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Hohenschurz-Schmidt D, Cherkin D, Rice ASC, Dworkin RH, Turk DC, McDermott MP, Bair MJ, DeBar LL, Edwards RR, Evans SR, Farrar JT, Kerns RD, Rowbotham MC, Wasan AD, Cowan P, Ferguson M, Freeman R, Gewandter JS, Gilron I, Grol-Prokopczyk H, Iyengar S, Kamp C, Karp BI, Kleykamp BA, Loeser JD, Mackey S, Malamut R, McNicol E, Patel KV, Schmader K, Simon L, Steiner DJ, Veasley C, Vollert J. Methods for pragmatic randomized clinical trials of pain therapies: IMMPACT statement. Pain 2024; 165:2165-2183. [PMID: 38723171 PMCID: PMC11404339 DOI: 10.1097/j.pain.0000000000003249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Accepted: 03/08/2024] [Indexed: 09/18/2024]
Abstract
ABSTRACT Pragmatic, randomized, controlled trials hold the potential to directly inform clinical decision making and health policy regarding the treatment of people experiencing pain. Pragmatic trials are designed to replicate or are embedded within routine clinical care and are increasingly valued to bridge the gap between trial research and clinical practice, especially in multidimensional conditions, such as pain and in nonpharmacological intervention research. To maximize the potential of pragmatic trials in pain research, the careful consideration of each methodological decision is required. Trials aligned with routine practice pose several challenges, such as determining and enrolling appropriate study participants, deciding on the appropriate level of flexibility in treatment delivery, integrating information on concomitant treatments and adherence, and choosing comparator conditions and outcome measures. Ensuring data quality in real-world clinical settings is another challenging goal. Furthermore, current trials in the field would benefit from analysis methods that allow for a differentiated understanding of effects across patient subgroups and improved reporting of methods and context, which is required to assess the generalizability of findings. At the same time, a range of novel methodological approaches provide opportunities for enhanced efficiency and relevance of pragmatic trials to stakeholders and clinical decision making. In this study, best-practice considerations for these and other concerns in pragmatic trials of pain treatments are offered and a number of promising solutions discussed. The basis of these recommendations was an Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials (IMMPACT) meeting organized by the Analgesic, Anesthetic, and Addiction Clinical Trial Translations, Innovations, Opportunities, and Networks.
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Affiliation(s)
- David Hohenschurz-Schmidt
- Pain Research, Department of Surgery & Cancer, Faculty of Medicine, Imperial College London, United Kingdom
- Research Department, University College of Osteopathy, London, United Kingdom
| | - Dan Cherkin
- Osher Center for Integrative Health, Department of Family Medicine, University of Washington, Seattle, WA, United States
| | - Andrew S C Rice
- Pain Research, Department of Surgery & Cancer, Faculty of Medicine, Imperial College London, United Kingdom
| | - Robert H Dworkin
- Department of Anesthesiology and Perioperative Medicine, University of Rochester Medical Center, Rochester, NY, United States
| | - Dennis C Turk
- Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, United States
| | - Michael P McDermott
- Department of Biostatistics and Computational Biology, University of Rochester, Rochester, NY, United States
| | - Matthew J Bair
- VA Center for Health Information and Communication, Regenstrief Institute, and Indiana University School of Medicine, Indianapolis, IN, United States
| | - Lynn L DeBar
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, United States
| | | | - Scott R Evans
- Biostatistics Center and the Department of Biostatistics and Bioinformatics, Milken Institute School of Public Health, George Washington University, Rockville, MD, United States
| | - John T Farrar
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, PA, United States
| | - Robert D Kerns
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, United States
| | - Michael C Rowbotham
- Department of Anesthesia, University of California San Francisco School of Medicine, San Francisco, CA, United States
| | - Ajay D Wasan
- Departments of Anesthesiology & Perioperative Medicine, and Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Penney Cowan
- American Chronic Pain Association, Rocklin, CA, United States
| | - McKenzie Ferguson
- Department of Pharmacy Practice, Southern Illinois University Edwardsville, Edwardsville, IL, United States
| | - Roy Freeman
- Department of Neurology, Harvard Medical School, Boston, MA, United States
| | - Jennifer S Gewandter
- Department of Anesthesiology and Perioperative, University of Rochester, Rochester, NY, United States
| | - Ian Gilron
- Departments of Anesthesiology & Perioperative Medicine, Biomedical & Molecular Sciences, Centre for Neuroscience Studies, and School of Policy Studies, Queen's University, Kingston Health Sciences Centre, Kingston, ON, Canada
| | - Hanna Grol-Prokopczyk
- Department of Sociology, University at Buffalo, State University of New York, Buffalo, NY, United States
| | | | - Cornelia Kamp
- Center for Health and Technology (CHeT), Clinical Materials Services Unit (CMSU), University of Rochester Medical Center, Rochester, NY, United States
| | - Barbara I Karp
- National Institutes of Health, Bethesda, MD, United States
| | - Bethea A Kleykamp
- University of Maryland, School of Medicine, Baltimore, MD, United States
| | - John D Loeser
- Departments of Neurological Surgery and Anesthesia and Pain Medicine, University of Washington, Seattle, WA, United States
| | - Sean Mackey
- Stanford University School of Medicine, Department of Anesthesiology, Perioperative, and Pain Medicine, Neurosciences and Neurology, Palo Alto, CA, United States
| | | | - Ewan McNicol
- Department of Pharmacy Practice, Massachusetts College of Pharmacy and Health Sciences University, Boston, MA, United States
| | - Kushang V Patel
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, United States
| | - Kenneth Schmader
- Department of Medicine-Geriatrics, Center for the Study of Aging, Duke University Medical Center, and Geriatrics Research Education and Clinical Center, Durham VA Medical Center, Durham, NC, United States
| | - Lee Simon
- SDG, LLC, Cambridge, MA, United States
| | | | | | - Jan Vollert
- Department of Clinical and Biomedical Sciences, Faculty of Health and Life Sciences, University of Exeter, Exeter, United Kingdom
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Gabbard JL, Brenes GA, Callahan KE, Dharod A, Bundy R, Foley KL, Moses A, Williamson JD, Pajewski NM. Promoting serious illness conversations in primary care through telehealth among persons living with cognitive impairment. J Am Geriatr Soc 2024. [PMID: 39041185 DOI: 10.1111/jgs.19100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2024] [Revised: 06/25/2024] [Accepted: 06/30/2024] [Indexed: 07/24/2024]
Abstract
BACKGROUND serious illness conversations (SIC), particularly for persons living with cognitive impairment (PLCI), inconsistently happen in primary care. Pragmatic, scalable strategies are needed to promote SIC for PLCI. DESIGN Pragmatic, prospective single-arm pilot study that occurred between July 1, 2021 and May 30, 2022 across seven primary care practices in North Carolina. PARTICIPANTS Community-dwelling patients aged 65 and older with known or probable mild cognitive impairment or dementia (with decision-making capacity) and their care partners (if available). INTERVENTION SIC telehealth intervention (TeleVoice) via video or telephone to assist PLCI in discussing their current goals, values, and future medical preferences, while facilitating documentation within the EHR. MAIN OUTCOMES Main feasibility outcomes included reach/enrollment, intervention completion, and adoption rates at the clinic and provider level. Primary effectiveness outcomes included SIC documentation and quality within the EHR and usage of advance care planning billing (ACP) codes. RESULTS Of the 163 eligible PLCI approached, 107 (66%) enrolled (mean age 83.7 years, 68.2% female, 16.8% Black, 22% living in a geographic area of high socioeconomic disadvantage) and 81 (76%) completed the SIC telehealth intervention; 45 care partners agreed to participate (mean age 71.5 years, 80% female). Adoption at clinic level was 50%, while 75% of providers within these clinics participated. Among PLCI that completed the intervention, SIC documentation and usage of ACP billing codes was 100% and 96%, respectively, with 96% (n = 78) having high-quality SIC documentation. No significant differences were observed between telephone and video visits. CONCLUSION These findings provide preliminary evidence to support the feasibility of conducting SICs through telehealth to specifically meet the needs of community-dwelling PLCI. Further investigation of the sustainability of the intervention and its long-term impact on patient and caregiver outcomes is needed.
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Affiliation(s)
- Jennifer L Gabbard
- Section of Gerontology and Geriatric Medicine, Department of Internal Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Gretchen A Brenes
- Section of Gerontology and Geriatric Medicine, Department of Internal Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Kathryn E Callahan
- Section of Gerontology and Geriatric Medicine, Department of Internal Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
- Division of Public Health Sciences, Department of Implementation Science, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Ajay Dharod
- Division of Public Health Sciences, Department of Implementation Science, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
- Section of General Internal Medicine, Department of Internal Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Richa Bundy
- Division of Public Health Sciences, Department of Implementation Science, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
- Section of General Internal Medicine, Department of Internal Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Kristie L Foley
- Division of Public Health Sciences, Department of Implementation Science, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Adam Moses
- Section of General Internal Medicine, Department of Internal Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Jeff D Williamson
- Section of Gerontology and Geriatric Medicine, Department of Internal Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Nicholas M Pajewski
- Division of Public Health Sciences, Department of Biostatistics and Data Science, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
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Piché A, Santa Mina D, Lambert S, Doré I. Assessing real-world implementability of a multimodal group-based tele-prehabilitation program in cancer care: a pragmatic feasibility study. Front Oncol 2023; 13:1271812. [PMID: 37965450 PMCID: PMC10641394 DOI: 10.3389/fonc.2023.1271812] [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: 08/02/2023] [Accepted: 10/04/2023] [Indexed: 11/16/2023] Open
Abstract
Introduction Multimodal prehabilitation is intended to optimize a patient's mental and physical health prior to surgery. Most multimodal prehabilitation interventions are delivered on a one-on-one format, which may limit benefits associated with social interactions that can be achieved in a group context, and are delivered in-person, which may limit the accessibility. The purpose of this study was to develop a group-based, multimodal, tele-prehabilitation intervention for individuals diagnosed with cancer (iACTIF) and assess its implementability in a "real-world" clinical setting by measuring feasibility, acceptability, fidelity, and preliminary effects. Methods A prospective, single-group, pragmatic feasibility study was conducted with assessments at baseline, pre-surgery, and 12-weeks post-surgery. iACTIF consisted of three 90-min live videoconference sessions per week, including exercise and educational components. Descriptive statistics were used to document feasibility, acceptability, and fidelity indicators. Paired t-test, Wilcoxon test, and Cohen's D-test were conducted to assess changes in health-related outcomes. Results A total of 25 participants (mean age ± SD= 60.2 ± 14.0) were recruited. The feasibility assessment revealed a low referral rate (31.4%) and a high study retention (98%) and program attendance [session attended/possible session] (70.2%), with a prehabilitation window of 32.7 days (SD= 20.9, median= 28). Acceptability was high (84%-100%) according to satisfaction, utility and safety, delivery modality, and intention to continue physical activity and to recommend iACTIF to a relative. Pre-post-intervention assessments suggest positive changes on physical functional capacity based on the 2-min step test (mean difference= +18.9 steps, p=0.005), the 30-s sit-to-stand (mean difference= +1.1 repetition, p=0.011), and volume of moderate intensity physical activity per week (mean difference= +104.8 min, p<0.001). Fidelity was supported by conformity and coherence, with only minimal adjustments required to meet participants' needs. Discussion iACTIF implementability in a "real-world" clinical setting is promising, and preliminary outcomes suggest moderate benefits on physical health and small increase in mental health indicators.
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Affiliation(s)
- Alexia Piché
- Centre de recherche du Centre hospitalier de l’Université de Montréal, Montréal, QC, Canada
- School of Kinesiology and Physical Activity Sciences, Faculty of Medicine, Université de Montréal, Montréal, QC, Canada
| | - Daniel Santa Mina
- Faculty of Kinesiology and Physical Education, University of Toronto, Toronto, ON, Canada
- Department of Anesthesia and Pain Management, University Health Network, Toronto, ON, Canada
| | - Sylvie Lambert
- St. Mary’s Research Centre, Montréal, QC, Canada
- Ingram School of Nursing, McGill University, Montréal, QC, Canada
| | - Isabelle Doré
- Centre de recherche du Centre hospitalier de l’Université de Montréal, Montréal, QC, Canada
- School of Kinesiology and Physical Activity Sciences, Faculty of Medicine, Université de Montréal, Montréal, QC, Canada
- Department of Social and Preventive Medicine, School of Public Health, Université de Montréal, Montréal, QC, Canada
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Douglas NF, Browning S, Claypool K. Preliminary Evidence for Dementia Collaborative Coaching. AMERICAN JOURNAL OF SPEECH-LANGUAGE PATHOLOGY 2023; 32:2146-2157. [PMID: 37437528 PMCID: PMC10567118 DOI: 10.1044/2023_ajslp-22-00367] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 03/11/2023] [Accepted: 05/08/2023] [Indexed: 07/14/2023]
Abstract
PURPOSE The primary purpose of this study was to obtain preliminary evidence for a communication coaching intervention, Dementia Collaborative Coaching. The secondary aim of this study was to assess the acceptability, appropriateness, and feasibility of the intervention according to routine care providers. METHOD In a pre-/posttest design, speech-language pathologists (SLPs) delivered Dementia Collaborative Coaching to certified nursing assistants (CNAs) and people living with dementia (PLWD) in six different skilled nursing facilities over a period of 6 weeks. A self-perceived knowledge and efficacy measure regarding the use of external memory aids to support communication in PLWD was administered to CNA and SLP participants. The Cohen-Mansfield Agitation Inventory was administered to PLWD participants. The Acceptability of Intervention Measure, Intervention Appropriateness Measure, and Feasibility of Intervention Measure were administered post-intervention. RESULTS For CNAs, self-perceived knowledge and efficacy increased from pre-intervention (M = 3.73, SD = 0.69) to post-intervention (M = 4.07, SD = 0.44), t(11) = -1.97, one-sided p = .037. There was a significant improvement (e.g., reduction) in scores on the Cohen-Mansfield Agitation Inventory for PLWD (n = 10) from pre-intervention (M = 73.10, SD = 29.98) to post-intervention (M = 58.6, SD = 18.82), t(9) = 2.83, p = .01. CNA participants (n = 12) rated the intervention as acceptable (M = 4.48, SD = 0.48), appropriate (M = 4.33, SD = 0.61), and feasible (M = 4.19, SD = 0.48). SLPs rated the intervention as slightly more acceptable, appropriate, and feasible than CNAs with scores of M = 4.54, SD = 0.51; M = 4.54, SD = 0.51; and M = 4.46, SD = 0.51, respectively. CONCLUSIONS Dementia Collaborative Coaching showed preliminary positive outcomes for CNAs and PLWD. The intervention was acceptable, appropriate, and feasible for routine providers and warrants further study.
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Affiliation(s)
- Natalie F. Douglas
- Department of Communication Sciences and Disorders, Central Michigan University, Mount Pleasant
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Tellor Pennington BR, Colquhoun DA, Neuman MD, Politi MC, Janda AM, Spino C, Thelen-Perry S, Wu Z, Kumar SS, Gregory SH, Avidan MS, Kheterpal S. Feasibility pilot trial for the Trajectories of Recovery after Intravenous propofol versus inhaled VolatilE anesthesia (THRIVE) pragmatic randomised controlled trial. BMJ Open 2023; 13:e070096. [PMID: 37068889 PMCID: PMC10111921 DOI: 10.1136/bmjopen-2022-070096] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/19/2023] Open
Abstract
INTRODUCTION Millions of patients receive general anaesthesia for surgery annually. Crucial gaps in evidence exist regarding which technique, propofol total intravenous anaesthesia (TIVA) or inhaled volatile anaesthesia (INVA), yields superior patient experience, safety and outcomes. The aim of this pilot study is to assess the feasibility of conducting a large comparative effectiveness trial assessing patient experiences and outcomes after receiving propofol TIVA or INVA. METHODS AND ANALYSIS This protocol was cocreated by a diverse team, including patient partners with personal experience of TIVA or INVA. The design is a 300-patient, two-centre, randomised, feasibility pilot trial. Patients 18 years of age or older, undergoing elective non-cardiac surgery requiring general anaesthesia with a tracheal tube or laryngeal mask airway will be eligible. Patients will be randomised 1:1 to propofol TIVA or INVA, stratified by centre and procedural complexity. The feasibility endpoints include: (1) proportion of patients approached who agree to participate; (2) proportion of patients who receive their assigned randomised treatment; (3) completeness of outcomes data collection and (4) feasibility of data management procedures. Proportions and 95% CIs will be calculated to assess whether prespecified thresholds are met for the feasibility parameters. If the lower bounds of the 95% CI are above the thresholds of 10% for the proportion of patients agreeing to participate among those approached and 80% for compliance with treatment allocation for each randomised treatment group, this will suggest that our planned pragmatic 12 500-patient comparative effectiveness trial can likely be conducted successfully. Other feasibility outcomes and adverse events will be described. ETHICS AND DISSEMINATION This study is approved by the ethics board at Washington University (IRB# 202205053), serving as the single Institutional Review Board for both participating sites. Recruitment began in September 2022. Dissemination plans include presentations at scientific conferences, scientific publications, internet-based educational materials and mass media. TRIAL REGISTRATION NUMBER NCT05346588.
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Affiliation(s)
| | - Douglas A Colquhoun
- Anesthesiology, University of Michigan Health System, Ann Arbor, Michigan, USA
| | - Mark D Neuman
- Anesthesiology & Critical Care, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Mary C Politi
- Surgery, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Allison M Janda
- Anesthesiology, University of Michigan Health System, Ann Arbor, Michigan, USA
| | - Cathie Spino
- Biostatistics, University of Michigan, Ann Arbor, Michigan, USA
| | | | - Zhenke Wu
- Biostatistics, University of Michigan, Ann Arbor, Michigan, USA
| | - Sathish S Kumar
- Anesthesiology, University of Michigan Health System, Ann Arbor, Michigan, USA
| | - Stephen H Gregory
- Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Michael S Avidan
- Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Sachin Kheterpal
- Anesthesiology, University of Michigan Health System, Ann Arbor, Michigan, USA
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Gettel CJ, Yiadom MYA, Bernstein SL, Grudzen CR, Nath B, Li F, Hwang U, Hess EP, Melnick ER. Pragmatic clinical trial design in emergency medicine: Study considerations and design types. Acad Emerg Med 2022; 29:1247-1257. [PMID: 35475533 PMCID: PMC9790188 DOI: 10.1111/acem.14513] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Revised: 04/04/2022] [Accepted: 04/25/2022] [Indexed: 01/25/2023]
Abstract
Pragmatic clinical trials (PCTs) focus on correlation between treatment and outcomes in real-world clinical practice, yet a guide highlighting key study considerations and design types for emergency medicine investigators pursuing this important study type is not available. Investigators conducting emergency department (ED)-based PCTs face multiple decisions within the planning phase to ensure robust and meaningful study findings. The PRagmatic Explanatory Continuum Indicator Summary 2 (PRECIS-2) tool allows trialists to consider both pragmatic and explanatory components across nine domains, shaping the trial design to the purpose intended by the investigators. Aside from the PRECIS-2 tool domains, ED-based investigators conducting PCTs should also consider randomization techniques, human subjects concerns, and integration of trial components within the electronic health record. The authors additionally highlight the advantages, disadvantages, and rationale for the use of four common randomized study design types to be considered in PCTs: parallel, crossover, factorial, and stepped-wedge. With increasing emphasis on the conduct of PCTs, emergency medicine investigators will benefit from a rigorous approach to clinical trial design.
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Affiliation(s)
- Cameron J. Gettel
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, USA
- Center for Outcomes Research and Evaluation, Yale School of Medicine, New Haven, CT, USA
| | - Maame Yaa A.B. Yiadom
- Department of Emergency Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | | | - Corita R. Grudzen
- Ronald O. Perelman Department of Emergency Medicine and Department of Population Health, New York University Grossman School of Medicine, New York, NY, USA
| | - Bidisha Nath
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Fan Li
- Department of Biostatistics, Yale School of Public Health, New Haven, CT, USA
| | - Ula Hwang
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, USA
- Geriatrics Research, Education and Clinical Center, James J. Peters VA Medical Center, Bronx, NY, USA
| | - Erik P. Hess
- Department of Emergency Medicine, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Edward R. Melnick
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, USA
- Department of Biostatistics, Yale School of Public Health, New Haven, CT, USA
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