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Talbot R, Higham R, Croft J, Ainsworth G, Brown S, Kelly R, Stocken D, Thomson S, Rousseau N. Rapid qualitative analysis of recruitment obstacles in the FORVAD (Posterior Cervical Foraminotomy surgery versus Anterior Cervical Discectomy surgery in the treatment of cervical brachialgia) randomised, controlled trial. Trials 2024; 25:546. [PMID: 39152476 PMCID: PMC11330054 DOI: 10.1186/s13063-024-08391-4] [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] [Received: 03/12/2024] [Accepted: 08/08/2024] [Indexed: 08/19/2024] Open
Abstract
BACKGROUND The number of surgical trials is increasing but such trials can be complex to deliver and pose specific challenges. A multi-centre, Phase III, RCT comparing Posterior Cervical Foraminotomy versus Anterior Cervical Discectomy and Fusion in the Treatment of Cervical Brachialgia (FORVAD Trial) was unable to recruit to target. A rapid qualitative study was conducted during trial closedown to understand the experiences of healthcare professionals who participated in the FORVAD Trial, with the aim of informing future research in this area. METHODS Semi-structured interviews were conducted with 18 healthcare professionals who had participated in the FORVAD Trial. Interviews explored participants' experiences of the FORVAD trial. A rapid qualitative analysis was conducted, informed by Normalisation Process Theory. RESULTS Four main themes were generated in the data analysis: (1) individual vs. community equipoise; (2) trial set-up and delivery; (3) identifying and approaching patients; and (4) timing of randomisation. The objectives of the FORVAD trial made sense to participants and they supported the idea that there was clinical or collective equipoise regarding the two FORVAD interventions; however, many surgeons had treatment preferences and lacked individual equipoise. The site which had most recruitment success had adopted a more structured process for identification and recruitment of patients, whereas other sites that adopted more "ad hoc" screening strategies struggled to identify patients. Randomisation on the day of surgery caused both medico-legal and practical concerns at some sites. CONCLUSIONS Organisation and implementation of a surgical trial in neurosurgery is complex and presents many challenges. Sites often reported low recruitment and discussed the logistical issues of conducting a complex surgical RCT. Future trials in neurosurgery may need to offer more flexibility and time during set-up to maximise opportunities for larger recruitment numbers. Rapid qualitative analysis informed by Normalisation Process Theory was able to quickly identify key issues with trial implementation so rapid qualitative analysis may be a useful approach for teams conducting qualitative research in trials. TRIAL REGISTRATION ISRCTN, ISRCTN reference: 10,133,661. Registered 23rd November 2018.
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Affiliation(s)
- Rebecca Talbot
- 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
| | - Julie Croft
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Gemma Ainsworth
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Sarah Brown
- 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
| | - Deborah Stocken
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Simon Thomson
- Department of Neurosurgery, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Nikki Rousseau
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK.
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Quigley M, McKenna C, Webb TL. Best practices for recruitment in veterinary clinical trials. Front Vet Sci 2024; 11:1418747. [PMID: 39086763 PMCID: PMC11288851 DOI: 10.3389/fvets.2024.1418747] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2024] [Accepted: 06/11/2024] [Indexed: 08/02/2024] Open
Abstract
A successful clinical trial requires participants, but many factors can impede effective study recruitment. To better recruit for quality veterinary clinical trials in client-owned animals that lead to improved evidence-based patient care and outcomes, there is a collective need to share and implement current best practices for recruitment strategies. These strategies should utilize a holistic view of recruitment, encompassing study design and logistics, representative participation, incentives, personnel resources, advertising, and participant retention. Although human clinical trial data and resources can provide guidance, effort also needs to be put into evaluating current practices and opportunities for process improvement that are specific to the conduct of veterinary clinical trials. Considering the power of pets as naturally occurring models of disease and as sentinels, improved conduct of veterinary clinical research has the potential to inform human health outcomes. Continued development of collaborations surrounding best practices and training opportunities in veterinary clinical research will improve the impact of veterinary clinical trials teams, while also promoting workforce development and alternate career paths for veterinary professionals.
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Affiliation(s)
- Mindy Quigley
- Veterinary Clinical Research Office, Virginia-Maryland College of Veterinary Medicine, Virginia Tech, Blacksburg, VA, United States
| | - Charly McKenna
- Clinical Studies, Department of Clinical Sciences, Ontario Veterinary College, University of Guelph, Guelph, ON, Canada
| | - Tracy L. Webb
- Department of Clinical Sciences, College of Veterinary Medicine and Biomedical Sciences, Colorado State University, Fort Collins, CO, United States
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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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Arundel C, Mott A. Recruitment and retention interventions in surgical and wound care trials: A systematic review. PLoS One 2023; 18:e0288028. [PMID: 37471398 PMCID: PMC10358880 DOI: 10.1371/journal.pone.0288028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Accepted: 06/16/2023] [Indexed: 07/22/2023] Open
Abstract
BACKGROUND Recruitment and retention to surgical trials has previously been reported to be problematic, resulting in research waste. Surgery often results in wounds, meaning these trials are likely to have similar populations. There is currently no systematic assessment of effective strategies for these populations and hence, systematic assessment of these was deemed to be of importance. METHODS A systematic review was conducted. Studies were eligible if they were randomised controlled trials undertaken to test an intervention to improve recruitment or retention within a surgical or wound based host randomised controlled trial. MEDLINE, EMBASE, Cochrane Library, ORRCA Database and the Northern Ireland Hub for Trials Methodology Research SWAT Repository Store were searched. Two independent reviewers screened the search results and extracted data for eligible studies using a piloted extraction form. A narrative synthesis was used due to a lack of heterogeneity between strategies which prevented meta-analysis. RESULTS A total of 2133 records were identified which resulted in 13 ultimately being included in the review; seven on recruitment and six on retention. All included studies were based within surgical host trials. Four of the seven recruitment studies focussed on the provision of consent information to participants, one focussed on study set up and one on staff training, with only one relating to consent information finding any significant effect. A range of retention strategies were assessed by the included studies, however only two found (pen vs no pen, mailing strategies) found any significant effect. CONCLUSION The included studies within a trial were all conducted within surgical trials. There was significant variation in strategies used, and limited replications and therefore further assessment may be warranted. Given the lack of studies embedded within wound care trials, further studies in this area are recommended. TRIAL REGISTRATION PROSPERO (CRD42020205475).
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Affiliation(s)
- Catherine Arundel
- York Trials Unit, Department of Health Sciences, University of York, Heslington, York, United Kingdom
| | - Andrew Mott
- York Trials Unit, Department of Health Sciences, University of York, Heslington, York, United Kingdom
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Beard DJ, Campbell MK, Blazeby JM, Carr AJ, Weijer C, Cuthbertson BH, Buchbinder R, Pinkney T, Bishop FL, Pugh J, Cousins S, Harris I, Lohmander LS, Blencowe N, Gillies K, Probst P, Brennan C, Cook A, Farrar-Hockley D, Savulescu J, Huxtable R, Rangan A, Tracey I, Brocklehurst P, Ferreira ML, Nicholl J, Reeves BC, Hamdy F, Rowley SC, Lee N, Cook JA. Placebo comparator group selection and use in surgical trials: the ASPIRE project including expert workshop. Health Technol Assess 2021; 25:1-52. [PMID: 34505829 PMCID: PMC8450778 DOI: 10.3310/hta25530] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND The use of placebo comparisons for randomised trials assessing the efficacy of surgical interventions is increasingly being considered. However, a placebo control is a complex type of comparison group in the surgical setting and, although powerful, presents many challenges. OBJECTIVES To provide a summary of knowledge on placebo controls in surgical trials and to summarise any recommendations for designers, evaluators and funders of placebo-controlled surgical trials. DESIGN To carry out a state-of-the-art workshop and produce a corresponding report involving key stakeholders throughout. SETTING A workshop to discuss and summarise the existing knowledge and to develop the new guidelines. RESULTS To assess what a placebo control entails and to assess the understanding of this tool in the context of surgery is considered, along with when placebo controls in surgery are acceptable (and when they are desirable). We have considered ethics arguments and regulatory requirements, how a placebo control should be designed, how to identify and mitigate risk for participants in these trials, and how such trials should be carried out and interpreted. The use of placebo controls is justified in randomised controlled trials of surgical interventions provided that there is a strong scientific and ethics rationale. Surgical placebos might be most appropriate when there is poor evidence for the efficacy of the procedure and a justified concern that results of a trial would be associated with a high risk of bias, particularly because of the placebo effect. CONCLUSIONS The use of placebo controls is justified in randomised controlled trials of surgical interventions provided that there is a strong scientific and ethics rationale. Feasibility work is recommended to optimise the design and implementation of randomised controlled trials. An outline for best practice was produced in the form of the Applying Surgical Placebo in Randomised Evaluations (ASPIRE) guidelines for those considering the use of a placebo control in a surgical randomised controlled trial. LIMITATIONS Although the workshop participants involved international members, the majority of participants were from the UK. Therefore, although every attempt was made to make the recommendations applicable to all health systems, the guidelines may, unconsciously, be particularly applicable to clinical practice in the UK NHS. FUTURE WORK Future work should evaluate the use of the ASPIRE guidelines in making decisions about the use of a placebo-controlled surgical trial. In addition, further work is required on the appropriate nomenclature to adopt in this space. FUNDING Funded by the Medical Research Council UK and the National Institute for Health Research as part of the Medical Research Council-National Institute for Health Research Methodology Research programme.
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Affiliation(s)
- David J Beard
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | | | - Jane M Blazeby
- Centre for Surgical Research, NIHR Bristol and Weston Biomedical Research Centre, Population Health Sciences, University of Bristol, Bristol, UK
| | - Andrew J Carr
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Charles Weijer
- Departments of Medicine, Epidemiology and Biostatistics, and Philosophy, Western University, London, ON, Canada
| | - Brian H Cuthbertson
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Rachelle Buchbinder
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Thomas Pinkney
- Academic Department of Surgery, University of Birmingham, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Felicity L Bishop
- Faculty of Environmental and Life Sciences, University of Southampton, Southampton, UK
| | - Jonathan Pugh
- The Oxford Uehiro Centre for Practical Ethics, University of Oxford, Oxford, UK
| | - Sian Cousins
- Centre for Surgical Research, NIHR Bristol and Weston Biomedical Research Centre, Population Health Sciences, University of Bristol, Bristol, UK
| | - Ian Harris
- Faculty of Medicine, South Western Sydney Clinical School, University of New South Wales, Sydney, NSW, Australia
| | - L Stefan Lohmander
- Department of Clinical Sciences Lund, Orthopedics, Clinical Epidemiology Unit, Lund University, Lund, Sweden
| | - Natalie Blencowe
- Centre for Surgical Research, NIHR Bristol and Weston Biomedical Research Centre, Population Health Sciences, University of Bristol, Bristol, UK
| | - Katie Gillies
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Pascal Probst
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | | | - Andrew Cook
- Wessex Institute, University of Southampton, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | | | - Julian Savulescu
- The Oxford Uehiro Centre for Practical Ethics, University of Oxford, Oxford, UK
| | - Richard Huxtable
- Centre for Surgical Research, NIHR Bristol and Weston Biomedical Research Centre, Population Health Sciences, University of Bristol, Bristol, UK
| | - Amar Rangan
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
- Department of Health Sciences, University of York, York, UK
| | - Irene Tracey
- Nuffield Department of Clinical Neurosciences, University of Oxford, John Radcliffe Hospital, Oxford, UK
| | - Peter Brocklehurst
- Birmingham Clinical Trials Unit, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Manuela L Ferreira
- Faculty of Medicine and Health, Institute of Bone and Joint Research, Northern Clinical School, The University of Sydney, Sydney, NSW, Australia
| | - Jon Nicholl
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Barnaby C Reeves
- Clinical Trials Evaluation Unit Bristol Medical School, University of Bristol, Bristol Royal Infirmary, Bristol, UK
| | - Freddie Hamdy
- Nuffield Department of Surgical Sciences, University of Oxford, John Radcliffe Hospital, Oxford, UK
| | | | - Naomi Lee
- Editorial Department, The Lancet, London, UK
| | - Jonathan A Cook
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
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Crouse JJ, Morley KC, Buckley N, Dawson A, Seth D, Monds LA, Tickell A, Kay-Lambkin F, Chitty KM. Online interventions for people hospitalized for deliberate self-harm and problematic alcohol use: Lessons learned from the iiAIM trial. Bull Menninger Clin 2021; 85:123-142. [PMID: 34032460 DOI: 10.1521/bumc.2021.85.2.123] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Deliberate self-harm and suicide affect all age groups, sexes, and regions, and their prevention is a global health priority. Acute alcohol misuse and chronic alcohol misuse are strong, modifiable risk factors, and Internet interventions aiming to reduce alcohol misuse and comorbid mental health problems (e.g., depression) are a promising and effective treatment modality. The research team aimed to evaluate the feasibility and effectiveness of an Internet-based comorbidity intervention primarily aiming to reduce alcohol consumption, and secondarily to reduce readmission for deliberate self-harm and improve psychological outcomes among people hospitalized for deliberate self-harm who also engage in problematic alcohol use. However, due to several barriers to recruitment, the trial could not be completed and was discontinued. The authors present a "Lessons Learned" discussion and describe the Internet Intervention for Alcohol Improvement (iiAIM) trial, discuss the key barriers experienced by the research team, and recommend potential solutions that may help future trials in this area.
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Affiliation(s)
- Jacob J Crouse
- University of Sydney, Youth Mental Health and Technology Team, Brain & Mind Centre, Central Clinical School, Sydney, NSW, Australia
| | - Kirsten C Morley
- University of Sydney, Discipline of Addiction Medicine, Central Clinical School, Sydney, NSW, Australia
| | - Nicholas Buckley
- University of Sydney Faculty of Medicine and Health, Discipline of Pharmacology, Translational Australian Clinical Toxicology Program, Sydney, NSW, Australia
| | - Andrew Dawson
- University of Sydney Faculty of Medicine and Health, Discipline of Pharmacology, Translational Australian Clinical Toxicology Program, Sydney, NSW, Australia.,Royal Prince Alfred Hospital, Drug Health Services, Sydney, NSW, Australia
| | - Devanshi Seth
- Royal Prince Alfred Hospital, Drug Health Services, Sydney, NSW, Australia.,University of Sydney, Centenary Institute of Cancer Medicine and Cell Biology, Sydney, NSW, Australia, and the University of Sydney, Faculty of Medicine and Health, Sydney, NSW, Australia
| | - Lauren A Monds
- University of Sydney, Discipline of Addiction Medicine, Central Clinical School, Sydney, NSW, Australia
| | - Ashleigh Tickell
- University of Sydney, Youth Mental Health and Technology Team, Brain & Mind Centre, Central Clinical School, Sydney, NSW, Australia
| | - Frances Kay-Lambkin
- University of Newcastle, Centre for Brain and Mental Health Priority Research Centre, Newcastle, Australia
| | - Kate M Chitty
- University of Sydney Faculty of Medicine and Health, Discipline of Pharmacology, Translational Australian Clinical Toxicology Program, Sydney, NSW, Australia
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Vluggen S, Hoving C, Vonken L, Schaper NC, de Vries H. Exploring factors influencing recruitment results of nurses recruiting diabetes patients for a randomized controlled trial. Clin Trials 2020; 17:448-458. [PMID: 32367737 PMCID: PMC7814094 DOI: 10.1177/1740774520914609] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Effective recruitment of patients by health professionals is challenging but pivotal to the success of clinical trials. Many trials fail to include the required number of participants, which affects the power of the study, generalizability of results, and timely dissemination of positive outcomes. Existing research is inconclusive regarding factors influencing recruitment results, and most research does not focus on perceptions of recruiting health professionals themselves. Therefore, thorough evaluations of recruitment facilitators and barriers in trials are needed in order to optimize future patient recruitment in trials. We observed divergent recruitment results among nurses who recruited diabetes patients to our trial, which examined the effectiveness of an eHealth programme. Therefore, we aimed to describe nurses' recruitment results and related shifts over time, and to qualitatively explore factors influencing nurses' recruitment results. METHODS Nurses' recruitment results and related temporal shifts were derived from trial data (NTR6840). Based on their recruitment results, nurses were categorized as non-, low-, medium-, or high-recruiters. Subsequently, a subset of nurses per group participated in an individual semi-structured telephone interview. Interviews were analysed using NVivo software, applying an inductive coding approach. RESULTS Ninety-six nurses participated in our trial and recruited on average seven patients (range: 0-32). Fifteen nurses did not recruit any patients. Most patients were recruited close to recruitment onset. Nurses who did not recruit patients close to recruitment onset generally ended up recruiting no patients. Data show a relatively high number of early recruited patients that progressively declined over time. High-recruiters were generally successful throughout the entire recruitment period. Recruitment facilitators and barriers comprised organizational, study, patient, and especially recruiter characteristics. Contrary to non- and low-recruiters, medium- and high-recruiters reported more in-depth knowledge about the study and trial requirements, expressed more personal participation-related benefits and fewer barriers, and incorporated more recruitment activities, reminders, and barrier-focused coping strategies. CONCLUSION AND IMPLICATIONS To optimize patient recruitment to clinical trials, suggested intervention targets include the continued inclusion of recruiters after initial recruitment onset and the encouragement of early recruitment success. A personalized approach may aid recruiters to become and remain successful. Primarily, it is important to provide recruiters with sufficient information on trial requirements and to address salient benefits for participation in the trial, both for themselves and for their patients. Finally, teaching recruiters skills on how to overcome barriers may further enhance motivation and recruitment capacities.
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Affiliation(s)
- Stan Vluggen
- Department of Health Promotion, Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, The Netherlands
| | - Ciska Hoving
- Department of Health Promotion, Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, The Netherlands
| | - Lieve Vonken
- Department of Health Promotion, Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, The Netherlands
| | - Nicolaas C Schaper
- Department of Endocrinology and Internal Medicine, Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands
| | - Hein de Vries
- Department of Health Promotion, Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, The Netherlands
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Davidson B, Gurusamy K, Corrigan N, Croft J, Ruddock S, Pullan A, Brown J, Twiddy M, Birtwistle J, Morris S, Woodward N, Bandula S, Hochhauser D, Prasad R, Olde Damink S, Coolson M, Laarhoven KV, de Wilt JH. Liver resection surgery compared with thermal ablation in high surgical risk patients with colorectal liver metastases: the LAVA international RCT. Health Technol Assess 2020; 24:1-38. [PMID: 32370822 DOI: 10.3310/hta24210] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Although surgical resection has been considered the only curative option for colorectal liver metastases, thermal ablation has recently been suggested as an alternative curative treatment. There have been no adequately powered trials comparing surgery with thermal ablation. OBJECTIVES Main objective - to compare the clinical effectiveness and cost-effectiveness of thermal ablation versus liver resection surgery in high surgical risk patients who would be eligible for liver resection. Pilot study objectives - to assess the feasibility of recruitment (through qualitative study), to assess the quality of ablations and liver resection surgery to determine acceptable standards for the main trial and to centrally review the reporting of computed tomography scan findings relating to ablation and outcomes and recurrence rate in both arms. DESIGN A prospective, international (UK and the Netherlands), multicentre, open, pragmatic, parallel-group, randomised controlled non-inferiority trial with a 1-year internal pilot study. SETTING Tertiary liver, pancreatic and gallbladder (hepatopancreatobiliary) centres in the UK and the Netherlands. PARTICIPANTS Adults with a specialist multidisciplinary team diagnosis of colorectal liver metastases who are at high surgical risk because of their age, comorbidities or tumour burden and who would be suitable for liver resection or thermal ablation. INTERVENTIONS Thermal ablation conducted as per local policy (but centres were encouraged to recruit within Cardiovascular and Interventional Radiological Society of Europe guidelines) versus surgical liver resection performed as per centre protocol. MAIN OUTCOME MEASURES Pilot study - patients' and clinicians' acceptability of the trial to assist in optimisation of recruitment. Primary outcome - disease-free survival at 2 years post randomisation. Secondary outcomes - overall survival, timing and site of recurrence, additional therapy after treatment failure, quality of life, complications, length of hospital stay, costs, trial acceptability, and disease-free survival measured from end of intervention. It was planned that 5-year survival data would be documented through record linkage. Randomisation was performed by minimisation incorporating a random element, and this was a non-blinded study. RESULTS In the pilot study over 1 year, a total of 366 patients with colorectal liver metastases were screened and 59 were considered eligible. Only nine participants were randomised. The trial was stopped early and none of the planned statistical analyses was performed. The key issues inhibiting recruitment included fewer than anticipated patients eligible for both treatments, misconceptions about the eligibility criteria for the trial, surgeons' preference for one of the treatments ('lack of clinical equipoise' among some of the surgeons in the centre) with unconscious bias towards surgery, patients' preference for one of the treatments, and lack of dedicated research nurses for the trial. CONCLUSIONS Recruitment feasibility was not demonstrated during the pilot stage of the trial; therefore, the trial closed early. In future, comparisons involving two very different treatments may benefit from an initial feasibility study or a longer period of internal pilot study to resolve these difficulties. Sufficient time should be allowed to set up arrangements through National Institute for Health Research (NIHR) Research Networks. TRIAL REGISTRATION Current Controlled Trials ISRCTN52040363. FUNDING This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 21. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Brian Davidson
- Royal Free Campus, Division of Surgery and Interventional Science, University College London, London, UK
| | - Kurinchi Gurusamy
- Royal Free Campus, Division of Surgery and Interventional Science, University College London, London, UK
| | - Neil Corrigan
- 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
| | - Sharon Ruddock
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Alison Pullan
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Julia Brown
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Maureen Twiddy
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK.,Institute of Clinical and Applied Health Research, Faculty of Health Science, University of Hull, Hull, UK
| | | | - Stephen Morris
- Department of Applied Health Research, University College London, London, UK
| | | | | | | | - Raj Prasad
- Surgery and Transplantation, Leeds Teaching Hospital, Leeds, UK
| | | | - Marielle Coolson
- General Surgery, Maastricht University, Maastricht, the Netherlands
| | - K van Laarhoven
- Surgery, Radboud University Medical Centre, Nijmegen, the Netherlands
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9
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Suppli MH, Munck Af Rosenschold P, Dahl B, Berthelsen AK, Engelholm SA, Pappot H. Premature Termination of a Randomized Controlled Trial on Image-Guided Stereotactic Body Radiotherapy of Metastatic Spinal Cord Compression. Oncologist 2020; 25:210-e422. [PMID: 32162821 DOI: 10.1634/theoncologist.2019-0672] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Accepted: 09/02/2019] [Indexed: 12/25/2022] Open
Abstract
LESSONS LEARNED It is possible to plan and treat some patients with stereotactic body radiotherapy (SBRT) in a timely fashion in an acute setting. Advanced and, in some indications, already implemented technologies such as SBRT are difficult to test in a randomized trial. BACKGROUND Stereotactic body radiotherapy (SBRT) in metastatic spinal cord compression (MSCC) could be an alternative to decompressive surgery followed by fractionated radiotherapy. METHODS In a randomized, single-institution, noninferiority trial, patients with MSCC were assigned to stereotactic body radiotherapy of 16 Gy in 1 fraction or decompression surgery followed by fractionated radiotherapy of 30 Gy in 10 fractions. Primary endpoint was ability to walk by EQ5D-5L questionnaire. Based on power calculations, 130 patients had to be included to be 89% sure that a 15% difference between the treatment arm and the experimental arm could be detected. RESULTS Ten patients were accrued in 23 months, with six patients allocated to surgery and four patients to stereotactic body radiotherapy. The trial was closed prematurely because of poor accrual. One patient undergoing surgery and one patient undergoing stereotactic body radiotherapy were unable to walk at 6 weeks. Two patients were not evaluable at 6 weeks. CONCLUSION A randomized, phase II, clinical trial comparing surgery followed by fractionated radiotherapy or image-guided SBRT of MSCC was initiated. SBRT was shown to be feasible, with three out of four patients retaining walking function. The trial was determined futile as a result of low accrual.
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Affiliation(s)
- Morten Hiul Suppli
- Department of Oncology, Section of Radiotherapy, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | | | - Benny Dahl
- Spine Unit, Department of Orthopaedic Surgery, Rigshospitalet, University Hospital of Copenhagen, Copenhagen, Denmark
| | - Anne Kiil Berthelsen
- Department of Oncology, Rigshospitalet, University Hospital of Copenhagen, Copenhagen, Denmark
| | - Svend Aage Engelholm
- Department of Oncology, Rigshospitalet, University Hospital of Copenhagen, Copenhagen, Denmark
| | - Helle Pappot
- Department of Oncology, Rigshospitalet, University Hospital of Copenhagen, Copenhagen, Denmark
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10
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Watson M, Bewick BM, Tharmanathan P. The current role and perceived benefits and barriers of secondary care pharmacists facilitating patient participation in Clinical Trials of Investigational Medicinal Products (CTIMPs) conducted within the NHS: A cross-sectional survey. J Eval Clin Pract 2020; 26:142-148. [PMID: 30689249 DOI: 10.1111/jep.13104] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Revised: 09/27/2018] [Accepted: 01/04/2019] [Indexed: 11/28/2022]
Abstract
RATIONALE, AIMS, AND OBJECTIVES Secondary care pharmacists are well positioned within the healthcare system to communicate with patients and provide guidance and advice regarding drug treatments. They are able to broaden the opportunities to raise the profile of Clinical Trials of Investigational Medicinal Products (CTIMPs) and positively influence research. This research aimed to investigate the perceived benefits and barriers of secondary care pharmacists being involved in CTIMPs, their current role, and the perceived benefits and barriers of developing their role in facilitating patient participation for CTIMPs (eg, by identifying or recruiting potential participants). METHODS A cross-sectional quantitative online survey circulated to pharmacy professionals within the UK. RESULTS Involvement in CTIMPs and the facilitation of patient participation offered several benefits including improved communication and relationships with other healthcare professionals, developing the profession, developing training and knowledge, and exploring a personal interest. The main barriers to involvement included a lack of opportunities or awareness of opportunities, time, and funding or resources. Those employed at sites with a larger number of CTIMPs agreed more with the disadvantages; however, they also showed greater agreeance towards the benefits of pharmacy being involved in facilitating patient participation. CONCLUSIONS Most respondents do not currently have a role in identifying or recruiting potential participants. Despite this, being involved in CTIMPs and the facilitation of patient participation was suggested to offer several benefits. Given many participants agreed there are barriers to their involvement, future research should focus on exploring organizational and individual challenges with the aim of enabling pharmacists to support recruitment activities.
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Affiliation(s)
- Michelle Watson
- School of Medicine, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK.,York Trials Unit, University of York, York, UK
| | - Bridgette M Bewick
- School of Medicine, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
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11
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Bracken K, Askie L, Keech AC, Hague W, Wittert G. Recruitment strategies in randomised controlled trials of men aged 50 years and older: a systematic review. BMJ Open 2019; 9:e025580. [PMID: 30948584 PMCID: PMC6500287 DOI: 10.1136/bmjopen-2018-025580] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2018] [Revised: 12/17/2018] [Accepted: 02/13/2019] [Indexed: 01/21/2023] Open
Abstract
OBJECTIVES To identify and review evaluations of strategies to recruit men aged 50 years and over to randomised controlled trials (RCTs). DESIGN Systematic review and narrative synthesis. DATA SOURCES MEDLINE, EMBASE, CINAHL and ORRCA databases were searched to 1 December 2017. ELIGIBILITY CRITERIA Studies using quantitative methods to evaluate recruitment strategies to RCTs of men aged 50 years and older. DATA EXTRACTION AND SYNTHESIS A single reviewer extracted data (for each strategy, number of participants approached, screened and randomised, and cost). Study quality was assessed using National Heart, Lung and Blood Institute Quality Assessment Tools and considered study design, description of interventions, description and measurement of outcomes, completeness of outcome reporting, performance of statistical testing and consideration of confounders. Recruitment strategies were categorised by the recruitment stage they addressed. RESULTS Sixteen studies (n >14 000) were included: one good quality, ten fair quality and five poor quality. Studies evaluated strategies to identify prospective participants, and to improve the processes for assessing participant eligibility, providing participant information and seeking consent. In good and fair quality studies, the most effective strategies for identifying participants were referral from an affiliated health service provider (two studies), mass mailing (five studies) and media coverage (two studies). Community outreach activities such as displaying posters and attending local community events were not effective (two studies). Trial-specific training of site recruitment staff, developed using qualitative analysis of recruitment visits (two studies), and provision of study information to prospective participants at a multidisciplinary, group information session (one study) both improved recruitment. CONCLUSION Improved engagement of men aged 50 years and older in RCTs is needed. A gender-sensitised approach to RCT recruitment may help to address this need. We have identified several promising recruitment strategies that merit further evaluation. PROSPERO REGISTRATION NUMBER CRD42017060301.
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Affiliation(s)
- Karen Bracken
- NHMRC Clinical Trials Centre, Camperdown, New South Wales, Australia
| | - Lisa Askie
- NHMRC Clinical Trials Centre, Camperdown, New South Wales, Australia
| | - Anthony C Keech
- NHMRC Clinical Trials Centre, Camperdown, New South Wales, Australia
| | - Wendy Hague
- NHMRC Clinical Trials Centre, Camperdown, New South Wales, Australia
| | - Gary Wittert
- Department of Medicine, University of Adelaide, Adelaide, South Australia, Australia
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12
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Fogel DB. Factors associated with clinical trials that fail and opportunities for improving the likelihood of success: A review. Contemp Clin Trials Commun 2018; 11:156-164. [PMID: 30112460 PMCID: PMC6092479 DOI: 10.1016/j.conctc.2018.08.001] [Citation(s) in RCA: 465] [Impact Index Per Article: 77.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Revised: 07/19/2018] [Accepted: 08/06/2018] [Indexed: 12/18/2022] Open
Abstract
Clinical trials are time consuming, expensive, and often burdensome on patients. Clinical trials can fail for many reasons. This survey reviews many of these reasons and offers insights on opportunities for improving the likelihood of creating and executing successful clinical trials. Literature from the past 30 years was reviewed for relevant data. Common patterns in reported successful trials are identified, including factors regarding the study site, study coordinator/investigator, and the effects on participating patients. Specific instances where artificial intelligence can help improve clinical trials are identified.
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13
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Nguyen TK, Nguyen EK, Warner A, Louie AV, Palma DA. Failed Randomized Clinical Trials in Radiation Oncology: What Can We Learn? Int J Radiat Oncol Biol Phys 2018; 101:1018-1024. [PMID: 29859791 DOI: 10.1016/j.ijrobp.2018.04.030] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Revised: 04/05/2018] [Accepted: 04/10/2018] [Indexed: 10/17/2022]
Abstract
PURPOSE Randomized clinical trials (RCTs) are essential to evidence-based medicine, yet a significant proportion fail to be completed. In radiation oncology, factors contributing to trial failure are not well understood. We sought to compare completed and incomplete clinical trials involving radiation therapy (RT) to identify predictors of trial failure. METHODS AND MATERIALS We undertook a review of ClinicalTrials.gov to identify RCTs involving RT. Eligible trials mandated external beam RT in ≥1 arm of the study and were registered between September 27, 2007, and December 31, 2010. Univariate and multivariate logistic regression analyses were performed to determine factors predictive of trial failure. RESULTS We included 134 eligible studies, of which 94 (70.1%) were successful and 40 (29.9%) failed. The reasons for trial failure were categorized as follows: lack of accrual (57.5%), inadequate funding (15.0%), drug unavailability (7.5%), interim data-monitoring report recommendations (7.5%), and other (12.5%). Over time, significantly more trials were failing to be completed (P = .010), with rates increasing from 11.8% (before 2007) to 34.0% (2007-2008) to 39.5% (2009-2012). On univariate analysis, predictors of failure were trials with a surgical comparator (odds ratio [OR], 8.12; P = .013), government sponsorship (vs non-government; OR, 3.67; P = .025), inclusion of a safety endpoint (OR, 2.85; P = .022), and studies starting after 2006 (P = .033). On multivariate analysis, surgical trials were strongly predictive of failure (OR, 12.30; P = .025) while behavioral trials were associated with success (OR, 0.11; P = .045). CONCLUSIONS RT RCTs involving ≥1 surgical arms are at a very high risk of failure, with 75% failing to be completed. In contrast, behavioral studies are associated with study completion, with 94% of studies being successful. Future RT trials involving surgical interventions should consider novel methods to reduce the risk of trial failure.
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Affiliation(s)
- Timothy K Nguyen
- Department of Radiation Oncology, London Health Sciences Centre, London, Ontario, Canada
| | - Eric K Nguyen
- Department of Radiation Oncology, Juravinski Cancer Centre, Hamilton, Ontario, Canada
| | - Andrew Warner
- Department of Radiation Oncology, London Health Sciences Centre, London, Ontario, Canada
| | - Alexander V Louie
- Department of Radiation Oncology, London Health Sciences Centre, London, Ontario, Canada; Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada
| | - David A Palma
- Department of Radiation Oncology, London Health Sciences Centre, London, Ontario, Canada.
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14
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Chhatre S, Jefferson A, Cook R, Meeker CR, Kim JH, Hartz KM, Wong YN, Caruso A, Newman DK, Morales KH, Jayadevappa R. Patient-centered recruitment and retention for a randomized controlled study. Trials 2018; 19:205. [PMID: 29587805 PMCID: PMC5870194 DOI: 10.1186/s13063-018-2578-7] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2017] [Accepted: 03/09/2018] [Indexed: 11/17/2022] Open
Abstract
Background Recruitment and retention strategies for patient-centered outcomes research are evolving and research on the subject is limited. In this work, we present a conceptual model of patient-centered recruitment and retention, and describe the recruitment and retention activities and related challenges in a patient-centered comparative effectiveness trial. Methods This is a multicenter, longitudinal randomized controlled trial in localized prostate cancer patients. Results We recruited 743 participants from three sites over 15 months period (January 2014 to March 2015), and followed them for 24 months. At site 1, of the 773 eligible participants, 551 (72%) were enrolled. At site 2, 34 participants were eligible and 23 (68%) enrolled. Of the 434 eligible participants at site 3, 169 (39%) enrolled. We observed that strategies related to the concepts of trust (e.g., physician involvement, ensuring protection of information), communication (e.g., brochures and pamphlets in physicians’ offices, continued contact during regular clinic visits and calling/emailing assessment), attitude (e.g., emphasizing the altruistic value of research, positive attitude of providers and research staff), and expectations (e.g., full disclosure of study requirements and time commitment, update letters) facilitated successful patient recruitment and retention. A stakeholders’ advisory board provided important input for the recruitment and retention activities. Active engagement, reminders at the offices, and personalized update letters helped retention during follow-up. Usefulness of telephone recruitment was site specific and, at one site, the time requirement for telephone recruitment was a challenge. Conclusions We have presented multilevel strategies for successful recruitment and retention in a clinical trial using a patient-centered approach. Our strategies were flexible to accommodate site-level requirements. These strategies as well as the challenges can aid recruitment and retention efforts of future large-scale, patient-centered research studies. Trial registration Clinicaltrials.gov, ID: NCT02032550. Registered on 22 November 2013.
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Affiliation(s)
- Sumedha Chhatre
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, 3535 Market St. Suite 4051, Philadelphia, PA, 19104, USA.
| | - Ashlie Jefferson
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Ratna Cook
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Caitlin R Meeker
- Fox Chase Cancer Center, Temple University Health System, Philadelphia, PA, USA
| | - Ji Hyun Kim
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | | | - Yu-Ning Wong
- Fox Chase Cancer Center, Temple University Health System, Philadelphia, PA, USA
| | - Adele Caruso
- Division of Urology, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Diane K Newman
- Division of Urology, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Knashawn H Morales
- Department of Biostatistics and Epidemiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Ravishankar Jayadevappa
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,Division of Urology, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,Corporal Michael J. Crescenz VAMC, Philadelphia, PA, USA.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA.,Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA, USA
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15
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van den Bor RM, Grobbee DE, Oosterman BJ, Vaessen PWJ, Roes KCB. Predicting enrollment performance of investigational centers in phase III multi-center clinical trials. Contemp Clin Trials Commun 2017; 7:208-216. [PMID: 29696188 PMCID: PMC5898520 DOI: 10.1016/j.conctc.2017.07.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2017] [Revised: 07/07/2017] [Accepted: 07/18/2017] [Indexed: 11/28/2022] Open
Abstract
Failure to meet subject recruitment targets in clinical trials continues to be a widespread problem with potentially serious scientific, logistical, financial and ethical consequences. On the operational level, enrollment-related issues may be mitigated by careful site selection and by allocating monitoring or training resources proportionally to the anticipated risk of poor enrollment. Such procedures require estimates of the expected recruitment performance that are sufficiently reliable to allow centers to be sensibly categorized. In this study, we investigate whether information obtained from feasibility questionnaires can potentially be used to predict which centers will and which centers will not meet their enrollment targets by means of multivariable logistic regression analysis. From a large set of 59 candidate predictors, we determined the subset that is optimal for predictive purposes using Least Absolute Shrinkage and Selection Operator (LASSO) regularization. Although the extent to which the results are generalizable remains to be determined, they indicate that the prediction accuracy of the optimal model is only a marginal improvement over the intercept-only model, illustrating the difficulty of prediction in this setting.
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Affiliation(s)
- Rutger M van den Bor
- Julius Clinical Ltd., Broederplein 41-43, 3703 CD Zeist, The Netherlands.,Julius Center for Health Sciences and Primary Care, UMC Utrecht, P.O. Box 85500, 3508 GA Utrecht, The Netherlands
| | - Diederick E Grobbee
- Julius Clinical Ltd., Broederplein 41-43, 3703 CD Zeist, The Netherlands.,Julius Center for Health Sciences and Primary Care, UMC Utrecht, P.O. Box 85500, 3508 GA Utrecht, The Netherlands
| | - Bas J Oosterman
- Julius Clinical Ltd., Broederplein 41-43, 3703 CD Zeist, The Netherlands
| | - Petrus W J Vaessen
- Julius Clinical Ltd., Broederplein 41-43, 3703 CD Zeist, The Netherlands
| | - Kit C B Roes
- Julius Center for Health Sciences and Primary Care, UMC Utrecht, P.O. Box 85500, 3508 GA Utrecht, The Netherlands
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16
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Wacher NH, Reyes-Sánchez M, Vargas-Sánchez HR, Gamiochipi-Cano M, Rascón-Pacheco RA, Gómez-Díaz RA, Doubova SV, Valladares-Salgado A, Sánchez-Becerra MC, Méndez-Padrón A, Valdez-González LA, Mondragón-González R, Cruz M, Salinas-Martinez AM, Garza-Sagástegui MG, Hernández-Rubí J, González-Hermosillo A, Borja-Aburto VH. Stepwise strategies to successfully recruit diabetes patients in a large research study in Mexican population. Prim Care Diabetes 2017; 11:297-304. [PMID: 28343902 DOI: 10.1016/j.pcd.2017.02.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2016] [Revised: 02/24/2017] [Accepted: 02/26/2017] [Indexed: 11/24/2022]
Abstract
AIMS Describe stepwise strategies (electronic chart review, patient preselection, call-center, personnel dedicated to recruitment) for the successful recruitment of >5000 type 2 diabetes patients in four months. METHODS Twenty-five family medicine clinics from Mexico City and the State of Mexico participated: 13 usual care, 6 specialized diabetes care and 6 chronic disease care. Appointments were scheduled from 11/3/2015 to 3/31/2016. Phone calls were generated automatically from an electronic database. A telephone questionnaire verified inclusion criteria, and scheduled an appointment, with a daily report of appointments, patient attendance, acceptance rate, and questionnaire completeness. Another recruitment log reviewed samples collected. Absolute number (percentage) of patients are reported. Means and standard deviations were estimated for continuous variables, χ2 test and independent "t" tests were used. OR and 95% CI were estimated. RESULTS 14,358 appointments were scheduled, 9146 (63.7%) attended their appointment: 5710 (62.4%) fulfilled inclusion criteria and 5244 agreed to participate (91.8% acceptance). Those accepting participation were more likely women, younger and with longer disease duration (p<0.05). The cost of the call-center service was $3,010,000.00 Mexican pesos (∼$31.70 USD per recruited patient). CONCLUSIONS Stepwise strategies recruit a high number of patients in a short time. Call centers offer a low cost per patient.
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Affiliation(s)
- Niels H Wacher
- Unidad de Investigación en Epidemiología Clínica, UMAE Hospital de Especialidades, Centro Médico Siglo XXI, IMSS, Mexico City, Mexico.
| | - Mario Reyes-Sánchez
- División de Medicina Familiar, Unidad de Atención Primaria, IMSS, Mexico City, Mexico
| | | | - Mireya Gamiochipi-Cano
- Unidad de Investigación en Epidemiología Clínica, UMAE Hospital de Especialidades, Centro Médico Siglo XXI, IMSS, Mexico City, Mexico
| | | | - Rita A Gómez-Díaz
- Unidad de Investigación en Epidemiología Clínica, UMAE Hospital de Especialidades, Centro Médico Siglo XXI, IMSS, Mexico City, Mexico
| | - Svetlana V Doubova
- Unidad de Investigación en Epidemiología y Servicios de Salud, Centro Médico Siglo XXI, IMSS, Mexico City, Mexico
| | - Adán Valladares-Salgado
- Unidad de Investigación Médica en Bioquímica, UMAE Hospital de Especialidades, Centro Médico Siglo XXI, IMSS, Mexico City, Mexico
| | - Martha Catalina Sánchez-Becerra
- Unidad de Investigación Médica en Bioquímica, UMAE Hospital de Especialidades, Centro Médico Siglo XXI, IMSS, Mexico City, Mexico
| | - Araceli Méndez-Padrón
- Unidad de Investigación Médica en Bioquímica, UMAE Hospital de Especialidades, Centro Médico Siglo XXI, IMSS, Mexico City, Mexico
| | - Leticia A Valdez-González
- Unidad de Investigación en Epidemiología Clínica, UMAE Hospital de Especialidades, Centro Médico Siglo XXI, IMSS, Mexico City, Mexico
| | - Rafael Mondragón-González
- Unidad de Investigación en Epidemiología Clínica, UMAE Hospital de Especialidades, Centro Médico Siglo XXI, IMSS, Mexico City, Mexico
| | - Miguel Cruz
- Unidad de Investigación Médica en Bioquímica, UMAE Hospital de Especialidades, Centro Médico Siglo XXI, IMSS, Mexico City, Mexico
| | | | | | - Jaime Hernández-Rubí
- Departamento de Ingeniería en Sistemas Computacionales y Automatización, Instituto de Investigaciones en Matemáticas Aplicadas y en Sistemas, Universidad Nacional Autónoma de México, Mexico City, Mexico
| | - Arturo González-Hermosillo
- Departamento de Ingeniería en Sistemas Computacionales y Automatización, Instituto de Investigaciones en Matemáticas Aplicadas y en Sistemas, Universidad Nacional Autónoma de México, Mexico City, Mexico
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17
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Powell K, Wilson VJ, Redmond NM, Gaunt DM, Ridd MJ. Exceeding the recruitment target in a primary care paediatric trial: an evaluation of the Choice of Moisturiser for Eczema Treatment (COMET) feasibility randomised controlled trial. Trials 2016; 17:550. [PMID: 27855723 PMCID: PMC5114843 DOI: 10.1186/s13063-016-1659-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2016] [Accepted: 10/15/2016] [Indexed: 11/22/2022] Open
Abstract
Background Recruiting to target in randomised controlled trials of investigational medicinal products (CTIMPs) in primary care and paediatric populations is notoriously difficult. More evidence is needed for effective recruitment strategies in these settings. We report on the impact of different recruitment strategies used in the Choice of Moisturiser in Eczema Treatment (COMET) study – a feasibility trial comparing the effectiveness of four emollients for the treatment of childhood eczema – recruiting via general practitioner (GP) surgeries. Methods Initially, 16 GP practices invited potentially eligible children to take part in the trial by sending an invitation letter (self-referral pathway) or by consenting and randomising them into the study during a visit to the practice (in-consultation referral). Measures implemented during the study to maximise accrual included signing up six additional GP practices, increasing the upper age limit eligibility criterion from 3 to 5 years, and permitting healthcare professionals other than doctors to confirm participant eligibility. We used descriptive statistics and univariate linear regression models to explore associations with practice recruitment rates. Results A total of 197 participants were recruited, exceeding the target of 160. Of these, 107 children entered via self-referral and 90 by in-consultation pathways. Of the recruited population, 12.6 % were aged between 3 and 5 years (the raised upper age limit). The six additional practices contributed 37.4 % (40 of 107) of participants recruited by self-referral. Only almost one-third (18 of 56 [32.1 %]) of potential recruiting clinicians recruited one or more participants in-consultation, which was a more problematic pathway because of data verification issues. Three research nurses and a pharmacist from four practices recruited 48.9 % (44 of 90) of participants via this pathway. Univariate linear regression models showed no evidence of association between the number of children recruited via the self-referral pathway by practice and practice list size (p = 0.092) or practice deprivation decile (p = 0.270), but practice deprivation was associated with a higher number of children recruited in-consultation (p = 0.020) by practice. Conclusions Self-referral and in-consultation recruitment yielded similar numbers, but the in-consultation pathway was more problematic. Future trials of this type should consider the condition, normal care pathway and number of potentially eligible children and be prepared to use multiple recruitment strategies to achieve recruitment targets. Trial registration ISRCTN21828118. Registered on 1 May 2014. EudraCT2013-003001-26. Registered on 23 Dec 2013.
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Affiliation(s)
- Kingsley Powell
- Centre for Academic Primary Care, School of Social and Community Medicine, University of Bristol, 39 Whatley Road, Bristol, BS8 2PS, UK.
| | - Victoria J Wilson
- Centre for Academic Primary Care, School of Social and Community Medicine, University of Bristol, 39 Whatley Road, Bristol, BS8 2PS, UK
| | - Niamh M Redmond
- Centre for Academic Primary Care, School of Social and Community Medicine, University of Bristol, 39 Whatley Road, Bristol, BS8 2PS, UK.,National Institute for Health Research Collaborations for Leadership in Applied Health Research and Care West (NIHR CLAHRC West), University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Daisy M Gaunt
- Bristol Randomised Trials Collaboration, School of Social and Community Medicine, University of Bristol, 39 Whatley Road, Bristol, BS8 2PS, UK
| | - Matthew J Ridd
- Centre for Academic Primary Care, School of Social and Community Medicine, University of Bristol, 39 Whatley Road, Bristol, BS8 2PS, UK
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18
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Blewer AL, Li J, Ikeda DJ, Leary M, Buckler DG, Riegel B, Desai S, Groeneveld PW, Putt ME, Abella BS. Recruitment for a hospital-based pragmatic clinical trial using volunteer nurses and students. Clin Trials 2016; 13:425-33. [PMID: 27094486 PMCID: PMC4942370 DOI: 10.1177/1740774516643265] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND/AIMS Recruitment of subjects is critical to the success of any clinical trial, but achieving this goal can be a challenging endeavor. Volunteer nurse and student enrollers are potentially an important source of recruiters for hospital-based trials; however, little is known of either the efficacy or cost of these types of enrollers. We assessed volunteer clinical nurses and health science students in their rates of enrolling family members in a hospital-based, pragmatic clinical trial of cardiopulmonary resuscitation education, and their ability to achieve target recruitment goals. We hypothesized that students would have a higher enrollment rate and are more cost-effective compared to nurses. METHODS Volunteer nurses and student enrollers were recruited from eight institutions. Participating nurses were primarily bedside nurses or nurse educators while students were pre-medical, pre-nursing, and pre-health students at local universities. We recorded the frequency of enrollees recruited into the clinical trial by each enroller. Enrollers' impressions of recruitment were assessed using mixed-methods surveys. Cost was estimated based on enrollment data. Overall enrollment data were analyzed using descriptive statistics and generalized estimating equations. RESULTS From February 2012 to November 2014, 260 hospital personnel (167 nurses and 93 students) enrolled 1493 cardiac patients' family members, achieving target recruitment goals. Of those recruited, 822 (55%) were by nurses, while 671 (45%) were by students. Overall, students enrolled 5.44 (95% confidence interval (CI): 2.88, 10.27) more subjects per month than nurses (p < 0.01). After consenting to participate in recruitment, students had a 2.85 (95% CI: 1.09, 7.43) increased chance of enrolling at least one family member (p = 0.03). Among those who enrolled at least one subject, nurses enrolled a mean of 0.51(95% CI: 0.42, 0.59) subjects monthly, while students enrolled 1.63 (95% CI: 1.37, 1.90) per month (p < 0.01). Of 198 surveyed hospital personnel (127 nurses, 71 students), 168/198 (85%) felt confident conducting enrollment. The variable cost per enrollee recruited was $25.38 per subject for nurses and $23.30 per subject for students. CONCLUSIONS Overall, volunteer students enrolled more subjects per month at a lower cost than nurses. This work suggests that recruitment goals for a pragmatic clinical trial can be successfully obtained using both nurses and students.
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Affiliation(s)
- Audrey L Blewer
- Department of Emergency Medicine and Center for Resuscitation Science, University of Pennsylvania, Philadelphia, PA, USA Department of Biostatistics and Epidemiology, University of Pennsylvania, Philadelphia, PA, USA
| | - Jiaqi Li
- Department of Emergency Medicine and Center for Resuscitation Science, University of Pennsylvania, Philadelphia, PA, USA Department of Biostatistics and Epidemiology, University of Pennsylvania, Philadelphia, PA, USA
| | - Daniel J Ikeda
- Department of Emergency Medicine and Center for Resuscitation Science, University of Pennsylvania, Philadelphia, PA, USA
| | - Marion Leary
- Department of Emergency Medicine and Center for Resuscitation Science, University of Pennsylvania, Philadelphia, PA, USA School of Nursing, University of Pennsylvania, Philadelphia, PA, USA
| | - David G Buckler
- Department of Emergency Medicine and Center for Resuscitation Science, University of Pennsylvania, Philadelphia, PA, USA
| | - Barbara Riegel
- School of Nursing, University of Pennsylvania, Philadelphia, PA, USA
| | - Sunita Desai
- Department of Health Care Policy, Harvard Medical School, Boston, MA, USA
| | - Peter W Groeneveld
- Department of Medicine, University of Pennsylvania, Philadelphia, PA, USA Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA, USA
| | - Mary E Putt
- Department of Biostatistics and Epidemiology, University of Pennsylvania, Philadelphia, PA, USA
| | - Benjamin S Abella
- Department of Emergency Medicine and Center for Resuscitation Science, University of Pennsylvania, Philadelphia, PA, USA
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Abstract
AbstractBackgroundRadiotherapy randomised controlled trials provide evidence to support the development of new techniques and dose/fractionation regimens. Some radiotherapy trials have previously had to close early or revise targets due to low recruitment rates. Many authors have recommended research into recruitment strategies for many areas of medicine, however little work has been carried out in the specific field of radiotherapy.MethodUsing a survey of research radiographers followed by radiotherapy patient interviews, this project provides perspectives on motives for patient participation in radiotherapy clinical trials, and how to best support people through this decision-making process.FindingsThe main factors influencing participation identified by the radiographers were altruism, treatment fatigue and concerns about the trial arms, lack of resources and lack of commitment from some medical colleagues. For patients the main factors were mainly emotional; altruism, and fears for efficacy of different trial arms featured, with requests for timely communication of trial information.ConclusionWe recommend that strategies should be offered proactively to support patients through the decision-making process when considering trial participation. Research radiographers are ideally qualified to offer support and expert knowledge to these patients.
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Strong S, Paramasivan S, Mills N, Wilson C, Donovan JL, Blazeby JM. 'The trial is owned by the team, not by an individual': a qualitative study exploring the role of teamwork in recruitment to randomised controlled trials in surgical oncology. Trials 2016; 17:212. [PMID: 27113592 PMCID: PMC4845366 DOI: 10.1186/s13063-016-1341-1] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2015] [Accepted: 04/14/2016] [Indexed: 11/18/2022] Open
Abstract
Background Challenges exist in recruitment to trials involving interventions delivered by different clinical specialties. Collaboration is required between clinical specialty and research teams. The aim of this study was to explore how teamwork influences recruitment to a multicentre randomised controlled trial (RCT) involving interventions delivered by different clinical specialties. Methods Semi-structured interviews were conducted in three centres with a purposeful sample of members of the surgical, oncology and research teams recruiting to a feasibility RCT comparing definitive chemoradiotherapy with chemoradiotherapy and surgery for oesophageal squamous cell carcinoma. Interviews explored factors known to influence healthcare team effectiveness and were audio-recorded and thematically analysed. Sampling, data collection and analysis were undertaken iteratively and concurrently. Results Twenty-one interviews were conducted. Factors that influenced how team working impacted upon trial recruitment were centred on: (1) the multidisciplinary team (MDT) meeting, (2) leadership of the trial, and (3) the recruitment process. The weekly MDT meeting was reported as central to successful recruitment and formed the focus for creating a ‘study team’, bringing together clinical and research teams. Shared study leadership positively influenced healthcare professionals’ willingness to participate. Interviewees perceived their clinical colleagues to have strong treatment preferences which led to scepticism regarding whether the treatments were being described to patients in a balanced manner. Conclusions This study has highlighted a number of aspects of team functioning that are important for recruitment to RCTs that span different clinical specialties. Understanding these issues will aid the production of guidance on team-relevant issues that should be considered in trial management and the development of interventions that will facilitate teamwork and improve recruitment to these challenging RCTs. Trial registration International Standard Randomised Controlled Trial Number (ISRCTN): ISRCTN89052791.
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Affiliation(s)
- Sean Strong
- Centre for Surgical Research, School of Social and Community Medicine, University of Bristol, Canynge Hall, 39 Whatley Road, BS8 2PS, Bristol, UK.
| | - Sangeetha Paramasivan
- Centre for Surgical Research, School of Social and Community Medicine, University of Bristol, Canynge Hall, 39 Whatley Road, BS8 2PS, Bristol, UK
| | - Nicola Mills
- Centre for Surgical Research, School of Social and Community Medicine, University of Bristol, Canynge Hall, 39 Whatley Road, BS8 2PS, Bristol, UK
| | - Caroline Wilson
- Centre for Surgical Research, School of Social and Community Medicine, University of Bristol, Canynge Hall, 39 Whatley Road, BS8 2PS, Bristol, UK
| | - Jenny L Donovan
- Centre for Surgical Research, School of Social and Community Medicine, University of Bristol, Canynge Hall, 39 Whatley Road, BS8 2PS, Bristol, UK
| | - Jane M Blazeby
- Centre for Surgical Research, School of Social and Community Medicine, University of Bristol, Canynge Hall, 39 Whatley Road, BS8 2PS, Bristol, UK.,Division of Surgery, Head and Neck, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
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21
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Madurasinghe VW. Guidelines for reporting embedded recruitment trials. Trials 2016; 17:27. [PMID: 26767365 PMCID: PMC4714476 DOI: 10.1186/s13063-015-1126-y] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2015] [Accepted: 12/16/2015] [Indexed: 11/10/2022] Open
Abstract
Background Recruitment to clinical trials is difficult with many trials failing to recruit to target and within time. Embedding trials of recruitment interventions within host trials may provide a successful way to improve this. There are no guidelines for reporting such embedded methodology trials. As part of the Medical Research Council funded Systematic Techniques for Assisting Recruitment to Trials (MRC START) programme designed to test interventions to improve recruitment to trials, we developed guidelines for reporting embedded trials. Methods We followed a three-phase guideline development process: (1) pre-meeting literature review to generate items for the reporting guidelines; (2) face-to-face consensus meetings to draft the reporting guidelines; and (3) post-meeting feedback review, and pilot testing, followed by finalisation of the reporting guidelines. Results We developed a reporting checklist based on the Consolidated Standards for Reporting Trials (CONSORT) statement 2010. Embedded trials evaluating recruitment interventions should follow the CONSORT statement 2010 and report all items listed as essential. We used a number of examples to illustrate key issues that arise in embedded trials and how best to report them, including (a) how to deal with description of the host trial; (b) the importance of describing items that may differ in the host and embedded trials (such as the setting and the eligible population); and (c) the importance of identifying clearly the point at which the recruitment interventions were embedded in the host trial. Conclusions Implementation of these guidelines will improve the quality of reports of embedded recruitment trials while advancing the science, design and conduct of embedded trials as a whole. Electronic supplementary material The online version of this article (doi:10.1186/s13063-015-1126-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Vichithranie W Madurasinghe
- Pragmatic Clinical Trials Unit (PCTU), Centre for Primary Care and Public Health, Blizard Institute, Yvonne Carter Building, 58 Turner Street, London, E1 2AB, UK.
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22
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Wall PDH, Sprowson AP, Parsons N, Parsons H, Achten J, Balasubramanian S, Costa ML. Protocol for a single-centre randomised controlled trial of multimodal periarticular anaesthetic infiltration versus single-agent femoral nerve blockade as analgesia for total knee arthroplasty: Perioperative Analgesia for Knee Arthroplasty (PAKA). BMJ Open 2015; 5:e009898. [PMID: 26692559 PMCID: PMC4691770 DOI: 10.1136/bmjopen-2015-009898] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
INTRODUCTION Total knee arthroplasty (TKA) surgery causes postoperative pain. The use of perioperative injections around the knee containing local anaesthetic, opiates and non-steroidal anti-inflammatory drugs has increased in popularity to manage pain. Theoretical advantages include reduced requirements for analgesia and earlier mobilisation. We propose a single-centre randomised controlled trial of multimodal periarticular anaesthetic infiltration versus femoral nerve anaesthetic blockade as analgesia for TKA. The aim is to determine, in patients undergoing TKA, if there is a difference in patient-reported pain scores on the visual analogue scale (VAS) prior to physiotherapy on day 1 postoperatively between treatment groups. METHODS AND ANALYSIS Patients undergoing a primary unilateral TKA at University Hospitals Coventry and Warwickshire Hospitals will be assessed for eligibility. A total of 264 patients will provide 90% power to detect a difference of 12 mm on the VAS on day 1 postoperatively at the 5% level. The trial will use 1:1 randomisation, stratified by mode of anaesthetic. Primary outcome measure will be the VAS for pain prior to physiotherapy on day 1. Secondary outcome measures include VAS on day 2, total use of opiate analgesia up to 48 h, ordinal pain scores up to 40 min after surgery, independent functional knee physiotherapist assessment on days 1 and 2. Oxford knee Scores (OKS), EuroQol (EQ-5D) and Douleur Neuropathic Pain Scores (DN2) will be recorded at baseline, 6 weeks and 12 months. Adverse events will be recorded up to 12 months. Analysis will investigate differences in VAS on day 1 between the two treatment groups on an intention-to-treat basis. Tests will be two-sided and considered to provide evidence for a significant difference if p values are less than 0.05. ETHICS AND DISSEMINATION NRES Committee West Midlands, 23 September 2013 (ref: 13/WM/0316). The results will be disseminated via peer-reviewed publications and conference presentations. TRIAL REGISTRATION NUMBERS ISRCTN 60611146 and EUDRACT Number 2013-002439-10 (protocol code number PAKA-33601-AS117013); Pre-results.
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Affiliation(s)
- P D H Wall
- Warwick Clinical Trials Unit, Warwick University, Coventry, UK
- University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - A P Sprowson
- Warwick Clinical Trials Unit, Warwick University, Coventry, UK
- University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - N Parsons
- Warwick Clinical Trials Unit, Warwick University, Coventry, UK
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Science, Oxford University, Oxford, UK
| | - H Parsons
- Warwick Clinical Trials Unit, Warwick University, Coventry, UK
| | - J Achten
- Warwick Clinical Trials Unit, Warwick University, Coventry, UK
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Science, Oxford University, Oxford, UK
| | - S Balasubramanian
- University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - M L Costa
- Warwick Clinical Trials Unit, Warwick University, Coventry, UK
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Science, Oxford University, Oxford, UK
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23
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MacLennan S, Bekema HJ, Williamson PR, Campbell MK, Stewart F, MacLennan SJ, N'Dow JMO, Lam TBL. A core outcome set for localised prostate cancer effectiveness trials: protocol for a systematic review of the literature and stakeholder involvement through interviews and a Delphi survey. Trials 2015; 16:76. [PMID: 25887437 PMCID: PMC4355995 DOI: 10.1186/s13063-015-0598-0] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2014] [Accepted: 02/10/2015] [Indexed: 12/29/2022] Open
Abstract
Background Prostate cancer is a growing health problem worldwide. The management of localised prostate cancer is controversial. It is unclear which of several surgical, radiotherapeutic, ablative, and surveillance treatments is the most effective. All have cost, process and recovery, and morbidity implications which add to treatment decision-making complexity for patients and healthcare professionals. Evidence from randomised controlled trials (RCTs) is not optimal because of uncertainty as to what constitutes important outcomes. Another issue hampering evidence synthesis is heterogeneity of outcome definition, measurement, and reporting. This project aims to determine which outcomes are the most important to patients and healthcare professionals, and use these findings to recommend a standardised core outcome set for comparative effectiveness trials of treatments for localised prostate cancer, to optimise decision-making. Methods/Design The range of potentially important outcomes and measures will be identified through systematic reviews of the literature and semi-structured interviews with patients. A consultation exercise involving representatives from two key stakeholder groups (patients and healthcare professionals) will ratify the list of outcomes to be entered into a three round Delphi study. The Delphi process will refine and prioritise the list of identified outcomes. A methodological substudy (nested RCT design) will also be undertaken. Participants will be randomised after round one of the Delphi study to one of three feedback groups, based on different feedback strategies, in order to explore the potential impact of feedback strategies on participant responses. This may assist the design of a future core outcome set and Delphi studies. Following the Delphi study, a final consensus meeting attended by representatives from both stakeholder groups will determine the final recommended core outcome set. Discussion This study will inform clinical practice and future trials of interventions of localised prostate cancer by standardising a core outcome set which should be considered in comparative effectiveness studies for localised prostate cancer. Electronic supplementary material The online version of this article (doi:10.1186/s13063-015-0598-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Steven MacLennan
- Academic Urology Unit, University of Aberdeen, Cornhill Road, Aberdeen, UK, AB25 2ZD.
| | - Hendrika J Bekema
- Department of Critical Care, University of Groningen, University Medical Center Groningen, Hanzleplein, Groningen, The Netherlands, 9700 RB.
| | - Paula R Williamson
- Department of Biostatistics, University of Liverpool, Crown Street, Liverpool, UK, L69 3BX.
| | - Marion K Campbell
- Health Services Research Unit, University of Aberdeen, Cornhill Road, Aberdeen, UK, AB25 2ZD.
| | - Fiona Stewart
- Academic Urology Unit, University of Aberdeen, Cornhill Road, Aberdeen, UK, AB25 2ZD.
| | - Sara J MacLennan
- Academic Urology Unit, University of Aberdeen, Cornhill Road, Aberdeen, UK, AB25 2ZD.
| | - James M O N'Dow
- Academic Urology Unit, University of Aberdeen, Cornhill Road, Aberdeen, UK, AB25 2ZD. .,Department of Urology, Aberdeen Royal Infirmary, Foresterhill Road, Aberdeen, UK, AB25 2ZD.
| | - Thomas B L Lam
- Academic Urology Unit, University of Aberdeen, Cornhill Road, Aberdeen, UK, AB25 2ZD. .,Department of Urology, Aberdeen Royal Infirmary, Foresterhill Road, Aberdeen, UK, AB25 2ZD.
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Rick J, Graffy J, Knapp P, Small N, Collier DJ, Eldridge S, Kennedy A, Salisbury C, Treweek S, Torgerson D, Wallace P, Madurasinghe V, Hughes-Morley A, Bower P. Systematic techniques for assisting recruitment to trials (START): study protocol for embedded, randomized controlled trials. Trials 2014; 15:407. [PMID: 25344684 PMCID: PMC4230578 DOI: 10.1186/1745-6215-15-407] [Citation(s) in RCA: 54] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2014] [Accepted: 09/29/2014] [Indexed: 11/10/2022] Open
Abstract
Background Randomized controlled trials play a central role in evidence-based practice, but recruitment of participants, and retention of them once in the trial, is challenging. Moreover, there is a dearth of evidence that research teams can use to inform the development of their recruitment and retention strategies. As with other healthcare initiatives, the fairest test of the effectiveness of a recruitment strategy is a trial comparing alternatives, which for recruitment would mean embedding a recruitment trial within an ongoing host trial. Systematic reviews indicate that such studies are rare. Embedded trials are largely delivered in an ad hoc way, with interventions almost always developed in isolation and tested in the context of a single host trial, limiting their ability to contribute to a body of evidence with regard to a single recruitment intervention and to researchers working in different contexts. Methods/Design The Systematic Techniques for Assisting Recruitment to Trials (START) program is funded by the United Kingdom Medical Research Council (MRC) Methodology Research Programme to support the routine adoption of embedded trials to test standardized recruitment interventions across ongoing host trials. To achieve this aim, the program involves three interrelated work packages: (1) methodology - to develop guidelines for the design, analysis and reporting of embedded recruitment studies; (2) interventions - to develop effective and useful recruitment interventions; and (3) implementation - to recruit host trials and test interventions through embedded studies. Discussion Successful completion of the START program will provide a model for a platform for the wider trials community to use to evaluate recruitment interventions or, potentially, other types of intervention linked to trial conduct. It will also increase the evidence base for two types of recruitment intervention. Trial registration The START protocol covers the methodology for embedded trials. Each embedded trial is registered separately or as a substudy of the host trial.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | - Peter Bower
- Medical Research Council North West Hub for Trials Methodology Research, Manchester Academic Health Science Centre, Centre for Primary Care, University of Manchester, Oxford Road, Manchester M13 9PL, UK.
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Mills N, Blazeby JM, Hamdy FC, Neal DE, Campbell B, Wilson C, Paramasivan S, Donovan JL. Training recruiters to randomized trials to facilitate recruitment and informed consent by exploring patients' treatment preferences. Trials 2014; 15:323. [PMID: 25115160 PMCID: PMC4138384 DOI: 10.1186/1745-6215-15-323] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2014] [Accepted: 07/24/2014] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Patients' treatment preferences are often cited as barriers to recruitment in randomized controlled trials (RCTs). We investigated how RCT recruiters reacted to patients' treatment preferences and identified key strategies to improve informed decision-making and trial recruitment. METHODS Audio-recordings of 103 RCT recruitment appointments with 96 participants in three UK multicenter pragmatic RCTs were analyzed using content and thematic analysis. Recruiters' responses to expressed treatment preferences were assessed in one RCT (ProtecT - Prostate testing for cancer and Treatment) in which training on exploring preferences had been given, and compared with two other RCTs where this specific training had not been given. RESULTS Recruiters elicited treatment preferences similarly in all RCTs but responses to expressed preferences differed substantially. In the ProtecT RCT, patients' preferences were not accepted at face value but were explored and discussed at length in three key ways: eliciting and acknowledging the preference rationale, balancing treatment views, and emphasizing the need to keep an open mind and consider all treatments. By exploring preferences, recruiters enabled participants to become clearer about whether their views were robust enough to be sustained or were sufficiently weak that participation in the RCT became possible. Conversely, in the other RCTs, treatment preferences were often readily accepted without further discussion or understanding the reasoning behind them, suggesting that patients were not given the opportunity to fully consider all treatments and trial participation. CONCLUSIONS Recruiters can be trained to elicit and address patients' treatment preferences, enabling those who may not have considered trial participation to do so. Without specific guidance, some RCT recruiters are likely to accept initial preferences at face value, missing opportunities to promote more informed decision-making. Training interventions for recruiters that incorporate key strategies to manage treatment preferences, as in the ProtecT study, are required to facilitate recruitment and informed consent. TRIAL REGISTRATION ProtecT RCT: Current Controlled Trials ISRCTN20141297. The other two trials are registered but have asked to be anonymized.
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Affiliation(s)
- Nicola Mills
- />School of Social and Community Medicine, University of Bristol, Canynge Hall, Bristol, 39 Whatley Road, BS8 2PS UK
| | - Jane M Blazeby
- />School of Social and Community Medicine, University of Bristol, Canynge Hall, Bristol, 39 Whatley Road, BS8 2PS UK
| | - Freddie C Hamdy
- />Nuffield Department of Surgery, University of Oxford, John Radcliffe Hospital, Headley Way, Headington, Oxford, OX3 9DU UK
| | - David E Neal
- />University Department of Oncology, Addenbrooke’s Hospital, Hills Road, Cambridge, CB2 0QQ UK
| | - Bruce Campbell
- />Royal Devon and Exeter Hospital, University of Exeter Medical School, Barrack Road, Exeter, EX2 5DW UK
| | - Caroline Wilson
- />School of Social and Community Medicine, University of Bristol, Canynge Hall, Bristol, 39 Whatley Road, BS8 2PS UK
| | - Sangeetha Paramasivan
- />School of Social and Community Medicine, University of Bristol, Canynge Hall, Bristol, 39 Whatley Road, BS8 2PS UK
| | - Jenny L Donovan
- />School of Social and Community Medicine, University of Bristol, Canynge Hall, Bristol, 39 Whatley Road, BS8 2PS UK
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Huynh L, Johns B, Liu SH, Vedula SS, Li T, Puhan MA. Cost-effectiveness of health research study participant recruitment strategies: a systematic review. Clin Trials 2014; 11:576-83. [PMID: 24980278 DOI: 10.1177/1740774514540371] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
BACKGROUND A large fraction of the cost of conducting clinical trials is allocated to recruitment of participants. A synthesis of findings from studies that evaluate the cost and effectiveness of different recruitment strategies will inform investigators in designing cost-efficient clinical trials. PURPOSE To systematically identify, assess, and synthesize evidence from published comparisons of the cost and yield of strategies for recruitment of participants to health research studies. METHODS We included randomized studies in which two or more strategies for recruitment of participants had been compared. We focused our economic evaluation on studies that randomized participants to different recruitment strategies. RESULTS We identified 10 randomized studies that compared recruitment strategies, including monetary incentives (cash or prize), direct contact (letters or telephone call), and medical referral strategies. Only two of the 10 studies compared strategies for recruiting participants to clinical trials. We found that allocating additional resources to recruit participants using monetary incentives or direct contact yielded between 4% and 23% additional participants compared to using neither strategy. For medical referral, recruitment of prostate cancer patients by nurses was cost-saving compared to recruitment by consultant urologists. For all underlying study designs, monetary incentives cost more than direct contact with potential participants, with a median incremental cost per recruitment ratio of Int$72 (Int$-International dollar, a theoretical unit of currency) for monetary incentive strategy compared to Int$28 for direct contact strategy. Only monetary incentives and source of referral were evaluated for recruiting participants into clinical trials. LIMITATIONS We did not review studies that presented non-monetary cost or lost opportunity cost. We did not adjust for the number of study recruitment sites or the study duration in our economic evaluation analysis. CONCLUSIONS Systematic and explicit reporting of cost and effectiveness of recruitment strategies from randomized comparisons is required to aid investigators to select cost-efficient strategies for recruiting participants to health research studies including clinical trials.
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Affiliation(s)
| | - Benjamin Johns
- Department of International Health, Abt Associates, Inc., Bethesda, MD, USA
| | - Su-Hsun Liu
- Department of Family Medicine, Chang Gung Memorial Hospital, Taipei, Taiwan College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - S Swaroop Vedula
- Department of Computer Science, The Johns Hopkins University, Baltimore, MD, USA
| | - Tianjing Li
- Department of Epidemiology, The Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Milo A Puhan
- Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
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Donovan JL, de Salis I, Toerien M, Paramasivan S, Hamdy FC, Blazeby JM. The intellectual challenges and emotional consequences of equipoise contributed to the fragility of recruitment in six randomized controlled trials. J Clin Epidemiol 2014; 67:912-20. [PMID: 24811157 PMCID: PMC4067744 DOI: 10.1016/j.jclinepi.2014.03.010] [Citation(s) in RCA: 100] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2013] [Revised: 01/29/2014] [Accepted: 03/17/2014] [Indexed: 01/09/2023]
Abstract
Objective The aim of the study was to investigate how doctors considered and experienced the concept of equipoise while recruiting patients to randomized controlled trials (RCTs). Study Design and Setting In-depth interviews with 32 doctors in six publicly funded pragmatic RCTs explored their perceptions of equipoise as they undertook RCT recruitment. The RCTs varied in size, duration, type of complex intervention, and clinical specialties. Interview data were analyzed using qualitative content and thematic analytical methods derived from grounded theory and synthesized across six RCTs. Results All six RCTs suffered from poor recruitment. Doctors wanted to gather robust evidence but experienced considerable discomfort and emotion in relation to their clinical instincts and concerns about patient eligibility and safety. Although they relied on a sense of community equipoise to justify participation, most acknowledged having “hunches” about particular treatments and patients, some of which undermined recruitment. Surgeons experienced these issues most intensely. Training and support promoted greater confidence in equipoise and improved engagement and recruitment. Conclusion Recruitment to RCTs is a fragile process and difficult for doctors intellectually and emotionally. Training and support can enable most doctors to become comfortable with key RCT concepts including equipoise, uncertainty, patient eligibility, and randomization, promoting a more resilient recruitment process in partnership with patients.
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Affiliation(s)
- Jenny L Donovan
- School of Social and Community Medicine, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol BS8 2PS, UK.
| | - Isabel de Salis
- School of Social and Community Medicine, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol BS8 2PS, UK
| | - Merran Toerien
- Department of Sociology, Wentworth College, University of York, Heslington, York YO10 5DD, UK
| | - Sangeetha Paramasivan
- School of Social and Community Medicine, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol BS8 2PS, UK
| | - Freddie C Hamdy
- Nuffield Department of Surgical Sciences, University of Oxford, Old Road Campus Research Building, Oxford OX3 7DQ, UK
| | - Jane M Blazeby
- School of Social and Community Medicine, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol BS8 2PS, UK
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Newington L, Metcalfe A. Factors influencing recruitment to research: qualitative study of the experiences and perceptions of research teams. BMC Med Res Methodol 2014; 14:10. [PMID: 24456229 PMCID: PMC3903025 DOI: 10.1186/1471-2288-14-10] [Citation(s) in RCA: 127] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2013] [Accepted: 01/16/2014] [Indexed: 12/01/2022] Open
Abstract
Background Recruiting the required number of participants is vital to the success of clinical research and yet many studies fail to achieve their expected recruitment rate. Increasing research participation is a key agenda within the NHS and elsewhere, but the optimal methods of improving recruitment to clinical research remain elusive. The aim of this study was to identify the factors that researchers perceive as influential in the recruitment of participants to clinically focused research. Methods Semi-structured interviews were conducted with 11 individuals from three clinical research teams based in London. Sampling was a combination of convenience and purposive. The interviews were audio recorded, transcribed verbatim and analysed using the framework method to identify key themes. Results Four themes were identified as influential to recruitment: infrastructure, nature of the research, recruiter characteristics and participant characteristics. The main reason individuals participate in clinical research was believed to be altruism, while logistical issues were considered important for those who declined. Suggestions to improve recruitment included reducing participant burden, providing support for individuals who do not speak English, and forming collaborations with primary care to improve the identification of, and access to, potentially eligible participants. Conclusions Recruiting the target number of research participants was perceived as difficult, especially for clinical trials. New and diverse strategies to ensure that all potentially eligible patients are invited to participate may be beneficial and require further exploration in different settings. Establishing integrated clinical and academic teams with shared responsibilities for recruitment may also facilitate this process. Language barriers and long journey times were considered negative influences to recruitment; although more prominent, these issues are not unique to London and are likely to be important influences in other locations.
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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, London, UK.
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Eccles BK, Cross W, Rosario DJ, Doble A, Parker C, Logue J, Little L, Stanton L, Bottomley D. SABRE 1 (Surgery Against Brachytherapy - a Randomised Evaluation): feasibility randomised controlled trial (RCT) of brachytherapy vs radical prostatectomy in low-intermediate risk clinically localised prostate cancer. BJU Int 2013; 112:330-7. [PMID: 23826842 DOI: 10.1111/bju.12127] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To determine the feasibility of a phase III randomised controlled trial of brachytherapy vs radical prostatectomy (RP) in men with low-intermediate risk localised prostate cancer. PATIENTS AND METHODS This parallel, two-group, multicentre, randomised controlled feasibility trial enrolled men with histologically confirmed localised, low-risk prostate cancer and good performance status from five UK hospitals. Participants were randomly allocated (1:1) by remote computer allocation to receive a decision aid (DA) DVD or standard information (control group), followed by a second randomisation (1:1) to brachytherapy or RP. There was no 'blinding' of staff or patients. Primary outcome was feasibility: a recruitment rate of six patients per centre over the last 6 months of recruitment would deem a phase III trial feasible. RESULTS Between May 2009 and May 2011, 30 patients were randomised (15 in the DA group and 15 in the control group), and four continued to the second treatment randomisation (one from the DA group and three from the control group). One patient was allocated and received brachytherapy and three RP. SABRE 1 closed early due to poor recruitment. All patients were analysed. Screening logbook analysis showed that the main reasons for declining trial entry were a wish to choose treatment or opting for active monitoring. Results from the DA questionnaire (completed by 10 men) showed that four of the men 'felt surgery and radiotherapy had been proven in a high quality trial' and seven felt 'they should make their treatment decision while knowing their doctors opinion'. CONCLUSION Recruitment to a RP vs brachytherapy trial in localised prostate cancer was not feasible by the use of this two-step randomisation using a DA and previous trials in early prostate cancer have had similar difficulties in recruitment, with only a few achieving their accrual target. The best treatment method for treating low-risk prostate cancer is still unproven in a head-to-head trial and the increasing number of options will make choices correspondingly more difficulty without good quality comparative research. More sophisticated techniques for recruitment may be more successful in future trials in this patient population.
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Affiliation(s)
- Bryony K Eccles
- University of Southampton Clinical Trials Unit, Southampton, UK
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Redmond NM, Hollinghurst S, Costelloe C, Montgomery AA, Fletcher M, Peters TJ, Hay AD. An evaluation of the impact and costs of three strategies used to recruit acutely unwell young children to a randomised controlled trial in primary care. Clin Trials 2013; 10:593-603. [DOI: 10.1177/1740774513494503] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background Recruitment to primary care trials, particularly those involving young children, is known to be difficult. There are limited data available to inform researchers about the effectiveness of different trial recruitment strategies and their associated costs. Purpose To describe, evaluate, and investigate the costs of three strategies for recruiting febrile children to a community-based randomised trial of antipyretics. Methods The three recruitment strategies used in the trial were termed as follows: (1) ‘local’, where paediatric research nurses stationed in primary care sites invited parents of children to participate; (2) ‘remote’, where clinicians at primary care sites faxed details of potentially eligible children to the trial office; and (3) ‘community’, where parents, responding to trial publicity, directly contacted the trial office when their child was unwell. Results Recruitment rates increased in response to the sequential introduction of three recruitment strategies, which were supplemented by additional recruiting staff, flexible staff work patterns, and improved clinician reimbursement schemes. The three strategies yielded different randomisation rates. They also appeared to be interdependent and highly effective together. Strategy-specific costs varied from £297 to £857 per randomised participant and represented approximately 10% of the total trial budget. Limitations Because the recruitment strategies were implemented sequentially, it was difficult to measure their independent effects. The cost analysis was performed retrospectively. Conclusions Trial recruiter expertise and deployment of several interdependent, illness-specific strategies were key factors in achieving rapid recruitment of young children to a community-based randomised controlled trial (RCT). The ‘remote’ recruitment strategy was shown to be more cost-effective compared to ‘community’ and ‘local’ strategies in the context of this trial. Future trialists should report recruitment costs to facilitate a transparent evaluation of recruitment strategy cost-effectiveness.
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Affiliation(s)
- Niamh M Redmond
- Centre for Academic Primary Care, NIHR School for Primary Care Research, School of Social and Community Medicine, University of Bristol, UK
| | - Sandra Hollinghurst
- Centre for Academic Primary Care, NIHR School for Primary Care Research, School of Social and Community Medicine, University of Bristol, UK
| | - Céire Costelloe
- Centre for Academic Primary Care, NIHR School for Primary Care Research, School of Social and Community Medicine, University of Bristol, UK
| | - Alan A Montgomery
- Centre for Academic Primary Care, NIHR School for Primary Care Research, School of Social and Community Medicine, University of Bristol, UK
- Nottingham Clinical Trials Unit, Nottingham Health Science Partners, Queen’s Medical Centre, University of Nottingham, Nottingham, UK
| | - Margaret Fletcher
- Faculty of Health and Social Care, University of the West of England Bristol, Bristol, UK
| | - Tim J Peters
- Centre for Academic Primary Care, NIHR School for Primary Care Research, School of Social and Community Medicine, University of Bristol, UK
- School of Clinical Sciences, University of Bristol, Bristol, UK
| | - Alastair D Hay
- Centre for Academic Primary Care, NIHR School for Primary Care Research, School of Social and Community Medicine, University of Bristol, UK
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Wilt TJ. The Prostate Cancer Intervention Versus Observation Trial: VA/NCI/AHRQ Cooperative Studies Program #407 (PIVOT): design and baseline results of a randomized controlled trial comparing radical prostatectomy with watchful waiting for men with clinically localized prostate cancer. J Natl Cancer Inst Monogr 2013; 2012:184-90. [PMID: 23271771 DOI: 10.1093/jncimonographs/lgs041] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Prostate cancer is the most common noncutaneous malignancy and the second leading cause of cancer death in men. In the United States, 90% of men with prostate cancer are more than age 60 years, diagnosed by early detection with the prostate-specific antigen (PSA) blood test, and have disease believed confined to the prostate gland (clinically localized). Common treatments for clinically localized prostate cancer include watchful waiting (WW), surgery to remove the prostate gland (radical prostatectomy), external-beam radiation therapy and interstitial radiation therapy (brachytherapy), and androgen deprivation. Little is known about the relative effectiveness and harms of treatments because of the paucity of randomized controlled trials. The Department of Veterans Affairs/National Cancer Institute/Agency for Healthcare Research and Quality Cooperative Studies Program Study #407:Prostate Cancer Intervention Versus Observation Trial (PIVOT), initiated in 1994, is a multicenter randomized controlled trial comparing radical prostatectomy with WW in men with clinically localized prostate cancer. We describe the study rationale, design, recruitment methods, and baseline characteristics of PIVOT enrollees. We provide comparisons with eligible men declining enrollment and men participating in another recently reported randomized trial of radical prostatectomy vs WW conducted in Scandinavia. We screened 13 022 men with prostate cancer at 52 US medical centers for potential enrollment. From these, 5023 met initial age, comorbidity, and disease eligibility criteria, and a total of 731 men agreed to participate and were randomized. The mean age of enrollees was 67 years. Nearly one-third were African American. Approximately 85% reported that they were fully active. The median PSA was 7.8ng/mL (mean 10.2ng/mL). In three-fourths of men, the primary reason for biopsy leading to a diagnosis of prostate cancer was a PSA elevation or rise. Using previously developed tumor risk categorizations incorporating PSA levels, Gleason histologic grade, and tumor stage, it was found that approximately 40% had low-risk, 34% had medium-risk, and 21% had high-risk prostate cancer based on local histopathology. Comparison to our national sample of eligible men declining PIVOT participation as well as to men enrolled in the Scandinavian trial indicated that PIVOT enrollees are representative of men being diagnosed and treated in the United States and quite different from men in the Scandinavian trial. PIVOT enrolled an ethnically diverse population representative of men diagnosed with prostate cancer in the United States. Results will yield important information regarding the relative effectiveness and harms of surgery compared with WW for men with predominately PSA-detected clinically localized prostate cancer.
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Affiliation(s)
- Timothy J Wilt
- Minneapolis VA Center for Chronic Disease Outcomes Research, 1 Veterans Drive (111-0), Minneapolis, MN 55417, USA.
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Donovan JL. Presenting treatment options to men with clinically localized prostate cancer: the acceptability of active surveillance/monitoring. J Natl Cancer Inst Monogr 2013; 2012:191-6. [PMID: 23271772 DOI: 10.1093/jncimonographs/lgs030] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Presenting treatment options to men with localized prostate cancer is difficult because of the lack of definitive evidence and the range of treatment options available. Active surveillance and monitoring programs are now a recognized treatment option for men with low-risk localized prostate cancer, but many patients are not fully aware of the details of such programs, and most still opt for immediate radical (surgery or radiotherapy) treatment. The provision of high-quality information with decision aids has been shown to increase the acceptability of active surveillance/monitoring programs. This chapter outlines techniques for providing high-quality information about active surveillance/monitoring, based on the findings of a randomized controlled trial of treatments for localized prostate cancer. The ProtecT (Prostate testing for cancer and Treatment) trial has randomized over 1500 men between active monitoring, radical surgery, and radical radiotherapy by ensuring that information was tailored to men's existing knowledge and views. Care was taken with the content, order, and enthusiasm of the presentation of treatments by recruitment staff, and clinicians and other health professionals were supported to feel comfortable with being open about the uncertainties in the evidence and helped to rephrase terminology likely to be misinterpreted by patients. These techniques of information provision should be added to the use of decision aids to enable patients diagnosed with clinically localized prostate cancer in routine practice to reach well-informed and reasoned decisions about their treatment, including full consideration of active surveillance and monitoring programs.
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Affiliation(s)
- Jenny L Donovan
- School of Social and Community Medicine, University of Bristol, 39 Whatley Road, Bristol, UK.
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Vanhelst J, Hardy L, Bert D, Duhem S, Coopman S, Libersa C, Deplanque D, Gottrand F, Béghin L. Effect of child health status on parents' allowing children to participate in pediatric research. BMC Med Ethics 2013; 14:7. [PMID: 23414421 PMCID: PMC3582492 DOI: 10.1186/1472-6939-14-7] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2012] [Accepted: 02/12/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND To identify motivational factors linked to child health status that affected the likelihood of parents' allowing their child to participate in pediatric research. METHODS Parents were invited to return their completed questionnaires anonymously to assess motivational factors and factors that might improve participation in pediatric research. RESULTS Of 573 eligible parents, 261 returned the completed questionnaires. Of these, 126 were parents of healthy children (group 1), whereas 135 were parents of sick children who were divided into two groups according to the severity of their pathology, i.e., 99 ambulatory children (group 2) and 36 nonambulatory children (group 3). The main factor motivating participation in a pediatric clinical research study was "direct benefits for their child" (87.7%, 100%, and 100% for groups 1, 2, and 3, respectively). The other factors differed significantly between the three groups, depending on the child's health status (all p < 0.05). Factors that might have a positive impact on parental consent to the participation of their child in a pediatric clinical research study differed significantly (χ2 test, all p ≤ 0.04), depending on the child's health status. The main factor was "a better understanding of the study and its regulation" for the healthy children and ambulatory sick children groups (31.2% and 82.1%, respectively), whereas this was the third factor for the nonambulatory sick children group (50%). CONCLUSIONS Innovative strategies should be developed based on a child's health status to improve information provision when seeking a child's participation in pediatric research. Parents would like to spend more time in discussions with investigators.
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Affiliation(s)
- Jérémy Vanhelst
- Centre d’Investigation Clinique, CIC-PT-9301-Inserm-CH&U, Lille, 59037, France
- Unité Inserm U995 & Université Lille Nord de France, Lille, France
| | - Ludovic Hardy
- Centre d’Investigation Clinique, CIC-PT-9301-Inserm-CH&U, Lille, 59037, France
| | - Dina Bert
- Centre d’Investigation Clinique, CIC-PT-9301-Inserm-CH&U, Lille, 59037, France
| | - Stéphane Duhem
- Centre d’Investigation Clinique, CIC-PT-9301-Inserm-CH&U, Lille, 59037, France
- Comité de Protection des Personnes Nord Ouest IV, Lille, France
| | - Stéphanie Coopman
- Centre d’Investigation Clinique, CIC-PT-9301-Inserm-CH&U, Lille, 59037, France
| | - Christian Libersa
- Centre d’Investigation Clinique, CIC-PT-9301-Inserm-CH&U, Lille, 59037, France
- Département de Pharmacologie, Faculté de Médecine, Université Lille Nord de France, Lille, France
| | - Dominique Deplanque
- Centre d’Investigation Clinique, CIC-PT-9301-Inserm-CH&U, Lille, 59037, France
- Département de Pharmacologie, Faculté de Médecine, Université Lille Nord de France, Lille, France
| | - Frédéric Gottrand
- Centre d’Investigation Clinique, CIC-PT-9301-Inserm-CH&U, Lille, 59037, France
- Unité Inserm U995 & Université Lille Nord de France, Lille, France
| | - Laurent Béghin
- Centre d’Investigation Clinique, CIC-PT-9301-Inserm-CH&U, Lille, 59037, France
- Unité Inserm U995 & Université Lille Nord de France, Lille, France
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Sureshkumar P, Caldwell P, Lowe A, Simpson JM, Williams G, Craig JC. Parental consent to participation in a randomised trial in children: associated child, family, and physician factors. Clin Trials 2012; 9:645-51. [PMID: 22831821 DOI: 10.1177/1740774512453219] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Low participation rates in randomised controlled trials involving children are almost a universal problem, leading to high cost and low statistical power. Trial, parent/family, child, and physician factors have been reported to influence parental willingness to consent for paediatric trials. PURPOSE To identify modifiable and unmodifiable factors associated with parental consent. METHODS Demographic and clinical characteristics of children and their families and physician characteristics associated with parental consent were evaluated in a recent randomised placebo-controlled trial of prophylactic antibiotics to prevent recurrent urinary tract infection. RESULTS Of 1109 eligible children identified (mean age, 2.0 years), 412 parents (37.2%) consented. On a multivariate analysis, the only modifiable factor associated with consent was request for consent by a member of the research study team rather than by a member of the clinical team (risk ratio (RR) = 1.9, 95% confidence interval (CI): 1.2-2.9). The unmodifiable factors significantly associated with consent were age of the child (≥4 years) (RR = 1.2, 95% CI: 1.1-1.4), presence of vesicoureteric reflux (RR = 1.5, 95% CI: 1.3-1.8), inpatient management of the index infection (RR = 0.8, 95% CI: 0.7-0.9), and multiple (≥4) symptoms at presentation (RR = 1.3, 95% CI: 1.1-1.5). LIMITATIONS We have reported data from only one of the four participating centres in this trial. Data on non-consenters in other participating centres were not completely collected. Data on characteristics of the recruiting physician were limited. These findings are applicable for those considering a single randomised controlled trial. CONCLUSIONS Parent, child, and physician factors are associated with consent for trial participation, with most not being modifiable. Having a member of the research study team approach the parent for consent appears to be the only feasible strategy for increasing recruitment to randomised trials in this setting.
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Affiliation(s)
- Premala Sureshkumar
- Centre for Kidney Research, NHMRC Centre for Clinical Research Excellence, The Children's Hospital at Westmead, Westmead, Sydney, NSW, Australia.
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Halkoaho A, Kirsi Vähäkangas, Häggman-Laitila A, Pietilä AM. Views of midwives about ethical aspects of participation in placental perfusion studies. Midwifery 2012; 28:131-7. [DOI: 10.1016/j.midw.2011.02.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2010] [Revised: 01/12/2011] [Accepted: 02/12/2011] [Indexed: 01/31/2023]
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Fletcher B, Gheorghe A, Moore D, Wilson S, Damery S. Improving the recruitment activity of clinicians in randomised controlled trials: a systematic review. BMJ Open 2012; 2:e000496. [PMID: 22228729 PMCID: PMC3253423 DOI: 10.1136/bmjopen-2011-000496] [Citation(s) in RCA: 227] [Impact Index Per Article: 18.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2011] [Accepted: 12/01/2011] [Indexed: 11/06/2022] Open
Abstract
Background Poor recruitment to randomised controlled trials (RCTs) is a widespread problem. Provision of interventions aimed at supporting or incentivising clinicians may improve recruitment to RCTs. Objectives To quantify the effects of strategies aimed at improving the recruitment activity of clinicians in RCTs, complemented with a synthesis of qualitative evidence related to clinicians' attitudes towards recruiting to RCTs. Data sources A systematic review of English and non-English articles identified from: The Cochrane Library, Ovid MEDLINE, Ovid EMBASE, Ovid PsycINFO, Ebsco CINAHL, Index to Theses and Open SIGLE from 2001 to March 2011. Additional reports were identified through citation searches of included articles. Study eligibility criteria Quantitative studies were included if they evaluated interventions aimed at improving the recruitment activity of clinicians or compared recruitment by different groups of clinicians. Information about host trial, study design, participants, interventions, outcomes and host RCT was extracted by one researcher and checked by another. Studies that met the inclusion criteria were assessed for quality using a standardised tool, the Effective Public Health Practice Project tool. Qualitative studies were included if they investigated clinicians' attitudes to recruiting patients to RCTs. All results/findings were extracted, and content analysis was carried out. Overarching themes were abstracted, followed by a metasummary analysis. Studies that met the inclusion criteria were assessed for quality using the Critical Appraisal Skills Programme qualitative checklist. Data extraction Data extraction was carried out by one researcher using predefined data fields, including study quality indicators, and verified by another. Results Eight quantitative studies were included describing four interventions and a comparison of recruiting clinicians. One study was rated as strong, one as moderate and the remaining six as weak when assessed for quality using the Effective Public Health Practice Project tool. Effective interventions included the use of qualitative research to identify and overcome barriers to recruitment, reduction of the clinical workload associated with participation in RCTs and the provision of extra training and protected research time. Eleven qualitative studies were identified, and eight themes were abstracted from the data: understanding of research, communication, perceived patient barriers, patient-clinician relationship, effect on patients, effect on clinical practice, individual benefits for clinicians and methods associated with successful recruitment. Metasummary analysis identified the most frequently reported subthemes to be: difficulty communicating trial methods, poor understanding of research and priority given to patient well-being. Overall, the qualitative studies were found to be of good quality when assessed using the Critical Appraisal Skills Programme checklist. Conclusions There were few high-quality trials that tested interventions to improve clinicians' recruitment activity in RCTs. The most promising intervention was the use of qualitative methods to identify and overcome barriers to clinician recruitment activity. More good quality studies of interventions are needed to add to the evidence base. The metasummary of qualitative findings identified understanding and communicating RCT methods as a key target for future interventions to improve recruitment. Reinforcement of the potential benefits, both for clinicians and for their patients, could also be a successful factor in improving recruitment. A bias was found towards investigating barriers to recruitment, so future work should also encompass a focus on successfully recruiting trials.
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Affiliation(s)
- Ben Fletcher
- School of Health and Population Sciences, The University of Birmingham, Edgbaston, Birmingham, UK
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Lane JA, Hamdy FC, Martin RM, Turner EL, Neal DE, Donovan JL. Latest results from the UK trials evaluating prostate cancer screening and treatment: the CAP and ProtecT studies. Eur J Cancer 2011; 46:3095-101. [PMID: 21047592 DOI: 10.1016/j.ejca.2010.09.016] [Citation(s) in RCA: 117] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2010] [Revised: 08/11/2010] [Accepted: 09/07/2010] [Indexed: 11/19/2022]
Abstract
The European Randomised Study of Screening for Prostate Cancer (ERSPC) demonstrated a significant reduction in prostate cancer-specific mortality. The ongoing Comparison Arm for ProtecT (CAP) cluster randomised controlled trial (RCT) evaluates prostate cancer screening effectiveness by comparing primary care centres allocated to a round of prostate specific antigen (PSA) testing (intervention) or standard clinical care. Over 550 centres (around 450,000 men) were randomised in eight United Kingdom areas (2002-2008). Intervention group participants were also eligible for the ProtecT (Prostate testing for cancer and Treatment) RCT evaluating active monitoring, radiotherapy and radical prostatectomy treatments for localised prostate cancer. In ProtecT, over 1500 of around 3000 men with prostate cancer were randomised from over 10,000 with an elevated PSA in around 111,000 attendees at clinics. Investigation of the psychological impact of screening in a sub-sample showed that 10% of men still experienced high distress up to 3 months following prostate biopsies (22/227), although most were relatively unaffected. The risk of prostate cancer with a raised PSA was lower if urinary symptoms were present (frequent nocturia odds ratio (OR) 0.44, 95% confidence interval (CI) 0.22-0.83) or if a repeat PSA decreased by > or = 20% prior to biopsy (OR 0.43, 95% CI 0.35-0.52). Men aged 45-49 years attended PSA clinics less frequently (442/1299, 34%) in a nested cohort with a cancer detection rate of 2.3% (10/442). The CAP and ProtecT trials (ISRCTN92187251 and ISRCTN20141217) will help resolve the prostate cancer screening debate, define the optimum treatment for localised disease and generate evidence to improve men's health.
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Affiliation(s)
- J A Lane
- School of Social and Community Medicine, University of Bristol, Bristol, UK.
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Hegarty J, Beirne PV, Walsh E, Comber H, Fitzgerald T, Wallace Kazer M. Radical prostatectomy versus watchful waiting for prostate cancer. Cochrane Database Syst Rev 2010:CD006590. [PMID: 21069689 DOI: 10.1002/14651858.cd006590.pub2] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND The lack of evidence regarding the effectiveness of treatment options for clinically localised prostate cancer continues to impact on clinical decision-making. Two such options are radical prostatectomy (RP) and watchful waiting (WW). WW involves providing no initial treatment and monitoring the patient with the intention of providing palliative treatment if there is evidence of disease progression. OBJECTIVES To compare the beneficial and harmful effects of RP versus WW for the treatment of localised prostate cancer. SEARCH STRATEGY MEDLINE, EMBASE, The Cochrane Library, ISI Science Citation Index, DARE and LILACS were searched through 30 July 2010. SELECTION CRITERIA Randomised or quasi-randomised controlled trials comparing the effects of RP versus WW for clinically localised prostate cancer. DATA COLLECTION AND ANALYSIS Data extraction and quality assessment were carried out independently by two authors. MAIN RESULTS Two trials met the inclusion criteria. Both trials commenced prior to the widespread availability of prostate-specific antigen (PSA) screening; hence the results may not be applicable to men with PSA-detected disease.One trial (N = 142), conducted in the US, was judged to be of poor quality. All cause (overall) mortality was not significantly different between RP and WW groups after fifteen years of follow up (Hazard Ratio (HR) 0.9 (95% Confidence Interval (CI) 0.56 to 1.43).The second trial (N = 695), conducted in Scandinavia, was judged to be of good quality. After 12 years of follow up, the trial results were compatible with a beneficial effect of RP on the risks of overall mortality, prostate cancer mortality and distant metastases compared with WW but the precise magnitude of the effect is uncertain as indicated by the width of the confidence intervals for all estimates (risk difference (RD) -7.1% (95% CI -14.7 to 0.5); RD -5.4% (95% CI -11.1 to 0.2); RD -6.7% (95% CI -13.2 to -0.2), respectively). Compared to WW, RP increased the absolute risks of erectile dysfunction (RD 35% (95% CI 25 to 45)) and urinary leakage (RD 27% (95% CI 17 to 37)). These estimates must be interpreted cautiously as they are derived from data obtained from a self-administered questionnaire survey of a sample of the trial participants (N = 326), no baseline quality of life data were obtained and nerve-sparing surgery was not routinely performed on trial participants undergoing RP. AUTHORS' CONCLUSIONS The existing trials provide insufficient evidence to allow confident statements to be made about the relative beneficial and harmful effects of RP and WW for patients with localised prostate cancer. The results of ongoing trials should help to inform treatment decisions for men with screen-detected localised prostate cancer.
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Affiliation(s)
- Josephine Hegarty
- School of Nursing and Midwifery, University College Cork, Brookfield Health Sciences Complex, College Road, Cork, Ireland
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Caldwell PHY, Hamilton S, Tan A, Craig JC. Strategies for increasing recruitment to randomised controlled trials: systematic review. PLoS Med 2010; 7:e1000368. [PMID: 21085696 PMCID: PMC2976724 DOI: 10.1371/journal.pmed.1000368] [Citation(s) in RCA: 204] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2010] [Accepted: 09/30/2010] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Recruitment of participants into randomised controlled trials (RCTs) is critical for successful trial conduct. Although there have been two previous systematic reviews on related topics, the results (which identified specific interventions) were inconclusive and not generalizable. The aim of our study was to evaluate the relative effectiveness of recruitment strategies for participation in RCTs. METHODS AND FINDINGS A systematic review, using the PRISMA guideline for reporting of systematic reviews, that compared methods of recruiting individual study participants into an actual or mock RCT were included. We searched MEDLINE, Embase, The Cochrane Library, and reference lists of relevant studies. From over 16,000 titles or abstracts reviewed, 396 papers were retrieved and 37 studies were included, in which 18,812 of at least 59,354 people approached agreed to participate in a clinical RCT. Recruitment strategies were broadly divided into four groups: novel trial designs (eight studies), recruiter differences (eight studies), incentives (two studies), and provision of trial information (19 studies). Strategies that increased people's awareness of the health problem being studied (e.g., an interactive computer program [relative risk (RR) 1.48, 95% confidence interval (CI) 1.00-2.18], attendance at an education session [RR 1.14, 95% CI 1.01-1.28], addition of a health questionnaire [RR 1.37, 95% CI 1.14-1.66]), or a video about the health condition (RR 1.75, 95% CI 1.11-2.74), and also monetary incentives (RR1.39, 95% CI 1.13-1.64 to RR 1.53, 95% CI 1.28-1.84) improved recruitment. Increasing patients' understanding of the trial process, recruiter differences, and various methods of randomisation and consent design did not show a difference in recruitment. Consent rates were also higher for nonblinded trial design, but differential loss to follow up between groups may jeopardise the study findings. The study's main limitation was the necessity of modifying the search strategy with subsequent search updates because of changes in MEDLINE definitions. The abstracts of previous versions of this systematic review were published in 2002 and 2007. CONCLUSION Recruitment strategies that focus on increasing potential participants' awareness of the health problem being studied, its potential impact on their health, and their engagement in the learning process appeared to increase recruitment to clinical studies. Further trials of recruitment strategies that target engaging participants to increase their awareness of the health problems being studied and the potential impact on their health may confirm this hypothesis. Please see later in the article for the Editors' Summary.
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Affiliation(s)
- Patrina H Y Caldwell
- Centre for Kidney Research, The Children's Hospital at Westmead, New South Wales, Australia.
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Patient Recruitment Methods to Evaluate Treatment Decision Making for Localized Prostate Cancer. Am J Clin Oncol 2010; 33:381-6. [DOI: 10.1097/coc.0b013e3181b215d5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Graffy J, Bower P, Ward E, Wallace P, Delaney B, Kinmonth AL, Collier D, Miller J. Trials within trials? Researcher, funder and ethical perspectives on the practicality and acceptability of nesting trials of recruitment methods in existing primary care trials. BMC Med Res Methodol 2010; 10:38. [PMID: 20433728 PMCID: PMC2873514 DOI: 10.1186/1471-2288-10-38] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2009] [Accepted: 04/30/2010] [Indexed: 11/13/2022] Open
Abstract
Background Trials frequently encounter difficulties in recruitment, but evidence on effective recruitment methods in primary care is sparse. A robust test of recruitment methods involves comparing alternative methods using a randomized trial, 'nested' in an ongoing 'host' trial. There are potential scientific, logistical and ethical obstacles to such studies. Methods Telephone interviews were undertaken with four groups of stakeholders (funders, principal investigators, trial managers and ethics committee chairs) to explore their views on the practicality and acceptability of undertaking nested trials of recruitment methods. These semi-structured interviews were transcribed and analysed thematically. Results Twenty people were interviewed. Respondents were familiar with recruitment difficulties in primary care and recognised the case for 'nested' studies to build an evidence base on effective recruitment strategies. However, enthusiasm for this global aim was tempered by the challenges of implementation. Challenges for host studies included increasing complexity and management burden; compatibility between the host and nested study; and the impact of the nested study on trial design and relationships with collaborators. For nested recruitment studies, there were concerns that host study investigators might have strong preferences, limiting the nested study investigators' control over their research, and also concerns about sample size which might limit statistical power. Nested studies needed to be compatible with the main trial and should be planned from the outset. Good communication and adequate resources were seen as important. Conclusions Although research on recruitment was welcomed in principle, the issue of which study had control of key decisions emerged as critical. To address this concern, it appeared important to align the interests of both host and nested studies and to reduce the burden of hosting a recruitment trial. These findings should prove useful in devising a programme of research involving nested studies of recruitment interventions.
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Affiliation(s)
- Jonathan Graffy
- NIHR School for Primary Care Research, University of Cambridge, Cambridge, UK.
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Potter R, Dale J, Caramlau I. A qualitative study exploring practice nurses’ experience of participating in a primary care–based randomised controlled trial. J Res Nurs 2009. [DOI: 10.1177/1744987108098228] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Abstract The aim of this study is to explore the views of practice nurses’ recruiting into a primary care–based randomised controlled trial, and to investigate factors that influence the success of trial recruitment. It is known that time pressures, forgetfulness and lack of interest in the research topic negatively influence recruitment into research trials by General Practitioners (GPs), but no studies appear to have explored practice nurses’ experience of recruiting into trials. Semi-structured telephone interviews were conducted with a non-random purposive sample of 10 practice nurses who had participated in recruiting patients for the trial, and data were analysed using a thematic framework approach. Nurses who had been asked to take part in the study found it a positive experience, and had decided to take part because the area of research was of interest and could potentially benefit patients. Nurses who had been delegated the role of recruitment by the GP felt put upon and recruited less well. None of the nurses reported difficulties remembering to recruit patients and developed useful strategies to aid memory. Nurses often acted as gatekeepers, selecting which patients they offered the intervention to. Nurses with dedicated time for research recruited more successfully. For nurses who recruited during routine consultation, it was often the patient’s lack of interest in taking part in the trial, rather than time limitations that hindered recruitment. Overall, nurses were positive about recruiting into the trial, particularly if the research area could benefit patients and if directly asked to take part.
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Affiliation(s)
- Rachel Potter
- Health Sciences Research Institute, Warwick Medical School, University of Warwick, Coventry, UK
| | - Jeremy Dale
- Health Sciences Research Institute, Warwick Medical School, University of Warwick, Coventry, UK
| | - Isabela Caramlau
- Health Sciences Research Institute, Warwick Medical School, University of Warwick, Coventry, UK
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Moore AL, Dimitropoulou P, Lane A, Powell PH, Greenberg DC, Brown CH, Donovan JL, Hamdy FC, Martin RM, Neal DE. Population-based prostate-specific antigen testing in the UK leads to a stage migration of prostate cancer. BJU Int 2009; 104:1592-8. [PMID: 19549125 DOI: 10.1111/j.1464-410x.2009.08652.x] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To determine, within the UK, the stage and grade of prostate cancers that would be found through population-based prostate specific antigen (PSA) testing and biopsy. SUBJECTS AND METHODS In the 'Prostate Testing for Cancer and Treatment' trial (ProtecT), men aged 50-69 years were recruited from nine cities in the UK and from randomly selected practices of general practitioners. Those with a PSA level of >3 ng/mL were offered a prostate biopsy. Age, PSA, stage and grade at diagnosis of ProtecT participants with cancer were compared with contemporaneous incident cases aged 50-69 years (age-restricted Cancer Registry cases) registered with the Eastern Cancer Registration and Information Centre (ECRIC). RESULTS Within ProtecT, 94,427 men agreed to be tested (50% of men contacted), 8807 ( approximately 9%) had a raised PSA level and 2022 (23%) had prostate cancer; 229 ( approximately 12%) had locally advanced (T3 or T4) or metastatic cancers, the rest having clinically localized (T1c or T2) disease. Within ECRIC, 12,661 cancers were recorded over the same period; 3714 were men aged 50-69 years at diagnosis. Men in ProtecT had a lower age distribution and PSA level, and the cancers were of lower stage and grade (P < 0.001 for all comparisons). If population-based PSA testing were introduced in the UK, approximately 2660 men per 100,000 aged 50-69 years would be found to have prostate cancer, compared to current rates of approximately 130 per 100,000. If half of men accepted PSA testing, approximately 160,000 cancers would be found, compared to 30,000 diagnosed each year at present. CONCLUSIONS Population-based PSA testing resulted in a significant downward stage and grade migration, and most such cancers were of low stage and grade, which could lead to risks of over-treatment for some men.
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Affiliation(s)
- Alison L Moore
- Department of Social Medicine, University of Bristol, Bristol, UK
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Oliver RTD, Neal DE. Treatment for PSA screen-detected prostate cancer: what are the options? Nat Rev Urol 2009; 6:132-4. [DOI: 10.1038/ncpuro1297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2008] [Accepted: 12/08/2008] [Indexed: 11/09/2022]
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de Salis I, Tomlin Z, Toerien M, Donovan J. Using qualitative research methods to improve recruitment to randomized controlled trials: the Quartet study. J Health Serv Res Policy 2009; 13 Suppl 3:92-6. [PMID: 18806198 DOI: 10.1258/jhsrp.2008.008028] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE Randomized controlled trials (RCTs) are considered the optimum method for evaluating health care interventions, yet many fail to recruit sufficient participants in a timely manner. The ProtecT (Prostate testing for cancer and Treatment) study employed qualitative research methods as part of a complex intervention to improve recruitment to the RCT. The Quartet (Qualitative research to improve recruitment to trials) study was set up to evalute whether the ProtecT study's success in increasing randomization rates could be replicated in other trials experiencing recruitment difficulties. This paper reports on the issues that emerged from the attempts to apply qualitative research methods to improve recruitment rates in RCTs collaborating with the Quartet team. METHODS The methods used were: investigation of RCT documents; semi-structured interviews and focus groups with RCT staff; audio-recording of recruitment appointments; and individual and group feedback sessions for RCT staff. Data were analysed using content and thematic analysis. RESULTS Barriers arose when we attempted to establish collaborations with RCTs. Difficulties were encountered in securing the commitment of all relevant staff because of poor communication between lead investigators and other staff as well as RCT staff's concerns about having recruitment appointments audio-recorded. Recruitment processes were often more complex than anticipated. Governance procedures took considerable time and resources, limiting the time available for data collection and implementation of the intervention before recruitment closure. CONCLUSION Straightforward replication of the ProtecT complex intervention was more complicated than expected. However, the study has increased understanding of RCT recruitment and identified ways to overcome barriers to collaboration. Such research is more easily undertaken in the feasibility stage of an RCT, and greater success will be achieved if the research is integrated into the everyday conduct of RCTs.
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Affiliation(s)
- Isabel de Salis
- Department of Social Medicine, University of Bristol, Bristol, UK
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Wilt TJ, Brawer MK, Barry MJ, Jones KM, Kwon Y, Gingrich JR, Aronson WJ, Nsouli I, Iyer P, Cartagena R, Snider G, Roehrborn C, Fox S. The Prostate cancer Intervention Versus Observation Trial:VA/NCI/AHRQ Cooperative Studies Program #407 (PIVOT): design and baseline results of a randomized controlled trial comparing radical prostatectomy to watchful waiting for men with clinically localized prostate cancer. Contemp Clin Trials 2008; 30:81-7. [PMID: 18783735 DOI: 10.1016/j.cct.2008.08.002] [Citation(s) in RCA: 117] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2008] [Revised: 08/13/2008] [Accepted: 08/16/2008] [Indexed: 11/26/2022]
Abstract
BACKGROUND Prostate cancer is the most common noncutaneous malignancy and the second leading cause of cancer death in men. Ninety percent of men with prostate cancer are over aged 60 years, diagnosed by early detection with the prostate specific antigen (PSA) blood test and have disease believed confined to the prostate gland (clinically localized). Common treatments for clinically localized prostate cancer include watchful waiting surgery to remove the prostate gland (radical prostatectomy), external beam radiation therapy and interstitial radiation therapy (brachytherapy) and androgen deprivation. Little is known about the relative effectiveness and harms of treatments due to the paucity of randomized controlled trials. The VA/NCI/AHRQ Cooperative Studies Program Study #407: Prostate cancer Intervention Versus Observation Trial (PIVOT), initiated in 1994, is a multicenter randomized controlled trial comparing radical prostatectomy to watchful waiting in men with clinically localized prostate cancer. METHODS We describe the study rationale, design, recruitment methods and baseline characteristics of PIVOT enrollees. We provide comparisons with eligible men declining enrollment and men participating in another recently reported randomized trial of radical prostatectomy versus watchful waiting conducted in Scandinavia. RESULTS We screened 13,022 men with prostate cancer at 52 United States medical centers for potential enrollment. From these, 5023 met initial age, comorbidity and disease eligibility criteria and a total of 731 men agreed to participate and were randomized. The mean age of enrollees was 67 years. Nearly one-third were African-American. Approximately 85% reported they were fully active. The median prostate specific antigen (PSA) was 7.8 ng/mL (mean 10.2 ng/mL). In three-fourths of men the primary reason for biopsy leading to a diagnosis of prostate cancer was a PSA elevation or rise. Using previously developed tumor risk categorizations incorporating PSA levels, Gleason histologic grade and tumor stage, approximately 43% had low risk, 36% had medium risk and 20% had high-risk prostate cancer. Comparison to our national sample of eligible men declining PIVOT participation as well as to men enrolled in the Scandinavian trial indicated that PIVOT enrollees are representative of men being diagnosed and treated in the U.S. and quite different from men in the Scandinavian trial. CONCLUSIONS PIVOT enrolled an ethnically diverse population representative of men diagnosed with prostate cancer in the United States. Results will yield important information regarding the relative effectiveness and harms of surgery compared to watchful waiting for men with predominately PSA detected clinically localized prostate cancer.
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Affiliation(s)
- Timothy J Wilt
- Minneapolis VA Center for Chronic Disease Outcomes Research, Minneapolis, MN 55417, United States.
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Development of a complex intervention improved randomization and informed consent in a randomized controlled trial. J Clin Epidemiol 2008; 62:29-36. [PMID: 18619811 DOI: 10.1016/j.jclinepi.2008.02.010] [Citation(s) in RCA: 121] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2007] [Revised: 12/19/2007] [Accepted: 02/12/2008] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Multicenter randomized trials are required for pragmatic evaluations of health care interventions, but recruitment is difficult. Systematic reviews failed to identify robust strategies to improve recruitment. We developed and evaluated a complex intervention to increase levels of randomization and informed consent. STUDY DESIGN AND SETTING The ProtecT (Prostate testing for cancer and Treatment) trial compares radical surgery, radical conformal radiotherapy, and active monitoring for men aged 50-69 years with localized prostate cancer. The intervention was developed using qualitative research methods (content, thematic and conversation analysis). Rates of randomization and immediate acceptance of allocation were measured every 6 months to evaluate the impact of the intervention. RESULTS The complex intervention comprised reviews of centers falling below study targets, training programmes, documents and individually tailored feedback. Over 65% of eligible participants consented to randomization. Trial participants became increasingly well informed as immediate acceptance of allocation rose from 65% to 81% between 2001 and 2005. CONCLUSION This complex intervention resulted in high levels of randomization and informed consent in a difficult trial. The generic aspects of the intervention could be applied to other trials to maximize randomization and informed consent, and allow the mounting of trials previously considered too difficult.
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de Salis I, Tomlin Z, Toerien M, Donovan J. Qualitative research to improve RCT recruitment: issues arising in establishing research collaborations. Contemp Clin Trials 2008; 29:663-70. [PMID: 18479977 DOI: 10.1016/j.cct.2008.03.003] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2007] [Revised: 03/07/2008] [Accepted: 03/11/2008] [Indexed: 10/22/2022]
Abstract
INTRODUCTION Strategies to improve recruitment to RCTs (randomised controlled trials) are limited. The ProtecT (Prostate testing for cancer and Treatment) study successfully developed a complex intervention based on qualitative research methods to increase recruitment rates. The Quartet study (Qualitative Research to Improve Recruitment to RCTs) was established to evaluate whether the ProtecT qualitative methods could be transferred into other RCTs. This paper reports on the barriers and facilitators in setting up these collaborations. METHODS The Quartet study collaborated with five RCTs. Qualitative methods used were: interviews and focus groups with RCT staff; audio-recording recruitment interactions; and feedback sessions for RCT staff based on qualitative findings. Data were audio-recorded, transcribed and analysed using content and thematic analyses. Issues arising during establishment of collaborations were recorded and analysed. RESULTS Establishing collaborations proved challenging and not always surmountable. Difficulties were encountered in gaining agreement of RCT staff to participate because of central RCT staff's lack of authority over recruitment staff, poor communication within RCTs and recruiters' reluctance to have their practice scrutinised. The complexity of the recruitment process also hindered translation of ProtecT methods. Although Quartet enabled significant recruitment issues to surface, the bureaucratic tasks involved in securing governance approval delayed onset of collaborations, reducing the time to address issues and evaluate Quartet's impact. DISCUSSION The Quartet study established collaborations with a range of RCTs and gained valuable insights for future collaborations between qualitative researchers and RCTs. Qualitative research methods need to be included at the feasibility stage of a RCT or fully integrated into the RCT, as in the ProtecT study, with routine audio-recording for monitoring and training purposes. Quartet-like collaborations could then be established without delay, and recruitment processes of RCTs could become transparent, monitored and improved.
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Affiliation(s)
- Isabel de Salis
- Department of Social Medicine, University of Bristol, Canynge Hall, Whiteladies Road, Bristol, BS8 2PR, United Kingdom
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Larré S, Salomon L, Abbou CC. Choices for Surgery. Prostate Cancer 2007; 175:163-78. [PMID: 17432559 DOI: 10.1007/978-3-540-40901-4_10] [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: 10/23/2022] Open
Abstract
Surgical treatment of prostate cancer has seen many improvements in the past two decades, including laparoscopy, robotic surgery, and better assessment of quality of life and functional results. The limits of surgery for locally advanced disease and after failure of radiotherapy have been better defined, together with the roles of neoadjuvant and adjuvant treatment. Patients with clinically organ-confined prostate cancer, reasonable life expectancy, and little or no co-morbidity are the best candidates for radical prostatectomy. This chapter reviews the different technical options for the treatment of prostate cancer, with their respective indications and functional and oncological results.
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Affiliation(s)
- Stéphane Larré
- Department of Urology, University Hospital Henri Mondor, Créteil, France
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Williams B, Irvine L, McGinnis AR, McMurdo MET, Crombie IK. When "no" might not quite mean "no"; the importance of informed and meaningful non-consent: results from a survey of individuals refusing participation in a health-related research project. BMC Health Serv Res 2007; 7:59. [PMID: 17462081 PMCID: PMC1866231 DOI: 10.1186/1472-6963-7-59] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2006] [Accepted: 04/26/2007] [Indexed: 11/10/2022] Open
Abstract
Background Low participation rates can lead to sampling bias, delays in completion and increased costs. Strategies to improve participation rates should address reasons for non-participation. However, most empirical research has focused on participants' motives rather than the reasons why non-participants refuse to take part. In this study we investigated the reasons why older people choose not to participate in a research project. Methods Follow-up study of people living in Tayside, Scotland who had opted-out of a cross-sectional survey on activities in retirement. Eight hundred and eighty seven people aged 65–84 years were invited to take part in a home-based cross-sectional survey. Of these, 471 refused to take part. Permission was obtained to follow-up 417 of the refusers. Demographic characteristics of people who refused to take part and the reasons they gave for not taking part were collected. Results 54% of those invited to take part in the original cross-sectional survey refused to do so. However, 61% of these individuals went on to participate in the follow-up study and provided reasons for their original refusal. For the vast majority of people initial non-participation did not reflect an objection to participating in research in principle but frequently stemmed from barriers or misunderstandings about the nature or process of the project itself. Only 28% indicated that they were "not interested in research". The meaningfulness of expressions of non-consent may therefore be called into question. Hierarchical log-linear modelling showed that refusal was independently influenced by age, gender and social class. However, this response pattern was different for the follow-up study in which reasons for non-participation in the first survey were sought. This difference in pattern and response rates supports the likely importance of recruitment issues that are research and context specific. Conclusion An expression of non-consent does not necessarily mean that a fully informed evaluation of the pros and cons of participation and non-participation has taken place. The meaningfulness of expressions of non-consent may therefore be a cause for concern and should be subject to further research. Many reasons for non-participation may be specific to a particular research topic or population. Information sheets should reflect this by going beyond standardised guidelines for their design and instead proactively seek out and address areas of concern or potential misunderstanding. The use of established behavioural theory in their design could also be considered.
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Affiliation(s)
- Brian Williams
- Section of Public Health, Division of Community Health Sciences, Mackenzie Building, Kirsty Semple Way, University of Dundee, Dundee, UK
| | - Linda Irvine
- Section of Public Health, Division of Community Health Sciences, Mackenzie Building, Kirsty Semple Way, University of Dundee, Dundee, UK
| | - Alison R McGinnis
- Section of Public Health, Division of Community Health Sciences, Mackenzie Building, Kirsty Semple Way, University of Dundee, Dundee, UK
| | - Marion ET McMurdo
- Division of Medicine & Therapeutics, Ninewells Hospital & Medical School, University of Dundee, Dundee, UK
| | - Iain K Crombie
- Section of Public Health, Division of Community Health Sciences, Mackenzie Building, Kirsty Semple Way, University of Dundee, Dundee, UK
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