Core outcome sets in dermatology: report from the second meeting of the International Cochrane Skin Group Core Outcome Set Initiative

Methods for Neuroscience Drug Development: Guidance on Standardization of the Process for Defining Clinical Outcome Strategies in Clinical Trials

Neurosciences clinical trials continue to have notoriously high failure rates. Appropriate outcomes selection in early clinical trials is key to maximizing the likelihood of identifying new treatments in psychiatry and neurology. The field lacks good standards for designing outcome strategies, therefore The Outcomes Research Group was formed to develop and promote good practices in outcome selection. This article describes the first published guidance on the standardization of the process for clinical outcomes in neuroscience. A minimal step process is defined starting as early as possible, covering key activities for evidence generation in support of content validity, patient-centricity, validity requirements and considerations for regulatory acceptance. Feedback from expert members is provided, regarding the risks of shortening the process and examples supporting the recommended process are summarized. This methodology is now available to researchers in industry, academia or clinics aiming to implement consensus-based standard practices for clinical outcome selection, contributing to maximizing the efficiency of clinical research.

A core domain set for pyoderma gangrenosum trial outcomes: an international eDelphi and consensus study from the UPGRADE initiative

BACKGROUND

Pyoderma gangrenosum (PG) is a rare ulcerative skin condition with no current standardized outcomes or outcome measures. With a rich investigational therapeutic pipeline, standardization of outcomes and improvement of data quality and interpretability will promote the appropriate and consistent evaluation of potential new therapies. Core outcome sets (COS) are agreed, standardized sets of outcomes that represent the minimum that should be measured and reported in all clinical trials of a specific condition.

OBJECTIVES

To identify and reach a consensus on which domains (what to be measured) should be included in the Understanding Pyoderma Gangrenosum: Review and Analysis of Disease Effects (UPGRADE) core domain set for clinical trials in PG.

METHODS

Collaborative discussions between patients and PG experts, and a systematic review of the literature identified items and prospective domains. A three-round international eDelphi exercise was performed to prioritize the domains and refine the provisional items (consensus: ≥ 70% of participants rating a domain as 'extremely important' and < 15% of participants voting 'not important'), followed by an international meeting to reach consensus on the core domain set (consensus: < 30% disagreement). Item-generation discussions and consensus meetings were hosted via online videoconferences. The eDelphi exercise and consensus voting were performed using Qualtrics survey software. Participants were adults with PG, healthcare professionals, researchers and industry representatives.

RESULTS

Collaborative discussions and systematic reviews yielded 115 items, which were distilled into 15 prospective domains. The eDelphi exercise removed the three lowest-priority domains ('laboratory tests', 'treatment costs' and 'disease impact on family') and ranked 'pain', 'quality of life' and 'physical symptoms' as the highest-priority prospective domains. Consensus was reached on the domains of 'pain', 'quality of life' and 'clinical signs'. The domain of 'disease course/disease progression' narrowly failed to reach consensus for inclusion in the core set (32% of participants voted 'no'). Refinement of this domain definition will be required and presented for consideration at future consensus meetings.

CONCLUSIONS

The UPGRADE core domain set for clinical trials in PG has been agreed by international multistakeholder consensus. Future work will develop and/or select outcome measurement instruments for these domains to establish a COS.

What outcomes should be measured in feline chronic kidney disease treatment trials? Establishing a core outcome set for research

Chronic Kidney Disease (CKD) is an important cause of feline morbidity and mortality. There is currently no agreement on which outcomes are most important in CKD treatment trials to assist evidence-based decision making. Core Outcome Sets (COSs) originated in human healthcare and are an agreed set of outcomes to be measured and reported as a minimum in any trial conducted relating to a particular disease. To establish a COS for feline CKD, this study used a systematic review and two consensus methodologies (an electronic Delphi (eDelphi), and an in-person consensus meeting), with an international panel of key stakeholders. The systematic review identified 104 unique published parameters, which were rated by panellists in round 1 of the eDelphi. Panellists were also asked to suggest additional parameters. In round 2 these additional parameters were rated and any parameters not understood by >10 % of panellists in round 1 were redefined and re-rated. Parameters reaching consensus in rounds 1 and 2 were removed from round 3, when all remaining parameters were re-rated by panellists who could view their own previous rating alongside the median rating of the whole panel. To reach inclusion in the COS, parameters had to be rated 8 or 9 on a Likert scale of 1-9 (where 1 was not important and 9 was very important) by more than 80 % of panellists. In the consensus meeting, panellists discussed and re-rated borderline parameters and streamlined the final COS. Borderline parameters were those that had been closest to, but not achieved, the 80 % threshold for inclusion. The eDelphi panel (n = 73) rated 24/104 parameters highly enough for inclusion and proposed an additional 20 parameters, of which 3 reached the inclusion threshold. This totalled 27 parameters for inclusion. The consensus meeting panel (n = 16) rated an additional 6/20 borderline parameters highly enough for inclusion. During the streamlining process, 4 parameters were removed as one was considered not an outcome, and three were already addressed by other parameters. The remaining COS totalled 29 parameters. These were grouped into 9 core themes: clinical examination, quality of life, serum biochemistry, complete blood count, urinalysis, total amount of food eaten, CKD progression, survival time and cause of death. This is the first COS for feline medicine. In future treatment efficacy trials the COS will strengthen the evidence-base for this condition, by facilitating easier comparison of results between studies, and reduce research waste.

Oral mini-pulse therapy in vitiligo: a systematic review

BACKGROUND

There is limited evidence supporting the use of alternative treatments for patients with nonstable vitiligo.

OBJECTIVE

This study aimed to review the effects of oral mini-pulse (OMP) therapy in the management of nonsegmental vitiligo.

METHODS

The following databases were searched between inception and May 2020 for relevant studies: Scopus, Web of Science, MEDLINE, and Embase. All randomized controlled trials that compared OMP therapy with any other active treatment or placebo for nonstable vitiligo were included. The Cochrane's risk of bias tool was used to evaluate the risk of bias (ROB) in selected studies, and the overall quality of evidence of each outcome was assessed using the Grading Recommendations, Assessment, Development, and Evaluations (GRADE) system.

RESULTS

Four studies met our selection criteria. All of them were conducted in India and included 246 patients. OMP therapy included betamethasone or dexamethasone. The duration of treatment was 6 months in all studies. Up to 32% of patients achieved a repigmentation rate of >75% when OMP therapy was administered as monotherapy. No difference was observed between OMP therapy and other treatments in arresting the disease, and weight gain was the most frequent adverse effect. The overall ROB in all included studies was relatively high because of the randomization process, outcome measurement and informed selection of outcomes.

CONCLUSION

Based on the findings of these studies, OMP therapy did not demonstrate additional value compared with other treatments. Hence, there is an urgent need to conduct high-quality clinical trials to evaluate this therapy.

Development of an international core domain set for medium, large and giant congenital melanocytic naevi as a first step towards a core outcome set for clinical practice and research

BACKGROUND

Medium, large and giant congenital melanocytic naevi (CMN) can impose a psychosocial burden on patients and families, and are associated with increased risk of developing melanoma or neurological symptoms. Lack of consensus on what outcomes to measure makes it difficult to advise patients and families about treatment and to set up best practice for CMN.

OBJECTIVES

Fostering consensus among patient representatives and professionals, we aim to develop a core outcome set, defined as the minimum set of outcomes to measure and report in care and all clinical trials of a specific health condition. We focused on the 'what to measure' aspect, the so-called core domain set (CDS), following the COMET and CS-COUSIN guidelines.

METHODS

We conducted a systematic review to identify outcomes reported in the literature. Focus groups with patient representatives identified patient-reported outcomes. All these outcomes were classified into domains. Through e-Delphi surveys, 144 stakeholders from 27 countries iteratively rated the importance of domains and outcomes. An online consensus meeting attended by seven patient representatives and seven professionals finalized the CDS.

RESULTS

We reached consensus on six domains, four of which were applied to both care and research: 'quality of life', 'neoplasms', 'nervous system' and 'anatomy of skin'. 'Adverse events' was specific to care and 'pathology' to research.

CONCLUSIONS

We have developed a CDS for medium-to-giant CMN. Its application in reporting care and research of CMN will facilitate treatment comparisons. The next step will be to reach consensus on the specific outcomes for each of the domains and what instruments should be used to measure these domains and outcomes.

Development of a core outcome set for cutaneous squamous cell carcinoma trials: identification of core domains and outcomes

BACKGROUND

The lack of uniformity in the outcomes reported in clinical studies of the treatment of cutaneous squamous cell carcinoma (cSCC) complicates efforts to compare treatment effectiveness across trials.

OBJECTIVES

To develop a core outcome set (COS), a minimum set of agreed-upon outcomes to be measured in all clinical trials of a given disease or outcome, for the treatment of cSCC.

METHODS

One hundred and nine outcomes were identified via a systematic literature review and interviews with 28 stakeholders. After consolidation of this long list, 55 candidate outcomes were rated by 19 physician and 10 patient stakeholders, in two rounds of Delphi exercises. Outcomes scored 'critically important' (score of 7, 8 or 9) by ≥ 70% of patients and ≥ 70% of physicians were provisionally included. At the consensus meeting, after discussion and voting of 44 international experts and patients, the provisional list was reduced to a final core set, for which consensus was achieved among all meeting participants.

RESULTS

A core set of seven outcomes was finalized at the consensus meeting: (i) serious or persistent adverse events, (ii) patient-reported quality of life, (iii) complete response, (iv) partial response, (v) recurrence-free survival, (vi) progression-free survival and (vii) disease-specific survival.

CONCLUSIONS

In order to increase the comparability of results across trials and to reduce selective reporting bias, cSCC researchers should consider reporting these core outcomes. Further work needs to be performed to identify the measures that should be reported for each of these outcomes.

Outcome assessment in dermatology clinical trials and cochrane reviews: call for a dermatology-specific outcome taxonomy

BACKGROUND

Standardized outcome reporting is crucial for trial evidence synthesis and translation of findings into clinical decision-making. The OMERACT 2.0 Filter and COMET outcome domain taxonomy propose frameworks for consistent reporting of outcomes. There is an absence of a uniform dermatology-specific reporting strategy that uses precise and consistent outcome definitions.

OBJECTIVES

Our aim was to map efficacy/effectiveness outcomes assessed in dermatological trials to the OMERACT 2.0 Filter as a starting point for developing an outcome taxonomy in dermatology.

METHODS

We critically appraised 10 Cochrane Skin Reviews randomly selected from all 69 Cochrane Skin Reviews published until 01/2015 and the 220 trials included covering a broad spectrum of dermatological conditions and interventions. Efficacy/effectiveness outcomes were mapped to core areas and domains according to the OMERACT 2.0 Filter. The extracted trial outcomes were used for critical appraisal of outcome reporting in dermatology trials and for the preliminary development of a dermatology-specific outcome taxonomy.

RESULTS

The allocation of 1086 extracted efficacy/effectiveness outcomes to the OMERACT 2.0 Filter resulted in a hierarchically structured dermatology-specific outcome classification. In 506 outcomes (47%), the outcome concept to be measured was insufficiently described, hindering meaningful evidence synthesis. Although the core areas assessed in different dermatology trials of the same condition overlap considerably, quantitative evidence synthesis usually failed due to imprecise outcome definitions, non-comparable outcome measurement instruments, metrics and reporting.

CONCLUSIONS

We present an efficacy/effectiveness outcome classification as a starting point for a dermatology-specific taxonomy to provide trialists and reviewers with the opportunity to better synthesize and compare evidence.

Vitiligo: A Review

Vitiligo, a common depigmenting skin disorder, has an estimated prevalence of 0.5–2% of the population worldwide. The disease is characterized by the selective loss of melanocytes which results in typical nonscaly, chalky-white macules. In recent years, considerable progress has been made in our understanding of the pathogenesis of vitiligo which is now clearly classified as an autoimmune disease. Vitiligo is often dismissed as a cosmetic problem, although its effects can be psychologically devastating, often with a considerable burden on daily life. In 2011, an international consensus classified segmental vitiligo separately from all other forms of vitiligo, and the term vitiligo was defined to designate all forms of nonsegmental vitiligo. This review summarizes the current knowledge on vitiligo and attempts to give an overview of the future in vitiligo treatment.

Maintaining skin integrity in the aged: A systematic review

BACKGROUND

In aged nursing care receivers, the prevalence of adverse skin conditions such as xerosis cutis, intertrigo, pressure ulcers or skin tears is high. Adequate skin care strategies are an effective method for maintaining and enhancing skin health and integrity in this population.

OBJECTIVES

The objective was to summarize the empirical evidence about the effects and effectiveness of non-drug topical skin care interventions to promote and to maintain skin integrity and skin barrier function in the aged, to identify outcome domains and outcome measurement instruments in this field.

DESIGN

An update of a previous systematic review published in 2013 was conducted.

DATA SOURCES

Databases MEDLINE and EMBASE via OvidSP and CINAHL (original search January 1990 to August 2012, update September 2012 to May 2018) and reference lists were searched. Forward searches in Web of Science were conducted.

METHODS

A review protocol was registered in Prospero (CRD42018100792). Main inclusion criteria were primary intervention studies reporting treatment effects of basic skin care strategies in aged people with a lower limit of age range of 50 years and published between 1990 and 2018. Primary empirical studies were included with experimental study designs including randomized controlled trials and quasi-experimental designs. Methodological quality of included randomized controlled trials was evaluated using the Cochrane Collaboration's Tool for assessing risk of bias. Levels of evidence were assigned to all included studies.

RESULTS

Sixty-three articles were included in the final analysis reporting effects of interventions to treat and/or to prevent skin dryness, pruritus, general skin barrier improvement, incontinence-associated dermatitis, skin tears and pressure ulcers. Skin cleansers containing syndets or amphotheric surfactants compared with standard soap and water improved skin dryness. Lipophilic leave-on products containing humectants decreased skin dryness and reduced pruritus. Products with pH 4 improved the skin barrier. Application of skin protectants and structured skin care protocols decreased the severity of incontinence-associated dermatitis. Formulations containing glycerin and petrolatum reduced the incidence of skin tears. Thirty-five outcome domains were identified with nearly 100 different outcome measurement instruments.

CONCLUSION

Included studies showed substantial heterogeneity regarding design, interventions and outcomes. Basic skin care strategies including low-irritating cleansers and lipophilic humectant-containing leave-on products are helpful for treating dry skin and improving skin barrier in the aged. Lower pH of leave-on products improves the skin barrier. The number of different outcome domains was unexpectedly high. We recommend to identify critical outcome domains in the field of skin care to make trial results more comparable in the future and to measure possible performance differences between different skin care strategies and products.

Protocol for the development of core set of domains of the core outcome set for patients with congenital melanocytic naevi (OCOMEN project)

BACKGROUND

Having large congenital melanocytic naevi (CMN) is associated with a psychosocial burden on patients and their parents because of its remarkable appearance and the extra care it may require. Large CMN also pose an increased risk of malignant melanoma or neurocutaneous melanosis. There is a lack of international consensus on what important outcome domains to measure in relation to treatment. This makes it difficult to compare options, to properly inform patients and their parents, and to set up treatment policy for CMN. Therefore, we aim to develop a core outcome set (COS), i.e. the minimum set of outcomes that are recommended to be measured and reported in all clinical trials of a specific health condition. This COS can be used in the follow-up of CMN patients with or without treatment, in clinical research and practice.

METHODS

In the Outcomes for Congenital Melanocytic Nevi (OCOMEN) projects, we follow the recommendations from the Core Outcome Measures in Effectiveness Trials (COMET) initiative and the Cochrane Skin Core Outcomes Set Initiative (CS-COUSIN). This project entails the following: (i) a systematic review to identify the previous reported outcomes in literature; (ii) focus groups with national and international patients and parents to identify patient-important outcomes; (iii) classification of outcomes into outcome domains; (iv) e-Delphi surveys in which stakeholders (patients/parents and professionals) can rate the importance of domains and outcomes; and (v) an online consensus meeting to finalize the core outcome domains of the COS.

RESULTS

The results will be disseminated by means of publication in a leading journal and presentations in international meetings or conferences. We engage international experts in CMN, both patients and professionals, to ensure the international utility and applicability of the COS.

Navigating the landscape of core outcome set development in dermatology

The development of core outcome sets (COSs; ie, a minimum set of core outcomes that should be measured and reported in all trials or in clinical practice for a specific condition) in dermatology is increasing in pace. A total of 44 dermatology-related COS projects have been registered in the online Core Outcome Measures in Effectiveness Trials database (http://www.comet-initiative.org/studies/search) and include studies on 26 different skin diseases. With the increasing number of COSs in dermatology, care is needed to ensure the delivery of high-quality COSs that meet quality standards when using state-of-the-art methods. In 2015, the Cochrane Skin-Core Outcome Set Initiative (CS-COUSIN) was established. CS-COUSIN is an international, multidisciplinary working group aiming to improve the development and implementation of COSs in dermatology. CS-COUSIN has developed guidance on how to develop high-quality COSs for skin diseases and supports dermatology-specific COS initiatives. Currently, 17 COS development groups are affiliated with CS-COUSIN and following standardized COS development processes. To ensure successful uptake of COSs in dermatology, researchers, clinicians, systematic reviewers, guideline developers, and other stakeholders should use existing COSs in their work.