrained settings. FRONTIERS IN HEALTH SERVICES 2022; 2:1000150. [PMID: 36925850 PMCID: PMC10012690 DOI: 10.3389/frhs.2022.1000150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Accepted: 08/23/2022] [Indexed: 11/13/2022]
Abstract
Introduction We assessed the implementation context and image quality in preparation for a clinical study evaluating the effectiveness of automated visual assessment devices within cervical cancer screening of women living without and with HIV. Methods We developed a semi-structured questionnaire based on three Consolidated Framework for Implementation Research (CFIR) domains; intervention characteristics, inner setting, and process, in Cape Town, South Africa. Between December 1, 2020, and August 6, 2021, we evaluated two devices: MobileODT handheld colposcope; and a commercially-available cell phone (Samsung A21ST). Colposcopists visually inspected cervical images for technical adequacy. Descriptive analyses were tabulated for quantitative variables, and narrative responses were summarized in the text. Results Two colposcopists described the devices as easy to operate, without data loss. The clinical workspace and gynecological workflow were modified to incorporate devices and manage images. Providers believed either device would likely perform better than cytology under most circumstances unless the squamocolumnar junction (SCJ) were not visible, in which case cytology was expected to be better. Image quality (N = 75) from the MobileODT device and cell phone was comparable in terms of achieving good focus (81% vs. 84%), obtaining visibility of the squamous columnar junction (88% vs. 97%), avoiding occlusion (79% vs. 87%), and detection of lesion and range of lesion includes the upper limit (63% vs. 53%) but differed in taking photographs free of glare (100% vs. 24%). Conclusion Novel application of the CFIR early in the conduct of the clinical study, including assessment of image quality, highlight real-world factors about intervention characteristics, inner clinical setting, and workflow process that may affect both the clinical study findings and ultimate pace of translating to clinical practice. The application and augmentation of the CFIR in this study context highlighted adaptations needed for the framework to better measure factors relevant to implementing digital interventions.
Collapse
Affiliation(s)
- Delivette Castor
- Division of Infectious Diseases, Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, New York, NY, United States.,Department of Epidemiology, Mailman School of Public Health, Columbia University Irving Medical Center, New York, NY, United States
| | - Rakiya Saidu
- Department of Obstetrics and Gynaecology, University of Cape Town, Cape Town, South Africa.,Groote Schuur Hospital and South African Medical Research Council, Gynaecology Cancer Research Centre, University of Cape Town, Cape Town, South Africa
| | - Rosalind Boa
- Department of Obstetrics and Gynaecology, University of Cape Town, Cape Town, South Africa.,Groote Schuur Hospital and South African Medical Research Council, Gynaecology Cancer Research Centre, University of Cape Town, Cape Town, South Africa
| | - Nomonde Mbatani
- Department of Obstetrics and Gynaecology, University of Cape Town, Cape Town, South Africa.,Groote Schuur Hospital and South African Medical Research Council, Gynaecology Cancer Research Centre, University of Cape Town, Cape Town, South Africa
| | - Tinashe E M Mutsvangwa
- Division of Biomedical Engineering, Department of Human Biology, University of Cape Town, Cape Town, South Africa
| | - Jennifer Moodley
- Groote Schuur Hospital and South African Medical Research Council, Gynaecology Cancer Research Centre, University of Cape Town, Cape Town, South Africa.,Women's Health Research Unit, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Lynette Denny
- Department of Obstetrics and Gynaecology, University of Cape Town, Cape Town, South Africa.,Groote Schuur Hospital and South African Medical Research Council, Gynaecology Cancer Research Centre, University of Cape Town, Cape Town, South Africa
| | - Louise Kuhn
- Department of Epidemiology, Mailman School of Public Health, Columbia University Irving Medical Center, New York, NY, United States.,Gertrude H. Sergievsky Center, Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, New York, NY, United States
| |
Collapse
|
3
|
Zuidgeest MGP, Goetz I, Meinecke AK, Boateng D, Irving EA, van Thiel GJM, Welsing PMJ, Oude-Rengerink K, Grobbee DE, Initiative G. The GetReal Trial Tool: Design, Assess and Discuss Clinical Drug Trials in Light of RWE Generation. J Clin Epidemiol 2021; 149:244-253. [PMID: 34929319 DOI: 10.1016/j.jclinepi.2021.12.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Revised: 10/25/2021] [Accepted: 12/13/2021] [Indexed: 10/19/2022]
Abstract
Methodologies incorporating Real World Elements into clinical trial design (also called pragmatic trials) offer an attractive opportunity to assess the effect of a treatment strategy in routine care and as such guide decision making in practice. Uptake of these methods is slow for several reasons, including uncertainty about acceptability of trial results, lack of experience with the methodology and operational challenges. We developed the 'Get Real Trial Tool', an easy-to-use interface, which allows users to assess the impact of design choices on generalisability to routine clinical practice, while taking into account risk of bias, precision, acceptability and operational feasibility. The tool is grounded in the scientific literature on pragmatic trials combined with knowledge of experts from academia, pharmaceutical companies, HTA bodies, patient organisations, and regulators. The aim is to help researchers optimise trial design and facilitate translation of evidence from pragmatic trials to clinical practice. In this paper we describe the development, structure and application of the GetReal Trial Tool.
Collapse
Affiliation(s)
- Mira G P Zuidgeest
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands.
| | | | - Anna-Katharina Meinecke
- Partnerships and IEG Office, Integrated Evidence Generation & Business Innovation, Medical Affairs & Pharmacovigilance, Bayer AG
| | - Daniel Boateng
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Elaine A Irving
- Clinical Development, GSK Research & Development Ltd., Stevenage, Hertfordshire, SG1 2NY, UK
| | - Ghislaine J M van Thiel
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Paco M J Welsing
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands; Department of Rheumatology & Clinical immunology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Katrien Oude-Rengerink
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Diederick E Grobbee
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands; Julius Clinical, Zeist, the Netherlands
| | - GetReal Initiative
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands; Eli Lilly & Co Ltd, Bracknell, UK; Partnerships and IEG Office, Integrated Evidence Generation & Business Innovation, Medical Affairs & Pharmacovigilance, Bayer AG; Clinical Development, GSK Research & Development Ltd., Stevenage, Hertfordshire, SG1 2NY, UK; Department of Rheumatology & Clinical immunology, University Medical Center Utrecht, Utrecht, the Netherlands; Julius Clinical, Zeist, the Netherlands
| |
Collapse
|
4
|
Simmonds KP, Burke J, Kozlowski AJ, Andary M, Luo Z, Reeves MJ. Rationale for a Clinical Trial That Compares Acute Stroke Rehabilitation at Inpatient Rehabilitation Facilities to Skilled Nursing Facilities: Challenges and Opportunities. Arch Phys Med Rehabil 2021; 103:1213-1221. [PMID: 34480886 DOI: 10.1016/j.apmr.2021.08.004] [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] [Received: 05/17/2021] [Revised: 08/02/2021] [Accepted: 08/06/2021] [Indexed: 11/26/2022]
Abstract
In the United States, approximately 400,000 patients with acute stroke are discharged annually to inpatient rehabilitation facilities (IRFs) or skilled nursing facilities (SNFs). Typically, IRFs provide time-intensive therapy for an average of 2-3 weeks, whereas SNFs provide more moderately intensive therapy for 4-5 weeks. The factors that influence discharge to an IRF or SNF are multifactorial and poorly understood. The complexity of these factors in combination with subjective clinical indications contributes to large variations in the use of IRFs and SNFs. This has significant financial implications for health care expenditure, given that stroke rehabilitation at IRFs costs approximately double that at SNFs. To control health care spending without compromising outcomes, the Institute of Medicine has stated that policy reforms that promote more efficient use of IRFs and SNFs are critically needed. A major barrier to the formulation of such policies is the highly variable and low-quality evidence for the comparative effectiveness of IRF- vs SNF-based stroke rehabilitation. The current evidence is limited by the inability of observational data to control for residual confounding, which contributes to substantial uncertainty around any magnitude of benefit for IRF- vs SNF-based care. Furthermore, it is unclear which specific patients would receive the most benefit from each setting. A randomized controlled trial addresses these issues, because random treatment allocation facilitates an equitable distribution of measured and unmeasured confounders. We discuss several measurement, practical, and ethical issues of a trial and provide our rationale for design suggestions that overcome some of these issues.
Collapse
Affiliation(s)
- Kent P Simmonds
- Department of Epidemiology and Biostatistics, College of Human Medicine, Michigan State University, East Lansing, MI
| | - James Burke
- Department of Neurology, University of Michigan School of Medicine, Ann Arbor, MI
| | - Allan J Kozlowski
- Department of Epidemiology and Biostatistics, College of Human Medicine, Michigan State University, East Lansing, MI; John F. Butzer Center for Research and Innovation, Mary Free Bed Rehabilitation Hospital, Grand Rapids, MI
| | - Michael Andary
- Department of Physical Medicine & Rehabilitation, College of Osteopathic Medicine, Michigan State University, East Lansing, MI
| | - Zhehui Luo
- Department of Epidemiology and Biostatistics, College of Human Medicine, Michigan State University, East Lansing, MI
| | - Mathew J Reeves
- Department of Epidemiology and Biostatistics, College of Human Medicine, Michigan State University, East Lansing, MI.
| |
Collapse
|
5
|
Dal-Ré R, de Boer A, James SK. The design can limit PRECIS-2 retrospective assessment of the clinical trial explanatory/pragmatic features. J Clin Epidemiol 2020; 126:193-201. [DOI: 10.1016/j.jclinepi.2020.03.027] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Revised: 03/02/2020] [Accepted: 03/18/2020] [Indexed: 11/26/2022]
|
6
|
Gemzoe K, Crawford R, Caress A, McCorkindale S, Conroy R, Collier S, Doward L, Vekaria RM, Worsley S, Leather DA, Irving E. Patient and healthcare professional experiences of the Salford Lung Studies: qualitative insights for future effectiveness trials. Trials 2020; 21:798. [PMID: 32943093 PMCID: PMC7499906 DOI: 10.1186/s13063-020-04655-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Accepted: 08/05/2020] [Indexed: 01/09/2023] Open
Abstract
Background Randomized controlled trials (RCTs) conducted in the routine care setting provide the opportunity to better understand the effectiveness of new medicines but can present recruitment difficulties. An improved understanding of the challenges/opportunities for patient and healthcare professional (HCP) engagement in clinical research is needed to enhance participation and trial experience. In this study, we explored patient and HCP drivers for, and experiences of, participation in the Salford Lung Studies (SLS), and their views on future trial participation and the overall value of such trials. Methods This was a qualitative study set in Salford, UK, comprising patient telephone interviews (N = 10) and HCP advisory boards (one with general practitioners [GPs], one with practice managers [PMs]); all individuals had participated in the SLS. Semi-structured telephone interviews were recorded, transcribed and analysed thematically. Advisory board meetings were analysed based on transcriptions of audio recordings and field notes. Results For patients, key positive aspects of the SLS were the ease/convenience of study assessments and excellent relationships with study nurses. GPs and PMs considered the SLS to be well-organized and highlighted the value of research nurse support; they also described minor challenges relating to trial systems, initial financial strain on practices and staff turnover. All participants indicated that they were very likely to participate in future trials, citing a design closely aligned with routine care practice as essential. Several strategies to encourage trial participation were suggested, such as clearly communicating benefits to patients and ensuring flexible study assessments. Conclusions Patients and HCPs had positive experiences of the SLS. The study design, closely aligned with routine care, was considered important to their high likelihood of participating in future trials. The experiences of patients and HCPs in the SLS provide valuable insights that will help inform future best practice in the design and conduct of future real-world effectiveness RCTs in primary care. The detailed first-hand experiences of HCPs will be of significant value to others considering engaging in clinical research and participating in effectiveness RCTs.
Collapse
Affiliation(s)
- Kim Gemzoe
- Real World Study Delivery, Value Evidence and Outcomes, GlaxoSmithKline plc., Research & Development Ltd., Stockley Park West, 1-3 Ironbridge Road, Uxbridge, Middlesex, UB11 1BT, UK.
| | | | - Ann Caress
- School of Human and Health Sciences, University of Huddersfield, Huddersfield, HD1 3DH, UK
| | | | | | - Susan Collier
- UK Medical, GlaxoSmithKline plc, Uxbridge, UB11 1BT, UK
| | | | | | - Sally Worsley
- Real World Study Delivery, Value Evidence and Outcomes, GlaxoSmithKline plc., Research & Development Ltd., Stevenage, SG1 2NY, UK
| | - David A Leather
- Global Respiratory Franchise, GlaxoSmithKline plc., Brentford, TW8 9GS, UK
| | - Elaine Irving
- Real World Study Delivery, Value Evidence and Outcomes, GlaxoSmithKline plc., Research & Development Ltd., Stevenage, SG1 2NY, UK
| |
Collapse
|
7
|
Byhoff E, Kangovi S, Berkowitz SA, DeCamp M, Dzeng E, Earnest M, Gonzalez CM, Hartigan S, Karani R, Memari M, Roy B, Schwartz MD, Volerman A, DeSalvo K. A Society of General Internal Medicine Position Statement on the Internists' Role in Social Determinants of Health. J Gen Intern Med 2020; 35:2721-2727. [PMID: 32519320 PMCID: PMC7459005 DOI: 10.1007/s11606-020-05934-8] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Accepted: 05/18/2020] [Indexed: 02/06/2023]
Affiliation(s)
- Elena Byhoff
- Department of Medicine, Institute for Clinical Research and Health Policy Studies Tufts Medical Center, Tufts University School of Medicine, Boston, MA, USA.
| | - Shreya Kangovi
- Department of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Seth A Berkowitz
- Department of Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Matthew DeCamp
- Department of Medicine, University of Colorado, Aurora, CO, USA
| | - Elizabeth Dzeng
- Department of Medicine, University of California, San Francisco, CA, USA
| | - Mark Earnest
- Department of Medicine, University of Colorado, Aurora, CO, USA
| | - Cristina M Gonzalez
- Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY, USA
| | - Sarah Hartigan
- Department of Medicine, Virginia Commonwealth University, Midlothian, VA, USA
| | - Reena Karani
- Department of Medicine, Medicine and Geriatrics and Palliative Medicine Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Milad Memari
- Departments of Medical Education, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Brita Roy
- Department of Medicine, Yale Medicine, New Haven, CT, USA
| | - Mark D Schwartz
- Departments of Population Health and of Medicine, NYU Grossman School of Medicine, New York, NY, USA
| | - Anna Volerman
- Department of Medicine, University of Chicago, Chicago, IL, USA
| | | |
Collapse
|
8
|
How Pragmatic are Trials in Nursing Home Settings? J Am Med Dir Assoc 2020; 21:1821-1823. [PMID: 32859515 DOI: 10.1016/j.jamda.2020.07.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Revised: 07/08/2020] [Accepted: 07/09/2020] [Indexed: 11/22/2022]
|
9
|
Ochodo EA, Kalema N, Schumacher S, Steingart K, Young T, Mallett S, Deeks J, Cobelens F, Bossuyt PM, Nicol MP, Cattamanchi A. Variation in the observed effect of Xpert MTB/RIF testing for tuberculosis on mortality: A systematic review and analysis of trial design considerations. Wellcome Open Res 2020; 4:173. [PMID: 32851196 PMCID: PMC7438967 DOI: 10.12688/wellcomeopenres.15412.2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/06/2020] [Indexed: 12/21/2022] Open
Abstract
Background: Most studies evaluating the effect of Xpert MTB/RIF testing for tuberculosis (TB) concluded that it did not reduce overall mortality compared to usual care. We conducted a systematic review to assess whether key study design and execution features contributed to earlier identification of patients with TB and decreased pre-treatment loss to follow-up, thereby reducing the potential impact of Xpert MTB/RIF testing. Methods: We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, and Scopus for literature published from 1 st January 2009 to February 2019. We included all primary intervention studies that had evaluated the effect of Xpert MTB/RIF on mortality compared to usual care in participants with presumptive pulmonary TB. We critically reviewed features of included studies across: Study setting and context, Study population, Participant recruitment and enrolment, Study procedures, and Study follow-up. Results: We included seven randomised and one non-randomised study. All included studies demonstrated relative reductions in overall mortality in the Xpert MTB/RIF arm ranging from 6% to 40%. However, mortality reduction was reported to be statistically significant in two studies. Study features that could explain the lack of observed effect on mortality included: the higher quality of care at study sites; inclusion of patients with a higher pre-test probability of TB leading to higher than expected empirical rates; performance of additional diagnostic testing not done in usual care leading to increased TB diagnosis or empiric treatment initiation; the recruitment of participants likely to return for follow-up; and involvement of study staff in ensuring adherence with care and follow-up. Conclusion: Most studies of Xpert MTB/RIF were designed and conducted in a manner that resulted in more patients being diagnosed and treated for TB, minimising the potential difference in mortality Xpert MTB/RIF testing could have achieved compared to usual care.
Collapse
Affiliation(s)
- Eleanor A. Ochodo
- Department of Global Health, Stellenbosch University, Cape Town, Western Cape, 8000, South Africa
| | - Nelson Kalema
- Infectious Diseases Institute, Makerere University, Kampala, 22418, Uganda
| | - Samuel Schumacher
- Tuberculosis Department, Foundation for Innovative New Diagnostics, Geneva, 1202, Switzerland
| | - Karen Steingart
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, L3 5QA, UK
| | - Taryn Young
- Department of Global Health, Stellenbosch University, Cape Town, Western Cape, 8000, South Africa
| | - Susan Mallett
- NIHR Birmingham Biomedical Research Centre, University Hospitals Birmingham NHS Trust, University of Birmingham, Edgbaston, Birmingham, UK
- Test Evaluation Research Group, Institute of Applied Health Research, University of Birmingham, Edgbaston, Birmingham, UK
| | - Jon Deeks
- NIHR Birmingham Biomedical Research Centre, University Hospitals Birmingham NHS Trust, University of Birmingham, Edgbaston, Birmingham, UK
- Test Evaluation Research Group, Institute of Applied Health Research, University of Birmingham, Edgbaston, Birmingham, UK
| | - Frank Cobelens
- Amsterdam Institute for Global Health and Development, Amsterdam University Medical Centers, Amsterdam, 1105 BP, The Netherlands
| | - Patrick M. Bossuyt
- Deapartment of Clinical Epidemiology, Biostatistics and Bioinformatics, Amsterdam University Medical Centers, Amsterdam, 1105 AZ, The Netherlands
| | - Mark P. Nicol
- School of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Western Australia, Perth, WA, 6009, Australia
| | - Adithya Cattamanchi
- Division of Pulmonary and Critical Care Medicine, University of California San Francisco Medical Center, San Francisco, California, 94110, USA
| |
Collapse
|
10
|
Bradburn MJ, Lee EC, White DA, Hind D, Waugh NR, Cooke DD, Hopkins D, Mansell P, Heller SR. Treatment effects may remain the same even when trial participants differed from the target population. J Clin Epidemiol 2020; 124:126-138. [DOI: 10.1016/j.jclinepi.2020.05.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Revised: 04/15/2020] [Accepted: 05/04/2020] [Indexed: 02/06/2023]
|
11
|
Leather DA, Jones R, Woodcock A, Vestbo J, Jacques L, Thomas M. Real-World Data and Randomised Controlled Trials: The Salford Lung Study. Adv Ther 2020; 37:977-997. [PMID: 31927698 PMCID: PMC7147238 DOI: 10.1007/s12325-019-01192-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Indexed: 01/31/2023]
Abstract
Traditional efficacy double-blind randomised controlled trials (DBRCTs) measure the benefit a treatment produces under near-ideal test conditions in highly selected patient populations; however, the behaviour of patients and investigators in such trials is highly controlled, highly compliant and adherent, and non-representative of routine clinical practice. Pragmatic effectiveness trials measure the benefit a treatment produces in patients in everyday "real-world" practice. Ideally, effectiveness trials should recruit patients as similar as possible to those who will ultimately be prescribed the medicine, and create freedom within the study design to allow normal behaviours of patients and healthcare professionals (HCPs) to be expressed. The Salford Lung Study (SLS) was a world-first, prospective, phase III, pragmatic randomised controlled trial (RCT) programme in patients with chronic obstructive pulmonary disease and asthma to evaluate the effectiveness of a pre-licensed medication (fluticasone furoate/vilanterol) in real-world practice using electronic health records and through collaboratively engaging general practitioners and community pharmacists in clinical research. The real-world aspect of SLS was unique, requiring careful planning and attention to the goals of maximising the external validity of the trials while maintaining scientific rigour and securing suitable electronic processes for proper interpretation of safety data. Key learnings from SLS that may inform the design of future pragmatic effectiveness RCTs include: (1) ensuring the trial setting and operational infrastructure are aligned with routine clinical care; (2) recruiting a broad patient population with characteristics as close as possible to patients in routine clinical practice, to maximise the generalisability and applicability of trial results; (3) ensuring that patients and HCPs are suitably engaged in the trial, to maximise the chances of successful trial delivery; and (4) careful study design, incorporating outcomes of value to patients, HCPs, policymakers and payers, and using pre-planned analyses to address scientifically valid research hypotheses to ensure robustness of the trial data.
Collapse
Affiliation(s)
- David A Leather
- Global Respiratory Franchise, GlaxoSmithKline plc., Brentford, Middlesex, UK.
| | - Rupert Jones
- Community and Primary Health Care, Faculty of Health, Plymouth University, Plymouth, UK
| | - Ashley Woodcock
- Division of Infection, Immunity and Respiratory Medicine, Manchester Academic Health Sciences Centre, The University of Manchester and Manchester University NHS Foundation Trust, Manchester, UK
| | - Jørgen Vestbo
- Division of Infection, Immunity and Respiratory Medicine, Manchester Academic Health Sciences Centre, The University of Manchester and Manchester University NHS Foundation Trust, Manchester, UK
| | - Loretta Jacques
- Clinical Sciences, GlaxoSmithKline plc., Uxbridge, Middlesex, UK
| | - Mike Thomas
- Primary Care and Population Sciences, University of Southampton, Southampton, UK
| |
Collapse
|
12
|
Brunette CA, Miller SJ, Majahalme N, Hau C, MacMullen L, Advani S, Ludin SA, Zimolzak AJ, Vassy JL. Pragmatic Trials in Genomic Medicine: The Integrating Pharmacogenetics In Clinical Care (I-PICC) Study. Clin Transl Sci 2020; 13:381-390. [PMID: 31808996 PMCID: PMC7070795 DOI: 10.1111/cts.12723] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Accepted: 10/31/2019] [Indexed: 12/19/2022] Open
Abstract
Pragmatic clinical trials (PCTs) have an established presence in clinical research and yet have only recently garnered attention within the landscape of genomic medicine. Using the PRagmatic-Explanatory Continuum Indicator Summary 2 (PRECIS-2) as a framework, this paper illustrates the application of PCT principles to The Integrating Pharmacogenetics In Clinical Care (I-PICC) Study, a trial of pharmacogenetic testing prior to statin initiation for cardiovascular disease prevention in primary care. The trial achieved high engagement with providers (85% enrolled of those approached) and enrolled a representative sample of participants for which statin therapy would be recommended. The I-PICC Study has a high level of pragmatism, which should enhance the generalizability of its findings. The PRECIS-2 may be useful in the design and evaluation of PCTs of genomic medicine interventions, contributing to the generation of evidence that can bridge the gap between genomics innovation and clinical adoption.
Collapse
Affiliation(s)
| | | | | | - Cynthia Hau
- VA Boston Healthcare SystemBostonMassachusettsUSA
| | | | | | - Sophie A. Ludin
- VA Boston Healthcare SystemBostonMassachusettsUSA
- Cornell UniversityIthacaNew YorkUSA
| | - Andrew J. Zimolzak
- VA Boston Healthcare SystemBostonMassachusettsUSA
- Baylor College of MedicineHoustonTexasUSA
- Michael E. DeBakey VA Medical CenterHoustonTexasUSA
| | - Jason L. Vassy
- VA Boston Healthcare SystemBostonMassachusettsUSA
- Harvard Medical SchoolBostonMassachusettsUSA
- Division of General Internal Medicine and Primary CareBrigham and Women's HospitalBostonMassachusettsUSA
| |
Collapse
|
13
|
Ochodo EA, Kalema N, Schumacher S, Steingart K, Young T, Mallett S, Deeks J, Cobelens F, Bossuyt PM, Nicol MP, Cattamanchi A. Variation in the observed effect of Xpert MTB/RIF testing for tuberculosis on mortality: A systematic review and analysis of trial design considerations. Wellcome Open Res 2019; 4:173. [PMID: 32851196 PMCID: PMC7438967 DOI: 10.12688/wellcomeopenres.15412.1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/16/2019] [Indexed: 02/15/2024] Open
Abstract
Background: Most studies evaluating the effect of Xpert MTB/RIF testing for tuberculosis (TB) concluded that it did not reduce overall mortality compared to usual care. We conducted a systematic review to assess whether key study design and execution features contributed to earlier identification of patients with TB and decreased pre-treatment loss to follow-up, thereby reducing the potential impact of Xpert MTB/RIF testing. Methods: We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, and Scopus for literature published from 1 st January 2009 to February 2019. We included all primary intervention studies that had evaluated the effect of Xpert MTB/RIF on mortality compared to usual care in participants with presumptive pulmonary TB. We critically reviewed features of included studies across: Study setting and context, Study population, Participant recruitment and enrolment, Study procedures, and Study follow-up. Results: We included seven randomised and one non-randomised study. All included studies demonstrated relative reductions in overall mortality in the Xpert MTB/RIF arm ranging from 6% to 40%. However, mortality reduction was reported to be statistically significant in two studies. Study features that could explain the lack of observed effect on mortality included: the higher quality of care at study sites; inclusion of patients with a higher pre-test probability of TB leading to higher than expected empirical rates; performance of additional diagnostic testing not done in usual care leading to increased TB diagnosis or empiric treatment initiation; the recruitment of participants likely to return for follow-up; and involvement of study staff in ensuring adherence with care and follow-up. Conclusion: Most studies of Xpert MTB/RIF were designed and conducted in a manner that resulted in more patients being diagnosed and treated for TB, minimising the potential difference in mortality Xpert MTB/RIF testing could have achieved compared to usual care.
Collapse
Affiliation(s)
- Eleanor A. Ochodo
- Department of Global Health, Stellenbosch University, Cape Town, Western Cape, 8000, South Africa
| | - Nelson Kalema
- Infectious Diseases Institute, Makerere University, Kampala, 22418, Uganda
| | - Samuel Schumacher
- Tuberculosis Department, Foundation for Innovative New Diagnostics, Geneva, 1202, Switzerland
| | - Karen Steingart
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, L3 5QA, UK
| | - Taryn Young
- Department of Global Health, Stellenbosch University, Cape Town, Western Cape, 8000, South Africa
| | - Susan Mallett
- NIHR Birmingham Biomedical Research Centre, University Hospitals Birmingham NHS Trust, University of Birmingham, Edgbaston, Birmingham, UK
- Test Evaluation Research Group, Institute of Applied Health Research, University of Birmingham, Edgbaston, Birmingham, UK
| | - Jon Deeks
- NIHR Birmingham Biomedical Research Centre, University Hospitals Birmingham NHS Trust, University of Birmingham, Edgbaston, Birmingham, UK
- Test Evaluation Research Group, Institute of Applied Health Research, University of Birmingham, Edgbaston, Birmingham, UK
| | - Frank Cobelens
- Amsterdam Institute for Global Health and Development, Amsterdam University Medical Centers, Amsterdam, 1105 BP, The Netherlands
| | - Patrick M. Bossuyt
- Deapartment of Clinical Epidemiology, Biostatistics and Bioinformatics, Amsterdam University Medical Centers, Amsterdam, 1105 AZ, The Netherlands
| | - Mark P. Nicol
- School of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Western Australia, Perth, WA, 6009, Australia
| | - Adithya Cattamanchi
- Division of Pulmonary and Critical Care Medicine, University of California San Francisco Medical Center, San Francisco, California, 94110, USA
| |
Collapse
|
14
|
Worsley S, Snowise N, Halpin DM, Midwinter D, Ismaila AS, Irving E, Sansbury L, Tabberer M, Leather D, Compton C. Clinical effectiveness of once-daily fluticasone furoate/umeclidinium/vilanterol in usual practice: the COPD INTREPID study design. ERJ Open Res 2019; 5:00061-2019. [PMID: 31720293 PMCID: PMC6826246 DOI: 10.1183/23120541.00061-2019] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Accepted: 09/02/2019] [Indexed: 01/12/2023] Open
Abstract
Effectiveness studies complement conventional randomised controlled trials by providing a holistic view of treatments in the setting of usual clinical practice. We present the protocol for the ongoing INTREPID (INvestigation of TRelegy Effectiveness: usual PractIce Design; ClinicalTrials.gov identifier: NCT03467425) study, a randomised, open-label, 24-week effectiveness study of once-daily fluticasone furoate/umeclidinium/vilanterol (FF/UMEC/VI; Trelegy) delivered by the ELLIPTA inhaler versus non-ELLIPTA multiple-inhaler triple therapy in patients with chronic obstructive pulmonary disease (COPD) in usual practice settings. INTREPID was designed to provide evidence of FF/UMEC/VI effectiveness in patients with COPD managed in routine healthcare systems across multiple European countries. Between study initiation and end-of-study visits, patients will receive their medication and care as they would ordinarily receive it, from their usual healthcare provider at their usual healthcare centre. Study-specific intervention will be minimal. The primary end-point will be the proportion of COPD assessment test (CAT) responders, defined as a clinically meaningful improvement from baseline of ≥2 units, at week 24. The CAT was chosen as it provides health status information relevant to patients, physicians, health technology agencies and payers. Lung function (forced expiratory volume in 1 s) and critical inhaler errors will also be assessed in a subgroup of patients. The strengths and weaknesses of the protocol and some of the challenges associated with conducting this multicountry study, such as differences in healthcare systems and treatment practices across sites, will also be discussed.
Collapse
Affiliation(s)
- Sally Worsley
- Medical Engagement & Value Evidence and Outcomes, GlaxoSmithKline plc., Stevenage, UK
| | - Neil Snowise
- Global Respiratory Franchise, GlaxoSmithKline plc., Brentford, UK
- Faculty of Life Sciences and Medicine, King's College, London, UK
| | - David M.G. Halpin
- Dept of Respiratory Medicine, Royal Devon and Exeter Hospital, Exeter, UK
| | - Dawn Midwinter
- Clinical Statistics, GlaxoSmithKline plc., Stockley Park, UK
| | - Afisi S. Ismaila
- Medical Engagement & Value Evidence and Outcomes, GlaxoSmithKline plc., Collegeville, PA, USA
- Dept of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Elaine Irving
- Medical Engagement & Value Evidence and Outcomes, GlaxoSmithKline plc., Stevenage, UK
| | - Leah Sansbury
- Medical Engagement & Value Evidence and Outcomes, GlaxoSmithKline plc., Collegeville, PA, USA
| | - Maggie Tabberer
- Medical Engagement & Value Evidence and Outcomes, GlaxoSmithKline plc., Stockley Park, UK
| | - David Leather
- Global Respiratory Franchise, GlaxoSmithKline plc., Brentford, UK
| | - Chris Compton
- Global Respiratory Franchise, GlaxoSmithKline plc., Brentford, UK
| |
Collapse
|
15
|
He Y, May BH, Zhang AL, Guo X, Liu Y, Qu Y, Chang X, Lu CJ, Xue CC, Zhang H. Acupuncture for cancer pain: protocol for a pilot pragmatic randomised controlled trial. BMJ Open 2019; 9:e025564. [PMID: 31289059 PMCID: PMC6629396 DOI: 10.1136/bmjopen-2018-025564] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
INTRODUCTION Although acupuncture has been recommended for alleviating cancer pain by clinical guidelines, the level of the supporting evidence needs to be improved. A pragmatic randomised controlled trial (pRCT) in a hospital setting would provide real-world assessments of the overall clinical effects of acupuncture. This pilot trial aims to explore the feasibility and provide data for sample size calculations for a pRCT evaluating the effectiveness of acupuncture as an adjunctive therapy to routine medical care for cancer pain. METHODS AND ANALYSIS Thirty patients with cancer admitted to the oncology department with moderate or severe pain will be recruited. Participants will be randomised at a ratio of 1:1 to the adjunctive acupuncture group or a control group which receives routine pain management without acupuncture. The standardised section of the acupuncture protocol will be developed based on the results of reviews of the literature, recommendations in clinical guidelines and interviews with clinical experts. The acupuncturist will be allowed to tailor the protocol according to the individual situation of each participant. Primary outcomes relevant to the feasibility of conducting a fully powered trial include: numbers and proportions of participants recruited, screened, consented and randomised; numbers and reasons for withdrawals and dropouts; numbers and types of adverse events; feasibility of implementing the trial procedures; evaluation of the comprehensiveness and ease-of-use of the case report form. Secondary outcomes are clinical measurements of the effectiveness of the treatment that are intended for use in the full-scale trial. Analysis of feasibility will be descriptive and pain intensity measures will be analysed using mixed-effects regression. ETHICS AND DISSEMINATION Ethics approval was obtained from the Institutional Ethics Committee of Guangdong Provincial Hospital of Chinese Medicine (approval no: Z2017-184-01) and RMIT University Human Research Ethics Committee (reference no: 21361). Results will be disseminated in a peer-reviewed journal, and trial participants will be informed via email and/or phone calls. TRIAL REGISTRATION NUMBER ChiCTR1800017023.
Collapse
Affiliation(s)
- Yihan He
- Guangdong Provincial Hospital of Chinese Medicine (The Second Affiliated Hospital of Guangzhou University of Chinese Medicine), Guangdong Provincial Academy of Chinese Medical Science, Guangzhou, Guangdong, China
- China-Australia International Research Centre for Chinese Medicine, School of Health and Biomedical Sciences, RMIT University, Melbourne, Victoria, Australia
- The Second Clinical College, Guangzhou University of Chinese Medicine, Guangzhou, Guangdong, China
| | - Brian H May
- China-Australia International Research Centre for Chinese Medicine, School of Health and Biomedical Sciences, RMIT University, Melbourne, Victoria, Australia
| | - Anthony Lin Zhang
- China-Australia International Research Centre for Chinese Medicine, School of Health and Biomedical Sciences, RMIT University, Melbourne, Victoria, Australia
| | - Xinfeng Guo
- Guangdong Provincial Hospital of Chinese Medicine (The Second Affiliated Hospital of Guangzhou University of Chinese Medicine), Guangdong Provincial Academy of Chinese Medical Science, Guangzhou, Guangdong, China
- China-Australia International Research Centre for Chinese Medicine, School of Health and Biomedical Sciences, RMIT University, Melbourne, Victoria, Australia
- The Second Clinical College, Guangzhou University of Chinese Medicine, Guangzhou, Guangdong, China
| | - Yihong Liu
- Guangdong Provincial Hospital of Chinese Medicine (The Second Affiliated Hospital of Guangzhou University of Chinese Medicine), Guangdong Provincial Academy of Chinese Medical Science, Guangzhou, Guangdong, China
- China-Australia International Research Centre for Chinese Medicine, School of Health and Biomedical Sciences, RMIT University, Melbourne, Victoria, Australia
- The Second Clinical College, Guangzhou University of Chinese Medicine, Guangzhou, Guangdong, China
| | - Yanchun Qu
- Guangdong Provincial Hospital of Chinese Medicine (The Second Affiliated Hospital of Guangzhou University of Chinese Medicine), Guangdong Provincial Academy of Chinese Medical Science, Guangzhou, Guangdong, China
- China-Australia International Research Centre for Chinese Medicine, School of Health and Biomedical Sciences, RMIT University, Melbourne, Victoria, Australia
- The Second Clinical College, Guangzhou University of Chinese Medicine, Guangzhou, Guangdong, China
| | - Xuesong Chang
- The Second Clinical College, Guangzhou University of Chinese Medicine, Guangzhou, Guangdong, China
| | - Chuan-jian Lu
- Guangdong Provincial Hospital of Chinese Medicine (The Second Affiliated Hospital of Guangzhou University of Chinese Medicine), Guangdong Provincial Academy of Chinese Medical Science, Guangzhou, Guangdong, China
- China-Australia International Research Centre for Chinese Medicine, School of Health and Biomedical Sciences, RMIT University, Melbourne, Victoria, Australia
- The Second Clinical College, Guangzhou University of Chinese Medicine, Guangzhou, Guangdong, China
| | - Charlie Changli Xue
- Guangdong Provincial Hospital of Chinese Medicine (The Second Affiliated Hospital of Guangzhou University of Chinese Medicine), Guangdong Provincial Academy of Chinese Medical Science, Guangzhou, Guangdong, China
- China-Australia International Research Centre for Chinese Medicine, School of Health and Biomedical Sciences, RMIT University, Melbourne, Victoria, Australia
- The Second Clinical College, Guangzhou University of Chinese Medicine, Guangzhou, Guangdong, China
| | - Haibo Zhang
- Guangdong Provincial Hospital of Chinese Medicine (The Second Affiliated Hospital of Guangzhou University of Chinese Medicine), Guangdong Provincial Academy of Chinese Medical Science, Guangzhou, Guangdong, China
- China-Australia International Research Centre for Chinese Medicine, School of Health and Biomedical Sciences, RMIT University, Melbourne, Victoria, Australia
- The Second Clinical College, Guangzhou University of Chinese Medicine, Guangzhou, Guangdong, China
| |
Collapse
|
16
|
Husbands S, Caskey F, Winton H, Gibson A, Donovan JL, Rooshenas L. Pre-trial qualitative work with health care professionals to refine the design and delivery of a randomised controlled trial on kidney care. Trials 2019; 20:224. [PMID: 30992024 PMCID: PMC6469088 DOI: 10.1186/s13063-019-3281-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Accepted: 03/07/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Recruitment to randomised controlled trials (RCTs) is challenging. Pre-trial qualitative research provides insights into the feasibility and acceptability of proposed trial designs and delivery; however, this is rarely conducted. This paper reports on work undertaken in advance of the Prepare for Kidney Care trial (formerly PrepareME), which compares preparing for dialysis with preparing for conservative care for patients with chronic kidney disease. The paper describes how the findings refined plans for the forthcoming trial. METHODS Semi-structured interviews were undertaken with health-care professionals involved in delivering or recruiting to the trial. Interview findings were considered in relation to observations of a patient advisory group workshop and introductory site visits, which were set up to present the trial to professionals involved in the internal pilot phase of the RCT. The use of findings and input from multiple sources was intended to support suggested refinements to the forthcoming trial. The findings were fed back to the trial management group and other expert stakeholders. RESULTS Sixteen health-care professionals were interviewed, and one patient advisory group workshop and six introductory visits to sites involved in the internal pilot were observed. The professionals interviewed included renal consultants, nurses and renal social workers. Key themes identified from the interviews, supported by the observations, were concerns around the eligibility criteria, the feasibility of the trial intervention, imbalances in the presentation of the trial arms, and anticipated recruitment issues arising from patients' and clinicians' preferences for one arm or the other. Changes to the design were made in response, including to the content of the intervention, the presentation of the trial arms and the name of the RCT. CONCLUSIONS This study highlights the value of carrying out pre-trial work with health-care professionals to identify issues with delivering the proposed trial. This work can be particularly valuable in trials of new interventions, for which the barriers to their integration into routine care are unknown. This work has important implications for facilitating the identification of further obstacles in the main RCT. We suggest that pre-trial qualitative work is undertaken to address design issues early on, in addition to ongoing qualitative research to monitor the emergence of obstacles affecting recruitment.
Collapse
Affiliation(s)
- Samantha Husbands
- Population Health Sciences, Bristol Medical School, University of Bristol, 1-5 Whiteladies Road, Bristol, BS8 1NU UK
| | - Fergus Caskey
- Population Health Sciences, Bristol Medical School, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS UK
| | - Helen Winton
- Population Health Sciences, Bristol Medical School, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS UK
| | - Andy Gibson
- Department of Health and Applied Social Sciences, University of West of England, Bristol, UK
| | - Jenny L. Donovan
- Population Health Sciences, Bristol Medical School, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS UK
| | - Leila Rooshenas
- Population Health Sciences, Bristol Medical School, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS UK
| |
Collapse
|
17
|
Gamerman V, Cai T, Elsäßer A. Pragmatic randomized clinical trials: best practices and statistical guidance. HEALTH SERVICES AND OUTCOMES RESEARCH METHODOLOGY 2018. [DOI: 10.1007/s10742-018-0192-5] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
|
18
|
Analysis of nutrition clinical studies involving children in the Middle East and globally. Future Sci OA 2018; 4:FSO334. [PMID: 30416743 PMCID: PMC6222273 DOI: 10.4155/fsoa-2018-0067] [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: 06/20/2018] [Accepted: 07/13/2018] [Indexed: 11/17/2022] Open
Abstract
Aim: To assess pediatric clinical nutrition research by analyzing clinical studies in the Middle East (ME) and globally. Methods: Using ClinicalTrials.gov, the numbers of clinical studies in the ME and globally were analyzed. Results: The majority of clinical nutrition trials are in North America and Europe. The ME accounts for 4% of all nutrition trials. The majority of pediatric nutrition studies in the ME are in the later phases or are observational and/or epidemiological studies with a focus on poor nutrition or nutrition disorders. Industry funding in the ME is mostly by regional or local companies; few major global companies are involved. Conclusion: The ME is not well represented in clinical nutrition studies involving children. Effort should be expended to rectify this. Nutritional disorders have become an important worldwide disease burden during the last several decades. The development of effective therapies for nutritional disorders requires clinical trials in the affected populations. Our results showed that although the Middle East currently has the highest proportion of children worldwide, it is not well represented in clinical trials on nutritional studies in children. Furthermore, there is suboptimal funding from the multinational nutrition industry. This analysis indicates that there is a reasonable rationale for inclusion of the Middle East in nutritional clinical research in children, and that there is an untapped opportunity for the expansion of clinical research in this region.
Collapse
|
19
|
Chaplin K, Bower P, Man MS, Brookes ST, Gaunt D, Guthrie B, Mann C, Mercer SW, Rafi I, Shaw ARG, Salisbury C. Understanding usual care for patients with multimorbidity: baseline data from a cluster-randomised trial of the 3D intervention in primary care. BMJ Open 2018; 8:e019845. [PMID: 30158215 PMCID: PMC6119425 DOI: 10.1136/bmjopen-2017-019845] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
OBJECTIVES Recent evidence has highlighted the high prevalence and impact of multimorbidity, but the evidence base for improving management is limited. We have tested a new complex intervention for multimorbidity (the 3D model). The paper describes the baseline characteristics of practices and patients in order to establish the external validity of trial participants. It also explores current 'usual primary care' for multimorbidity, against which the 3D intervention was tested. DESIGN Analysis of baseline data from patients in a cluster-randomised controlled trial and additional data from practice staff. SETTING Primary care in the UK. PARTICIPANTS Patients with multimorbidity (n=5253) and 154 practice staff. PRIMARY AND SECONDARY OUTCOME MEASURES Using surveys and routinely available data, we compared the characteristics of participating and non-participating practices and participating and non-participating eligible patients.Baseline questionnaire data from patient participants was used to examine participant illness burden, treatment burden and perceptions of receiving patient-centred care. We obtained data about usual care preintervention from practice staff using questionnaires and a structured pro forma. RESULTS Participating practices were slightly larger, in less deprived areas, and with slightly higher scores for patient satisfaction compared with non-participating practices. Patients with dementia or learning difficulties were likely to be excluded by their general practitioners, but comparison of participants with non-participants identified only minor differences in characteristics, suggesting that the sample was otherwise representative. Patients reported substantial illness burden, and an important minority reported high treatment burden. Although patients reported relatively high levels of satisfaction with care, many reported not having received potentially important components of care. CONCLUSION This trial achieved good levels of external validity. Although patients were generally satisfied with primary care services, there was significant room for improvement in important aspects of care for multimorbidity that are targeted by the 3D intervention. TRIAL REGISTRATION NUMBER ISRCTN06180958; Post-results.
Collapse
Affiliation(s)
- Katherine Chaplin
- Centre for Academic Primary Care, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Peter Bower
- NIHR School for Primary Care Research, Centre for Primary Care, Division of Population of Health, Health Services Research and Primary Care, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
| | - Mei-See Man
- Centre for Academic Primary Care, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- Bristol Randomised Trials Collaboration (BRTC), Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Sara T Brookes
- Bristol Randomised Trials Collaboration (BRTC), Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Daisy Gaunt
- Bristol Randomised Trials Collaboration (BRTC), Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Bruce Guthrie
- Population Health Sciences Division, School of Medicine, University of Dundee, Dundee, UK
| | - Cindy Mann
- Centre for Academic Primary Care, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Stewart W Mercer
- Institute of Health and Wellbeing, General Practice and Primary Care, University of Glasgow, Glasgow, UK
| | - Imran Rafi
- Clinical Innovation and Research, Royal College of General Practitioners, London, UK
| | - Alison R G Shaw
- Centre for Academic Primary Care, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Chris Salisbury
- Centre for Academic Primary Care, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| |
Collapse
|
20
|
McCarthy MW, Walsh TJ. The rise of hospitalists: an opportunity for infectious diseases investigators. Expert Rev Anti Infect Ther 2018; 16:385-389. [PMID: 29620478 DOI: 10.1080/14787210.2018.1462158] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
INTRODUCTION Despite the essential role played by infectious diseases specialists in patient care, public health, cost-containment, and biomedical research, the field has a substantially higher percentage of vacant positions than other medicine sub-specialties. While much has been written about what this disturbing trend means for patient care, comparatively little attention has been focused on the dire implications for clinical research and the development of novel anti-infective therapy. Areas covered: We examine the ways that hospitalists and infectious disease specialists might collaborate to study emerging diagnostic platforms, novel antimicrobial agents, and strengthen antimicrobial stewardship programs to improve the delivery of high-quality health care. Through the use of PubMed, the manuscript reviews existing collaborations as well as those that might develop in the years to come. Expert commentary: In this paper, we propose potential strategies to confront this emerging problem, focusing on novel collaborations with the hospitalist - the specialist in inpatient medicine - to bolster the pipeline of funding for clinical infectious diseases investigators.
Collapse
Affiliation(s)
- Matthew W McCarthy
- a Medicine, Weill Cornell Medical College, Division of General Internal Medicine , New York-Presbyterian Hospital , New York , NY , USA
| | - Thomas J Walsh
- b Transplantation-Oncology Infectious Diseases Program, Medical Mycology Research Laboratory, Medicine, Pediatrics, and Microbiology & Immunology, Weill Cornell Medical Center, Henry Schueler Foundation Scholar , Sharpe Family Foundation Scholar in Pediatric Infectious Diseases , New York , NY , USA
| |
Collapse
|
21
|
Series: Pragmatic trials and real world evidence: Paper 7. Safety, quality and monitoring. J Clin Epidemiol 2017; 91:6-12. [DOI: 10.1016/j.jclinepi.2017.05.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2016] [Revised: 12/14/2016] [Accepted: 05/03/2017] [Indexed: 11/18/2022]
|
22
|
Welsing PM, Oude Rengerink K, Collier S, Eckert L, van Smeden M, Ciaglia A, Nachbaur G, Trelle S, Taylor AJ, Egger M, Goetz I. Series: Pragmatic trials and real world evidence: Paper 6. Outcome measures in the real world. J Clin Epidemiol 2017; 90:99-107. [PMID: 28502810 DOI: 10.1016/j.jclinepi.2016.12.022] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2016] [Revised: 12/05/2016] [Accepted: 12/12/2016] [Indexed: 10/19/2022]
Abstract
Results from pragmatic trials should reflect the comparative treatment effects encountered in patients in real-life clinical practice to guide treatment decisions. Therefore, pragmatic trials should focus on outcomes that are relevant to patients, clinical practice, and treatment choices. This sixth article in the series (see Box) discusses different types of outcomes and their suitability for pragmatic trials, design choices for measuring these outcomes, and their implications and challenges. Measuring outcomes in pragmatic trials should not interfere with real-world clinical practice to ensure generalizability of trial results, and routinely collected outcomes should be prioritized. Typical outcomes include mortality, morbidity, functional status, well-being, and resource use. Surrogate endpoints are typically avoided as primary outcome. It is important to measure outcomes over a relevant time horizon and obtain valid and precise results. As pragmatic trials are often open label, a less subjective outcome can reduce bias. Methods that decrease bias or enhance precision of the results, such as standardization and blinding of outcome assessment, should be considered when a high risk of bias or high variability is expected. The selection of outcomes in pragmatic trials should be relevant for decision making and feasible in terms of executing the trial in the context of interest. Therefore, this should be discussed with all stakeholders as early as feasible to ensure the relevance of study results for decision making in clinical practice and the ability to perform the study.
Collapse
Affiliation(s)
- Paco M Welsing
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Universiteitsweg 100, 3584 CG Utrecht, The Netherlands.
| | - Katrien Oude Rengerink
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Universiteitsweg 100, 3584 CG Utrecht, The Netherlands
| | - Sue Collier
- GSK, Respiratory R&D, Stockley Park West, Brentford, Middlesex TW89GS, UK
| | - Laurent Eckert
- Health Economics and Outcome Research, Sanofi, Avenue Pierre Brossolette, 91385, Chilly-Mazarin, France
| | - Maarten van Smeden
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Universiteitsweg 100, 3584 CG Utrecht, The Netherlands
| | - Antonio Ciaglia
- International Alliance of Patients' Organizations, 49-51 East Road, London, N1 6AH, UK
| | - Gaelle Nachbaur
- Medical Department, GSK, 100 route de Versailles, Marly-le-Roi 78163, France
| | - Sven Trelle
- Department of Clinical Research, CTU, University of Bern, Finkenhubelweg 11, CH-3012, Bern, Switzerland
| | - Aliki J Taylor
- Global Outcomes Research, Takeda Development Centre Europe Ltd, 61 Aldwych, WC2B 4AE, London, UK
| | - Matthias Egger
- Institute of Social and Preventive Medicine, University of Bern, Finkenhubelweg 11, CH-3012, Bern, Switzerland
| | - Iris Goetz
- Global Patient Outcomes & Real World Evidence, Eli Lilly and Company Ltd, Erl Wood Manor, Sunninghill Road, Windlesham, Surrey, GU20 6PH, UK
| | | |
Collapse
|
23
|
Oude Rengerink K, Kalkman S, Collier S, Ciaglia A, Worsley SD, Lightbourne A, Eckert L, Groenwold RHH, Grobbee DE, Irving EA. Series: Pragmatic trials and real world evidence: Paper 3. Patient selection challenges and consequences. J Clin Epidemiol 2017; 89:173-180. [PMID: 28502808 DOI: 10.1016/j.jclinepi.2016.12.021] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2016] [Revised: 12/02/2016] [Accepted: 12/12/2016] [Indexed: 12/29/2022]
Abstract
This paper addresses challenges of identifying, enrolling, and retaining participants in a trial conducted within a routine care setting. All patients who are potential candidates for the treatments in routine clinical practice should be considered eligible for a pragmatic trial. To ensure generalizability, the recruited sample should have a similar distribution of the treatment effect modifiers as the target population. In practice, this can be best achieved by including-within the selected sites-all patients without further selection. If relevant heterogeneity between subgroups is expected, increasing the relative proportion of the subgroup of patients in the heterogeneous trial could be considered (oversampling) or a separate trial in this subgroup can be planned. Selection will nevertheless occur. Low enrollment and loss to follow-up can introduce selection and can jeopardize validity as well as generalizability. Pragmatic trials are conducted in clinical practice rather than in a dedicated research setting, which could reduce recruitment rates. However, if a trial poses a minimal burden to the physician and the patient and routine clinical practice is maximally adhered to, the participation rate may be high and loss to follow-up will not be a specific problem for pragmatic trials.
Collapse
Affiliation(s)
- Katrien Oude Rengerink
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Universiteitsweg 100, Utrecht 3584 CG, The Netherlands.
| | - Shona Kalkman
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Universiteitsweg 100, Utrecht 3584 CG, The Netherlands
| | - Susan Collier
- RD Respiratory Fibrosis DPU Clinical Development Pharma Research and Development GSK Stockley Park West, 1-3 Ironbridge Road, Uxbridge, Middlesex UB11 1BT, UK
| | - Antonio Ciaglia
- International Alliance of Patients' Organizations, 49-51 East Road, London N1 6AH, UK
| | - Sally D Worsley
- Real World Study Delivery, GSK Research & Development, Gunnels Wood Rd, Stevenage SG1 2NY, UK
| | - Alison Lightbourne
- International Alliance of Patients' Organizations, 49-51 East Road, London N1 6AH, UK
| | - Laurent Eckert
- Health Economics and Outcome Research, Sanofi Global Maket Access Center of Excellence, Chilly-Mazarin, France
| | - Rolf H H Groenwold
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Universiteitsweg 100, Utrecht 3584 CG, The Netherlands
| | - Diederick E Grobbee
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Universiteitsweg 100, Utrecht 3584 CG, The Netherlands; Julius Clinical, Broederplein 41-43, Zeist 3703 CD, The Netherlands
| | - Elaine A Irving
- Real World Study Delivery, GSK Research & Development, Gunnels Wood Rd, Stevenage SG1 2NY, UK
| |
Collapse
|