1
|
Guttmann KF, Li S, Wu YW, Juul SE, Wilfond BS, Weiss EM. Factors That Impact Hospital-Specific Enrollment Rates for a Neonatal Clinical Trial: An Analysis of the HEAL Study. Ethics Hum Res 2023; 45:29-38. [PMID: 36691692 PMCID: PMC9969810 DOI: 10.1002/eahr.500154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Inconsistent enrollment among hospitals for neonatal clinical trials may lead to study populations that are not representative of the patient population in the neonatal intensive care unit. The High-Dose Erythropoietin for Asphyxia and Encephalopathy (HEAL) trial was a multisite randomized clinical trial investigating erythropoietin as a neuroprotective treatment for term infants (those born between 37 and 42 complete weeks) with hypoxic ischemic encephalopathy. Substantial variability was noted in enrollment rate by hospital. We developed survey questions across five conceptual domains to understand systems-level issues that might contribute to variation in enrollment rate by hospital. Our study found that hospitals varied in their responses across these five domains. We propose three potential reasons that we found a lack of identifiable hospital-level factors that correlated with enrollment rates: sample-size limitations, methodological concerns, and confounding factors. Future studies with a larger sample size should be considered to evaluate contributors to hospital-level variability. This will lead to more robust recruitment strategies, improved enrollment, and decreases in the waste of research resources.
Collapse
Affiliation(s)
- Katherine F. Guttmann
- assistant professor in the Department of Pediatrics at the Icahn School of Medicine at Mount Sinai
| | - Sijia Li
- doctoral student in the Department of Biostatistics at the University of Washington School of Public Health
| | - Yvonne W. Wu
- professor of neurology and pediatrics in the Departments of Neurology and Pediatrics at the University of California San Francisco School of Medicine
| | - Sandra E. Juul
- professor in the Department of Pediatrics at the University of Washington School of Medicine
| | - Benjamin S. Wilfond
- professor in the Department of Pediatrics at the University of Washington School of Medicine and Treuman Katz Center for Pediatric Bioethics at the Seattle Children’s Research Institute
| | - Elliott Mark Weiss
- associate professor at the University of Washington School of Medicine and Treuman Katz Center for Pediatric Bioethics at the Seattle Children’s Research Institute
| | -
- Membership of the HEAL Recruitment Collaborative consists of Kaashif Ahmad, Uchenna E. Anani, Laura Bledsoe, Taeun Chang, Leah Engelstad, John B. Feltner, Fernando F. Gonzalez, Katherine F. Guttmann, Erin M. Havrilla, John Ibrahim, Sandra E. Juul, Sijia Li, Elizabeth N. Reichert, David Riley, Elliott Mark Weiss, Benjamin S. Wilfond, Tai-Wei Wu, Yvonne W. Wu, and Toby Debra Yanowitz
| |
Collapse
|
2
|
Lessons Learned from Phase II and Phase III Trials Investigating Therapeutic Agents for Cerebral Ischemia Associated with Aneurysmal Subarachnoid Hemorrhage. Neurocrit Care 2021; 36:662-681. [PMID: 34940927 DOI: 10.1007/s12028-021-01372-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Accepted: 10/04/2021] [Indexed: 12/20/2022]
Abstract
One of the challenges in bringing new therapeutic agents (since nimodipine) in for the treatment of cerebral ischemia associated with aneurysmal subarachnoid hemorrhage (aSAH) is the incongruence in therapeutic benefit observed between phase II and subsequent phase III clinical trials. Therefore, identifying areas for improvement in the methodology and interpretation of results is necessary to increase the value of phase II trials. We performed a systematic review of phase II trials that continued into phase III trials, evaluating a therapeutic agent for the treatment of cerebral ischemia associated with aSAH. We followed the Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines for systematic reviews, and review was based on a peer-reviewed protocol (International Prospective Register of Systematic Reviews no. 222965). A total of nine phase III trials involving 7,088 patients were performed based on eight phase II trials involving 1558 patients. The following therapeutic agents were evaluated in the selected phase II and phase III trials: intravenous tirilazad, intravenous nicardipine, intravenous clazosentan, intravenous magnesium, oral statins, and intraventricular nimodipine. Shortcomings in several design elements of the phase II aSAH trials were identified that may explain the incongruence between phase II and phase III trial results. We suggest the consideration of the following strategies to improve phase II design: increased focus on the selection of surrogate markers of efficacy, selection of the optimal dose and timing of intervention, adjustment for exaggerated estimate of treatment effect in sample size calculations, use of prespecified go/no-go criteria using futility design, use of multicenter design, enrichment of the study population, use of concurrent control or placebo group, and use of innovative trial designs such as seamless phase II to III design. Modifying the design of phase II trials on the basis of lessons learned from previous phase II and phase III trial combinations is necessary to plan more effective phase III trials.
Collapse
|
3
|
Johnson-Black P, Wong G, Starkman S, Sanossian N, Sharma L, Kim-Tenser M, Liebeskind D, Restrepo-Jimenez L, Valdes-Sueiras M, Stratton S, Eckstein M, Pratt F, Conwit R, Hamilton S, Guzy J, Grunberg I, Shkirkova K, Hemphill C, Saver J. A Prehospital Acute Stroke Trial has Only Modest Impact on Enrollment in Concurrent, Post-arrival-Recruiting Stroke Trials. J Stroke Cerebrovasc Dis 2020; 29:105200. [PMID: 33066919 DOI: 10.1016/j.jstrokecerebrovasdis.2020.105200] [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: 07/01/2020] [Revised: 07/20/2020] [Accepted: 07/22/2020] [Indexed: 10/23/2022] Open
Abstract
BACKGROUND Because "time is brain," acute stroke trials are migrating to the prehospital setting. The impact upon enrollment in post-arrival trials of earlier recruitment in a prehospital trial requires delineation. METHODS We analyzed all patients recruited into acute and prevention stroke trials during an 8-year period when an academic medical center (AMC) was participating in a prehospital treatment trial - the NIH Field Administration of Stroke Treatment - Magnesium (FAST-MAG) study. RESULTS During the study period, in addition to FAST-MAG, the AMC participated in 33 post-arrival stroke trials: 27 for acute cerebral ischemia, one for intracerebral hemorrhage, and 5 secondary prevention trials. Throughout the study period, the AMC was recruiting for at least 3 concurrent post-arrival acute trials. Among 199 patients enrolled in acute stroke trials, 98 (49%) were in FAST-MAG and 101 (51%) in concurrent, post-arrival acute trials. Among FAST-MAG patients, 67% were not eligible for any concurrent acute, post-arrival trial. Of 134 patients eligible for post-arrival acute trials, 101 (76%) were enrolled in post-arrival trials and 32 (24%) in FAST-MAG. Leading reasons FAST-MAG patients were ineligible for post-arrival acute trials were: NIHSS too low (23.4%), intracranial hemorrhage (17.9%), IV tPA used in standard management (9.0%), NIHSS too high (7.1%), and age too high (5.2%). CONCLUSIONS A prehospital hyperacute stroke trial with wide entry criteria reduced only modestly, by one-fourth, enrollment into concurrently active, post-arrival stroke trials. Simultaneous performance of prehospital and post-arrival acute and secondary prevention stroke trials in research networks is feasible.
Collapse
Affiliation(s)
| | - Gregory Wong
- University of Washington, St. Louis, MO, United States
| | - Sidney Starkman
- Univ of California, Los Angeles, Los Angeles, CA, United States
| | | | - Latisha Sharma
- Univ of California, Los Angeles, Los Angeles, CA, United States
| | - May Kim-Tenser
- Univ of California, Los Angeles, Los Angeles, CA, United States
| | | | | | | | - Samuel Stratton
- Univ of California, Los Angeles, Los Angeles, CA, United States
| | - Marc Eckstein
- Univ of Southern California, Los Angeles, CA, United States
| | - Frank Pratt
- Univ of California, Los Angeles, Los Angeles, CA, United States
| | | | | | - Judy Guzy
- Univ of California, Los Angeles, Los Angeles, CA, United States
| | - Ileana Grunberg
- Univ of California, Los Angeles, Los Angeles, CA, United States
| | | | - Claude Hemphill
- Univ of California, San Francisco, San Francisco, CA, United States
| | - Jeffrey Saver
- Univ of California, Los Angeles, Los Angeles, CA, United States
| | -
- University of California, Department of Neurology, Los Angeles, United States
| |
Collapse
|
4
|
Spokoyny I, Lansberg M, Thiessen R, Kemp SM, Aksoy D, Lee Y, Mlynash M, Hirsch KG. Development of a Mobile Tool That Semiautomatically Screens Patients for Stroke Clinical Trials. Stroke 2016; 47:2652-5. [PMID: 27608822 DOI: 10.1161/strokeaha.116.013456] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2016] [Accepted: 06/28/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Despite several national coordinated research networks, enrollment in many cerebrovascular trials remains challenging. An electronic tool was needed that would improve the efficiency and efficacy of screening for multiple simultaneous acute clinical stroke trials by automating the evaluation of inclusion and exclusion criteria, improving screening procedures and streamlining the communication process between the stroke research coordinators and the stroke clinicians. METHODS A multidisciplinary group consisting of physicians, study coordinators, and biostatisticians designed and developed an electronic clinical trial screening tool on a HIPAA (Health Insurance Portability and Accountability Act)-compliant platform. RESULTS A web-based tool was developed that uses branch logic to determine eligibility for simultaneously enrolling clinical trials and automatically notifies the study coordinator teams about eligible patients. After 12 weeks of use, 225 surveys were completed, and 51 patients were enrolled in acute stroke clinical trials. Compared with the 12 weeks before implementation of the tool, there was an increase in enrollment from 16.5% of patients screened to 23.4% of patients screened (P<0.05). Clinicians and coordinators reported increased satisfaction with the process and improved ease of screening. CONCLUSIONS We created a semiautomated electronic screening tool that uses branch logic to screen patients for stroke clinical trials. The tool has improved efficiency and efficacy of screening, and it could be adapted for use at other sites and in other medical fields.
Collapse
Affiliation(s)
- Ilana Spokoyny
- From the Stanford University Department of Neurology and Neurologic Sciences (I.S., M.L., K.G.H.); Stanford Stroke Center (R.T., S.M.K., D.A., M.M.); and Stanford Center for Clinical Informatics (Y.J.L.), Stanford, CA.
| | - Maarten Lansberg
- From the Stanford University Department of Neurology and Neurologic Sciences (I.S., M.L., K.G.H.); Stanford Stroke Center (R.T., S.M.K., D.A., M.M.); and Stanford Center for Clinical Informatics (Y.J.L.), Stanford, CA
| | - Rosita Thiessen
- From the Stanford University Department of Neurology and Neurologic Sciences (I.S., M.L., K.G.H.); Stanford Stroke Center (R.T., S.M.K., D.A., M.M.); and Stanford Center for Clinical Informatics (Y.J.L.), Stanford, CA
| | - Stephanie M Kemp
- From the Stanford University Department of Neurology and Neurologic Sciences (I.S., M.L., K.G.H.); Stanford Stroke Center (R.T., S.M.K., D.A., M.M.); and Stanford Center for Clinical Informatics (Y.J.L.), Stanford, CA
| | - Didem Aksoy
- From the Stanford University Department of Neurology and Neurologic Sciences (I.S., M.L., K.G.H.); Stanford Stroke Center (R.T., S.M.K., D.A., M.M.); and Stanford Center for Clinical Informatics (Y.J.L.), Stanford, CA
| | - YongJae Lee
- From the Stanford University Department of Neurology and Neurologic Sciences (I.S., M.L., K.G.H.); Stanford Stroke Center (R.T., S.M.K., D.A., M.M.); and Stanford Center for Clinical Informatics (Y.J.L.), Stanford, CA
| | - Michael Mlynash
- From the Stanford University Department of Neurology and Neurologic Sciences (I.S., M.L., K.G.H.); Stanford Stroke Center (R.T., S.M.K., D.A., M.M.); and Stanford Center for Clinical Informatics (Y.J.L.), Stanford, CA
| | - Karen G Hirsch
- From the Stanford University Department of Neurology and Neurologic Sciences (I.S., M.L., K.G.H.); Stanford Stroke Center (R.T., S.M.K., D.A., M.M.); and Stanford Center for Clinical Informatics (Y.J.L.), Stanford, CA
| |
Collapse
|
5
|
Wintermark M, Luby M, Bornstein NM, Demchuk A, Fiehler J, Kudo K, Lees KR, Liebeskind DS, Michel P, Nogueira RG, Parsons MW, Sasaki M, Wardlaw JM, Wu O, Zhang W, Zhu G, Warach SJ. International survey of acute stroke imaging used to make revascularization treatment decisions. Int J Stroke 2015; 10:759-62. [PMID: 25833105 DOI: 10.1111/ijs.12491] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2014] [Accepted: 01/06/2015] [Indexed: 11/30/2022]
Abstract
BACKGROUND To assess the differences across continental regions in terms of stroke imaging obtained for making acute revascularization therapy decisions, and to identify obstacles to participating in randomized trials involving multimodal imaging. METHODS STroke Imaging Repository (STIR) and Virtual International Stroke Trials Archive (VISTA)-Imaging circulated an online survey through its website, through the websites of national professional societies from multiple countries as well as through email distribution lists from STIR and the above mentioned societies. RESULTS We received responses from 223 centers (2 from Africa, 38 from Asia, 10 from Australia, 101 from Europe, 4 from Middle East, 55 from North America, 13 from South America). In combination, the sites surveyed administered acute revascularization therapy to a total of 25,326 acute stroke patients in 2012. Seventy-three percent of these patients received intravenous (i.v.) tissue plasminogen activator (tPA), and 27%, endovascular therapy. Vascular imaging was routinely obtained in 79% (152/193) of sites for endovascular therapy decisions, and also as part of standard IV tPA treatment decisions at 46% (92/198) of sites. Modality, availability and use of acute vascular and perfusion imaging before revascularization varied substantially between geographical areas. The main obstacles to participate in randomized trials involving multimodal imaging included: mainly insufficient research support and staff (50%, 79/158) and infrequent use of multimodal imaging (27%, 43/158) . CONCLUSION There were significant variations among sites and geographical areas in terms of stroke imaging work-up used tomake decisions both for intravenous and endovascular revascularization. Clinical trials using advanced imaging as a selection tool for acute revascularization therapy should address the need for additional resources and technical support, and take into consideration the lack of routine use of such techniques in trial planning.
Collapse
Affiliation(s)
- Max Wintermark
- Department of Radiology, Neuroradiology, Stanford University, Palo Alto, CA, USA
| | - Marie Luby
- National Institute of Neurological Disorders and Stroke (NINDS), National Institutes of Health (NIH), Bethesda, MD, USA.,Seton/UT Southwestern Clinical Research Institute of Austin, Department of Neurology and Neurotherapeutics, UT Southwestern Medical Center, Austin, TX, USA
| | - Natan M Bornstein
- Department of Neurology, Elias Sourasky Medical Centre, Sackler Faculty of Medicine, Tel-Aviv, Israel
| | - Andrew Demchuk
- Departments of Clinical Neurosciences and Radiology, Hotchkiss Brain Institute, University of Calgary, Calgary, Canada
| | - Jens Fiehler
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Kohsuke Kudo
- Department of Diagnostic Radiology, Hokkaido University Hospital, Sapporo, Japan
| | - Kennedy R Lees
- University Department of Medicine & Therapeutics, Western Infirmary, University of Glasgow, Glasgow, UK
| | | | - Patrik Michel
- Centre Hospitalier Universitaire Vaudois (CHUV), University of Lausanne, Lausanne, Switzerland
| | - Raul G Nogueira
- Marcus Stroke & Neuroscience Center/Grady Memorial Hospital, Emory University School of Medicine, Atlanta, GA, USA
| | - Mark W Parsons
- Department of Neurology, John Hunter Hospital, Hunter Medical Research Institute, University of Newcastle, Newcastle, NSW, Australia
| | - Makoto Sasaki
- Institute for Biomedical Sciences, Iwate Medical University, Yahaba, Japan
| | - Joanna M Wardlaw
- Brain Research Imaging Centre, Division of Neuroimaging Sciences, Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Ona Wu
- Martinos Center for Biomedical Imaging, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Weiwei Zhang
- Department of Neurology, Military General Hospital of Beijing PLA, Beijing, China
| | - Guangming Zhu
- Department of Neurology, Military General Hospital of Beijing PLA, Beijing, China
| | - Steven J Warach
- Seton/UT Southwestern Clinical Research Institute of Austin, Department of Neurology and Neurotherapeutics, UT Southwestern Medical Center, Austin, TX, USA
| |
Collapse
|
6
|
Atassi N, Yerramilli-Rao P, Szymonifka J, Yu H, Kearney M, Grasso D, Deng J, Levine-Weinberg M, Shapiro J, Lee A, Joseph L, Macklin EA, Cudkowicz ME. Analysis of start-up, retention, and adherence in ALS clinical trials. Neurology 2013; 81:1350-5. [PMID: 24005339 DOI: 10.1212/wnl.0b013e3182a823e0] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
OBJECTIVE To investigate predictors of trial start-up times, high attrition, and poor protocol adherence in amyotrophic lateral sclerosis (ALS) trials. METHODS Retrospective analysis of start-up times, retention, and protocol adherence was performed on 5 clinical studies conducted by the Northeast ALS Consortium and 50 ALS clinical trials identified by PubMed search. Predictors of start-up times were estimated by accelerated failure time models with random effects. Predictors of retention and protocol deviations were estimated by mixed-model logistic regression. RESULTS Median times for contract execution and institutional review board (IRB) approval were 105 days and 125 days, respectively. Contract execution was faster at sites with more ongoing trials (p = 0.005), and more full-time (p = 0.006) and experienced (p < 0.001) coordinators. IRB approval was faster at sites with more ongoing trials (p = 0.010) and larger ALS clinics (p = 0.038). Site activation after IRB approval was faster at sites with more full-time (p = 0.038) and experienced (p < 0.001) coordinators. Twenty-two percent of surviving participants withdrew before completing the trial. Better participant functional score at baseline was an independent predictor of trial completion (odds ratio 1.29, p = 0.002) and fewer protocol deviations (odds ratio 0.86, p = 0.030). CONCLUSION Delays in IRB review contribute the most to prolonged trial start-up times, and these timelines are faster in sites with more experienced staff. Strategies to improve protocol adherence and participants' retention may include enrolling people at early disease stages.
Collapse
Affiliation(s)
- Nazem Atassi
- From the Neurological Clinical Research Institute, Department of Neurology (N.A., P.Y.-R., H.Y., M.K., D.G., J.D., M.L.-W., J.S., A.L., L.J., M.E.C.), and Biostatistics Center (J.S., E.A.M.), Massachusetts General Hospital, Boston; and Harvard Medical School (N.A., P.Y.-R., E.A.M., M.E.C.), Boston, MA
| | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|