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Thermaenius I, Udo C, Alvariza A, Lundberg T, Holm M, Lövgren M. The Family Talk Intervention Among Families Affected by Severe Illness: Hospital Social Workers' Experiences of Facilitators and Barriers to its Use in Clinical Practice. JOURNAL OF SOCIAL WORK IN END-OF-LIFE & PALLIATIVE CARE 2024:1-19. [PMID: 38968160 DOI: 10.1080/15524256.2024.2364589] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/07/2024]
Abstract
Hospital social workers (HSW) play an important role in health care, providing psychosocial support to families affected by severe illness, and having palliative care needs involving dependent children. However, there are few evidence-based family interventions for HSWs to apply when supporting these families. The Family Talk intervention (FTI), a psychosocial family-based intervention, was therefore evaluated in an effectiveness-implementation study. Within the study, HSWs were educated and trained in the use of FTI in clinical practice. This study examined HSWs' experiences of barriers and facilitating factors during their initial use of FTI in clinical practice. Altogether, 10 semi-structured focus groups were held with HSWs (n = 38) employed in cancer care and specialized palliative home care for adults, pediatric hospital care, and a children's hospice. Data were analyzed using content analysis. HSWs considered FTI to be a suitable psychosocial intervention for families affected by severe illness with dependent children. However, the way in which the care was organized acted either as a barrier or facilitator to the use of FTI, such as the HSWs' integration in the team and their possibility to organize their own work. The HSWs' work environment also impacted the use of FTI, where time and support from managers was seen as a significant facilitating factor, but which varied between the healthcare contexts. In conclusion, HSWs believed that FTI was a suitable family intervention for families involving dependent children where one family member had a severe illness. For successful initial implementation, strategies should be multi-functional, targeting the care organization and the work environment.
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Affiliation(s)
- Ingrid Thermaenius
- Department of Health Care Sciences, Marie Cederschiöld University, Stockholm, Sweden
| | - Camilla Udo
- Department of Health Care Sciences, Marie Cederschiöld University, Stockholm, Sweden
- School of Health and Welfare, Dalarna University, Falun, Sweden
- Center for Clinical Research Dalarna, Uppsala University, Falun, Sweden
| | - Anette Alvariza
- Department of Health Care Sciences, Marie Cederschiöld University, Stockholm, Sweden
- Research and Development unit/Palliative care, Stockholms Sjukhem, Stockholm, Sweden
| | - Tina Lundberg
- Department of Health Care Sciences, Marie Cederschiöld University, Stockholm, Sweden
- Medical Unit: Clinical Social Work, Karolinska University Hospital, Stockholm, Sweden
| | - Maja Holm
- Department of Health Care Sciences, Marie Cederschiöld University, Stockholm, Sweden
- Department of Nursing Sciences, Sophiahemmet University, Stockholm, Sweden
| | - Malin Lövgren
- Department of Health Care Sciences, Marie Cederschiöld University, Stockholm, Sweden
- Advanced Pediatric Home Care, Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden
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Thomson S, Ainsworth G, Selvanathan S, Kelly R, Collier H, Mujica-Mota R, Talbot R, Brown ST, Croft J, Rousseau N, Higham R, Al-Tamimi Y, Buxton N, Carleton-Bland N, Gledhill M, Halstead V, Hutchinson P, Meacock J, Mukerji N, Pal D, Vargas-Palacios A, Prasad A, Wilby M, Stocken D. Posterior cervical foraminotomy versus anterior cervical discectomy for Cervical Brachialgia: the FORVAD RCT. Health Technol Assess 2023; 27:1-228. [PMID: 37929307 PMCID: PMC10641711 DOI: 10.3310/otoh7720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2023] Open
Abstract
Background Posterior cervical foraminotomy and anterior cervical discectomy are routinely used operations to treat cervical brachialgia, although definitive evidence supporting superiority of either is lacking. Objective The primary objective was to investigate whether or not posterior cervical foraminotomy is superior to anterior cervical discectomy in improving clinical outcome. Design This was a Phase III, unblinded, prospective, United Kingdom multicentre, parallel-group, individually randomised controlled superiority trial comparing posterior cervical foraminotomy with anterior cervical discectomy. A rapid qualitative study was conducted during the close-down phase, involving remote semistructured interviews with trial participants and health-care professionals. Setting National Health Service trusts. Participants Patients with symptomatic unilateral cervical brachialgia for at least 6 weeks. Interventions Participants were randomised to receive posterior cervical foraminotomy or anterior cervical discectomy. Allocation was not blinded to participants, medical staff or trial staff. Health-care use from providing the initial surgical intervention to hospital discharge was measured and valued using national cost data. Main outcome measures The primary outcome measure was clinical outcome, as measured by patient-reported Neck Disability Index score 52 weeks post operation. Secondary outcome measures included complications, reoperations and restricted American Spinal Injury Association score over 6 weeks post operation, and patient-reported Eating Assessment Tool-10 items, Glasgow-Edinburgh Throat Scale, Voice Handicap Index-10 items, PainDETECT and Numerical Rating Scales for neck and upper-limb pain over 52 weeks post operation. Results The target recruitment was 252 participants. Owing to slow accrual, the trial closed after randomising 23 participants from 11 hospitals. The qualitative substudy found that there was support and enthusiasm for the posterior cervical FORaminotomy Versus Anterior cervical Discectomy in the treatment of cervical brachialgia trial and randomised clinical trials in this area. However, clinical equipoise appears to have been an issue for sites and individual surgeons. Randomisation on the day of surgery and processes for screening and approaching participants were also crucial factors in some centres. The median Neck Disability Index scores at baseline (pre surgery) and at 52 weeks was 44.0 (interquartile range 36.0-62.0 weeks) and 25.3 weeks (interquartile range 20.0-42.0 weeks), respectively, in the posterior cervical foraminotomy group (n = 14), and 35.6 weeks (interquartile range 34.0-44.0 weeks) and 45.0 weeks (interquartile range 20.0-57.0 weeks), respectively, in the anterior cervical discectomy group (n = 9). Scores appeared to reduce (i.e. improve) in the posterior cervical foraminotomy group, but not in the anterior cervical discectomy group. The median Eating Assessment Tool-10 items score for swallowing was higher (worse) after anterior cervical discectomy (13.5) than after posterior cervical foraminotomy (0) on day 1, but not at other time points, whereas the median Glasgow-Edinburgh Throat Scale score for globus was higher (worse) after anterior cervical discectomy (15, 7, 6, 6, 2, 2.5) than after posterior cervical foraminotomy (3, 0, 0, 0.5, 0, 0) at all postoperative time points. Five postoperative complications occurred within 6 weeks of surgery, all after anterior cervical discectomy. Neck pain was more severe on day 1 following posterior cervical foraminotomy (Numerical Rating Scale - Neck Pain score 8.5) than at the same time point after anterior cervical discectomy (Numerical Rating Scale - Neck Pain score 7.0). The median health-care costs of providing initial surgical intervention were £2610 for posterior cervical foraminotomy and £4411 for anterior cervical discectomy. Conclusions The data suggest that posterior cervical foraminotomy is associated with better outcomes, fewer complications and lower costs, but the trial recruited slowly and closed early. Consequently, the trial is underpowered and definitive conclusions cannot be drawn. Recruitment was impaired by lack of individual equipoise and by concern about randomising on the day of surgery. A large prospective multicentre trial comparing anterior cervical discectomy and posterior cervical foraminotomy in the treatment of cervical brachialgia is still required. Trial registration This trial is registered as ISRCTN10133661. Funding This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 27, No. 21. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Simon Thomson
- Department of Neurosurgery, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Gemma Ainsworth
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | | | - Rachel Kelly
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Howard Collier
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | | | - Rebecca Talbot
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Sarah Tess Brown
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Julie Croft
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Nikki Rousseau
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Ruchi Higham
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Yahia Al-Tamimi
- Department of Neurosurgery, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Neil Buxton
- Department of Neurosurgery, The Walton Centre NHS Foundation Trust, Liverpool, UK
| | | | - Martin Gledhill
- Department of Speech and Language Therapy, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | | | - Peter Hutchinson
- Department of Clinical Neurosciences, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - James Meacock
- Department of Neurosurgery, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Nitin Mukerji
- Department of Neurosurgery, The James Cook University Hospital, South Tees Hospitals NHS Foundation Trust, Middlesbrough, UK
| | - Debasish Pal
- Department of Neurosurgery, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | | | - Anantharaju Prasad
- Department of Neurosurgery, Royal Preston Hospital, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, UK
| | - Martin Wilby
- Department of Neurosurgery, The Walton Centre NHS Foundation Trust, Liverpool, UK
| | - Deborah Stocken
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
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Menzies J, Tooke C, Jones T, Lavis A, Drury N. 'Just one interview': making visible the hidden workload associated with qualitative research. Nurse Res 2023; 31:36-43. [PMID: 37102315 DOI: 10.7748/nr.2023.e1872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/13/2023] [Indexed: 04/28/2023]
Abstract
BACKGROUND Appropriate costing and allocation of resources is vital to ensure that recruitment to a study is achieved on time and on target. However, there is little guidance concerning the workload associated with qualitative research. AIM To review the planned versus actual workloads in a qualitative sub-study following elective cardiac surgery in children. DISCUSSION Parents of children approached for a clinical trial were invited to participate in a semi-structured interview to explore their views about making decisions concerning their children's participation in the trial. A workload audit was conducted using anticipated points of contact with participants, and the duration of activities identified in the protocol and Health Research Authority statement of activities; these were compared with timed activities documented by the research team. CONCLUSION The current system did not anticipate or capture the workload associated with conducting a relatively straightforward qualitative sub-study of a clinical trial with a research-engaged patient group. IMPLICATIONS FOR PRACTICE Understanding the hidden workload associated with qualitative research is vital in ensuring that project timelines, recruitment targets and funding for research staff are realistic.
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Affiliation(s)
- Julie Menzies
- Paediatric Intensive Care Unit, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, England
| | - Carly Tooke
- Paediatric Intensive Care Unit, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, England
| | - Timothy Jones
- Department of Paediatric Cardiac Surgery, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, England
| | - Anna Lavis
- Institute of Applied Health Research, University of Birmingham Edgbaston Campus: University of Birmingham, Birmingham, England
| | - Nigel Drury
- Department of Paediatric Cardiac Surgery, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, England
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Dalgarno L, Birt L, Bond C, Blacklock J, Blyth A, Inch J, Notman F, Daffu-O’Reilly A, Spargo M, Watts L, Wright D, Poland F. Why the trial researcher matters: Day-to-day work viewed through the lens of normalization process theory. SSM. QUALITATIVE RESEARCH IN HEALTH 2023; 3:100254. [PMID: 37426703 PMCID: PMC10323713 DOI: 10.1016/j.ssmqr.2023.100254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Revised: 03/17/2023] [Accepted: 03/17/2023] [Indexed: 07/11/2023]
Abstract
Researchers working in the field, the places where research-relevant activity happens, are essential to recruitment and data collection in randomised controlled trials (RCTs). This study aimed to understand the nature of this often invisible work. Data were generated through an RCT of a pharmacist-led medication management service for older people in care homes. The study was conducted over three years and employed seven Research Associates (RA) working in Scotland, Northern Ireland, and England. Weekly research team meetings and Programme Management Group meetings naturally generated 129 sets of minutes. This documentary data was supplemented with two end-of-study RA debriefing meetings. Data were coded to sort the work being done in the field, then deductively explored through the lens of Normalization Process Theory to enable a greater understanding of the depth, breadth and complexity of work carried out by these trial delivery RAs. Results indicate RAs helped stakeholders and participants make sense of the research, they built relationships with participants to support retention, operationalised complex data collection procedures and reflected on their own work contexts to reach agreement on changes to trial procedures. The debrief discussions enabled RAs to explore and reflect on experiences from the field which had affected their day-to-day work. The learning from the challenges faced in facilitating care home research may be useful to inform future research team preparation for complex interventions. Scrutinising these data sources through the lens of NPT enabled us to identify RAs as linchpins in the successful conduct of a complex RCT study.
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Affiliation(s)
- Lindsay Dalgarno
- Institute of Applied Health Sciences, University of Aberdeen, Scotland, UK
- General Practice and Primary Care, University of Glasgow, Scotland, UK
| | - Linda Birt
- School Health Sciences, University of East Anglia, UK
- School of Healthcare, University of Leicester, UK
| | - Christine Bond
- Institute of Applied Health Sciences, University of Aberdeen, Scotland, UK
| | - Jeanette Blacklock
- School of Healthcare, University of Leicester, UK
- School of Pharmacy, University of East Anglia, UK
| | - Annie Blyth
- School of Pharmacy, University of East Anglia, UK
| | - Jacqueline Inch
- Institute of Applied Health Sciences, University of Aberdeen, Scotland, UK
| | - Frances Notman
- Institute of Applied Health Sciences, University of Aberdeen, Scotland, UK
| | | | | | - Laura Watts
- School of Pharmacy, University of East Anglia, UK
| | - David Wright
- School of Healthcare, University of Leicester, UK
| | - Fiona Poland
- School Health Sciences, University of East Anglia, UK
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Kehagia AA, North TK, Grose J, Jeffery AN, Cocking L, Chapman R, Carroll C. Enhancing Trial Delivery in Parkinson’s Disease: Qualitative Insights from PD STAT. JOURNAL OF PARKINSON'S DISEASE 2022; 12:1591-1604. [PMID: 35466952 PMCID: PMC9398073 DOI: 10.3233/jpd-212987] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Background: Recruitment and retention of participants in clinical trials for Parkinson’s disease (PD) is challenging. A qualitative study embedded in the PD STAT multi-centre randomised controlled trial of simvastatin for neuroprotection in PD explored the motivators, barriers and challenges of participants, care partners and research staff. Objective: To outline a set of considerations informing a patient-centred approach to trial recruitment, retention, and delivery. Method: We performed semi-structured interviews and focus groups with a subset of trial participants and their care partners. Quantitative and qualitative data were obtained through surveys circulated among the 235 participants across 23 UK sites at the beginning, middle and end of the 2-year trial. We also interviewed and surveyed research staff at trial closure. Results: Twenty-seven people with PD, 6 care partners and 9 researchers participated in interviews and focus groups. A total of 463 trial participant survey datasets were obtained across three timepoints, and 53 staff survey datasets at trial closure. Trial participants discussed the physical and psychological challenges they faced, especially in the context of OFF state assessments, relationships, and communication with research staff. Care partners shared their insights into OFF state challenges, and the value of being heard by research teams. Research staff echoed many concerns with suggestions on flexible, person-centred approaches to maximising convenience, comfort, and privacy. Conclusion: These considerations, in favour of person-centred research protocols informed by the variable needs of participants, care partners and staff, could be developed into a set of recommendations for future trials.
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Affiliation(s)
- Angie A. Kehagia
- University College Hospital, University London Hospitals NHS Trust, London, UK
- University of Plymouth, Faculty of Health, Plymouth, Devon, UK
| | - Tracie K. North
- University of Plymouth, Faculty of Health, Plymouth, Devon, UK
| | - Jane Grose
- University of Plymouth, Faculty of Health, Plymouth, Devon, UK
| | | | - Laura Cocking
- University of Plymouth, Faculty of Health, Plymouth, Devon, UK
| | - Rebecca Chapman
- University of Plymouth, Faculty of Health, Plymouth, Devon, UK
| | - Camille Carroll
- University of Plymouth, Faculty of Health, Plymouth, Devon, UK
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Menzies JC, Jennings C, Marshall R. A Survey of Resources and Nursing Workforce for Clinical Research Delivery in Paediatric Intensive Care Within the UK / Ireland. Front Pediatr 2022; 10:848378. [PMID: 35586827 PMCID: PMC9108499 DOI: 10.3389/fped.2022.848378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Accepted: 04/08/2022] [Indexed: 12/05/2022] Open
Abstract
Introduction Clinical research within Paediatric Intensive Care (PICU) is necessary to reduce morbidity and mortality associated within this resource-intensive environment. With UK PICUs encouraged to be research-active there was a drive to understand how centres support research delivery. Aim To identify the research workforce available within UK/Ireland PICUs to support clinical research delivery. Method An electronic survey, endorsed by the Paediatric Critical Care Society (PCCS), was designed and reported in accordance with CHERRIES guidelines. The survey was distributed by email to all UK/Ireland Nurse Managers and Medical/ Nursing Research leads, aiming for one response per site during the period of April-June 2021. Only one response per site was included in analysis. Results 44 responses were received, representing 24/30 UK/Ireland sites (80% response rate). Responses from n = 21/30 units are included (three excluded for insufficient data). 90% (n = 19/21) units were research active, although only 52% (n = 11) had permanent research roles funded within their staffing establishment. The majority of units (n = 18, 86%) had less than two WTE research nurses. Resources were felt to be sufficient for current research delivery by 43% of units (n = 9), but this confidence diminished to 19% (n = 4) when considering their ability to support future research. The top barriers to research conduct were insufficiently funded/unfunded studies (52%; n = 11), clinical staff too busy to support research activity (52%; n = 11) and short-term/fixed-term contracts for research staff (38%; n = 8). Conclusion Despite the perceived importance of research and 90% of responding UK/Ireland PICUs being research active, the majority have limited resources to support research delivery. This has implications for their ability to participate in future multi-centre trials and opportunities to support the development of future medical/nursing clinical academics. Further work is required to identify optimum models of clinical research delivery.
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Affiliation(s)
- Julie C. Menzies
- Paediatric Intensive Care Unit, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, United Kingdom
- College of Medical and Dental Sciences, Institute of Clinical Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Claire Jennings
- Paediatric Critical Care Unit, Royal Manchester Children's Hospital, Manchester, United Kingdom
| | - Rebecca Marshall
- Paediatric Critical Care Unit, Royal Manchester Children's Hospital, Manchester, United Kingdom
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Abstract
Background International evidence suggests that Clinical Research Nurses (CRN) can have a dual role incorporating both clinical care and research responsibilities. This duality of role often assists in meeting the clinical care and research needs of the participants and can contribute to the credibility of the CRN role. Conversely, it can also lead to feelings of confusion and role conflict as CRN's time is divided. Aim To identify and explore experiences of clinical and research roles among CRNs. This emerged as a theme in a wider research project exploring CRNs' experiences of working with clinical nurses. Methods Following an Interpretative Phenomenological Analysis approach, 10 CRNs participated in face-to-face semi-structured interviews. Transcribed data were analysed and a number of themes emerged. Duality of role was one of these. Findings Findings indicated that if CRNs fulfil a dual role, this can assist in care provision, research delivery and in building positive relationships with clinical nurses. However, there were also instances when a dual role led to clinical nurses questioning the value of research and to issues with competing demands of clinical care and research. These experiences had an important impact on some of the CRNs and led to reflection on the value of their role. Conclusions This study identifies new understandings of a dual role of the CRN. The findings will inform the preparation and practice of this group of nurses, whilst also leading to a deeper understanding of the CRN's role in care and research delivery. It will also contribute to a wider appreciation of organisational factors and social interactions that impact on health care research.
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Affiliation(s)
- Gordon Hill
- Gordon Hill, Department of Nursing and Community Health, Glasgow Caledonian University, 30 Craiglockhart Crescent, Edinburgh G4 0BA, UK.
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Factors Affecting Prescriber Implementation of Computer-Generated Medication Recommendations in the SENATOR Trial: A Qualitative Study. Drugs Aging 2020; 37:703-713. [DOI: 10.1007/s40266-020-00787-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Hanrahan V, Gillies K, Biesty L. Recruiters' perspectives of recruiting women during pregnancy and childbirth to clinical trials: A qualitative evidence synthesis. PLoS One 2020; 15:e0234783. [PMID: 32559236 PMCID: PMC7304625 DOI: 10.1371/journal.pone.0234783] [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: 02/12/2020] [Accepted: 06/02/2020] [Indexed: 01/19/2023] Open
Abstract
INTRODUCTION Research on research is key to enhancing efficacy in trial methodology. Clinical trials involving women during pregnancy and childbirth are limited, with a paucity of data guiding evidence-based practice. Following a prioritisation exercise that highlighted the top-ten unanswered recruitment questions, this qualitative evidence synthesis was designed specifically to focus on the barriers and enablers for clinicians/healthcare professionals in helping conduct randomised trials within the context of recruitment during pregnancy and childbirth. METHODS The synthesis was undertaken using Thomas and Harden's three stage thematic synthesis method and reported following the ENTREQ guidelines. Using a pre-determined SPIDER strategy, we conducted a comprehensive search of databases; Pubmed, CINAHL, PsycINFO, EMBASE, and grey searches for records until January 2019. We included all reports of qualitative data on recruiter's experiences, perceptions, views of recruiting women during pregnancy and childbirth to clinical trials. Altogether 13,401 records were screened, resulting in 31 full-text reviews, of which five were eligible for inclusion. Quality was appraised using CASP. Data were extracted onto a specifically defined form. We used thematic synthesis to identify descriptive and analytical themes, and to interpret and generate theory. Confidence was assessed using GRADE-CERQual. The review protocol is publicly available (OSF https://osf.io/g4dt9/). RESULTS Five papers (representing four individual studies) from two different countries were included. All studies focused on the experiences of trial recruiters in the maternity setting. We identified four analytical themes; Recruitment through a clinician's lens, Recruiters judgement on acceptability, From protocol to recruiters lived experience, Framing recruitment in context. These were linked by an overarching theme combining beliefs and power. CONCLUSION The overarching theme combining beliefs and power links the experiences and perceptions of recruiters. This synthesis shows a gap between the trial design study protocol and the recruiter's lived experience. Strategies such as collaborative trial design, mitigating gatekeeping behaviours, and training may support recruiters in their endeavour.
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Affiliation(s)
- Vivienne Hanrahan
- School of Nursing and Midwifery, National University of Ireland Galway, Galway, Ireland
| | - Katie Gillies
- Health Services Research Unit, University of Aberdeen, Aberdeen, Scotland, United Kingdom
| | - Linda Biesty
- School of Nursing and Midwifery, National University of Ireland Galway, Galway, Ireland
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10
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Hart RI, Hallowell N, Harden J, Jesudason AB, Lawton J. Clinician-researchers and custodians of scarce resources: a qualitative study of health professionals' views on barriers to the involvement of teenagers and young adults in cancer trials. Trials 2020; 21:67. [PMID: 31924260 PMCID: PMC6954521 DOI: 10.1186/s13063-019-3942-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Accepted: 11/28/2019] [Indexed: 12/15/2022] Open
Abstract
Background Equipoise and role conflict have been previously identified as important factors in professionals’ engagement with trials, inducing behaviours which can impact on recruitment. We explored these phenomena as potential explanations for the low levels of involvement of teenagers and young adults (TYA) with cancer in clinical trials in oncology. Methods We report findings from interviews with 30 purposively sampled direct-care professionals involved in delivering cancer care and/or facilitating clinical trials in Scotland. We undertook qualitative descriptive analysis, focussed on identifying key issues and themes. Results Interviewees largely identified as clinician–researchers and portrayed oncology as a specialty in which research was integral to care. They saw their primary responsibility as ensuring patients received the best treatment, but asserted that, in general, trials provided a vehicle for optimal care. Role conflict in its traditional form was rarely evident; however, other tensions were manifest. Professionals found the significant time costs of delivering trials difficult to reconcile with the increasing pressures on clinical services. They felt a responsibility to make prudent choices about the trials with which to engage. Guided by utilitarian principles, these choices were oriented towards benefiting the largest number of patients. This favoured trials in high volume diseases; as TYA tend to have rarer forms of cancer, professionals’ support for—and TYA’s access to—relevant trials was, by default, more limited. Conclusions Neither lack of individual equipoise nor experiences of traditional forms of role conflict accounted for the low levels of involvement of TYA with cancer in clinical trials. However, prominent tensions around the management of scarce resources provided an alternative explanation for TYA’s limited access to cancer trials. The prevailing approach to decision-making about whether and which trials to support was recognised as contributing to inequalities in access and care. Professionals’ choices, however, were made in the context of scarcity, and structured by incentives and sanctions understood by them as signalling governmental priorities. A franker discussion of the extent and distribution of the costs and benefits of trials work is needed, for change to be achieved.
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Affiliation(s)
- Ruth I Hart
- Usher Institute, University of Edinburgh, Edinburgh, EH8 9AG, UK.
| | - Nina Hallowell
- Wellcome Centre for Ethics and Humanities and Ethox Centre, Nuffield Department of Population Health, Big Data Institute, Li Ka Shing Centre for Health Information and Discovery, University of Oxford, Oxford, OX3 7LF, UK
| | - Jeni Harden
- Usher Institute, University of Edinburgh, Edinburgh, EH8 9AG, UK
| | - Angela B Jesudason
- Royal Hospital for Sick Children, Department of Paediatric Haematology and Oncology, Sciennes Road, Edinburgh, EH9 1LF, UK
| | - Julia Lawton
- Usher Institute, University of Edinburgh, Edinburgh, EH8 9AG, UK
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Hernon O, Dalton R, Dowling M. Clinical research nurses’ expectations and realities of their role: A qualitative evidence synthesis. J Clin Nurs 2019; 29:667-683. [DOI: 10.1111/jocn.15128] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Revised: 11/18/2019] [Accepted: 11/24/2019] [Indexed: 01/01/2023]
Affiliation(s)
- Orlaith Hernon
- Galway University Hospital Newcastle Road Galway Ireland
| | - Rachael Dalton
- Galway University Hospital Newcastle Road Galway Ireland
| | - Maura Dowling
- School of Nursing and Midwifery National University of Ireland Galway Ireland
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12
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Ambassadors of hope, research pioneers and agents of change-individuals' expectations and experiences of taking part in a randomised trial of an innovative health technology: longitudinal qualitative study. Trials 2019; 20:289. [PMID: 31133076 PMCID: PMC6537378 DOI: 10.1186/s13063-019-3373-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2018] [Accepted: 04/19/2019] [Indexed: 11/10/2022] Open
Abstract
Background While a growing body of research has explored why people take part in clinical trials, this research has not considered how people’s understandings, motivations and agendas might influence their conduct during a trial. This is an important area of enquiry because it is now widely recognised that an intervention might lead to different clinical outcomes when delivered as part of a trial than when implemented in routine clinical practice; however, the reasons for this are not fully understood. Methods/design We interviewed 24 individuals who took part in a trial of an innovative health technology under development for people with type 1 diabetes which automatically regulates blood glucose: the closed-loop system. Participants were interviewed following randomisation to a closed-loop and at trial closeout. Results Participants provided complex agendas for taking part in which altruistic and self-interested considerations were often inseparable. Many described belonging to a wider diabetes community and being beneficiaries of others’ participation in research and how this had given rise to attendant citizenship obligations. Participants also shared the excitement and pride they experienced from contributing to research which situated them at the forefront of technological innovation and enabled them to present themselves to others, by virtue of their trial participation, as ambassadors of hope and research pioneers. Given their desire to support the progression of a potentially life-changing technology, and be part of that innovation, participants, at follow-up, described having made extra effort during the trial. Specifically, participants described having been more focused on their diabetes management to help create conditions in which the closed-loop could work most effectively to optimize their blood glucose control. Conclusions Our findings contribute a new dimension to understandings of trial effects; specifically, we argue that, to aid interpretation of trial outcomes, participants’ understandings and motivations for participation need to be considered. We highlight the potential pertinence of our findings in the contemporary era of bio-citizenship where, increasingly, people are driving research agendas and see themselves as co-producers of knowledge. We also recommend a new concept be introduced into the literature—‘the altruselfish agenda’—to recognise potential inseparability of self-interested and altruistic motivations. Trial registration ClinicalTrials.gov, NCT02523131. Registered on 14 August 2015.
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Paleri V, Patterson J, Rousseau N, Moloney E, Craig D, Tzelis D, Wilkinson N, Franks J, Hynes AM, Heaven B, Hamilton D, Guerrero-Urbano T, Donnelly R, Barclay S, Rapley T, Stocken D. Gastrostomy versus nasogastric tube feeding for chemoradiation patients with head and neck cancer: the TUBE pilot RCT. Health Technol Assess 2019; 22:1-144. [PMID: 29650060 DOI: 10.3310/hta22160] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Approximately 9000 new cases of head and neck squamous cell cancers (HNSCCs) are treated by the NHS each year. Chemoradiation therapy (CRT) is a commonly used treatment for advanced HNSCC. Approximately 90% of patients undergoing CRT require nutritional support via gastrostomy or nasogastric tube feeding. Long-term dysphagia following CRT is a primary concern for patients. The effect of enteral feeding routes on swallowing function is not well understood, and the two feeding methods have, to date (at the time of writing), not been compared. The aim of this pilot randomised controlled trial (RCT) was to compare these two options. METHODS This was a mixed-methods multicentre study to establish the feasibility of a RCT comparing oral feeding plus pre-treatment gastrostomy with oral feeding plus as-required nasogastric tube feeding in patients with HNSCC. Patients were recruited from four tertiary centres treating cancer and randomised to the two arms of the study (using a 1 : 1 ratio). The eligibility criteria were patients with advanced-staged HNSCC who were suitable for primary CRT with curative intent and who presented with no swallowing problems. MAIN OUTCOME MEASURES The primary outcome was the willingness to be randomised. A qualitative process evaluation was conducted alongside an economic modelling exercise. The criteria for progression to a Phase III trial were based on a hypothesised recruitment rate of at least 50%, collection of outcome measures in at least 80% of those recruited and an economic value-of-information analysis for cost-effectiveness. RESULTS Of the 75 patients approached about the trial, only 17 consented to be randomised [0.23, 95% confidence interval (CI) 0.13 to 0.32]. Among those who were randomised, the compliance rate was high (0.94, 95% CI 0.83 to 1.05). Retention rates were high at completion of treatment (0.94, 95% CI 0.83 to 1.05), at the 3-month follow-up (0.88, 95% CI 0.73 to 1.04) and at the 6-month follow-up (0.88, 95% CI 0.73 to 1.04). No serious adverse events were recorded in relation to the trial. The qualitative substudy identified several factors that had an impact on recruitment, many of which are amenable to change. These included organisational factors, changing cancer treatments and patient and clinician preferences. A key reason for the differential recruitment between sites was the degree to which the multidisciplinary team gave a consistent demonstration of equipoise at all patient interactions at which supplementary feeding was discussed. An exploratory economic model generated from published evidence and expert opinion suggests that, over the 6-month model time horizon, pre-treatment gastrostomy tube feeding is not a cost-effective option, although this should be interpreted with caution and we recommend that this should not form the basis for policy. The economic value-of-information analysis indicates that additional research to eliminate uncertainty around model parameters is highly likely to be cost-effective. STUDY LIMITATIONS The recruitment issues identified for this cohort may not be applicable to other populations undergoing CRT. There remains substantial uncertainty in the economic evaluation. CONCLUSIONS The trial did not meet one of the three criteria for progression, as the recruitment rate was lower than hypothesised. Once patients were recruited to the trial, compliance and retention in the trial were both high. The implementation of organisational and operational measures can increase the numbers recruited. The economic analysis suggests that further research in this area is likely to be cost-effective. FUTURE WORK The implementation of organisational and operational measures can increase recruitment. The appropriate research question and design of a future study needs to be identified. More work is needed to understand the experiences of nasogastric tube feeding in patients undergoing CRT. TRIAL REGISTRATION Current Controlled Trials ISRCTN48569216. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 22, No. 16. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Vinidh Paleri
- Head and Neck Unit, The Royal Marsden Hospital, London, UK.,Division of Clinical Studies, Institute of Cancer Research, London, UK.,Northern Institute for Cancer Research, Newcastle University, Newcastle upon Tyne, UK
| | - Joanne Patterson
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | - Nikki Rousseau
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | - Eoin Moloney
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | - Dawn Craig
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | - Dimitrios Tzelis
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | - Nina Wilkinson
- Biostatistics Research group, Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | - Jeremy Franks
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | - Ann Marie Hynes
- Newcastle Clinical Trials Unit, Newcastle University, Newcastle upon Tyne, UK
| | - Ben Heaven
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | - David Hamilton
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | | | - Rachael Donnelly
- Department of Radiation Oncology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Stewart Barclay
- Department of Restorative Dentistry, The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Tim Rapley
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | - Deborah Stocken
- Biostatistics Research group, Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK.,Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
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Prothero L, Sturt J, de Souza S, Lempp H. Intensive management for moderate rheumatoid arthritis: a qualitative study of patients' and practitioners' views. BMC Rheumatol 2019; 3:12. [PMID: 30976751 PMCID: PMC6437952 DOI: 10.1186/s41927-019-0057-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Accepted: 02/26/2019] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND The TITRATE trial seeks to test whether intensive management is valuable in achieving disease remission in moderately active rheumatoid arthritis. Intensive management is a complex intervention consisting of: 1) 12 x monthly appointments, 2) tailored 'treatment support' based on motivational interviewing techniques, 3) optimised medication (including the opportunity for biologics), 4) provision of a Patient Handbook, and 5) shared treatment planning. This study aims to understand: a) patients' and practitioners' views on the feasibility and acceptability of intensive management, and b) patients' and practitioners' experience of receiving/providing intensive management. METHODS A qualitative study, nested within a randomised controlled trial. Participants were patients (n = 15) in the intensive management arm of the trial and rheumatology practitioners (n = 16) providing the intensive management intervention, from 18/42 clinics across England. Data were collected via semi-structured interviews and analysed using thematic analysis and iterative categorization. RESULTS Monthly appointments were largely acceptable to both groups who cited several treatment benefits (e.g. regular review of medication, practitioners built close relationships with patients). Practitioners were 'fairly confident' using the motivational interviewing techniques. Learning to pace was the most commonly reported self-management technique that patients and healthcare professionals worked on together, followed by gaining control over pain and fatigue. Practitioners liked having the option to offer biologics to patients with moderate RA. Most patients found the optimised medication (following monthly joint assessment) helpful and side-effects experienced were resolved. Variation existed in the extent to which patients engaged with the Patient Handbook and shared treatment planning, with those who did engage doing so in the early stages. CONCLUSIONS Feedback from patient participants about the intensive management intervention was positive. They found increased medication helpful. Continuity of care with the same healthcare professional at regular intensive management sessions, and the treatment support provided, were highly rated. Feedback from practitioners indicated that intensive management training is feasible. Evidence from the interviews showed that some practitioners applied motivational interviewing techniques during standard care appointments and they would like the opportunity to address lifestyle issues with patients.
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Affiliation(s)
- Louise Prothero
- Department of Inflammation Biology, School of Immunology and Microbial Sciences, Faculty of Life Sciences and Medicine, King’s College London, 10 Cutcombe Road, Denmark Hill, London, SE5 9RJ UK
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King’s College London, 57 Waterloo Road, London, SE1 8WA UK
| | - Jackie Sturt
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King’s College London, 57 Waterloo Road, London, SE1 8WA UK
| | - Savia de Souza
- Department of Inflammation Biology, School of Immunology and Microbial Sciences, Faculty of Life Sciences and Medicine, King’s College London, 10 Cutcombe Road, Denmark Hill, London, SE5 9RJ UK
| | - Heidi Lempp
- Department of Inflammation Biology, School of Immunology and Microbial Sciences, Faculty of Life Sciences and Medicine, King’s College London, 10 Cutcombe Road, Denmark Hill, London, SE5 9RJ UK
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15
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Should I stay or should I go? A qualitative study exploring participation in a urology clinical trial. Int Urogynecol J 2018; 30:9-16. [PMID: 30328486 PMCID: PMC6514084 DOI: 10.1007/s00192-018-3784-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Accepted: 09/28/2018] [Indexed: 11/23/2022]
Abstract
Introduction and hypothesis The aim of this study was to identify modifiable factors to improve recruitment in a urology clinical trial of women with recurrent urinary tract infection (rUTI). An embedded qualitative study was conducted with patients and recruiting clinicians in the first 8 months of the trial. We present a matrix of factors influencing how patients make decisions about trial participation. Methods This was a qualitative study using telephone interviews. When they were first approached about the trial, women were asked to complete an expression of interest form if they wished to be contacted for an interview. Data were analysed thematically. NVivo 10 software (Qualitative data analysis software. 10th ed: QSR International Pty Ltd; 2012) was used as a management tool. Results Thirty patients and 11 clinicians were interviewed. Influences on patient participation included the impact of rUTI on quality of life (QoL), understanding of antibiotic resistance, and previous experiences with antibiotics either positive or negative. Very few women who declined the trial agreed to be interviewed. However, some of those who participated had reservations about it. These included the perceived risk of trying a new treatment, trial length, and the burden of participating. One person interviewed left the trial because of repeated infections and difficulties getting general practitioner appointments. Conclusions A combination of factors worked to influence women to decide to participate, to remain in, or to leave the trial. A better understanding of how these factors interact and work can assist in the recruitment and retention of individual trial participants.
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16
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Heller S, White D, Lee E, Lawton J, Pollard D, Waugh N, Amiel S, Barnard K, Beckwith A, Brennan A, Campbell M, Cooper C, Dimairo M, Dixon S, Elliott J, Evans M, Green F, Hackney G, Hammond P, Hallowell N, Jaap A, Kennon B, Kirkham J, Lindsay R, Mansell P, Papaioannou D, Rankin D, Royle P, Smithson WH, Taylor C. A cluster randomised trial, cost-effectiveness analysis and psychosocial evaluation of insulin pump therapy compared with multiple injections during flexible intensive insulin therapy for type 1 diabetes: the REPOSE Trial. Health Technol Assess 2018; 21:1-278. [PMID: 28440211 DOI: 10.3310/hta21200] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Insulin is generally administered to people with type 1 diabetes mellitus (T1DM) using multiple daily injections (MDIs), but can also be delivered using infusion pumps. In the UK, pumps are recommended for patients with the greatest need and adult use is less than in comparable countries. Previous trials have been small, of short duration and have failed to control for training in insulin adjustment. OBJECTIVE To assess the clinical effectiveness and cost-effectiveness of pump therapy compared with MDI for adults with T1DM, with both groups receiving equivalent structured training in flexible insulin therapy. DESIGN Pragmatic, multicentre, open-label, parallel-group cluster randomised controlled trial, including economic and psychosocial evaluations. After participants were assigned a group training course, courses were randomly allocated in pairs to either pump or MDI. SETTING Eight secondary care diabetes centres in the UK. PARTICIPANTS Adults with T1DM for > 12 months, willing to undertake intensive insulin therapy, with no preference for pump or MDI, or a clinical indication for pumps. INTERVENTIONS Pump or MDI structured training in flexible insulin therapy, followed up for 2 years. MDI participants used insulin analogues. Pump participants used a Medtronic Paradigm® VeoTM (Medtronic, Watford, UK) with insulin aspart (NovoRapid, Novo Nordisk, Gatwick, UK). MAIN OUTCOME MEASURES Primary outcome - change in glycated haemoglobin (HbA1c) at 2 years in participants whose baseline HbA1c was ≥ 7.5% (58 mmol/mol). Key secondary outcome - proportion of participants with HbA1c ≤ 7.5% at 2 years. Other outcomes at 6, 12 and 24 months - moderate and severe hypoglycaemia; insulin dose; body weight; proteinuria; diabetic ketoacidosis; quality of life (QoL); fear of hypoglycaemia; treatment satisfaction; emotional well-being; qualitative interviews with participants and staff (2 weeks), and participants (6 months); and ICERs in trial and modelled estimates of cost-effectiveness. RESULTS We randomised 46 courses comprising 317 participants: 267 attended a Dose Adjustment For Normal Eating course (132 pump; 135 MDI); 260 were included in the intention-to-treat analysis, of which 235 (119 pump; 116 MDI) had baseline HbA1c of ≥ 7.5%. HbA1c and severe hypoglycaemia improved in both groups. The drop in HbA1c% at 2 years was 0.85 on pump and 0.42 on MDI. The mean difference (MD) in HbA1c change at 2 years, at which the baseline HbA1c was ≥ 7.5%, was -0.24% [95% confidence interval (CI) -0.53% to 0.05%] in favour of the pump (p = 0.098). The per-protocol analysis showed a MD in change of -0.36% (95% CI -0.64% to -0.07%) favouring pumps (p = 0.015). Pumps were not cost-effective in the base case and all of the sensitivity analyses. The pump group had greater improvement in diabetes-specific QoL diet restrictions, daily hassle plus treatment satisfaction, statistically significant at 12 and 24 months and supported by qualitative interviews. LIMITATION Blinding of pump therapy was not possible, although an objective primary outcome was used. CONCLUSION Adding pump therapy to structured training in flexible insulin therapy did not significantly enhance glycaemic control or psychosocial outcomes in adults with T1DM. RESEARCH PRIORITY To understand why few patients achieve a HbA1c of < 7.5%, particularly as glycaemic control is worse in the UK than in other European countries. TRIAL REGISTRATION Current Controlled Trials ISRCTN61215213. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 21, No. 20. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Simon Heller
- Academic Unit of Diabetes, Endocrinology and Metabolism, University of Sheffield, Sheffield, UK
| | - David White
- Clinical Trials Research Unit, University of Sheffield, Sheffield, UK
| | - Ellen Lee
- Clinical Trials Research Unit, University of Sheffield, Sheffield, UK
| | - Julia Lawton
- Centre for Population Health Sciences, University of Edinburgh, Edinburgh, UK
| | - Daniel Pollard
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Norman Waugh
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | | | - Katharine Barnard
- Human Development and Health, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Anita Beckwith
- King's College Hospital NHS Foundation Trust, London, UK
| | - Alan Brennan
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Michael Campbell
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Cindy Cooper
- Clinical Trials Research Unit, University of Sheffield, Sheffield, UK
| | | | - Simon Dixon
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Jackie Elliott
- Academic Unit of Diabetes, Endocrinology and Metabolism, University of Sheffield, Sheffield, UK
| | - Mark Evans
- Institute of Metabolic Science, University of Cambridge, Cambridge, UK.,Wolfson Diabetes Clinic, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Fiona Green
- Dumfries Royal Infirmary NHS Trust, Dumfries, UK
| | - Gemma Hackney
- Clinical Trials Research Unit, University of Sheffield, Sheffield, UK
| | - Peter Hammond
- Harrogate and District NHS Foundation Trust, Harrogate, UK
| | - Nina Hallowell
- Centre for Population Health Sciences, University of Edinburgh, Edinburgh, UK
| | - Alan Jaap
- Edinburgh Centre for Endocrinology and Diabetes, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Brian Kennon
- Queen Elizabeth University Hospital, NHS Greater Glasgow and Clyde, Glasgow, UK
| | - Jackie Kirkham
- Centre for Population Health Sciences, University of Edinburgh, Edinburgh, UK
| | - Robert Lindsay
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Peter Mansell
- Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Diana Papaioannou
- Clinical Trials Research Unit, University of Sheffield, Sheffield, UK
| | - David Rankin
- Centre for Population Health Sciences, University of Edinburgh, Edinburgh, UK
| | - Pamela Royle
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - W Henry Smithson
- Department of General Practice, University College Cork, Cork, Ireland
| | - Carolin Taylor
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
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Latter S, Hopkinson JB, Lowson E, Hughes JA, Hughes J, Duke S, Anstey S, Bennett MI, May C, Smith P, Richardson A. Supporting carers to manage pain medication in cancer patients at the end of life: A feasibility trial. Palliat Med 2018; 32:246-256. [PMID: 28679073 DOI: 10.1177/0269216317715197] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Carers of people with advanced cancer play a significant role in managing pain medication, yet they report insufficient information and support to do so confidently and competently. There is limited research evidence on the best ways for clinicians to help carers with medication management. AIMS To develop a pain medicines management intervention (Cancer Carers Medicines Management) for cancer patients' carers near the end of life and evaluate feasibility and acceptability to nurses and carers. To test the feasibility of trial research procedures and to inform decisions concerning a full-scale randomised controlled trial. DESIGN Phase I-II clinical trial. A systematic, evidence-informed participatory method was used to develop CCMM: a nurse-delivered structured conversational process. A two-arm, cluster randomised controlled feasibility trial of Cancer Carers Medicines Management was conducted, with an embedded qualitative study to evaluate participants' experiences of Cancer Carers Medicines Management and trial procedures. SETTING Community settings in two study sites. PARTICIPANTS Phase I comprises 57 carers, patients and healthcare professionals and Phase II comprises 12 nurses and 15 carers. RESULTS A novel intervention was developed. Nurses were recruited and randomised. Carer recruitment to the trial was problematic with fewer than predicted eligible participants, and nurses judged a high proportion unsuitable to recruit into the study. Attrition rates following recruitment were typical for the study population. Cancer Carers Medicines Management was acceptable to carers and nurses who took part, and some benefits were identified. CONCLUSION Cancer Carers Medicines Management is a robustly developed medicines management intervention which merits further research to test its effectiveness to improve carers' management of pain medicines with patients at the end of life. The study highlighted aspects of trial design that need to be considered in future research.
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Affiliation(s)
- Sue Latter
- 1 Faculty of Health Sciences, University of Southampton, Southampton, UK
| | - Jane B Hopkinson
- 2 School of Healthcare Sciences, Cardiff University, Cardiff, UK
| | - Elizabeth Lowson
- 1 Faculty of Health Sciences, University of Southampton, Southampton, UK
| | - Jane A Hughes
- 1 Faculty of Health Sciences, University of Southampton, Southampton, UK
| | - Jacki Hughes
- 2 School of Healthcare Sciences, Cardiff University, Cardiff, UK
| | - Sue Duke
- 1 Faculty of Health Sciences, University of Southampton, Southampton, UK
| | - Sally Anstey
- 2 School of Healthcare Sciences, Cardiff University, Cardiff, UK
| | - Michael I Bennett
- 3 Academic Unit of Palliative Care, Leeds Institute of Health Sciences, School of Medicine, University of Leeds, Leeds, UK
| | - Carl May
- 1 Faculty of Health Sciences, University of Southampton, Southampton, UK
| | - Peter Smith
- 1 Faculty of Health Sciences, University of Southampton, Southampton, UK
| | - Alison Richardson
- 1 Faculty of Health Sciences, University of Southampton, Southampton, UK.,4 Cancer Care, University Hospital Southampton NHS Foundation Trust, Southampton, UK
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Skea ZC, Treweek S, Gillies K. 'It's trying to manage the work': a qualitative evaluation of recruitment processes within a UK multicentre trial. BMJ Open 2017; 7:e016475. [PMID: 28801422 PMCID: PMC5629709 DOI: 10.1136/bmjopen-2017-016475] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVES To explore trial site staff's perceptions regarding barriers and facilitators to local recruitment. DESIGN Qualitative semi-structured interviews with a range of trial site staff from four trial sites in the UK. Interviews were analysed thematically to identify common themes across sites, barriers that could be addressed and facilitators that could be shared with other sites. PARTICIPANTS 11 members of staff from four trial sites: clinical grant Co-applicant (n=1); Principal Investigators (n=3); Consultant Urologist (n=1); Research Nurses (n=5); Research Assistant (n=1). SETTING Embedded within an ongoing randomised controlled trial (the TISU trial). TISU is a UK multicentre trial comparing therapeutic interventions for ureteric stones. RESULTS Our study draws attention to the initial and ongoing burden of trial work that is involved throughout the duration of a clinical trial. In terms of building and sustaining a research culture, trial staff described the ongoing work of engagement that was required to ensure that clinical staff were both educated and motivated to help with the process of identifying and screening potential participants. Having adequate and sufficient organisational and staffing resources was highlighted as being a necessary prerequisite to successful recruitment both in terms of accessing potentially eligible patients and being able to maximise recruitment after patient identification. The nature of the research study design can also potentially generate challenging communicative work for recruiting staff which can prove particularly problematic. CONCLUSIONS Our paper adds to existing research highlighting the importance of the hidden and complex work that is involved in clinical trial recruitment. Those designing and supporting the operationalisation of clinical trials must recognise and support the mitigation of this 'work'. While much of the work is likely to be contextually sensitive at the level of local sites and for individual trials, some aspects are ubiquitous issues for delivery of trials more generally. TRIAL REGISTRATION NUMBER ISRCTN No 92289221; Pre-results.
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Affiliation(s)
- Zoë Christina Skea
- Health Services Research Unit, Health Sciences Building, University of Aberdeen, Aberdeen, Scotland, UK
| | - Shaun Treweek
- Health Services Research Unit, Health Sciences Building, University of Aberdeen, Aberdeen, Scotland, UK
| | - Katie Gillies
- Health Services Research Unit, Health Sciences Building, University of Aberdeen, Aberdeen, Scotland, UK
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Minaya GE, Fuentes-Delgado DJ, Ugalde A, Homedes N. A Missing Piece in Clinical Trial Inspections in Latin America: Interviews With Research Subjects in Peru. J Empir Res Hum Res Ethics 2017; 12:232-245. [PMID: 28728496 DOI: 10.1177/1556264617720756] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Most regulatory agencies conduct clinical trial (CT) site inspections, but the experiences and behaviors of research subjects and their knowledge of the rights and obligations that ensue from participating in a CT are seldom explored. The authors assessed the technical feasibility of incorporating interviews with participants in CT inspections. This article analyzes the responses of 13 CT participants, 14% ( n = 96) of those included in three tuberculosis (TB) CTs. Participants did not object to being interviewed and provided information not obtained during regular inspections. Participants were appreciative of the agency's concern for the integrity of the CT process. Most interviewees did not understand the consent form and were unaware that they were participating in an experiment with unapproved new drugs. Participants' decision to enroll in CT related to undue inducement and therapeutic misconception. Some patients' behaviors, undisclosed to researchers, could have compromised the integrity of the data collected.
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Affiliation(s)
| | | | | | - Núria Homedes
- 3 School of Public Health, The University of Texas, El Paso, TX, USA
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20
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Presseau J, Mutsaers B, Al-Jaishi AA, Squires J, McIntyre CW, Garg AX, Sood MM, Grimshaw JM. Barriers and facilitators to healthcare professional behaviour change in clinical trials using the Theoretical Domains Framework: a case study of a trial of individualized temperature-reduced haemodialysis. Trials 2017; 18:227. [PMID: 28532509 PMCID: PMC5440991 DOI: 10.1186/s13063-017-1965-9] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2016] [Accepted: 04/30/2017] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Implementing the treatment arm of a clinical trial often requires changes to healthcare practices. Barriers to such changes may undermine the delivery of the treatment making it more likely that the trial will demonstrate no treatment effect. The 'Major outcomes with personalized dialysate temperature' (MyTEMP) is a cluster-randomised trial to be conducted in 84 haemodialysis centres across Ontario, Canada to investigate whether there is a difference in major outcomes with an individualized dialysis temperature (IDT) of 0.5 °C below a patient's body temperature measured at the beginning of each haemodialysis session, compared to a standard dialysis temperature of 36.5 °C. To inform how to deploy the IDT across many haemodialysis centres, we assessed haemodialysis physicians' and nurses' perceived barriers and enablers to IDT use. METHODS We developed two topic guides using the Theoretical Domains Framework (TDF) to assess perceived barriers and enablers to IDT ordering and IDT setting (physician and nurse behaviours, respectively). We recruited a purposive sample of haemodialysis physicians and nurses from across Ontario and conducted in-person or telephone interviews. We used directed content analysis to double-code transcribed utterances into TDF domains, and inductive thematic analysis to develop themes. RESULTS We interviewed nine physicians and nine nurses from 11 Ontario haemodialysis centres. We identified seven themes of potential barriers and facilitators to implementing IDTs: (1) awareness of clinical guidelines and how IDT fits with local policies (knowledge; goals), (2) benefits and motivation to use IDT (beliefs about consequences; optimism; reinforcement; intention; goals), (3) alignment of IDTs with usual practice and roles (social/professional role and identity; nature of the behaviour; beliefs about capabilities), (4) thermometer availability/accuracy and dialysis machine characteristics (environmental context and resources), (5) impact on workload (beliefs about consequences; beliefs about capabilities), (6) patient comfort (behavioural regulation; beliefs about consequences; emotion), and (7) forgetting to prescribe or set IDT (memory, attention, decision making processes; emotion). CONCLUSIONS There are anticipatable barriers to changing healthcare professionals' behaviours to effectively deliver an intervention within a randomised clinical trial. A behaviour change framework can help to systematically identify such barriers to inform better delivery and evaluation of the treatment, therefore potentially increasing the fidelity of the intervention to increase the internal validity of the trial. These findings will be used to optimise the delivery of IDT in the MyTEMP trial and demonstrate how this approach can be used to plan intervention delivery in other clinical trials. TRIAL REGISTRATION ClinicalTrials.gov NCT02628366 . Registered November 16 2015.
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Affiliation(s)
- Justin Presseau
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, General Campus, 501 Smyth Road, Ottawa, Canada
- School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa, Ottawa, Canada
| | - Brittany Mutsaers
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, General Campus, 501 Smyth Road, Ottawa, Canada
- School of Psychology, University of Ottawa, Ottawa, Canada
| | - Ahmed A. Al-Jaishi
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON Canada
| | - Janet Squires
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, General Campus, 501 Smyth Road, Ottawa, Canada
- School of Nursing, University of Ottawa, Ottawa, Canada
| | - Christopher W. McIntyre
- Division of Nephrology, Departments of Medicine, Epidemiology and Biostatistics, Western University, London, ON Canada
| | - Amit X. Garg
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON Canada
- Division of Nephrology, Departments of Medicine, Epidemiology and Biostatistics, Western University, London, ON Canada
| | - Manish M. Sood
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, General Campus, 501 Smyth Road, Ottawa, Canada
- School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa, Ottawa, Canada
| | - Jeremy M. Grimshaw
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, General Campus, 501 Smyth Road, Ottawa, Canada
- School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa, Ottawa, Canada
- Department of Medicine, University of Ottawa, Ottawa, Canada
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Staff experiences of closing out a clinical trial involving withdrawal of treatment: qualitative study. Trials 2017; 18:61. [PMID: 28173843 PMCID: PMC5297163 DOI: 10.1186/s13063-017-1813-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2016] [Accepted: 01/24/2017] [Indexed: 11/10/2022] Open
Abstract
Background The ending of a clinical trial may be challenging, particularly if staff are required to withdraw the investigated treatment(s); however, this aspect of trial work is surprisingly under-researched. To address this gap, we explored the experiences of staff involved in closing out a trial that entailed withdrawal of treatment (insulin pumps) from some patients. Methods Interviews were conducted with n = 22 staff, recruited from seven trial sites. Data were analysed thematically. Results Staff described a myriad of ethical and emotional challenges at closeout, many of which had been unforeseen when the trial began. A key challenge for staff was that, while patients gave their agreement to participate on the understanding that pump treatment could be withdrawn, they often found themselves benefitting from this regimen in ways they could not have foreseen. Hence, as the trial progressed, patients became increasingly anxious about withdrawal of treatment. This situation forced staff to consider whether the consent patients had given at the outset remained valid; it also presented them with a dilemma at closeout because many of those who had wanted to remain on a pump did not meet the clinical criteria required for post-trial funding. When deciding whether to withdraw treatment, staff not only had to take funding pressures and patient distress into account, but they also found themselves caught between an ethic of Hippocratic individualism and one of utilitarianism. These conflicting pressures and ethical considerations resulted in staff decision-making varying across the sites, an issue that some described as a further source of ethical unease. Staff concluded that, had there been more advanced planning and discussion, and greater accountability to an ethics committee, some of the challenges they had confronted at closeout could have been lessened or even prevented. Conclusions The same kinds of ethical issues that may vex staff at the beginning of a trial (e.g. patients having unrealistic expectations of trial participation; staff experiencing conflicts between research and clinical roles) may re-present themselves at the end. To safeguard the wellbeing of staff and patients, greater planning, coordination and ethical oversight should go into the closeout of trials involving withdrawal of treatment(s). Trial registration International Standard Randomised Controlled Trials Number (ISRCTN) Registry, ISRCTN61215213. Registered on 11 May 2011 Electronic supplementary material The online version of this article (doi:10.1186/s13063-017-1813-y) contains supplementary material, which is available to authorized users.
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Wozniak LA, Soprovich A, Rees S, Johnson ST, Majumdar SR, Johnson JA. A qualitative study examining healthcare managers and providers' perspectives on participating in primary care implementation research. BMC Health Serv Res 2016; 16:316. [PMID: 27473755 PMCID: PMC4965883 DOI: 10.1186/s12913-016-1577-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2015] [Accepted: 07/21/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Primary care reforms should be supported by high-quality evidence across the entire life cycle of research. Front-line healthcare providers play an increasing role in implementation research. We recently evaluated two interventions for people with type 2 diabetes (T2D) in partnership with four Primary Care Networks (PCNs) in Alberta, Canada. Here, we report healthcare professionals perspectives on participating in primary care implementation research. METHODS Guided by the RE-AIM framework, we collected qualitative data before, during, and after both interventions. We conducted 34 in-person or telephone interviews with 17 individual PCN professionals. We used content analysis to identify emerging codes and concepts. RESULTS Two major themes emerged from the data. First, healthcare managers were eager to conduct implementation research in a primary care setting. Second, regardless of willingness to conduct research, there were challenges to implementing experimental study designs for both interventions. PCN professionals presumed the interventions were better than usual care, expressed role conflict, and reported administrative burdens related to research participation. Perceptions of patient vulnerability and an obligation to intervene exacerbated these issues. CONCLUSIONS Healthcare professionals with limited practical research experience might not foresee the challenges in implementing experimental study designs in primary care settings to generate high-quality evidence. These issues are intensified when healthcare professionals perceive target patient populations as vulnerable and in need of intervention based on the presenting illness. Possible solutions include further research training, involving healthcare professionals in study design development, and using non-clinical staff to conduct research activities, particularly among acutely unwell patient populations.
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Affiliation(s)
- Lisa A Wozniak
- 2-040 Li Ka Shing Centre for Health Research Innovation, School of Public Health, University of Alberta, Edmonton, T6G 2G3, Canada
| | - Allison Soprovich
- 2-040 Li Ka Shing Centre for Health Research Innovation, School of Public Health, University of Alberta, Edmonton, T6G 2G3, Canada
| | - Sandra Rees
- 2-040 Li Ka Shing Centre for Health Research Innovation, School of Public Health, University of Alberta, Edmonton, T6G 2G3, Canada
| | - Steven T Johnson
- 2-040 Li Ka Shing Centre for Health Research Innovation, School of Public Health, University of Alberta, Edmonton, T6G 2G3, Canada.,Faculty of Health Disciplines, Athabasca University, Athabasca, AB, Canada
| | - Sumit R Majumdar
- 5-112 Clinical Sciences, Department of Medicine, University of Alberta, Edmonton, T6G 2G3, Canada
| | - Jeffrey A Johnson
- 2-040 Li Ka Shing Centre for Health Research Innovation, School of Public Health, University of Alberta, Edmonton, T6G 2G3, Canada.
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Keller PH, Grondin O, Tison F, Gonon F. How Health Professionals Conceptualize and Represent Placebo Treatment in Clinical Trials and How Their Patients Understand It: Impact on Validity of Informed Consent. PLoS One 2016; 11:e0155940. [PMID: 27195806 PMCID: PMC4873029 DOI: 10.1371/journal.pone.0155940] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2015] [Accepted: 05/08/2016] [Indexed: 12/30/2022] Open
Abstract
Context Previous studies suggested that many patients, who have given their informed consent to participate in randomized controlled trials (RCT), have somewhat limited understanding of what a placebo treatment is. We hypothesized that the relationship between patients and their health professionals plays a central role in this understanding. Methods We interviewed 12 patients included in RCTs (nine suffering from Parkinson’s disease and three from Huntington’s disease) and 18 health professionals involved with RCTs (eight principal investigators, four associated physicians and six clinical research associates). Semi-structured interviews were conducted after the RCTs had ended but before the treatment allocation was revealed. Results Only two patients clearly understood the aim of placebo-controlled RCTs. Only one principal investigator said she asks all her patients whether they agree to participate in RCTs. The seven others said they only ask patients who seem more likely to be compliant. Their selection criteria included docility and personality traits associated in other studies with enhanced placebo responses. According to 13 of the 18 health professionals, their relationship with patients may influence the amplitude of the placebo response. All but one clinical research associates added that the placebo response could result from a “maternal” type of care. All principal investigators said they have a strong influence on their patient's decision to participate. Finally, when interviewees were asked to narrate a memory of a medically unexplained healing, in eight of 11 physicians' narratives the beneficiary was a child while in 10 of 12 patients' narratives it was an adult. Conclusion Our observations suggest that the interrelationship between health professionals and patients involved in RCTs could be compared to that between parents and children. Therefore, adherence to formal rules regarding informed consent does not ensure a balanced relationship between patients and health professionals.
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Affiliation(s)
- Pascal-Henri Keller
- Department of Psychology, University of Poitiers, 86000, Poitiers, France
- * E-mail:
| | - Olivier Grondin
- Department of Psychology, University of Bordeaux, 33076 Bordeaux, France
| | - François Tison
- Institute of Neurodegenerative Diseases, University of Bordeaux, 33076 Bordeaux, France
- Centre National de la Recherche Scientifique, CNRS UMR5293, 33076 Bordeaux, France
| | - Francois Gonon
- Institute of Neurodegenerative Diseases, University of Bordeaux, 33076 Bordeaux, France
- Centre National de la Recherche Scientifique, CNRS UMR5293, 33076 Bordeaux, France
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Burridge LH, Foster MM, Donald M, Zhang J, Russell AW, Jackson CL. Making sense of change: patients' views of diabetes and GP-led integrated diabetes care. Health Expect 2016; 19:74-86. [PMID: 25565290 PMCID: PMC5055219 DOI: 10.1111/hex.12331] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/05/2014] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Health system reform is directed towards better management of diabetes. However, change can be difficult, and patients' perspectives are a key aspect of implementing change. OBJECTIVE This study investigated patients' perceptions and experiences of type 2 diabetes (T2DM), self-care and engagement with GP-led integrated diabetes care. DESIGN Qualitative interviews were conducted with purposively selected patients with T2DM following their initial medical appointment in the new model of care. Normalization process theory was used to orientate the thematic analysis, to explain the work of implementing change. SETTING Two specialist GP-based complex diabetes services in primary care in Brisbane, Australia. PARTICIPANTS Intervention group patients (n = 30) in a randomized controlled trial to evaluate a model of GP-led integrated care for complex T2DM. MAIN OUTCOME MEASURES Participants' experiences and perceptions of diabetes management and a GP-led model of care. RESULTS Three themes were identified: sensibility of change, 'diabetic life' and diabetes care alliance. The imperative of change made sense, but some participants experienced dissonance between this rational view and their lived reality. Diabetes invaded life, revealing incongruities between participants' values and living with diabetes. They appreciated a flexible and personalized approach to care. DISCUSSION Participants responded to advice in ways that seemed rational within the complexities of their life context. Their diabetes partnerships with health professionals coupled providers' biomedical expertise with patients' contextual expertise. CONCLUSIONS Learning to manage relationships with various health professionals adds to patients' diabetes-related work. Providers need to adopt a flexible, interactive approach and foster trust, to enable better diabetes care.
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Affiliation(s)
- Letitia H. Burridge
- Discipline of General PracticeSchool of MedicineThe University of QueenslandHerstonQueenslandAustralia
| | - Michele M. Foster
- Social Work and Social PolicySchool of Social Work and Human ServicesThe University of QueenslandSt LuciaQueenslandAustralia
| | - Maria Donald
- Discipline of General PracticeSchool of MedicineThe University of QueenslandHerstonQueenslandAustralia
| | - Jianzhen Zhang
- Discipline of General PracticeSchool of MedicineThe University of QueenslandHerstonQueenslandAustralia
| | - Anthony W. Russell
- Department of Diabetes and EndocrinologyPrincess Alexandra HospitalWoolloongabbaQueenslandAustralia
| | - Claire L. Jackson
- Discipline of General PracticeSchool of MedicineThe University of QueenslandHerstonQueenslandAustralia
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Thomas N, Plant S, Woodward-Nutt K, Prior Y, Tyson S. Health care professionals' views of the factors influencing the decision to refer patients to a stroke rehabilitation trial. Trials 2015; 16:577. [PMID: 26680020 PMCID: PMC4683768 DOI: 10.1186/s13063-015-1115-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2015] [Accepted: 12/09/2015] [Indexed: 11/23/2022] Open
Abstract
Background Effective recruitment is an essential element of successful research but notoriously difficult to achieve. This article examines health care professionals’ views on the factors influencing decision-making regarding referral to a stroke rehabilitation trial. Methods Semi-structured interviews and a card-sorting task were undertaken with stroke service staff in acute and community hospital trusts. Data analysis used a thematic framework approach. Results Twenty-seven qualified health care professionals from 12 (6 acute and 6 community) hospital trusts and one charity participated. Four main factors emerged: patient-related, professional views, the organisation and research logistics, which all contributed to staff’s decision about whether to refer patients to a trial. Clinicians identified patient-related factors as the most frequent influence and considered themselves the patients’ advocate. They used their knowledge of the patient to anticipate the patients’ reaction to possible participation and tended to only refer those whom they perceived would respond positively. Participants also identified experience of research, a sense of ownership of the project and a positive view of the intervention being evaluated as factors influencing referral. The need to prioritise clinical matters, meet managerial demands and cope with constant change were organisational factors impacting negatively on referral. Staff often simply forgot about recruitment in the face of other higher priorities. Quick, simple, flexible research processes that were closely aligned with existing ways of working were felt to facilitate recruitment. Conclusions Patient- and professional-related factors were the most frequent influence on clinicians’ recruitment decisions, which often had a ‘gate-keeping’ effect. Managerial and clinical responsibility to juggle multiple (often higher) priorities was also an important factor. To facilitate recruitment, researchers need to develop strategies to approach potential participants as directly as possible to enable them to make their own decisions about participation; ensure that research processes are as quick and simple as possible; align with existing clinical pathways and systems; and give regular reminders and ongoing support to promote recruitment. Trial registration ISRCTN, 98287938. Registered 6 May 2015 Electronic supplementary material The online version of this article (doi:10.1186/s13063-015-1115-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Nessa Thomas
- Salford Royal NHS Foundation Trust, Salford, UK.
| | - Sarah Plant
- School of Nursing, Midwifery & Social Work, University of Manchester, Manchester, UK.
| | - Kate Woodward-Nutt
- School of Nursing, Midwifery & Social Work, University of Manchester, Manchester, UK.
| | - Yeliz Prior
- Centre for Health Sciences Research, University of Salford, Salford, UK. .,Mid Cheshire Hospitals NHS Foundation Trust, Cheshire, UK.
| | - Sarah Tyson
- School of Nursing, Midwifery & Social Work, University of Manchester, Manchester, UK. .,Stroke Research Centre, University of Manchester, Jean McFarlane Building, Oxford Road, Manchester, M13 9PL, UK.
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Lawton J, Kirkham J, White D, Rankin D, Cooper C, Heller S. Uncovering the emotional aspects of working on a clinical trial: a qualitative study of the experiences and views of staff involved in a type 1 diabetes trial. Trials 2015; 16:3. [PMID: 25566971 PMCID: PMC4326295 DOI: 10.1186/1745-6215-16-3] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2014] [Accepted: 12/03/2014] [Indexed: 11/17/2022] Open
Abstract
Background The perspectives and experiences of trial staff are increasingly being investigated as these can be used to improve recruitment, adherence to trial protocols and support given to future staff. We interviewed staff working on a type 1 diabetes trial in order to aid interpretation of trial findings, inform recommendations for the rollout of the treatments investigated and provide recommendations for the conduct of future trials. However, our interviews uncovered aspects of trial work erstwhile unrecognised or underreported in the trials literature, and it is these which form the focus of this paper. Methods In-depth interviews were conducted with (n = 18) staff, recruited from seven centres, who were involved in recruitment and trial delivery. Data were analysed thematically. Results Alongside logistical and practical issues which made trial work challenging, staff often talked spontaneously and at length about how trial work had affected them emotionally. Staff not only described the emotional stresses arising from having to meet recruitment targets and from balancing research roles with clinical responsibilities, they also discussed having to emotionally manage patients and their colleagues. The emotional aspects of trial work particularly came to the fore when staff notified patients about their treatment allocation. On such occasions, staff described having to employ emotional strategies to pre-empt and manage potential patient disappointment and anger. Staff also described having to manage their own emotions when patients withdrew from the trial or were not randomised to the treatment arm which, in their clinical judgment, would have been in their best interests. To help address the emotional challenges they encountered, staff highlighted a need for more practical, emotional and specialist psychological support. Conclusions More attention should be paid to the emotional aspects of trial work to help ensure trial staff are adequately supported. Such support could comprise: increased training for staff to improve their own and patients’ understandings of randomization, role-play to develop techniques to manage patient anger and disappointment, sharing of good practice, formalised team support with psychological input and access to specialist psychological support to troubleshoot complex emotional and ethical issues.
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Affiliation(s)
- Julia Lawton
- Centre for Population Health Sciences, University of Edinburgh, Teviot Place, Edinburgh EH8 9AG, UK.
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Reynolds J, DiLiberto D, Mangham-Jefferies L, Ansah EK, Lal S, Mbakilwa H, Bruxvoort K, Webster J, Vestergaard LS, Yeung S, Leslie T, Hutchinson E, Reyburn H, Lalloo DG, Schellenberg D, Cundill B, Staedke SG, Wiseman V, Goodman C, Chandler CIR. The practice of 'doing' evaluation: lessons learned from nine complex intervention trials in action. Implement Sci 2014; 9:75. [PMID: 24935096 PMCID: PMC4079170 DOI: 10.1186/1748-5908-9-75] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2014] [Accepted: 06/13/2014] [Indexed: 01/16/2023] Open
Abstract
Background There is increasing recognition among trialists of the challenges in understanding how particular ‘real-life’ contexts influence the delivery and receipt of complex health interventions. Evaluations of interventions to change health worker and/or patient behaviours in health service settings exemplify these challenges. When interpreting evaluation data, deviation from intended intervention implementation is accounted for through process evaluations of fidelity, reach, and intensity. However, no such systematic approach has been proposed to account for the way evaluation activities may deviate in practice from assumptions made when data are interpreted. Methods A collective case study was conducted to explore experiences of undertaking evaluation activities in the real-life contexts of nine complex intervention trials seeking to improve appropriate diagnosis and treatment of malaria in varied health service settings. Multiple sources of data were used, including in-depth interviews with investigators, participant-observation of studies, and rounds of discussion and reflection. Results and discussion From our experiences of the realities of conducting these evaluations, we identified six key ‘lessons learned’ about ways to become aware of and manage aspects of the fabric of trials involving the interface of researchers, fieldworkers, participants and data collection tools that may affect the intended production of data and interpretation of findings. These lessons included: foster a shared understanding across the study team of how individual practices contribute to the study goals; promote and facilitate within-team communications for ongoing reflection on the progress of the evaluation; establish processes for ongoing collaboration and dialogue between sub-study teams; the importance of a field research coordinator bridging everyday project management with scientific oversight; collect and review reflective field notes on the progress of the evaluation to aid interpretation of outcomes; and these approaches should help the identification of and reflection on possible overlaps between the evaluation and intervention. Conclusion The lessons we have drawn point to the principle of reflexivity that, we argue, needs to become part of standard practice in the conduct of evaluations of complex interventions to promote more meaningful interpretations of the effects of an intervention and to better inform future implementation and decision-making.
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Affiliation(s)
- Joanna Reynolds
- Department of Social and Environmental Health Research, London School of Hygiene & Tropical Medicine, 15-17 Tavistock Place, London WC1H 9SH, UK.
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Conducting qualitative research within Clinical Trials Units: avoiding potential pitfalls. Contemp Clin Trials 2014; 38:338-43. [PMID: 24937019 DOI: 10.1016/j.cct.2014.06.002] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2014] [Revised: 05/30/2014] [Accepted: 06/05/2014] [Indexed: 11/23/2022]
Abstract
The value of using qualitative research within or alongside randomised controlled trials (RCTs) is becoming more widely accepted. Qualitative research may be conducted concurrently with pilot or full RCTs to understand the feasibility and acceptability of the interventions being tested, or to improve trial conduct. Clinical Trials Units (CTUs) in the United Kingdom (UK) manage large numbers of RCTs and, increasingly, manage the qualitative research or collaborate with qualitative researchers external to the CTU. CTUs are beginning to explicitly manage the process, for example, through the use of standard operating procedures for designing and implementing qualitative research with trials. We reviewed the experiences of two UK Clinical Research Collaboration (UKCRC) registered CTUs of conducting qualitative research concurrently with RCTs. Drawing on experiences gained from 15 studies, we identify the potential for the qualitative research to undermine the successful completion or scientific integrity of RCTs. We show that potential problems can arise from feedback of interim or final qualitative findings to members of the trial team or beyond, in particular reporting qualitative findings whilst the trial is on-going. The problems include: We make recommendations for improving the management of qualitative research within CTUs.
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Newington L, Metcalfe A. Researchers' and clinicians' perceptions of recruiting participants to clinical research: a thematic meta-synthesis. J Clin Med Res 2014; 6:162-72. [PMID: 24734142 PMCID: PMC3985558 DOI: 10.14740/jocmr1619w] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/08/2013] [Indexed: 11/16/2022] Open
Abstract
Background Recruiting the desired number of research participants is frequently problematic with resulting financial and clinical implications. The views of individuals responsible for participant recruitment have not been previously reviewed. This systematic review and thematic meta-synthesis explores researchers’ and clinicians’ experiences and perceptions of recruiting participants to clinical research, with the aim of informing improved recruitment systems and strategies. Methods Studies published between January 1995 and May 2013 were identified from: Ovid MEDLINE, Ovid EMBASE, Ovid PSYCHINFO, ASSIA, British Nursing Index, Scopus, Web of Science, CINAHL and PubMed. Included studies were original peer reviewed research, with qualitative methodologies and an aim of exploring the views of clinicians and/or researchers on recruitment to clinical research. Studies discussing the recruitment of patients unable to give informed consent were excluded. The findings sections of the relevant studies were free coded to identify key concepts which were grouped into hierarchical themes. The quality of the identified studies was assessed and the relative contribution of each paper was checked to ensure individual studies did not dominate in any theme. Results Eighteen relevant papers were identified which examined the views of researchers and clinicians in 10 clinical specialties. Five main themes emerged: building a research community, securing resources, the nature of research, professional identities and recruitment strategies. The views of researchers and clinicians were similar, although the role of ‘researcher’ was inconsistently defined. Conclusions The general experience of recruiting participants to clinical research was one of competition and compromise. Competition arose over funding, staffing and participants, and between clinical and research responsibilities. Compromise was needed to create study designs that were acceptable to patients, clinicians and researchers. Forging relationships between clinical and research teams featured extensively, however the involvement of patients and the public within the research community was rarely discussed.
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Affiliation(s)
- Lisa Newington
- NIHR Biomedical Research Centre, Guy's and St Thomas' NHS Foundation Trust and King's College London, Guy's Hospital, SE1 9RT, UK
| | - Alison Metcalfe
- Florence Nightingale School of Nursing and Midwifery, King's College London, James Clerk Maxwell Building, Waterloo Road, SE1 8WA, UK
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Donovan JL, Paramasivan S, de Salis I, Toerien M. Clear obstacles and hidden challenges: understanding recruiter perspectives in six pragmatic randomised controlled trials. Trials 2014; 15:5. [PMID: 24393291 PMCID: PMC3892115 DOI: 10.1186/1745-6215-15-5] [Citation(s) in RCA: 177] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2013] [Accepted: 12/20/2013] [Indexed: 11/11/2022] Open
Abstract
Background Recruitment of sufficient participants in an efficient manner is still widely acknowledged to be a major challenge to the mounting and completion of randomised controlled trials (RCTs). Few recruitment interventions have involved staff undertaking recruitment. This study aimed i) to understand the recruitment process from the perspective of recruiters actively recruiting RCT participants in six pragmatic RCTs, and ii) to identify opportunities for interventions to improve recruitment. Methods Interviews were undertaken with 72 individuals (32 doctors or RCT Chief investigators (CIs); 40 nurses/other health professionals) who were actively recruiting participants in six RCTs to explore their experiences of recruitment. The RCTs varied in scale, duration, and clinical contexts. Interviews were fully transcribed and analysed using qualitative content and thematic analytic methods derived from grounded theory. For this analysis, data were systematically extracted from each RCT and synthesised across all six RCTs to produce a detailed and nuanced understanding of the recruitment process from the perspectives of the recruiters. Results Recruiters readily identified organisational difficulties, fewer than expected eligible patients, and patients’ treatment preferences as the key barriers to recruitment. As they described their experiences of recruitment, several previously hidden issues related to their roles as researchers and clinicians emerged, imbued with discomfort and emotion. The synthesis across the RCTs showed that doctors were uncomfortable about aspects of patient eligibility and the effectiveness of interventions, whereas nurses were anxious about approaching potential RCT participants and conflicts between the research and their clinical responsibilities. Recruiters seemed unaware that their views contributed to recruitment difficulties. Their views were not known to RCT CIs. Training and support needs were identified for both groups of staff. Conclusions The synthesis showed that recruitment to these RCTs was a complex and fragile process. Clear obstacles were identified but hidden challenges related to recruiters’ roles undermined recruitment, unbeknown to RCT CIs. Qualitative research can elicit and identify the hidden challenges. Training and support are then needed for recruiters to become more comfortable with the design and principles of RCTs, so that they can engage more openly with potentially eligible participants and create a more resilient recruitment process.
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Affiliation(s)
- Jenny L Donovan
- School of Social and Community Medicine, University of Bristol, Canynge Hall, Bristol BS8 2PS, UK.
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Andergassen U, Kasprowicz NS, Hepp P, Schindlbeck C, Harbeck N, Kiechle M, Sommer H, Beckmann MW, Friese K, Janni W, Rack B, Scholz C. Participation in the SUCCESS-A Trial Improves Intensity and Quality of Care for Patients with Primary Breast Cancer. Geburtshilfe Frauenheilkd 2013; 73:63-69. [PMID: 24771886 DOI: 10.1055/s-0032-1328147] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2012] [Revised: 12/13/2012] [Accepted: 12/13/2012] [Indexed: 12/21/2022] Open
Abstract
The SUCCESS-A trial is a prospective, multicenter, phase III clinical trial for high-risk primary breast cancer. It compares disease-free survival after randomization in patients treated with fluorouracil, epirubicin and cyclophosphamide followed by 3 cycles of docetaxel (FEC-D) with that of patients treated with 3 cycles of FEC followed by 3 cycles of gemcitabine and docetaxel (FEC-DG). After a second randomization patients were treated with zoledronate for 2 or 5 years. A total of 251 centers took part in the trial and 3754 patients were recruited over a period of 18 months which ended in March 2007. In a questionnaire-based survey we investigated the impact of enrollment in the trial on patient care, the choice of chemotherapy protocol and access to current oncologic information as well as overall satisfaction in the respective centers. Analysis of the 78 questionnaires returned showed that 40 % of the centers had never previously enrolled patients with these indications in clinical studies. Prior to participating in the study, 4 % of the centers prescribed CMF or other protocols in patients with high-primary breast cancer risk, 46 % administered anthracycline-based chemotherapy and 50 % gave taxane-based chemotherapy. Around half of the participating centers noted that intensity of care and overall quality of care became even better and that access to breast cancer-specific information improved through participation in the trial. After their experience with the SUCCESS-A trial, all of the centers stated that they were prepared to enroll patients in clinical phase III trials again in the future. These data indicate that both patients and physicians benefit from clinical trials, as enrollment improves treatment strategies and individual patient care, irrespective of study endpoints.
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Affiliation(s)
- U Andergassen
- Klinik und Poliklinik für Frauenheilkunde und Geburtshilfe, Klinikum der Ludwig-Maximilians-Universität, München
| | - N S Kasprowicz
- Frauenklinik, Klinikum der Heinrich-Heine-Universität Düsseldorf, Düsseldorf
| | - P Hepp
- Frauenklinik, Klinikum der Heinrich-Heine-Universität Düsseldorf, Düsseldorf
| | | | - N Harbeck
- Klinik und Poliklinik für Frauenheilkunde und Geburtshilfe, Klinikum der Ludwig-Maximilians-Universität, München ; Brustzentrum der Universität, Klinikum der Ludwig-Maximilians-Universität, München
| | - M Kiechle
- Frauenklinik, Klinikum rechts der Isar der TU München, München
| | - H Sommer
- Klinik und Poliklinik für Frauenheilkunde und Geburtshilfe, Klinikum der Ludwig-Maximilians-Universität, München
| | | | - K Friese
- Klinik und Poliklinik für Frauenheilkunde und Geburtshilfe, Klinikum der Ludwig-Maximilians-Universität, München
| | - W Janni
- Frauenklinik, Klinikum der Universität Ulm, Ulm
| | - B Rack
- Klinik und Poliklinik für Frauenheilkunde und Geburtshilfe, Klinikum der Ludwig-Maximilians-Universität, München
| | - C Scholz
- Frauenklinik, Klinikum der Universität Ulm, Ulm
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