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Harari O, Park JJH, Lat PK, Mills EJ. Adaptive designs in public health: Vaccine and cluster randomized trials go Bayesian. Stat Med 2024; 43:2811-2829. [PMID: 38716764 DOI: 10.1002/sim.10104] [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: 08/22/2023] [Revised: 04/23/2024] [Accepted: 04/26/2024] [Indexed: 06/15/2024]
Abstract
Clinical trials in public health-particularly those conducted in low- and middle-income countries-often involve communicable and non-communicable diseases with high disease burden and unmet needs. Trials conducted in these regions often are faced with resource limitations, so improving the efficiencies of these trials is critical. Adaptive trial designs have the potential to save trial time and resources and reduce the number of patients receiving ineffective interventions. In this paper, we provide a detailed account of the implementation of vaccine and cluster randomized trials within the framework of Bayesian adaptive trials, with emphasis on computational efficiency and flexibility with regard to stopping rules and allocation ratios. We offer an educated approach to selecting prior distributions and a data-driven empirical Bayes method for plug-in estimates for nuisance parameters.
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Affiliation(s)
- Ofir Harari
- Core Clinical Sciences, Vancouver, British Columbia, Canada
| | - Jay J H Park
- Core Clinical Sciences, Vancouver, British Columbia, Canada
- Department of Health Research Methodology, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Prince Kumar Lat
- Biostatistics, Purpose Life Sciences, Vancouver, British Columbia, Canada
| | - Edward J Mills
- Department of Health Research Methodology, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Purpose Life Sciences, Vancouver, British Columbia, Canada
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Xie CX, De Simoni A, Eldridge S, Pinnock H, Relton C. Development of a conceptual framework for defining trial efficiency. PLoS One 2024; 19:e0304187. [PMID: 38781167 PMCID: PMC11115328 DOI: 10.1371/journal.pone.0304187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Accepted: 05/07/2024] [Indexed: 05/25/2024] Open
Abstract
BACKGROUND Globally, there is a growing focus on efficient trials, yet numerous interpretations have emerged, suggesting a significant heterogeneity in understanding "efficiency" within the trial context. Therefore in this study, we aimed to dissect the multifaceted nature of trial efficiency by establishing a comprehensive conceptual framework for its definition. OBJECTIVES To collate diverse perspectives regarding trial efficiency and to achieve consensus on a conceptual framework for defining trial efficiency. METHODS From July 2022 to July 2023, we undertook a literature review to identify various terms that have been used to define trial efficiency. We then conducted a modified e-Delphi study, comprising an exploratory open round and a subsequent scoring round to refine and validate the identified items. We recruited a wide range of experts in the global trial community including trialists, funders, sponsors, journal editors and members of the public. Consensus was defined as items rated "without disagreement", measured by the inter-percentile range adjusted for symmetry through the UCLA/RAND approach. RESULTS Seventy-eight studies were identified from a literature review, from which we extracted nine terms related to trial efficiency. We then used review findings as exemplars in the Delphi open round. Forty-nine international experts were recruited to the e-Delphi panel. Open round responses resulted in the refinement of the initial nine terms, which were consequently included in the scoring round. We obtained consensus on all nine items: 1) four constructs that collectively define trial efficiency containing scientific efficiency, operational efficiency, statistical efficiency and economic efficiency; and 2) five essential building blocks for efficient trial comprising trial design, trial process, infrastructure, superstructure, and stakeholders. CONCLUSIONS This is the first attempt to dissect the concept of trial efficiency into theoretical constructs. Having an agreed definition will allow better trial implementation and facilitate effective communication and decision-making across stakeholders. We also identified essential building blocks that are the cornerstones of an efficient trial. In this pursuit of understanding, we are not only unravelling the complexities of trial efficiency but also laying the groundwork for evaluating the efficiency of an individual trial or a trial system in the future.
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Affiliation(s)
- Charis Xuan Xie
- Wolfson Institute of Population Health, Queen Mary University of London, London, England, United Kingdom
| | - Anna De Simoni
- Wolfson Institute of Population Health, Queen Mary University of London, London, England, United Kingdom
| | - Sandra Eldridge
- Wolfson Institute of Population Health, Queen Mary University of London, London, England, United Kingdom
| | - Hilary Pinnock
- Usher Institute, Asthma UK Centre for Applied Research, The University of Edinburgh, Edinburgh, Scotland, United Kingdom
| | - Clare Relton
- Wolfson Institute of Population Health, Queen Mary University of London, London, England, United Kingdom
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Prowse SR, Treweek S, Kiezebrink K, Hanna C. Evidencing the impacts of health research: Insights from trials reported in the 2018 Australian Engagement and Impact Assessment. Health Promot J Austr 2024; 35:423-432. [PMID: 37493241 DOI: 10.1002/hpja.772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 06/03/2023] [Accepted: 06/23/2023] [Indexed: 07/27/2023] Open
Abstract
ISSUE ADDRESSED While definitions of impact may vary, they often refer to the wider benefits of research evidenced beyond academia. We evaluated case studies featuring randomised trials from the 2018 Engagement and Impact Assessment to better understand how the impacts of health research are evidenced and assessed within Australia. METHODS We collated and evaluated 'high' scoring case studies submitted by higher education institutions with a focus on randomised trials across all areas of health research. A qualitative coding system was used for manual content analysis to assess the key characteristics of trials reported, subsequent impacts and the methods used to evidence impacts. RESULTS A total of 14 case studies were identified citing 35 clinical trials. The majority of interventions were behavioural with a focus on mental, behavioural or neurodevelopmental disorders. Most trials were phase III, focused on the treatment of the indication and were funded by industry. Contribution to clinical guidelines was the highest cited research impact. While there was evidence of researchers seeking to maximise trial impact, case studies lacked details on the role of trial participants and other beneficiaries in generating impact. CONCLUSIONS The impacts of health research can be improved through a better understanding of the priorities and agendas of funders, providing evidence of tangible impact rather than information that is contextual or predictive, and through the early development of impact strategies involving both researchers and beneficiaries. SO WHAT?: Large-scale impact exercises intended for a broad range of disciplines may not be reflective of the depth and scope of health sciences research including trials.
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Affiliation(s)
- Sarah R Prowse
- School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, UK
| | - Shaun Treweek
- School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, UK
| | - Kirsty Kiezebrink
- School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, UK
| | - Catherine Hanna
- Institute of Cancer Sciences, University of Glasgow, Glasgow, UK
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Yarnell CJ, Saito H, Marshall JC. Understanding Heterogeneity in Acute Care Trials: Resource Availability Impacts Outcomes. Am J Respir Crit Care Med 2024; 209:469-471. [PMID: 38300151 PMCID: PMC10919105 DOI: 10.1164/rccm.202401-0232ed] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Accepted: 01/31/2024] [Indexed: 02/02/2024] Open
Affiliation(s)
- Christopher J Yarnell
- Department of Critical Care Medicine and Research Institute Scarborough Health Network Toronto, Ontario, Canada
- Interdepartmental Division of Critical Care Medicine University of Toronto Toronto, Ontario, Canada
| | - Hiroki Saito
- St. Marianna University School of Medicine Kanagawa, Japan
| | - John C Marshall
- Interdepartmental Division of Critical Care Medicine and Department of Surgery University of Toronto Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute Unity Health Toronto Toronto, Ontario, Canada
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Schutte AE, Abdool Karim Q. Reimagining Global Hypertension Research: From Helicopter Science to Meaningful Partnerships. Hypertension 2023; 80:2239-2242. [PMID: 37694447 DOI: 10.1161/hypertensionaha.123.20631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/12/2023]
Affiliation(s)
- Aletta E Schutte
- School of Population Health, University of New South Wales, Australia (A.E.S.)
- The George Institute for Global Health, Sydney, Australia (A.E.S.)
- Hypertension in Africa Research Team (HART), MRC Unit for Hypertension and Cardiovascular Disease, North-West University, Potchefstroom, South Africa (A.E.S.)
- MRC/WITS Developmental Pathways for Health Research Unit, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa (A.E.S.)
| | - Quarraisha Abdool Karim
- Centre for the AIDS Programme of Research in South Africa, Durban, South Africa (Q.A.K.)
- Mailman School of Public Health, Columbia University, New York (Q.A.K.)
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Zeraatkar D, Pitre T, Diaz-Martinez JP, Chu D, Rochwerg B, Lamontagne F, Kum E, Qasim A, Bartoszko JJ, Brignardello-Peterson R. Impact of Allocation Concealment and Blinding in Trials Addressing Treatments for COVID-19: A Methods Study. Am J Epidemiol 2023; 192:1678-1687. [PMID: 37254775 PMCID: PMC10558187 DOI: 10.1093/aje/kwad131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Revised: 03/19/2023] [Accepted: 05/26/2023] [Indexed: 06/01/2023] Open
Abstract
We aimed to assess the impact of allocation concealment and blinding on the results of coronavirus disease 2019 (COVID-19) trials, using the World Health Organization COVID-19 database (to February 2022). We identified 488 randomized trials comparing drug therapeutics with placebo or standard care in patients with COVID-19. We performed random-effects meta-regressions comparing the results of trials with and without allocation concealment and blinding of health-care providers and patients. We found that, compared with trials with allocation concealment, trials without allocation concealment may estimate treatments to be more beneficial for mortality, mechanical ventilation, hospital admission, duration of hospitalization, and duration of mechanical ventilation, but results were imprecise. We did not find compelling evidence that, compared with trials with blinding, trials without blinding produce consistently different results for mortality, mechanical ventilation, and duration of hospitalization. We found that trials without blinding may estimate treatments to be more beneficial for hospitalizations and duration of mechanical ventilation. We did not find compelling evidence that COVID-19 trials in which health-care providers and patients are blinded produce different results from trials without blinding, but trials without allocation concealment estimate treatments to be more beneficial compared with trials with allocation concealment. Our study suggests that lack of blinding may not always bias results but that evidence users should remain skeptical of trials without allocation concealment.
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Affiliation(s)
- Dena Zeraatkar
- Correspondence to Dena Zeraatkar, Department of Anesthesia, McMaster University, 1280 Main Street West, Hamilton, ON L8S 4L8 Canada (e-mail )
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Dee EC, Eala MAB, Robredo JPG, Ramiah D, Hubbard A, Ho FDV, Sullivan R, Aggarwal A, Booth CM, Legaspi GD, Nguyen PL, Pramesh CS, Grover S. Leveraging national and global political determinants of health to promote equity in cancer care. J Natl Cancer Inst 2023; 115:1157-1163. [PMID: 37402623 PMCID: PMC10560599 DOI: 10.1093/jnci/djad123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Revised: 05/26/2023] [Accepted: 06/22/2023] [Indexed: 07/06/2023] Open
Abstract
Health and politics are deeply intertwined. In the context of national and global cancer care delivery, political forces-the political determinants of health-influence every level of the cancer care continuum. We explore the "3-I" framework, which structures the upstream political forces that affect policy choices in the context of actors' interests, ideas, and institutions, to examine how political determinants of health underlie cancer disparities. Borrowing from the work of PA Hall, M-P Pomey, CJ Ho, and other thinkers, interests are the agendas of individuals and groups in power. Ideas represent beliefs or knowledge about what is or what should be. Institutions define the rules of play. We provide examples from around the world: Political interests have helped fuel the establishment of cancer centers in India and have galvanized the 2022 Cancer Moonshot in the United States. The politics of ideas underlie global disparities in cancer clinical trials-that is, in the distribution of epistemic power. Finally, historical institutions have helped perpetuate disparities related to racist and colonialist legacies. Present institutions have also been used to improve access for those in greatest need, as exemplified by the Butaro Cancer Center of Excellence in Rwanda. In providing these global examples, we demonstrate how interests, ideas, and institutions influence access to cancer care across the breadth of the cancer continuum. We argue that these forces can be leveraged to promote cancer care equity nationally and globally.
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Affiliation(s)
- Edward Christopher Dee
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York City, NY, USA
| | - Michelle Ann B Eala
- College of Medicine, University of the Philippines, Manila, Philippines
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, CA, USA
| | - Janine Patricia G Robredo
- School of Medicine and Public Health, Ateneo de Manila University, Pasig City, Philippines
- Blavatnik Institute of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
| | - Duvern Ramiah
- Division of Radiation Oncology, University of the Witwatersrand, Johannesburg and Charlotte Maxeke Johannesburg Academic Hospital, Johannesburg, South Africa
| | - Anne Hubbard
- American Society for Radiation Oncology, Arlington, VA, USA
| | | | - Richard Sullivan
- Kings Health Partners Comprehensive Cancer Centre, King's College London, Institute of Cancer Policy, London, UK
| | - Ajay Aggarwal
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
- Clinical Effectiveness Unit, Institute of Cancer Policy, King’s College London, London, UK
| | - Christopher M Booth
- Department of Oncology, Queen’s University, Kingston, ON, Canada
- Cancer Care and Epidemiology, Cancer Research Institute, Queen’s University, Kingston, ON, Canada
| | - Gerardo D Legaspi
- Division of Neurosurgery, Department of Neurosciences, College of Medicine and Philippine General Hospital, University of the Philippines Manila, Manila, Philippines
| | - Paul L Nguyen
- Department of Radiation Oncology, Dana-Farber Cancer Institute/Harvard Cancer Center, Boston, MA, USA
| | - C S Pramesh
- Tata Memorial Hospital, Thoracic Surgery (Surgical Oncology) at Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | - Surbhi Grover
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA, USA
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Chen DW, Lang BHH, McLeod DSA, Newbold K, Haymart MR. Thyroid cancer. Lancet 2023; 401:1531-1544. [PMID: 37023783 DOI: 10.1016/s0140-6736(23)00020-x] [Citation(s) in RCA: 55] [Impact Index Per Article: 55.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Revised: 12/20/2022] [Accepted: 01/03/2023] [Indexed: 04/08/2023]
Abstract
The past 5-10 years have brought in a new era in the care of patients with thyroid cancer, with the introduction of transformative diagnostic and management options. Several international ultrasound-based thyroid nodule risk stratification systems have been developed with the goal of reducing unnecessary biopsies. Less invasive alternatives to surgery for low-risk thyroid cancer, such as active surveillance and minimally invasive interventions, are being explored. New systemic therapies are now available for patients with advanced thyroid cancer. However, in the setting of these advances, disparities exist in the diagnosis and management of thyroid cancer. As new management options are becoming available for thyroid cancer, it is essential to support population-based studies and randomised clinical trials that will inform evidence-based clinical practice guidelines on the management of thyroid cancer, and to include diverse patient populations in research to better understand and subsequently address existing barriers to equitable thyroid cancer care.
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Affiliation(s)
- Debbie W Chen
- Division of Metabolism, Endocrinology, and Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Brian H H Lang
- Department of Surgery, The University of Hong Kong, Queen Mary Hospital, Hong Kong Special Administrative Region, China
| | - Donald S A McLeod
- Department of Endocrinology and Diabetes, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia; Population Health Department, QIMR Berghofer Medical Research Institute, Brisbane, QLD, Australia
| | - Kate Newbold
- Thyroid Unit, The Royal Marsden NHS Foundation Trust, London, UK
| | - Megan R Haymart
- Division of Metabolism, Endocrinology, and Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA.
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Davies A, Ormel I, Bernier A, Harriss E, Mumba N, Gobat N, Schwartz L, Cheah PY. A rapid review of community engagement and informed consent processes for adaptive platform trials and alternative design trials for public health emergencies. Wellcome Open Res 2023; 8:194. [PMID: 37654739 PMCID: PMC10465998 DOI: 10.12688/wellcomeopenres.19318.1] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/19/2023] [Indexed: 09/02/2023] Open
Abstract
Background : Public Health Emergencies (PHE) demand expeditious research responses to evaluate new or repurposed therapies and prevention strategies. Alternative Design Trials (ADTs) and Adaptive Platform Trials (APTs) have enabled efficient large-scale testing of biomedical interventions during recent PHEs. Design features of these trials may have implications for engagement and/or informed consent processes. We aimed to rapidly review evidence on engagement and informed consent for ADTs and APTs during PHE to consider what (if any) recommendations can inform practice. Method : In 2022, we searched 8 prominent databases for relevant peer reviewed publications and guidelines for ADTs/APTs in PHE contexts. Articles were selected based on pre-identified inclusion and exclusion criteria. We reviewed protocols and informed consent documents for a sample of large platform trials and consulted with key informants from ADTs/APT trial teams. Data were extracted and summarised using narrative synthesis. Results : Of the 49 articles included, 10 were guidance documents, 14 discussed engagement, 10 discussed informed consent, and 15 discussed both. Included articles addressed ADTs delivered during the West African Ebola epidemic and APTs delivered during COVID-19. PHE clinical research guidance documents highlight the value of ADTs/APTs and the importance of community engagement, but do not provide practice-specific guidance for engagement or informed consent. Engagement and consent practice for ADTs conducted during the West African Ebola epidemic have been well-documented. For COVID-19, engagement and consent practice was described for APTs primarily delivered in high income countries with well-developed health service structures. A key consideration is strong communication of the complexity of trial design in clear, accessible ways. Conclusion: We highlight key considerations for best practice in community engagement and informed consent relevant to ADTs and APTs for PHEs which may helpfully be included in future guidance. Protocol: The review protocol is published online at Prospero on 15/06/2022: registration number CRD42022334170.
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Affiliation(s)
- Alun Davies
- Health Systems Collaborative, Nuffield Department of Medicine, University of Oxford, Oxford, England, UK
| | - Ilja Ormel
- Faculty of Health Sciences, Department of Health Research Methods, Evidence & Impact, McMaster University, Hamilton, Ontario, Canada
| | - Alexe Bernier
- Faculty of Social Sciences, School of Social Work, McMaster University, Hamilton, Ontario, Canada
| | - Eli Harriss
- Bodleian Health Care Libraries, University of Oxford, Oxford, England, UK
| | - Noni Mumba
- The KEMRI-Wellcome Trust Research Programme, Kilifi, 80108, Kenya
| | - Nina Gobat
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, England, UK
| | - Lisa Schwartz
- Faculty of Health Sciences, Department of Health Research Methods, Evidence & Impact, McMaster University, Hamilton, Ontario, Canada
| | - Phaik Yeong Cheah
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Salaya, Nakhon Pathom, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, England, UK
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Opare-Addo PA, Sarfo FS, Berchie PO, Aikins M, Ovbiagele B. Participation by patients from low- and middle-income countries (LMICs) in trial evidence supporting secondary stroke prevention guideline recommendations. J Neurol Sci 2023; 448:120641. [PMID: 37028264 DOI: 10.1016/j.jns.2023.120641] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2023] [Revised: 03/27/2023] [Accepted: 03/28/2023] [Indexed: 04/03/2023]
Abstract
BACKGROUND One out of every four strokes is a highly preventable recurrent stroke. However, while low-and-middle-income countries (LMICs) experience a disproportionate global burden of stroke, individuals in these regions seldomly participate in pivotal clinical trials, which form the basis for international expert consensus guideline recommendations. OBJECTIVE To evaluate a contemporary and globally prominent expert consensus secondary stroke prevention guideline statement for the participation of clinical trial subjects recruited from LMICs in formulating key therapeutic recommendations. METHODS We examined the 2021 American Heart Association/American Stroke Association Guideline for the Prevention of Stroke in Patients with Stroke and TIA. All randomized controlled trials (RCTs) cited in the Guideline were independently reviewed by two authors for study populations and participating countries with a focus on trials for vascular risk factor control and management by underlying stroke mechanism. We also reviewed all cited systematic reviews and meta-analyses for the original RCTs. RESULTS Among 320 secondary stroke prevention clinical trials, 262 (82%) focused on vascular risk control addressing diabetes (n = 26), hypertension (n = 23), obstructive sleep apnea (n = 13), dyslipidaemia (n = 10), lifestyle (n = 188) and obesity (n = 2); and 58 focused on stroke mechanism management including atrial fibrillation (n = 10), large vessel atherosclerosis (n = 45) and small vessel disease (n = 3). Overall, 53 of 320 studies (16.6%) had contributions from LMICs ranging from 55.6% for dyslipidemia, 40.7% for diabetes, 26.1% for hypertension, 15.4% for OSA, 6.4% for lifestyle, 0% for obesity, and by mechanism: 60.0% for atrial fibrillation, 22.2% large vessel atherosclerosis and 33.3% for small vessel disease trials. Only 19 (5.9%) of the trials had participatory contributions from a country in sub-Saharan Africa (South Africa only). CONCLUSIONS Compared to their global burden of stroke, LMICs are underrepresented in key clinical trials used in formulating a prominent global stroke prevention guideline. While current therapeutic recommendations are likely applicable to practice settings throughout the world, greater involvement of patients from LMIC settings will enhance the contextual relevance and generalizability of recommendations to these disparate populations.
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Patel LN, Gurumurthy M, Bronson G, Sanders K, Rusen ID. Implementation challenges and lessons learned from the STREAM clinical trial-a survey of trial sites. Trials 2023; 24:51. [PMID: 36691098 PMCID: PMC9869607 DOI: 10.1186/s13063-023-07068-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Accepted: 01/03/2023] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND Design and implementation of multi-country clinical trials for multidrug-resistant tuberculosis (MDR-TB) are complex for several reasons, including trial duration, varying levels of experience and infrastructure across settings, and different regulatory requirements. STREAM was an MDR-TB clinical trial that recruited over 1000 participants. We documented challenges and best practices/lessons learned from the site perspective to improve implementation of future trials. METHODS We conducted a voluntary survey of trial staff at all sites to obtain information on challenges encountered and best practices/lessons learned from implementation of the STREAM trial. Respondents were asked to identify substantive aspects of trial implementation from a list that included: trial administration, laboratory strengthening/infrastructure, pharmacy and supply chain management, community engagement, regulatory and ethics requirements, health economics, and other (respondent designated) about which a practical guide would be useful to improve future trial implementation. For each aspect of trial implementation selected, respondents were asked to report challenges and best practices/lessons learned during STREAM. Lastly, respondents were asked to list up to three things they would do differently when implementing future trials. Summary statistics were generated for quantitative data and thematic analysis was undertaken for qualitative data. RESULTS Of 67 responses received from 13 of 15 sites, 47 (70%) were included in the analyses, after excluding duplicate or incomplete responses. Approximately half the respondents were investigators or trial coordinators. The top three aspects of trial implementation identified for a best practices/lessons learned practical guide to improve future trial implementation were: trial administration, community engagement, and laboratory strengthening/infrastructure. For both challenges and best practices/lessons learned, three common themes were identified across different aspects of trial implementation. Investment in capacity building and ongoing monitoring; investment in infrastructure and well-designed trial processes; and communication and coordination between staff and meaningful engagement of stakeholders were all thought to be critical to successful trial implementation. CONCLUSIONS Existing practices for clinical trial implementation should be reevaluated. Sponsors should consider the local context and the need to increase upfront investment in the cross-cutting thematic areas identified to improve trial implementation.
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Affiliation(s)
- Leena N. Patel
- grid.475681.9Vital Strategies, 100 Broadway, 4th Floor, New York, NY 10005 USA
| | - Meera Gurumurthy
- Vital Strategies Health Systems, Asia Pacific, Singapore, Singapore
| | - Gay Bronson
- grid.475681.9Vital Strategies, 100 Broadway, 4th Floor, New York, NY 10005 USA
| | - Karen Sanders
- grid.415052.70000 0004 0606 323XMedical Research Council Clinical Trials Unit at UCL, London, England
| | - I. D. Rusen
- grid.475681.9Vital Strategies, 100 Broadway, 4th Floor, New York, NY 10005 USA
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Butzin-Dozier Z, Athni TS, Benjamin-Chung J. A Review of the Ring Trial Design for Evaluating Ring Interventions for Infectious Diseases. Epidemiol Rev 2022; 44:29-54. [PMID: 35593400 PMCID: PMC10362935 DOI: 10.1093/epirev/mxac003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2021] [Revised: 03/25/2022] [Accepted: 05/12/2022] [Indexed: 12/29/2022] Open
Abstract
In trials of infectious disease interventions, rare outcomes and unpredictable spatiotemporal variation can introduce bias, reduce statistical power, and prevent conclusive inferences. Spillover effects can complicate inference if individual randomization is used to gain efficiency. Ring trials are a type of cluster-randomized trial that may increase efficiency and minimize bias, particularly in emergency and elimination settings with strong clustering of infection. They can be used to evaluate ring interventions, which are delivered to individuals in proximity to or contact with index cases. We conducted a systematic review of ring trials, compare them with other trial designs for evaluating ring interventions, and describe strengths and weaknesses of each design. Of 849 articles and 322 protocols screened, we identified 26 ring trials, 15 cluster-randomized trials, 5 trials that randomized households or individuals within rings, and 1 individually randomized trial. The most common interventions were postexposure prophylaxis (n = 23) and focal mass drug administration and screening and treatment (n = 7). Ring trials require robust surveillance systems and contact tracing for directly transmitted diseases. For rare diseases with strong spatiotemporal clustering, they may have higher efficiency and internal validity than cluster-randomized designs, in part because they ensure that no clusters are excluded from analysis due to zero cluster incidence. Though more research is needed to compare them with other types of trials, ring trials hold promise as a design that can increase trial speed and efficiency while reducing bias.
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Deen J, Clemens JD. Vaccine clinical trials in low- and middle-income countries: a brief review of standard, newer and proposed approaches. Expert Rev Vaccines 2022; 21:1595-1602. [DOI: 10.1080/14760584.2022.2126357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Jacqueline Deen
- Institute of Child Health and Human Development, National Institutes of Health, University of the Philippines, Pedro Gil Street, Ermita, Manila 1000, Philippines
| | - John D Clemens
- International Vaccine Institute, SNU Research Park, Gwanak-gu, Seoul, 08826 Korea
- UCLA Fielding School of Public Health, 650 Charles E Young Drive South, Los Angeles, California 90095-1772, USA
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A Systematic Review of Recent and Ongoing Clinical Trials in Patients With the Neurofibromatoses. Pediatr Neurol 2022; 134:1-6. [PMID: 35759947 DOI: 10.1016/j.pediatrneurol.2022.06.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Revised: 04/25/2022] [Accepted: 06/03/2022] [Indexed: 11/22/2022]
Abstract
INTRODUCTION The neurofibromatoses comprise three different genetic conditions causing considerable morbidity and mortality: neurofibromatosis type 1 (NF1), neurofibromatosis type 2 (NF2), and schwannomatosis (SWN). This review summarizes recent and ongoing clinical trials involving patients with neurofibromatoses to better understand the current state of clinical trial research centered around these conditions and inform areas of need. METHODS A search was conducted using the Cochrane Central Register of Controlled Trials and clinicaltrials.gov databases. Inclusion and exclusion criteria were designed to identify clinical trials focused on patients with NF1, NF2, or SWN completed in or after 2010 and in process as of December 31, 2021. Information was collected using standardized guidelines. RESULTS A total of 134 clinical trials were included, with 75 (56%) completed and 59 (44%) in process. For completed trials, 74% (n = 56) involved patients with NF1, and of those based on specific tumors (n = 26, 46%), the majority focused on plexiform neurofibromas (PNs) (n = 12, 46%). For ongoing trials, 79% (n = 47) involve patients with NF1, and of those based on specific tumors (n = 29, 61%), the majority are focused on PNs (n = 13, 45%). CONCLUSION Both recent and ongoing clinical trials have primarily focused on patients with NF1 and the treatment of PNs. This research has led to the first FDA-approved drug for NF1-PN and has changed management of these tumors, allowing for systemic therapy rather than reliance on only a surgical modality. Trials evaluating comorbid psychiatric conditions and quality of life among patients with any of the neurofibromatoses appear less common. These areas may warrant focus in future studies to improve clinical management.
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Abstract
Clinical trials are critically important to translate scientific innovations into clinical practice. Hearing healthcare depends on this translational approach to improve outcomes and quality of life. Across the spectrum of healthcare, there is a lack of diverse participation in clinical trials, a failure to recruit and retain underrepresented and underserved populations, and an absence of rigorous dissemination and implementation of novel research to broader populations. The field of hearing healthcare research would benefit from expanding the types and designs of clinical trials that extend hearing healthcare and novel interventions to diverse populations, as well as emphasizing trials that evaluate factors influencing how that care can be delivered effectively. This article explores the following: (1) the role, value, and design types of clinical trials (randomized controlled, cluster randomized, stepped wedge, and mixed methods) to address health equity; (2) the importance of integrating community and stakeholder involvement; and (3) dissemination and implementation frameworks and designs for clinical trials (hybrid trial designs). By adopting a broader range of clinical trial designs, hearing healthcare researchers may be able to extend scientific discoveries to a more diverse population.
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Geda YE, Krell-Roesch J, Fisseha Y, Tefera A, Beyero T, Rosenbaum D, Szabo TG, Araya M, Hayes SC. Acceptance and Commitment Therapy in a Low-Income Country in Sub-Saharan Africa: A Call for Further Research. Front Public Health 2021; 9:732800. [PMID: 34631649 PMCID: PMC8494766 DOI: 10.3389/fpubh.2021.732800] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Accepted: 08/23/2021] [Indexed: 11/13/2022] Open
Abstract
A worsening trend of critical shortages in senior health care workers across low- and middle-income countries (LMICs) in sub-Saharan Africa has been documented for decades. This is especially the case in Ethiopia that has severe shortage of mental health professionals. Consistent with the WHO recommended approach of task sharing for mental health care in LMICs, Acceptance and Commitment Therapy (ACT), which is an empirically validated psychological intervention aimed at increasing psychological flexibility, may be delivered by trained laypersons who have a grassroots presence. In this paper, we discuss the need for and potential role of ACT to be delivered by health extension workers (HEWs) to address mental health care needs across Ethiopia. To this end, we also reviewed previous studies that have examined the effectiveness of ACT-based interventions in African countries including in Nigeria, Sierra Leone, Uganda, and South Africa. All studies revealed significant improvements of various mental health-related outcome measures such as decreased psychological distress and depressive symptoms, or increased subjective wellbeing and life satisfaction in the groups that received an ACT-based intervention. However, to date, there is no study that applied ACT in Ethiopia. Thus, more research is warranted to examine the effectiveness and, if proven successful, to scale up a task sharing approach of an ACT-based intervention being delivered by trained HEWs at a grassroots level, possibly paving the way for an innovative, sustainable mental health service in Ethiopia as well as other African LMICs.
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Affiliation(s)
- Yonas E Geda
- Department of Neurology, Barrow Neurological Institute, Phoenix, AZ, United States
| | - Janina Krell-Roesch
- Department of Health Sciences Research, Mayo Clinic, Rochester, MN, United States.,Institute of Sports and Sports Science, Karlsruhe Institute of Technology, Karlsruhe, Germany
| | - Yaphet Fisseha
- Clinical PsyD Department, The Chicago School of Professional Psychology, Washington, DC, United States
| | - Aida Tefera
- Department of Psychiatry, Eka Kotebe Hospital, Addis Ababa, Ethiopia
| | - Teferra Beyero
- Department of Psychiatry, Eka Kotebe Hospital, Addis Ababa, Ethiopia
| | | | - Thomas G Szabo
- School of Behavior Analysis, Florida Institute of Technology, Melbourne, FL, United States
| | - Mesfin Araya
- Department of Psychiatry, College of Health Sciences, School of Medicine, Addis Ababa University, Addis Ababa, Ethiopia
| | - Steven C Hayes
- Department of Psychology, University of Nevada, Reno, NV, United States
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Park JJH, Ford N, Xavier D, Ashorn P, Grais RF, Bhutta ZA, Goossens H, Thorlund K, Socias ME, Mills EJ. Randomised trials at the level of the individual. LANCET GLOBAL HEALTH 2021; 9:e691-e700. [PMID: 33865474 DOI: 10.1016/s2214-109x(20)30540-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Revised: 12/08/2020] [Accepted: 12/10/2020] [Indexed: 12/31/2022]
Abstract
In global health research, short-term, small-scale clinical trials with fixed, two-arm trial designs that generally do not allow for major changes throughout the trial are the most common study design. Building on the introductory paper of this Series, this paper discusses data-driven approaches to clinical trial research across several adaptive trial designs, as well as the master protocol framework that can help to harmonise clinical trial research efforts in global health research. We provide a general framework for more efficient trial research, and we discuss the importance of considering different study designs in the planning stage with statistical simulations. We conclude this second Series paper by discussing the methodological and operational complexity of adaptive trial designs and master protocols and the current funding challenges that could limit uptake of these approaches in global health research.
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Affiliation(s)
- Jay J H Park
- Department of Experimental Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Nathan Ford
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Denis Xavier
- Department of Pharmacology and Divison of Clinical Research, St John's Medical College, Bangalore, India
| | - Per Ashorn
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | | | - Zulfiqar A Bhutta
- Centre for Global Child Health, Hospital for Sick Children, Toronto, ON, Canada; Institute of Global Health and Development, and Centre of Excellence in Women and Child Health, Aga Khan University, Karachi, Pakistan
| | - Herman Goossens
- Laboratory of Medical Microbiology, University of Antwerp, Antwerp, Belgium
| | - Kristian Thorlund
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Maria Eugenia Socias
- Fundación Huésped, Buenos Aires, Argentina; British Columbia Centre for Substance Use, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Edward J Mills
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada; School of Public Health, University of Rwanda, Kigali, Rwanda; Cytel, Vancouver, BC, Canada.
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Bhandari N, Upadhyay RP, Chowdhury R, Taneja S. Challenges of adopting new trial designs in LMICs. LANCET GLOBAL HEALTH 2021; 9:e575-e576. [PMID: 33865466 DOI: 10.1016/s2214-109x(21)00168-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Accepted: 03/15/2021] [Indexed: 10/21/2022]
Affiliation(s)
- Nita Bhandari
- Centre for Health Research and Development, Society for Applied Studies, New Delhi 110016, India.
| | - Ravi Prakash Upadhyay
- Centre for Health Research and Development, Society for Applied Studies, New Delhi 110016, India
| | - Ranadip Chowdhury
- Centre for Health Research and Development, Society for Applied Studies, New Delhi 110016, India
| | - Sunita Taneja
- Centre for Health Research and Development, Society for Applied Studies, New Delhi 110016, India
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Park JJH, Dron L, Mills EJ. Moving forward in clinical research with master protocols. Contemp Clin Trials 2021; 106:106438. [PMID: 34000408 PMCID: PMC8120789 DOI: 10.1016/j.cct.2021.106438] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Revised: 05/10/2021] [Accepted: 05/11/2021] [Indexed: 12/15/2022]
Abstract
With billions of dollars in research and development (R&D) funding continuing to be invested, the novel coronavirus disease 2019 (COVID-19) has become into a singular focus for the scientific community. However, the collective response from the scientific communities have seen poor return on investment, particularly for therapeutic research for COVID-19, revealing the existing weaknesses and inefficiencies of the clinical trial enterprise. In this article, we argue for the importance of structural changes to existing research programs for clinical trials in light of the lessons learned from COVID-19.
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Affiliation(s)
- Jay J H Park
- Experimental Medicine, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada.
| | - Louis Dron
- Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Edward J Mills
- Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
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20
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Park JJH, Mogg R, Smith GE, Nakimuli-Mpungu E, Jehan F, Rayner CR, Condo J, Decloedt EH, Nachega JB, Reis G, Mills EJ. How COVID-19 has fundamentally changed clinical research in global health. Lancet Glob Health 2021; 9:e711-e720. [PMID: 33865476 PMCID: PMC8049590 DOI: 10.1016/s2214-109x(20)30542-8] [Citation(s) in RCA: 106] [Impact Index Per Article: 35.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Revised: 12/07/2020] [Accepted: 12/10/2020] [Indexed: 01/07/2023]
Abstract
COVID-19 has had negative repercussions on the entire global population. Despite there being a common goal that should have unified resources and efforts, there have been an overwhelmingly large number of clinical trials that have been registered that are of questionable methodological quality. As the final paper of this Series, we discuss how the medical research community has responded to COVID-19. We recognise the incredible pressure that this pandemic has put on researchers, regulators, and policy makers, all of whom were doing their best to move quickly but safely in a time of tremendous uncertainty. However, the research community's response to the COVID-19 pandemic has prominently highlighted many fundamental issues that exist in clinical trial research under the current system and its incentive structures. The COVID-19 pandemic has not only re-emphasised the importance of well designed randomised clinical trials but also highlighted the need for large-scale clinical trials structured according to a master protocol in a coordinated and collaborative manner. There is also a need for structures and incentives to enable faster data sharing of anonymised datasets, and a need to provide similar opportunities to those in high-income countries for clinical trial research in low-resource regions where clinical trial research receives considerably less research funding.
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Affiliation(s)
- Jay J H Park
- Department of Experimental Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Robin Mogg
- Bill & Melinda Gates Medical Research Institute, Boston, MA, USA
| | - Gerald E Smith
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | | | - Fyezah Jehan
- Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Craig R Rayner
- Monash Institute of Pharmaceutical Sciences, Monash University, Melbourne, VIC, Australia; Certara, Princeton, NJ, USA
| | - Jeanine Condo
- School of Public Health, University of Rwanda, Kigali, Rwanda
| | - Eric H Decloedt
- Department of Medicine, Division of Clinical Pharmacology, Stellenbosch University, Cape Town, South Africa
| | - Jean B Nachega
- Department of Medicine and Center for Infectious Diseases, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa; Department of Epidemiology and Department of Infectious Diseases and Microbiology, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA, USA; Department of Epidemiology and Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Gilmar Reis
- Departamento de Medicina, Pontifícia Universidade Católica de Minas Gerais, Belo Horizonte, Brazil
| | - Edward J Mills
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada; Cytel, Vancouver, BC, Canada; School of Public Health, University of Rwanda, Kigali, Rwanda.
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