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Wilmont I, Loeffen M, Hoogeboom T. A qualitative study on the facilitators and barriers to adopting the N-of-1 trial methodology as part of clinical practice: potential versus implementation challenges. Int J Qual Stud Health Well-being 2024; 19:2318810. [PMID: 38417032 PMCID: PMC10903748 DOI: 10.1080/17482631.2024.2318810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Accepted: 02/10/2024] [Indexed: 03/01/2024] Open
Abstract
PURPOSE To investigate opinions among healthcare stakeholders whether implementation of the N-of-1 trial approach in clinical practice is a feasible way to optimize evidence-based treatment results for unique patients. METHODS We interviewed clinicians, researchers, and a patient advocate (n = 13) with an interest in or experience with N-of-1 trials on the following topics: experience with N-of-1, measurement, validity and reliability, informally gathered data usability, and influence on physician-patient relationship. Interviews were analysed using qualitative, thematic analysis. RESULTS The N-of-1 approach has the potential to shift the current healthcare system towards embracing personalized medicine. However, its application in clinical practice carries significant challenges in terms of logistics, time investment and acceptability. New skills will be required from patients and healthcare providers, which may alter the patient-physician relationship. The rise of consumer technology enabling self-measurement may leverage the uptake of N-of-1 approaches in clinical practice. CONCLUSIONS There is a strong belief that the N-of-1 approach has the potential to play a prominent role in transitioning the current healthcare system towards embracing personalized medicine. However, there are many barriers deeply ingrained in our healthcare system that hamper the uptake of the N-of-1 approach, making it momentarily only interesting for research purposes.
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Affiliation(s)
- Ilona Wilmont
- Data & Knowledge Engineering, HAN University of Applied Sciences, Arnhem, the Netherlands
- Institute for Computing and Information Sciences, Data Science, Radboud University Nijmegen, Nijmegen, the Netherlands
| | | | - Thomas Hoogeboom
- IQ healthcare, Radboud university medical center, Radboud Institute for Health Sciences, Nijmegen, the Netherlands
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Chatters R, Hawksworth O, Julious S, Cook A. The development of a set of key points to aid clinicians and researchers in designing and conducting n-of-1 trials. Trials 2024; 25:473. [PMID: 38992786 PMCID: PMC11241860 DOI: 10.1186/s13063-024-08261-z] [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: 07/12/2023] [Accepted: 06/18/2024] [Indexed: 07/13/2024] Open
Abstract
INTRODUCTION n-of-1 trials are undertaken to optimise the evaluation of health technologies in individual patients. They involve a single patient receiving treatments, both interventional and control, consecutively over set periods of time, the order of which is decided at random. Although n-of-1 trials are undertaken in medical research it could be argued they have the utility to be undertaken more frequently. We undertook the National Institute for Health Research (NIHR) commissioned DIAMOND (Development of generalisable methodology for n-of-1 trials delivery for very low volume treatments) project to develop key points to assist clinicians and researchers in designing and conducting n-of-1 trials. METHODS The key points were developed by undertaking a stakeholder workshop, followed by a discussion within the study team and then a stakeholder dissemination and feedback event. The stakeholder workshop sought to gain the perspectives of a variety of stakeholders (including clinicians, researchers and patient representatives) on the design and use of n-of-1 trials. A discussion between the study team was held to reflect on the workshop and draft the key points. Lastly, the stakeholders from the workshop were invited to a dissemination and feedback session where the proposed key points were presented and their feedback gained. RESULTS A set of 22 key points were developed based on the insights from the workshop and subsequent discussions. They provide guidance on when an n-of-1 trial might be a viable or appropriate study design and discuss key decisions involved in the design of n-of-1 trials, including determining an appropriate number of treatment periods and cycles, the choice of comparator, recommended approaches to randomisation and blinding, the use of washout periods and approaches to analysis. CONCLUSIONS The key points developed in the project will support clinical researchers to understand key considerations when designing n-of-1 trials. It is hoped they will support the wider implementation of the study design.
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Affiliation(s)
- Robin Chatters
- Sheffield Clinical Trials Research Unit (CTRU), Sheffield Centre for Health and Related Research (SCHARR), The University of Sheffield, Sheffield, UK.
| | - Olivia Hawksworth
- Sheffield Clinical Trials Research Unit (CTRU), Sheffield Centre for Health and Related Research (SCHARR), The University of Sheffield, Sheffield, UK
| | - Steven Julious
- Sheffield Centre for Health and Related Research (SCHARR), The University of Sheffield, Sheffield, UK
| | - Andrew Cook
- Clinical Trials Unit, University of Southampton, Southampton, UK
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3
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Goodwin AM, Miller D, D’Angelo S, Perrin A, Wiener R, Greene B, Romain AMN, Arader L, Chandereng T, Kuen Cheung Y, Davidson KW, Butler M. Protocol for randomized personalized trial for stress management compared to standard of care. Front Psychol 2023; 14:1233884. [PMID: 37794909 PMCID: PMC10546313 DOI: 10.3389/fpsyg.2023.1233884] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Accepted: 09/04/2023] [Indexed: 10/06/2023] Open
Abstract
Stress is a significant public health burden in the United States, with most Americans reporting unhealthy levels of stress. Stress management techniques include various evidence-based treatments shown to be effective but with heterogeneous treatment responses, indicating a lack of uniform benefits for all individuals. Designed to assess a participant's response to a specific intervention, personalized (N-of-1) trials provide guidance for which treatment (s) work (s) best for the individual. Prior studies examining the effects of mindfulness meditation, yoga, and walking for stress reduction found all three interventions to be associated with significant reductions in self-reported measures of stress. Delivering these treatments using a personalized trial approach has the potential to assist clinicians in identifying the best stress management techniques for individuals with persistently high stress while fostering treatment decisions that consider their personal condition/barriers. This trial will evaluate a personalized approach compared to standard of care for three interventions (guided mindfulness meditation; guided yoga; and guided brisk walking) to manage perceived stress. Participants will respond to daily surveys and wear a Fitbit device for 18 weeks. After a 2-week baseline period, participants in the personalized trial groups will receive 12 weeks of interventions in randomized order, while participants in the standard-of-care group will have access to all interventions for self-directed stress management. After intervention, all participants will undergo 2 weeks of observation, followed by two additional weeks of the stress management intervention of their choosing while continuing outcome measurement. At study completion, all participants will be sent a satisfaction survey. The primary analysis will compare perceived stress levels between the personalized and standard of care arms. The results of this trial will provide further support for the use of personalized designs for managing stress. Clinical Trial Registration: clinicaltrials.gov, NCT05408832. Protocol version: 9/14/2022, 21-0968-MRB.
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Affiliation(s)
- Ashley M. Goodwin
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, New York, NY, United States
| | - Danielle Miller
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, New York, NY, United States
| | - Stefani D’Angelo
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, New York, NY, United States
| | - Alexandra Perrin
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, New York, NY, United States
| | - Ruby Wiener
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, New York, NY, United States
| | - Brittney Greene
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, New York, NY, United States
- State University of New York at Buffalo, Buffalo, NY, United States
| | - Anne-Marie N. Romain
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, New York, NY, United States
- Gordon F. Derner School of Psychology, Adelphi University, Garden City, NY, United States
| | - Lindsay Arader
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, New York, NY, United States
- Department of Psychology, St. John’s University, Jamaica, NY, United States
| | - Thevaa Chandereng
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, New York, NY, United States
| | - Ying Kuen Cheung
- Mailman School of Public Health, Columbia University, New York, NY, United States
| | - Karina W. Davidson
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, New York, NY, United States
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Hempstead, NY, United States
| | - Mark Butler
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, New York, NY, United States
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Butler M, D'Angelo S, Perrin A, Rodillas J, Miller D, Arader L, Chandereng T, Cheung YK, Shechter A, Davidson KW. A Series of Remote Melatonin Supplement Interventions for Poor Sleep: Protocol for a Feasibility Pilot Study for a Series of Personalized (N-of-1) Trials. JMIR Res Protoc 2023; 12:e45313. [PMID: 37535419 PMCID: PMC10436115 DOI: 10.2196/45313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Revised: 03/27/2023] [Accepted: 03/27/2023] [Indexed: 03/30/2023] Open
Abstract
BACKGROUND Poor sleep, defined as short-duration or poor-quality sleep, is a frequently reported condition with many deleterious effects including poorer cognitive functioning, increased accidents, and poorer health. Melatonin has been shown to be an efficacious treatment to manage symptoms of poor sleep. However, the treatment effects of melatonin on sleep can vary greatly between participants. Personalized, or N-of-1, trial designs represent a method for identifying the best treatment for individual participants. Although using N-of-1 trials of melatonin to treat poor sleep is possible, the feasibility, acceptability, and effectiveness of N-of-1 trials using melatonin are unknown. Using the National Institutes of Health Stage Model for Behavioral Intervention Development, a stage IB (intervention refinement, modification, and adaptation and pilot testing) design appeared to be needed to address these feasibility questions. OBJECTIVE This trial series evaluates the feasibility, acceptability, and effectiveness of a series of personalized interventions for remote delivery of melatonin dose (3 and 0.5 mg) versus placebo supplements for self-reported poor sleep among 60 participants. The goal of this study is to provide valuable information about implementing remote N-of-1 randomized controlled trials to improve poor sleep. METHODS Participants will complete a 2-week baseline followed by six 2-week alternating intervention periods of 3 mg of melatonin, 0.5 mg of melatonin, and placebo. Participants will be randomly assigned to 2 intervention orders. The feasibility and acceptability of the personalized trial approach will be determined with participants' ratings of usability and satisfaction with the remote, personalized intervention delivery system. The effectiveness of the intervention will be measured using participants' self-reported sleep quality and duration and Fitbit tracker-measured sleep duration and efficiency. Additional measures will include ecological momentary assessment measures of fatigue, stress, pain, mood, concentration, and confidence as well as measures of participant adherence to the intervention, use of the Fitbit tracker, and survey data collection. RESULTS As of the submission of this protocol, recruitment for this National Institutes of Health stage IB personalized trial series is approximately 78.3% complete (47/60). We expect recruitment and data collection to be finalized by June 2023. CONCLUSIONS Evaluating the feasibility, acceptability, and effectiveness of a series of personalized interventions of melatonin will address the longer term aim of this program of research-is integrating N-of-1 trials useful patient care? The personalized trial series results will be published in a peer-reviewed journal and will follow the CONSORT (Consolidated Standards of Reporting Trials) extension for N-of-1 trials (CENT 2015) reporting guidelines. This trial series was approved by the Northwell Health institutional review board. TRIAL REGISTRATION ClinicalTrials.gov NCT05349188; https://www.clinicaltrials.gov/study/NCT05349188. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/45313.
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Affiliation(s)
- Mark Butler
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, United States
| | - Stefani D'Angelo
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, United States
| | - Alexandra Perrin
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, United States
| | - Jordyn Rodillas
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, United States
| | - Danielle Miller
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, United States
| | - Lindsay Arader
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, United States
- St John's University, New York, NY, United States
| | - Thevaa Chandereng
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, United States
| | - Ying Kuen Cheung
- Mailman School of Public Health, Columbia University, New York, NY, United States
| | - Ari Shechter
- Columbia University Irving Medical Center, New York, NY, United States
| | - Karina W Davidson
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, United States
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell Health, Hempstead, NY, United States
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5
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Suls J, Friel CP, Butler M, Duer-Hefele J, Robles PL, Vicari F, Chandereng T, Cheung YK(K, Davidson KW. Protocol of a feasibility study of a virtual personalized (N-of-1) trial for increasing low-intensity physical activity in older adults via habit formation. Contemp Clin Trials Commun 2023; 33:101135. [PMID: 37333978 PMCID: PMC10276207 DOI: 10.1016/j.conctc.2023.101135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Revised: 03/01/2023] [Accepted: 04/10/2023] [Indexed: 06/20/2023] Open
Abstract
Background Personalized interventions that can be delivered remotely are needed to increase physical activity (PA) in older adults to reduce risk of CV disease and mortality. Prior research indicates that Behavioral Change Techniques (BCTs) (e.g., goal setting, self-monitoring, behavioral repetition) can instill a habit for increasing daily walking. However, past interventions relied on between-subject randomized clinical trials, which can only only be informative about response of the hypothetical average person. Personalized trial designs can identify the benefits of an intervention for a specific individual although extended periods are required for collecting frequent measurements within-subject. Advances in remote, virtual technologies (e.g., text messaging, activity trackers), integrated with automatic platforms, can meet these requirements because they capacitate delivery of BCT interventions, and collection of data during daily life without personal contact. This Stage I-b trial is designed test whether a virtual, personalized intervention is feasible and acceptable to older adults, can elicit participant adherence and exhibit preliminary evidence for efficacy. Methods A series of up to 60 single-arm, personalized trials, involving no personal contact, will recruit adults, 45-75 years of age, to wear an activity tracker during a 2-week baseline and a 10-week intervention. Five BCT prompts to execute a walking plan will be delivered on a daily basis during the intervention phase. Participants will rate satisfaction with personalized trial components and whether automaticity of the walking plan can be achieved. Step-counts, adherence to the walking plan and self-monitoring of step-count will also be recorded.
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Affiliation(s)
- Jerry Suls
- Institute for Health System Science Feinstein Institutes for Medical Research Northwell Health 130 East 59th Street, Suite 14C, New York, NY, 10022, USA
| | - Ciarán P. Friel
- Institute for Health System Science Feinstein Institutes for Medical Research Northwell Health 130 East 59th Street, Suite 14C, New York, NY, 10022, USA
| | - Mark Butler
- Institute for Health System Science Feinstein Institutes for Medical Research Northwell Health 130 East 59th Street, Suite 14C, New York, NY, 10022, USA
| | - Joan Duer-Hefele
- Institute for Health System Science Feinstein Institutes for Medical Research Northwell Health 130 East 59th Street, Suite 14C, New York, NY, 10022, USA
| | - Patrick L. Robles
- Institute for Health System Science Feinstein Institutes for Medical Research Northwell Health 130 East 59th Street, Suite 14C, New York, NY, 10022, USA
| | - Frank Vicari
- Institute for Health System Science Feinstein Institutes for Medical Research Northwell Health 130 East 59th Street, Suite 14C, New York, NY, 10022, USA
| | - Thevaa Chandereng
- Institute for Health System Science Feinstein Institutes for Medical Research Northwell Health 130 East 59th Street, Suite 14C, New York, NY, 10022, USA
| | - Ying Kuen (Ken) Cheung
- Institute for Health System Science Feinstein Institutes for Medical Research Northwell Health 130 East 59th Street, Suite 14C, New York, NY, 10022, USA
| | - Karina W. Davidson
- Institute for Health System Science Feinstein Institutes for Medical Research Northwell Health 130 East 59th Street, Suite 14C, New York, NY, 10022, USA
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Goyal P, Kronish IM. N-of-1 Trials for Pediatric Hypertension? A Promising Approach to Increasing the Precision of Antihypertensive Treatment. Am J Hypertens 2023; 36:87-89. [PMID: 36335469 PMCID: PMC9922946 DOI: 10.1093/ajh/hpac125] [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: 11/02/2022] [Accepted: 11/04/2022] [Indexed: 11/09/2022] Open
Affiliation(s)
- Parag Goyal
- Department of Medicine, Weill Cornell Medicine, New York, New York, USA
| | - Ian M Kronish
- Center for Behavioral Cardiovascular Health, Columbia University Irving Medical Center, New York, New York, USA
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Butler M, D'Angelo S, Lewis C, Miller D, Perrin A, Suls J, Chandereng T, Cheung YK, Davidson KW. Series of virtual light therapy interventions for fatigue: a feasibility pilot study protocol for a series of personalised (N-of-1) trials. BMJ Open 2022; 12:e055518. [PMID: 36283748 PMCID: PMC9608534 DOI: 10.1136/bmjopen-2021-055518] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
INTRODUCTION Fatigue is one of the most commonly recorded patient symptoms that can result in deficits in aspects of psychomotor functioning, cognition, work performance and mood. Research shows that bright light and dim light therapy may be an efficacious way to reduce symptoms of fatigue. Still, the feasibility, scalability, individual treatment effects and adverse event heterogeneity of these treatments are unknown. METHODS AND ANALYSIS The current study evaluates the feasibility, acceptability and effectiveness of a series of personalised (N-of-1) interventions for virtual delivery of bright light therapy and dim light therapy versus usual care treatment for fatigue in 60 participants. We hypothesise that this study will provide valuable information about implementing virtual, N-of-1 randomised controlled trials (RCTs) for fatigue. It will also offer results about determining participants' ratings of usability and satisfaction with the virtual, personalised intervention delivery system; evaluating participants' improvement of fatigue symptoms; and, in the long term, identify ways to integrate N-of-1 light therapy trials into patient care. ETHICS AND DISSEMINATION This trial was approved by the Northwell Health Institutional Review Board. The trial results will be published in a peer-reviewed journal. All publications resulting from this series of personalised trials will follow the Consolidated Standards of Reporting Trials extension for N-of-1 trials CENT 2015 reporting guidelines. REGISTRATION DETAILS This trial is registered in www. CLINICALTRIALS gov (number NCT04707846). TRIAL REGISTRATION NUMBER NCT04707846.
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Affiliation(s)
- Mark Butler
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York, USA
| | - Stefani D'Angelo
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York, USA
| | - Courtney Lewis
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York, USA
| | - Danielle Miller
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York, USA
| | - Alexandra Perrin
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York, USA
| | - Jerry Suls
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York, USA
| | - Thevaa Chandereng
- Mailman School of Public Health, Columbia University, New York, New York, USA
| | - Ying Kuen Cheung
- Mailman School of Public Health, Columbia University, New York, New York, USA
| | - Karina W Davidson
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York, USA
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Hempstead, New York, USA
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D'Angelo S, Ahn H, Miller D, Monane R, Butler M. Personalized Feedback for Personalized Trials: Construction of Summary Reports for Participants in a Series of Personalized Trials for Chronic Lower Back Pain. HARVARD DATA SCIENCE REVIEW 2022; 4:10.1162/99608f92.d5b57784. [PMID: 38009134 PMCID: PMC10673635 DOI: 10.1162/99608f92.d5b57784] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2023] Open
Abstract
Personalized (N-of-1) trials offer a patient-centered research approach that can provide important clinical information for patients when selecting which treatment options best manage their chronic health concern. Researchers utilizing this approach should present trial results to patients in a clear and understandable manner in order for personalized research trials to be useful to participants. The current study provides participant feedback examples for personalized trial reports using lay summaries and multiple presentation styles from a series of 60 randomized personalized trials examining the effects of massage and yoga versus usual care on chronic lower back pain (CLBP). Researchers generated summary participant reports that describe individual participant results using multiple presentation modalities of data (e.g., visual, written, and auditory) to offer the most appealing style for various participants. The article discusses contents of the participant report as well as participant satisfaction with the personalized summary report, captured using a satisfaction survey administered after study completion. The results from the satisfaction survey in the current study show that participants were generally satisfied with their personalized summary report. Researchers will use feedback from the participants in the current study to refine personalized feedback reports for future studies.
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Affiliation(s)
- Stefani D'Angelo
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health; Manhasset, NY, USA
| | - Heejoon Ahn
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health; Manhasset, NY, USA
| | - Danielle Miller
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health; Manhasset, NY, USA
| | - Rachel Monane
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health; Manhasset, NY, USA
| | - Mark Butler
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health; Manhasset, NY, USA
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Using Artificial Intelligence to Enhance Ongoing Psychological Interventions for Emotional Problems in Real- or Close to Real-Time: A Systematic Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19137737. [PMID: 35805395 PMCID: PMC9266240 DOI: 10.3390/ijerph19137737] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Revised: 06/17/2022] [Accepted: 06/22/2022] [Indexed: 12/10/2022]
Abstract
Emotional disorders are the most common mental disorders globally. Psychological treatments have been found to be useful for a significant number of cases, but up to 40% of patients do not respond to psychotherapy as expected. Artificial intelligence (AI) methods might enhance psychotherapy by providing therapists and patients with real- or close to real-time recommendations according to the patient’s response to treatment. The goal of this investigation is to systematically review the evidence on the use of AI-based methods to enhance outcomes in psychological interventions in real-time or close to real-time. The search included studies indexed in the electronic databases Scopus, Pubmed, Web of Science, and Cochrane Library. The terms used for the electronic search included variations of the words “psychotherapy”, “artificial intelligence”, and “emotional disorders”. From the 85 full texts assessed, only 10 studies met our eligibility criteria. In these, the most frequently used AI technique was conversational AI agents, which are chatbots based on software that can be accessed online with a computer or a smartphone. Overall, the reviewed investigations indicated significant positive consequences of using AI to enhance psychotherapy and reduce clinical symptomatology. Additionally, most studies reported high satisfaction, engagement, and retention rates when implementing AI to enhance psychotherapy in real- or close to real-time. Despite the potential of AI to make interventions more flexible and tailored to patients’ needs, more methodologically robust studies are needed.
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Kane PB, Bittlinger M, Kimmelman J. Individualized therapy trials: navigating patient care, research goals and ethics. Nat Med 2021; 27:1679-1686. [PMID: 34642487 DOI: 10.1038/s41591-021-01519-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Accepted: 08/26/2021] [Indexed: 02/08/2023]
Abstract
'Individualized therapy' trials (sometimes called n-of-1 trials) use patients as their own controls to evaluate treatments. Here we divide such trials into three categories: multi-crossover trials aimed at individual patient management, multi-crossover trial series and pre-post trials. These trials all customize interventions for patients; however, the latter two categories also aim to inform medical practice and thus embody tensions between the goals of care and research that are typical of other types of clinical trials. In this Perspective, we discuss four domains where such tensions play out-clinical equipoise, informed consent, reporting and funding, and we provide recommendations for addressing each.
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Affiliation(s)
- Patrick Bodilly Kane
- Studies in Translation, Ethics and Medicine, Biomedical Ethics Unit, McGill University, Montreal, Quebec, Canada
| | - Merlin Bittlinger
- Studies in Translation, Ethics and Medicine, Biomedical Ethics Unit, McGill University, Montreal, Quebec, Canada
| | - Jonathan Kimmelman
- Studies in Translation, Ethics and Medicine, Biomedical Ethics Unit, McGill University, Montreal, Quebec, Canada.
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11
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Fringer A. Wenn die Evidenz am Einzelfall scheitert. Pflege 2021; 34:229-230. [PMID: 34546089 DOI: 10.1024/1012-5302/a000832] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- André Fringer
- MSc Pflege und Forschung & Entwicklung Pflege, Zürcher Hochschule für Angewandte Wissenschaften ZHAW, Winterthur
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Müller AR, Zinkstok JR, Rommelse NNJ, van de Ven PM, Roes KCB, Wijburg FA, de Rooij-Askes E, Linders C, Boot E, van Eeghen AM. Methylphenidate for attention-deficit/hyperactivity disorder in patients with Smith-Magenis syndrome: protocol for a series of N-of-1 trials. Orphanet J Rare Dis 2021; 16:380. [PMID: 34496899 PMCID: PMC8424817 DOI: 10.1186/s13023-021-02003-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Accepted: 08/24/2021] [Indexed: 12/29/2022] Open
Abstract
Background Smith–Magenis syndrome (SMS) is a rare genetic neurodevelopmental disorder characterized by intellectual disability and severe behavioural and sleep disturbances. Often, patients with SMS are diagnosed with attention-deficit/hyperactivity disorder (ADHD). However, the effectiveness of methylphenidate (MPH), the first-line pharmacological treatment for ADHD, in patients with SMS is unclear. Our objective is to examine the effectiveness of MPH for ADHD symptoms in individuals with SMS, proposing an alternative trial design as traditional randomized controlled trials are complex in these rare and heterogeneous patient populations. Methods and analysis We will initiate an N-of-1 series of double-blind randomized and placebo-controlled multiple crossover trials in six patients aged ≥ 6 years with a genetically confirmed SMS diagnosis and a multidisciplinary established ADHD diagnosis, according to a power analysis based on a summary measures analysis of the treatment effect. Each N-of-1 trial consists of a baseline period, dose titration phase, three cycles each including randomized intervention, placebo and washout periods, and follow-up. The intervention includes twice daily MPH (doses based on age and body weight). The primary outcome measure will be the subscale hyperactivity/inattention of the Strengths and Difficulties Questionnaire (SDQ), rated daily. Secondary outcome measures are the shortened version of the Emotion Dysregulation Inventory (EDI) reactivity index, Goal Attainment Scaling (GAS), and the personal questionnaire (PQ). Statistical analysis will include a mixed model analysis. All subjects will receive an assessment of their individual treatment effect and data will be aggregated to investigate the effectiveness of MPH for ADHD in SMS at a population level. Conclusions This study will provide information on the effectiveness of MPH for ADHD in SMS, incorporating personalized outcome measures. This protocol presents the first properly powered N-of-1 study in a rare genetic neurodevelopmental disorder, providing a much-needed bridge between science and practice to optimize evidence-based and personalized care. Trial registration This study is registered in the Netherlands Trial Register (NTR9125).
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Affiliation(s)
- A R Müller
- Advisium, 's Heeren Loo, Amersfoort, the Netherlands.,Department of Pediatrics, Emma Children's Hospital, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - J R Zinkstok
- Department of Psychiatry and Brain Center, University Medical Center Utrecht, Utrecht, The Netherlands
| | - N N J Rommelse
- Karakter, Child and Adolescent Psychiatry, Nijmegen, The Netherlands.,Department of Psychiatrics, Radboud University Medical Center, Nijmegen, The Netherlands
| | - P M van de Ven
- Department of Epidemiology and Data Science, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - K C B Roes
- Department of Health Evidence, Biostatistics, Radboud University Medical Center, Nijmegen, The Netherlands
| | - F A Wijburg
- Department of Pediatrics, Emma Children's Hospital, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | | | - C Linders
- Advisium, 's Heeren Loo, Amersfoort, the Netherlands
| | - E Boot
- Advisium, 's Heeren Loo, Amersfoort, the Netherlands.,Department of Psychiatry and Neuropsychology, Maastricht University, Maastricht, The Netherlands.,The Dalglish Family 22Q Clinic, University Health Network, Toronto, ON, Canada
| | - A M van Eeghen
- Advisium, 's Heeren Loo, Amersfoort, the Netherlands. .,Department of Pediatrics, Emma Children's Hospital, Amsterdam University Medical Center, Amsterdam, The Netherlands.
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13
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Nikles J, Onghena P, Vlaeyen JW, Wicksell RK, Simons LE, McGree JM, McDonald S. Establishment of an International Collaborative Network for N-of-1 Trials and Single-Case Designs. Contemp Clin Trials Commun 2021; 23:100826. [PMID: 34401597 PMCID: PMC8350373 DOI: 10.1016/j.conctc.2021.100826] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 06/15/2021] [Accepted: 07/26/2021] [Indexed: 11/24/2022] Open
Abstract
In this article we briefly examine the unique features of Single-Case Designs (SCDs) (studies in a single participant), their history and current trends, and real-world clinical applications. The International Collaborative Network for N-of-1 Trials and Single-Case Designs (ICN) is a formal collaborative network for individuals with an interest in SCDs. The ICN was established in 2017 to support the SCD scientific community and provide opportunities for collaboration, a global communication channel, resource sharing and knowledge exchange. In May 2021, there were more than 420 members in 31 countries. A member survey was undertaken in 2019 to identify priorities for the ICN for the following few years. This article outlines the key priorities identified and the ICN's progress to date in these key areas including network activities (developing a communications strategy to increase awareness, collecting/sharing a comprehensive set of resources, guidelines and tips, and incorporating the consumer perspective) and scientific activities (writing position papers and guest editing special journal issues, exploring key stakeholder perspectives about SCDs, and working to streamline ethical approval processes for SCDs). The ICN provides a practical means to engage with this methodology through membership. We encourage clinicians, researchers, industry, and healthcare consumers to learn more about and conduct SCDs, and to join us in our mission of using SCDs to improve health outcomes for individuals and populations.
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Affiliation(s)
- Jane Nikles
- Centre for Clinical Research, The University of Queensland, Australia
| | | | | | | | | | | | - Suzanne McDonald
- Centre for Clinical Research, The University of Queensland, Australia
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14
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Marrast L, Conigliaro J, Chan C, Kim EJ, Duer-Hefele J, Diefenbach MA, Davidson KW. Racial and ethnic minority patient participation in N-of-1 trials: perspectives of healthcare providers and patients. Per Med 2021; 18:347-359. [PMID: 34047197 DOI: 10.2217/pme-2020-0166] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Aim: Patients from racial and ethnic minority backgrounds in the USA have historically been under-represented in research trials. Understanding their viewpoints regarding participation in N-of-1 trials is imperative as we design and implement these studies. Materials & methods: We conducted six focus groups of racial and ethnic minority patients (n = 25) and providers (n = 9). We used content analysis to identify themes. Results: Our results noted the importance of considering family members in N-of-1 trial recruitment and participation, patients' desire for education as a design feature, for 'lifestyle' changes as a treatment option and for use of nonevidence-based treatments in the design of future N-of-1 trials. Conclusion: Personalized trials have the potential to change the way we deliver primary care and improve disparities for minorities.
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Affiliation(s)
- Lyndonna Marrast
- Department of Medicine, Division of General Internal Medicine, The Donald & Barbara Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, NY 11042, USA.,Institute for Health System Science, Center for Health Innovations & Outcomes Research, Feinstein Institutes for Medical Research, Manhasset, NY 11030, USA
| | - Joseph Conigliaro
- Department of Medicine, Division of General Internal Medicine, The Donald & Barbara Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, NY 11042, USA.,Institute for Health System Science, Center for Health Innovations & Outcomes Research, Feinstein Institutes for Medical Research, Manhasset, NY 11030, USA
| | - Camille Chan
- Institute for Health System Science, Center for Health Innovations & Outcomes Research, Feinstein Institutes for Medical Research, Manhasset, NY 11030, USA
| | - Eun Ji Kim
- Department of Medicine, Division of General Internal Medicine, The Donald & Barbara Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, NY 11042, USA.,Institute for Health System Science, Center for Health Innovations & Outcomes Research, Feinstein Institutes for Medical Research, Manhasset, NY 11030, USA
| | - Joan Duer-Hefele
- Institute for Health System Science, Center for Personalized Health, Feinstein Institutes for Medical Research, Manhasset, NY 11030, USA
| | - Michael A Diefenbach
- Institute for Health System Science, Center for Health Innovations & Outcomes Research, Feinstein Institutes for Medical Research, Manhasset, NY 11030, USA
| | - Karina W Davidson
- Institute for Health System Science, Center for Personalized Health, Feinstein Institutes for Medical Research, Manhasset, NY 11030, USA
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15
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Davidson KW, Silverstein M, Cheung K, Paluch RA, Epstein LH. Experimental Designs to Optimize Treatments for Individuals: Personalized N-of-1 Trials. JAMA Pediatr 2021; 175:404-409. [PMID: 33587109 PMCID: PMC8351788 DOI: 10.1001/jamapediatrics.2020.5801] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Conventional randomized clinical trials (RCTs) compare treatment effectiveness to provide support for evidence-based treatments that can be generalized to the average patient. However, the information obtained from RCTs may not always be useful for selecting the best treatment for individual patients. This article presents a complementary approach to identifying optimized treatments using experimental designs that focus on individuals. Personalized, or N-of-1, designs provide both a comparative analysis of treatments and a functional analysis demonstrating that changes in patient symptoms are likely because of the treatment implemented. This approach contributes to the zeitgeist of personalized medicine and provides clinicians with a paradigm for investigating optimal treatments for rare diseases for which RCTs are not always feasible, identifying personally effective treatments for patients with comorbidities who have historically been excluded from most RCTs, handling clinical situations in which patients respond idiosyncratically (either positively or negatively) to treatment, and shortening the time lag between identification and implementation of an evidence-based treatment. These designs merge experimental analysis of behavior methods used for decades in psychology with new methodological and statistical advances to assess significance levels of changes in individual patients, and they can be generalized to larger populations for meta-analytic purposes. This article presents a case for why these models are needed, an overview of how to apply personalized designs for different types of clinical scenarios, and a brief discussion of challenges associated with interpretation and implementation of personalized designs. The goal is to empower pediatricians to take personalized trial designs into clinical practice to identify optimal treatments for their patients.
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Affiliation(s)
- Karina W. Davidson
- Center for Personalized Health, Northwell Health, Long Island, NY,Donald and Barbara Zucker School of Medicine at Hofstra University, Long Island, NY
| | | | - Ken Cheung
- Mailman School of Public Health, Columbia University, New York, NY
| | - Rocco A. Paluch
- Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY
| | - Leonard H. Epstein
- Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY
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16
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Potter T, Vieira R, de Roos B. Perspective: Application of N-of-1 Methods in Personalized Nutrition Research. Adv Nutr 2021; 12:579-589. [PMID: 33460438 PMCID: PMC8166550 DOI: 10.1093/advances/nmaa173] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Revised: 11/20/2020] [Accepted: 12/11/2020] [Indexed: 01/19/2023] Open
Abstract
Personalized and precision nutrition aim to examine and improve health on an individual level, and this requires reconsideration of traditional dietary interventions or behavioral study designs. The limited frequency of measurements in group-level human nutrition trials cannot be used to infer individual responses to interventions, while in behavioral studies, retrospective data collection does not provide an accurate measure of how everyday behaviors affect individual health. This review introduces the concept of N-of-1 study designs, which involve the repeated measurement of a health outcome or behavior on an individual level. Observational designs can be used to monitor a participant's usual health or behavior in a naturalistic setting, with repeated measurements conducted in real time using an Ecological Momentary Assessment. Interventional designs can introduce a dietary or behavioral intervention with predictors and outcomes of interest measured repeatedly either during or after 1 or more intervention and control periods. Due to their flexibility, N-of-1 designs can be applied to both short-term physiological studies and longer-term studies of eating behaviors. As a growing number of disease markers can be measured outside of the clinic, with self-reported data delivered via electronic devices, it is now easier than ever to generate large amounts of data on an individual level. Statistical techniques can be utilized to analyze changes in an individual or to aggregate data from sets of N-of-1 trials, enabling hypotheses to be tested on a small number of heterogeneous individuals. Although their designs necessitate extra methodological and statistical considerations, N-of-1 studies could be used to investigate complex research questions and to study underrepresented groups. This may help to reveal novel associations between participant characteristics and health outcomes, with repeated measures providing power and precision to accurately determine an individual's health status.
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Affiliation(s)
- Tilly Potter
- Rowett Institute, University of Aberdeen, United Kingdom
| | - Rute Vieira
- Institute of Applied Health Sciences, University of Aberdeen, United Kingdom
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17
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Tsimberidou AM, Müller P, Ji Y. Innovative trial design in precision oncology. Semin Cancer Biol 2020; 84:284-292. [DOI: 10.1016/j.semcancer.2020.09.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2020] [Accepted: 09/09/2020] [Indexed: 01/01/2023]
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18
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Cheung YK, Wood D, Zhang K, Ridenour TA, Derby L, St Onge T, Duan N, Duer-Hefele J, Davidson KW, Kronish I, Moise N. Personal preferences for Personalised Trials among patients with chronic diseases: an empirical Bayesian analysis of a conjoint survey. BMJ Open 2020; 10:e036056. [PMID: 32513886 PMCID: PMC7282396 DOI: 10.1136/bmjopen-2019-036056] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE To describe individual patient preferences for Personalised Trials and to identify factors and conditions associated with patient preferences. DESIGN Each participant was presented with 18 conjoint questions via an online survey. Each question provided two choices of Personalised Trials that were defined by up to eight attributes, including treatment types, clinician involvement, study logistics and trial burden on a patient. SETTING Online survey of adults with at least two common chronic conditions in the USA. PARTICIPANTS A nationally representative sample of 501 individuals were recruited from the Chronic Illness Panel by Harris Poll Online. Participants were recruited from several sources, including emails, social media and telephone recruitment of the target population. MAIN OUTCOME MEASURES The choice of Personalised Trial design that the participant preferred with each conjoint question. RESULTS There was large variability in participants' preferences for the design of Personalised Trials. On average, they preferred certain attributes, such as a short time commitment and no cost. Notably, a population-level analysis correctly predicted 62% of the conjoint responses. An empirical Bayesian analysis of the conjoint data, which supported the estimation of individual-level preferences, improved the accuracy to 86%. Based on estimates of individual-level preferences, patients with chronic pain preferred a long study duration (p≤0.001). Asthma patients were less averse to participation burden in terms of data-collection frequency than patients with other conditions (p=0.002). Patients with hypertension were more cost-sensitive (p<0.001). CONCLUSION These analyses provide a framework for elucidating individual-level preferences when implementing novel patient-centred interventions. The data showed that patient preference in Personalised Trials is highly variable, suggesting that individual differences must be accounted for when marketing Personalised Trials. These results have implications for advancing precise interventions in Personalised Trials by indicating when rigorous scientific principles, such as frequent monitoring, is feasible in a substantial subset of patients.
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Affiliation(s)
- Ying Kuen Cheung
- Biostatistics, Columbia University Irving Medical Center, New York, New York, USA
| | - Dallas Wood
- RTI International, Research Triangle Park, North Carolina, USA
| | - Kangkang Zhang
- Biostatistics, Columbia University Irving Medical Center, New York, New York, USA
| | - Ty A Ridenour
- RTI International, Research Triangle Park, North Carolina, USA
| | - Lilly Derby
- Center Behavioral Cardiovascular Health, Columbia University Irving Medical Center, New York, New York, USA
| | - Tara St Onge
- Center Behavioral Cardiovascular Health, Columbia University Irving Medical Center, New York, New York, USA
| | - Naihua Duan
- Biostatistics, Columbia University Irving Medical Center, New York, New York, USA
| | - Joan Duer-Hefele
- Research, Feinstein Institute for Medical Research, Manhasset, New York, USA
| | - Karina W Davidson
- Research, Feinstein Institute for Medical Research, Manhasset, New York, USA
| | - Ian Kronish
- Center Behavioral Cardiovascular Health, Columbia University Irving Medical Center, New York, New York, USA
| | - Nathalie Moise
- Center Behavioral Cardiovascular Health, Columbia University Irving Medical Center, New York, New York, USA
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19
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Krone T, Boessen R, Bijlsma S, van Stokkum R, Clabbers NDS, Pasman WJ. The possibilities of the use of N-of-1 and do-it-yourself trials in nutritional research. PLoS One 2020; 15:e0232680. [PMID: 32374745 PMCID: PMC7202616 DOI: 10.1371/journal.pone.0232680] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Accepted: 04/21/2020] [Indexed: 12/02/2022] Open
Abstract
Background N-of-1 designs gain popularity in nutritional research because of the improving technological possibilities, practical applicability and promise of increased accuracy and sensitivity, especially in the field of personalized nutrition. This move asks for a search of applicable statistical methods. Objective To demonstrate the differences of three popular statistical methods in analyzing treatment effects of data obtained in N-of-1 designs. Method We compare Individual-participant data meta-analysis, frequentist and Bayesian linear mixed effect models using a simulation experiment. Furthermore, we demonstrate the merits of the Bayesian model including prior information by analyzing data of an empirical study on weight loss. Results The linear mixed effect models are to be preferred over the meta-analysis method, since the individual effects are estimated more accurately as evidenced by the lower errors, especially with lower sample sizes. Differences between Bayesian and frequentist mixed models were found to be small, indicating that they will lead to the same results without including an informative prior. Conclusion For empirical data, the Bayesian mixed model allows the inclusion of prior knowledge and gives potential for population based and personalized inference.
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20
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Borsook D, Upadhyay J, Hargreaves R, Wager T. Enhancing Choice and Outcomes for Therapeutic Trials in Chronic Pain: N-of-1 + Imaging (+ i). Trends Pharmacol Sci 2020; 41:85-98. [DOI: 10.1016/j.tips.2019.12.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Revised: 11/27/2019] [Accepted: 12/04/2019] [Indexed: 10/25/2022]
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21
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Bobe JR, Buros J, Golden E, Johnson M, Jones M, Percha B, Viglizzo R, Zimmerman N. Factors Associated With Trial Completion and Adherence in App-Based N-of-1 Trials: Protocol for a Randomized Trial Evaluating Study Duration, Notification Level, and Meaningful Engagement in the Brain Boost Study. JMIR Res Protoc 2020; 9:e16362. [PMID: 31913135 PMCID: PMC6996754 DOI: 10.2196/16362] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Revised: 12/03/2019] [Accepted: 12/03/2019] [Indexed: 11/13/2022] Open
Abstract
Background
N-of-1 trials promise to help individuals make more informed decisions about treatment selection through structured experiments that compare treatment effectiveness by alternating treatments and measuring their impacts in a single individual. We created a digital platform that automates the design, administration, and analysis of N-of-1 trials. Our first N-of-1 trial, the app-based Brain Boost Study, invited individuals to compare the impacts of two commonly consumed substances (caffeine and L-theanine) on their cognitive performance.
Objective
The purpose of this study is to evaluate critical factors that may impact the completion of N-of-1 trials to inform the design of future app-based N-of-1 trials. We will measure study completion rates for participants that begin the Brain Boost Study and assess their associations with study duration (5, 15, or 27 days) and notification level (light or moderate).
Methods
Participants will be randomized into three study durations and two notification levels. To sufficiently power the study, a minimum of 640 individuals must begin the study, and 97 individuals must complete the study. We will use a multiple logistic regression model to discern whether the study length and notification level are associated with the rate of study completion. For each group, we will also compare participant adherence and the proportion of trials that yield statistically meaningful results.
Results
We completed the beta testing of the N1 app on a convenience sample of users. The Brain Boost Study on the N1 app opened enrollment to the public in October 2019. More than 30 participants enrolled in the first month.
Conclusions
To our knowledge, this will be the first study to rigorously evaluate critical factors associated with study completion in the context of app-based N-of-1 trials.
Trial Registration
ClinicalTrials.gov NCT04056650; https://clinicaltrials.gov/ct2/show/NCT04056650
International Registered Report Identifier (IRRID)
PRR1-10.2196/16362
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Affiliation(s)
- Jason R Bobe
- Institute for Next Generation Healthcare, Department of Genetic and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Jacqueline Buros
- Institute for Next Generation Healthcare, Department of Genetic and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Eddye Golden
- Institute for Next Generation Healthcare, Department of Genetic and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Matthew Johnson
- Institute for Next Generation Healthcare, Department of Genetic and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Michael Jones
- Institute for Next Generation Healthcare, Department of Genetic and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Bethany Percha
- Institute for Next Generation Healthcare, Department of Genetic and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Ryan Viglizzo
- Institute for Next Generation Healthcare, Department of Genetic and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Noah Zimmerman
- Institute for Next Generation Healthcare, Department of Genetic and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY, United States
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22
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Bobe JR, De Freitas JK, Glicksberg BS. Exploring the Potential for Collaborative Use of an App-Based Platform for n-of-1 Trials Among Healthcare Professionals That Treat Patients With Insomnia. Front Psychiatry 2020; 11:530995. [PMID: 33101072 PMCID: PMC7498693 DOI: 10.3389/fpsyt.2020.530995] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Accepted: 08/17/2020] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND N-of-1 trials are single patient, multiple crossover, and comparative effectiveness experiments. Despite their rating as "level 1" evidence, they are not routinely used in clinical medicine to evaluate the effectiveness of treatments. OBJECTIVE We explored the potential for implementing a mobile app-based n-of-1 trial platform for collaborative use by clinicians and patients to support data-driven decisions around the treatment of insomnia. METHODS A survey assessing awareness and utilization of n-of-1 trials was administered to healthcare professionals that frequently treat patients with insomnia at the Icahn School of Medicine at Mount Sinai in New York City. RESULTS A total of 45 healthcare professionals completed the survey and were included in the analysis. We found that 64% (29/45) of healthcare professionals surveyed had not heard of n-of-1 trials. After a brief description of these methods, 75% (30/40) of healthcare professionals reported that they are likely or highly likely to use an app-based n-of-1 trial at least once in the next year if the service were free and easy to offer to their patients. CONCLUSIONS An app-based n-of-1 trials platform might be a valuable tool for clinicians and patients to identify the best treatments for insomnia. The lack of awareness of n-of-1 trials coupled with receptivity to their use suggests that educational interventions may address a current barrier to wider utilization of n-of-1 trials.
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Affiliation(s)
- Jason R Bobe
- Department of Genetic and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Jessica K De Freitas
- Department of Genetic and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY, United States.,Hasso Plattner Institute for Digital Health at Mount Sinai, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Benjamin S Glicksberg
- Department of Genetic and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY, United States.,Hasso Plattner Institute for Digital Health at Mount Sinai, Icahn School of Medicine at Mount Sinai, New York, NY, United States
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23
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Magaret AS, Mayer-Hamblett N, VanDevanter D. Expanding access to CFTR modulators for rare mutations: The utility of n-of-1 trials. J Cyst Fibros 2019; 19:1-2. [PMID: 31831338 DOI: 10.1016/j.jcf.2019.11.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Affiliation(s)
- Amalia S Magaret
- Departments of Pediatrics and Biostatistics, University of Washington, Seattle, WA, USA.
| | - Nicole Mayer-Hamblett
- Departments of Pediatrics and Biostatistics, University of Washington, Seattle, WA, USA
| | - Donald VanDevanter
- Department of Pediatrics, Case Western Reserve University School of Medicine, Cleveland, OH, USA
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Sierra-Arango F, Castaño DM, Forero JD, Pérez-Riveros ED, Ardila Duarte G, Botero ML, Cárdenas A, De la Hoz-Valle J. A Randomized Placebo-Controlled N-of-1 Trial: The Effect of Proton Pump Inhibitor in the Management of Gastroesophageal Reflux Disease. Can J Gastroenterol Hepatol 2019; 2019:3926051. [PMID: 31929980 PMCID: PMC6935808 DOI: 10.1155/2019/3926051] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2019] [Accepted: 09/30/2019] [Indexed: 01/10/2023] Open
Abstract
Background Gastroesophageal reflux disease (GERD) is the most frequent chronic gastrointestinal disorder. It is defined as a condition developed when the reflux of gastric contents causes troublesome symptoms (heartburn and regurgitation). This requires adequate treatment since it can lead to long-term complications including esophagus adenocarcinoma. Proton pump inhibitors (PPI) are generally used to treat GERD due to their high-security profile and efficiency on most patients. However, recurrent reflux despite initial treatment is frequent. N-of-1 trial is a study that allows the identification of the best treatment for each patient. The objective of this study is to compare the efficacy of standard dose with double dosage of esomeprazole, to improve the GERD symptoms in a single patient. Methods A single-patient trial, placebo-controlled, randomized, double-blind, was carried out from September 25th, 2012, to April 26th, 2013. It included one outpatient at the gastroenterology service in a fourth-level hospital, diagnosed with nonerosive reflux disease (NERD). Yet, his symptoms were heartburn and reflux, and his endoscopic results were normal esophageal mucosa, without hiatal hernia, though pathological pH values. A no-obese male without any tobacco or alcohol usage received esomeprazole 40 mg/day and 40 mg/bid for 24 weeks. A standardized gastroesophageal reflux disease questionnaire (GerdQ) was used weekly to evaluate symptom frequency and severity. The consumption of 90% of the capsules was considered as an adequate treatment adherence. D'agostino-Pearson and Wilcoxon test were used to determine normal or nonnormal distribution and compare both treatments, respectively, both with a significant statistical difference of p < 0.05. Results The patient completed the study with 96% of adherence. The double dosage of esomeprazole did not improve the control of symptoms compared with the standard dosage. Mean symptomatic score was 9.5±0.5 and 10.2±0.6 for each treatment, respectively (p > 0.05). Conclusion There was no significant improvement in the patient GERD symptoms increasing the dose of oral esomeprazole during the 6 months of study. N-of-1 trials in chronic pathologies including GERD are recommended due to their potential value as systematic methods that evaluate therapies without strong scientific evidence.
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Affiliation(s)
- Fernando Sierra-Arango
- Gastroenterology and Hepatology Department, Fundación Santa Fe de Bogotá, School of Medicine, Universidad de los Andes, Bogotá, Colombia
| | - D. M. Castaño
- Gastroenterology and Hepatology Department, Fundación Santa Fe de Bogotá, School of Medicine, Universidad de los Andes, Bogotá, Colombia
| | - Jennifer D. Forero
- Gastroenterology and Hepatology Department, Fundación Santa Fe de Bogotá, School of Medicine, Universidad de los Andes, Bogotá, Colombia
| | | | | | - Maria L. Botero
- Pathology Department, Hospital Universitari Vall de Hebron, Barcelona, Spain
| | - Andres Cárdenas
- GI/Endoscopy Unit, Institut de Malalties Digestives Metaboliques, Hospital Clinic, University of Barcelona, Barcelona, Spain
| | - Jose De la Hoz-Valle
- Head of Subdirección de Estudios Clínicos y Epidemiología Clínica (SECEC), Fundación Santa Fe de Bogotá, Bogotá, Colombia
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Evaluating the Comparative Effectiveness of Two Diets in Pediatric Inflammatory Bowel Disease: A Study Protocol for a Series of N-of-1 Trials. Healthcare (Basel) 2019; 7:healthcare7040129. [PMID: 31683925 PMCID: PMC6956096 DOI: 10.3390/healthcare7040129] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Revised: 10/09/2019] [Accepted: 10/23/2019] [Indexed: 01/27/2023] Open
Abstract
Inflammatory bowel disease (IBD) affects 3 million children and adults in the US. Treatment involves medications with considerable risk profiles. Dietary modification, such as the specific carbohydrate diet (SCD), may be helpful in treating IBD, but there is insufficient evidence of its effectiveness. N-of-1 trials are ideal for addressing this important research question. The Personalized Research on Diet in Ulcerative Colitis and Crohn’s Disease (PRODUCE) study employs a series of 50 individual N-of-1 trials that compare the SCD to a modified SCD. Treatment periods are assigned in blocks of two, with each patient completing two balanced treatment blocks. Patients are randomized to start with the SCD or modified SCD and alternate between conditions for four eight-week periods. A mobile app guides collecting and viewing data, transitioning diets, and reviewing personal results. Primary outcomes include patient reported outcomes (PROs) of stool frequency, stool consistency, pain interference, and gastrointestinal (GI) symptom severity. We examine changes in inflammation via fecal calprotectin. Participants will receive a personalized answer regarding comparative effectiveness between the SCD and a less restrictive diet option (modified SCD), as well as compared to their baseline diet. We will aggregate the results of completed N-of-1 trials across patients to estimate population level comparative effectiveness of these treatments and the effectiveness of each diet.
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Alemayehu C, Mitchell G, Nikles J, Aseffa A, Clavarino A. Acceptability and barriers to implementation of N-of-1 tests in Ethiopia - a qualitative study. BMC Med Res Methodol 2019; 19:192. [PMID: 31615422 PMCID: PMC6794767 DOI: 10.1186/s12874-019-0832-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Accepted: 09/11/2019] [Indexed: 11/24/2022] Open
Abstract
Background Locally produced generic drugs offer a cost–effective alternative to imported drugs to treat patients in Ethiopia. However, due to a lack of bioequivalence testing, additional assurance tests are needed to build trust in cheaper, locally made drugs. By testing bioequivalence of local drugs to gold standard, N-of-1 tests have the potential to promote patient centred quality use of medicines. Method We sought to assess the acceptability of, and explore barriers to, conducting N-of-1 tests to evaluate local medicines in a resource limited clinical setting. We conducted a descriptive qualitative study, analysing four focus group discussions and five key informant interviews. Participants were senior drug regulatory authority members, institutional review board members, physicians and patients. All interviews were audio taped and transcribed verbatim. Patient interviews were conducted in Amharic and translated to English prior to analysis. Data analysis used an inductive, thematic process. Results Five major themes were identified; (1) Appropriateness of N-of-1 tests to determine the therapeutic equivalence of local drugs, (2) N-of-1 therapeutic equivalence tests: clinical care or research? (3) Ethical and regulatory requirements (IRB), (4) Potential barriers to implementing N-of-1 tests and (5) Possible solutions to identified challenges. The study demonstrated considerable support for using N-of-1 tests for clinical equivalence studies between local and imported medicines, but important impediments were very likely to impact the feasibility of conducting N-of-1 tests in Ethiopia. Key informants from the regulatory authority did not support additional tests of local drugs. There were also mixed opinions regarding ethical requirements for conducting N-of-1 tests. The Institutional Review Board (IRB) members believed that IRB approval was sufficient to conduct N-of-1 tests, however, the regulatory authority members considered that N-of-1 tests constituted a clinical trial, and required approval at the regulatory level. Conclusion This study showed that there were key uncertainties that could impact the feasiblity of using N-of-1 testing local drugs in Ethiopia. Therefore, a number of protocol amendments to address contextual threats and regulatory challenges, would be needed before progressing to conducting these tests.
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Affiliation(s)
- Chalachew Alemayehu
- Faculty of Medicine, The University of Queensland, P.O. Box: 78, Scott road, Brisbane, QLD, 4006, Australia.
| | - Geoff Mitchell
- Faculty of Medicine, The University of Queensland, P.O. Box: 78, Scott road, Brisbane, QLD, 4006, Australia
| | - Jane Nikles
- UQCCR, The University of Queensland, Brisbane, Australia
| | - Abraham Aseffa
- Armauer Hanson Research Institute, Addis Ababa, Ethiopia
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Increasing the Precision of Hypertension Treatment Through Personalized Trials: a Pilot Study. J Gen Intern Med 2019; 34:839-845. [PMID: 30859504 PMCID: PMC6544735 DOI: 10.1007/s11606-019-04831-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Revised: 09/06/2018] [Accepted: 12/05/2018] [Indexed: 10/27/2022]
Abstract
BACKGROUND There are substantial differences in the effects of blood pressure (BP) medications in individual patients. Yet, the current standard approach to prescribing BP medications is not personalized. OBJECTIVE To determine the feasibility of individualizing the selection of BP medications through pragmatic personalized (i.e., N-of-1) trials. DESIGN Series of N-of-1 trials. SETTING Outpatient. PATIENTS Hypertensive adults prescribed none or one BP medication. INTERVENTION Participation in a flexible, open-label personalized trial of two to three BP medications (NCT02744456). MEASUREMENTS BP was measured twice per day with a validated home BP device. Frequency and severity of side effects were assessed at the end of the day via an electronic questionnaire. Patients' BP medication preference was assessed after reviewing BP lowering and side effect results with a study clinician. Feasibility was assessed by determining the proportion of patients who adhered to self-assessments. Benefit was assessed by asking patients to rate the helpfulness of participation and whether they would recommend personalized trials to other hypertensive patients. KEY RESULTS Of ten patients enrolled, two dropped out prior to initiation, one discovered white coat hypertension through ambulatory BP monitoring, and seven (mean age 58 years, 71% of women) completed personalized trials. All seven were compliant with home BP monitoring and side effect tracking. All seven recommended personalized trials of BP medications to others. Thiazides were preferred by three patients, renin-angiotensin system-blocking agents by two patients, a combination of thiazide and beta-blocker by one patient, and any of three classes by one patient. CONCLUSIONS Personalized trials of BP medications were feasible and led to improved treatment precision. Heterogeneity of patient preferences and of therapeutic BP response for first-line BP medications can be determined through a personalized trial approach.
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Percha B, Baskerville EB, Johnson M, Dudley JT, Zimmerman N. Designing Robust N-of-1 Studies for Precision Medicine: Simulation Study and Design Recommendations. J Med Internet Res 2019; 21:e12641. [PMID: 30932871 PMCID: PMC6462889 DOI: 10.2196/12641] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Revised: 12/28/2018] [Accepted: 12/29/2018] [Indexed: 11/28/2022] Open
Abstract
Background Recent advances in molecular biology, sensors, and digital medicine have led to an explosion of products and services for high-resolution monitoring of individual health. The N-of-1 study has emerged as an important methodological tool for harnessing these new data sources, enabling researchers to compare the effectiveness of health interventions at the level of a single individual. Objective N-of-1 studies are susceptible to several design flaws. We developed a model that generates realistic data for N-of-1 studies to enable researchers to optimize study designs in advance. Methods Our stochastic time-series model simulates an N-of-1 study, incorporating all study-relevant effects, such as carryover and wash-in effects, as well as various sources of noise. The model can be used to produce realistic simulated data for a near-infinite number of N-of-1 study designs, treatment profiles, and patient characteristics. Results Using simulation, we demonstrate how the number of treatment blocks, ordering of treatments within blocks, duration of each treatment, and sampling frequency affect our ability to detect true differences in treatment efficacy. We provide a set of recommendations for study designs on the basis of treatment, outcomes, and instrument parameters, and make our simulation software publicly available for use by the precision medicine community. Conclusions Simulation can facilitate rapid optimization of N-of-1 study designs and increase the likelihood of study success while minimizing participant burden.
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Affiliation(s)
- Bethany Percha
- Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | | | - Matthew Johnson
- Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Joel T Dudley
- Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Noah Zimmerman
- Icahn School of Medicine at Mount Sinai, New York, NY, United States
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Samuel JP, Tyson JE, Green C, Bell CS, Pedroza C, Molony D, Samuels J. Treating Hypertension in Children With n-of-1 Trials. Pediatrics 2019; 143:e20181818. [PMID: 30842257 PMCID: PMC6564074 DOI: 10.1542/peds.2018-1818] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/14/2019] [Indexed: 12/23/2022] Open
Abstract
OBJECTIVES Clinicians prescribe antihypertensive medication to children with primary hypertension, but without data to define a particular choice as first-line therapy. A one-size-fits-all approach may not be appropriate for these patients. Our aim was to develop a personalized approach to hypertension treatment, using repeated ambulatory blood pressure monitoring (ABPM) in n-of-1 trials (single-patient randomized crossover trials). METHODS Children undergoing hypertension management at a single pediatric referral center were offered participation in an n-of-1 trial with repeated ABPM to compare 3 commonly used medications. The medication producing the greatest blood pressure reduction, and without unacceptable side effects, was selected as the preferred therapy for the individual. RESULTS Forty-two children agreed to participate; 7 were normotensive without medication; and 3 failed to complete one treatment cycle. Of the remaining 32 patients, lisinopril was preferred for 16, amlodipine for 8, hydrochlorothiazide for 4, and 4 had uncontrolled blood pressure on maximum doses of monotherapy. In conservative Bayesian analyses, the proportion of patients who preferred lisinopril was 49% (95% credible interval [CrI]: 32% to 69%), 24% (95% CrI: 12% to 41%) preferred amlodipine, and 12% (95% CrI: 4% to 26%) preferred hydrochlorothiazide. The preferred therapy for the majority (67%) of African American participants was lisinopril. Unacceptable side effects were reported in 24% of assessments for hydrochlorothiazide, 16% for lisinopril, and 13% for amlodipine. CONCLUSIONS No single medication was preferred for more than half of hypertensive children. n of-1 trials with repeated ABPM may promote better informed and individualized decisions in pediatric hypertension management.
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Affiliation(s)
| | | | | | | | | | - Don Molony
- McGovern Medical School at University of Texas Health Science Center, Houston, Texas
| | - Joshua Samuels
- Department of Pediatrics
- McGovern Medical School at University of Texas Health Science Center, Houston, Texas
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Gerhart J, Hand D, Hoerger M, O'Mahony S. Single-Subject Designs and Practice-Based Research in Palliative Care: A Letter to the Editor. J Pain Symptom Manage 2019; 57:e3-e5. [PMID: 30557626 DOI: 10.1016/j.jpainsymman.2018.12.209] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Revised: 12/05/2018] [Accepted: 12/06/2018] [Indexed: 10/27/2022]
Affiliation(s)
- James Gerhart
- Department of Psychology, Central Michigan University, Mt. Pleasant, Michigan, USA.
| | - Dennis Hand
- Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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Comulada WS, Swendeman D, Rezai R, Ramanathan N. Time Series Visualizations of Mobile Phone-Based Daily Diary Reports of Stress, Physical Activity, and Diet Quality in Mostly Ethnic Minority Mothers: Feasibility Study. JMIR Form Res 2018; 2:e11062. [PMID: 30684407 PMCID: PMC6334694 DOI: 10.2196/11062] [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: 05/16/2018] [Revised: 10/08/2018] [Accepted: 10/09/2018] [Indexed: 11/18/2022] Open
Abstract
Background Health behavior patterns reported through daily diary data are important to understand and intervene upon at the individual level in N-of-1 trials and related study designs. There is often interest in relationships between multiple outcomes, such as stress and health behavior. However, analyses often utilize regressions that evaluate aggregate effects across individuals, and standard analyses target single outcomes. Objective This paper aims to illustrate how individuals’ daily reports of stress and health behavior (time series) can be explored using visualization tools. Methods Secondary analysis was conducted on 6 months of daily diary reports of stress and health behavior (physical activity and diet quality) from mostly ethnic minority mothers who pilot-tested a self-monitoring mobile health app. Time series with minimal missing data from 14 of the 44 mothers were analyzed. Correlations between stress and health behavior within each time series were reported as a preliminary step. Stress and health behavior time series patterns were visualized by plotting moving averages and time points where mean shifts in the data occurred (changepoints). Results Median correlation was small and negative for associations of stress with physical activity (r=−.14) and diet quality (r=−.08). Moving averages and changepoints for stress and health behavior were aligned for some participants but not for others. A third subset of participants exhibited little variation in stress and health behavior reports. Conclusions Median correlations in this study corroborate prior findings. In addition, time series visualizations highlighted variations in stress and health behavior across individuals and time points, which are difficult to capture through correlations and regression-based summary measures.
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Affiliation(s)
- W Scott Comulada
- Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, Los Angeles, CA, United States
| | - Dallas Swendeman
- Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, Los Angeles, CA, United States
| | - Roxana Rezai
- Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, Los Angeles, CA, United States
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Whitney RL, Ward DH, Marois MT, Schmid CH, Sim I, Kravitz RL. Patient Perceptions of Their Own Data in mHealth Technology-Enabled N-of-1 Trials for Chronic Pain: Qualitative Study. JMIR Mhealth Uhealth 2018; 6:e10291. [PMID: 30309834 PMCID: PMC6231865 DOI: 10.2196/10291] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Revised: 06/07/2018] [Accepted: 07/10/2018] [Indexed: 11/13/2022] Open
Abstract
Background N-of-1 (individual comparison) trials are a promising approach for comparing the effectiveness of 2 or more treatments for individual patients; yet, few studies have qualitatively examined how patients use and make sense of their own patient-generated health data (PGHD) in the context of N-of-1 trials. Objective The objective of our study was to explore chronic pain patients’ perceptions about the PGHD they compiled while comparing 2 chronic pain treatments and tracking their symptoms using a smartphone N-of-1 app in collaboration with their clinicians. Methods Semistructured interviews were recorded with 33 patients, a consecutive subset of the intervention group in a primary study testing the feasibility and effectiveness of the Trialist N-of-1 app. Interviews were transcribed verbatim, and a descriptive thematic analysis was completed. Results Patients were enthusiastic about recording and accessing their own data. They valued sharing data with clinicians but also used their data independently. Conclusions N-of-1 trials remain a promising approach to evidence-based decision making. Patients appear to value their roles as trial participants but place as much or more importance on the independent use of trial data as on comparative effectiveness results. Future efforts to design patient-centered N-of-1 trials might consider adaptable designs that maximize patient flexibility and autonomy while preserving a collaborative role with clinicians and researchers.
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Affiliation(s)
- Robin L Whitney
- Department of Internal Medicine, University of California, San Francisco Fresno Medical Education Program, University of California, San Francisco, Fresno, CA, United States.,Betty Irene Moore School of Nursing, University of California, Davis, Sacramento, CA, United States
| | - Deborah H Ward
- Betty Irene Moore School of Nursing, University of California, Davis, Sacramento, CA, United States
| | - Maria T Marois
- Center for Healthcare Policy and Research, University of California, Davis, Sacramento, CA, United States
| | - Christopher H Schmid
- Department of Biostatistics, School of Public Health, Brown University, Providence, RI, United States.,Center for Evidence Synthesis in Health, School of Public Health, Brown University, Providence, RI, United States
| | - Ida Sim
- Division of General Internal Medicine, School of Medicine, University of California, San Francisco, San Francisco, CA, United States
| | - Richard L Kravitz
- Center for Healthcare Policy and Research, University of California, Davis, Sacramento, CA, United States.,Department of Internal Medicine, University of California, Davis, Sacramento, CA, United States
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Kravitz RL, Schmid CH, Marois M, Wilsey B, Ward D, Hays RD, Duan N, Wang Y, MacDonald S, Jerant A, Servadio JL, Haddad D, Sim I. Effect of Mobile Device-Supported Single-Patient Multi-crossover Trials on Treatment of Chronic Musculoskeletal Pain: A Randomized Clinical Trial. JAMA Intern Med 2018; 178:1368-1377. [PMID: 30193253 PMCID: PMC6233756 DOI: 10.1001/jamainternmed.2018.3981] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Individually designed single-patient multi-crossover (n-of-1) trials can facilitate tailoring of treatments directed at various conditions, including chronic musculoskeletal pain (CMSP) but are potentially burdensome, which may limit uptake in research and practice. OBJECTIVES To determine whether patients randomized to participate in an n-of-1 trial supported by a mobile health (mHealth) app would experience less pain and improved global health, adherence, satisfaction, and shared decision making compared with patients assigned to usual care. DESIGN, SETTING, AND PARTICIPANTS This randomized clinical trial compared participation in an individualized, mHealth-supported n-of-1 trial vs usual care. The participating 215 patients had CMSP for at least 6 weeks, had a smartphone or tablet with a data plan, were enrolled in northern California from July 2014 through July 2016, and were followed for up to 1 year by 48 clinicians in academic, community, Veterans Affairs, and military settings. INTERVENTIONS Intervention patients met with their clinicians and used a desktop interface to select treatments and trial parameters for an n-of-1 trial comparing 2 pain-management regimens. The mHealth app provided reminders to take designated treatments on assigned days and to upload responses to daily questions on pain and treatment-associated adverse effects. Control patients received care as usual. MAIN OUTCOMES AND MEASURES The primary outcome was change in the PROMIS (Patient-Reported Outcomes Measurement Information System) pain-related interference 8-item short-form scale (full scale range, 41-78) from baseline to 6 months. Secondary outcomes included patient-reported pain intensity, overall health, analgesic adherence, trust in clinician, satisfaction with care, medication-related shared decision making, and, for the n-of-1 group only, participant engagement and experience. RESULTS Among 215 patients (108 randomized to the n-of-1 intervention and 107 to control), 102 (47%) were women, and the mean (SD) age was 55.5 (11.1) years. At the 6-month follow-up, pain interference was reduced in both groups, though there was no difference between the intervention and control groups (-1.36 points; 95% CI, -2.91 to 0.19 points; P = .09). There were no advantages in secondary outcomes for intervention patients vs control patients except for higher medication-related shared decision making at 6 months (between-group difference, 11.9 points; 95% CI, 2.6-21.2 points; P = .01). Among patients assigned to the n-of-1 group, 88% (n = 86) affirmed that the mHealth app could help people like them manage their pain. CONCLUSIONS AND RELEVANCE In this population of patients with CMSP, mHealth-supported n-of-1 trials were feasible and associated with a satisfactory user experience, but n-of-1 trial participation did not significantly improve pain interference at 6 months vs usual care. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT02116621.
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Affiliation(s)
- Richard L Kravitz
- Department of Internal Medicine, University of California, Davis, Sacramento.,Center for Health Care Policy and Research, University of California, Davis, Sacramento
| | - Christopher H Schmid
- Department of Biostatistics and Center for Evidence Synthesis in Health, Brown University School of Public Health, Providence, Rhode Island
| | - Maria Marois
- Center for Health Care Policy and Research, University of California, Davis, Sacramento
| | - Barth Wilsey
- Veterans Affairs Northern California Health Care System, Sacramento Medical Center, Mather.,Department of Psychiatry, University of California, San Diego, San Diego
| | - Deborah Ward
- Betty Irene Moore School of Nursing, University of California, Davis, Sacramento
| | - Ron D Hays
- Division of General Internal Medicine & Health Services Research, Department of Medicine, University of California, Los Angeles, Los Angeles
| | - Naihua Duan
- Department of Psychiatry, Columbia University, New York, New York
| | - Youdan Wang
- Department of Biostatistics and Center for Evidence Synthesis in Health, Brown University School of Public Health, Providence, Rhode Island
| | - Scott MacDonald
- Department of Clinical Informatics, University of California, Davis Medical Center, Sacramento
| | - Anthony Jerant
- Department of Family and Community Medicine, University of California, Davis, Sacramento
| | - Joseph L Servadio
- Department of Biostatistics and Center for Evidence Synthesis in Health, Brown University School of Public Health, Providence, Rhode Island.,Division of Environmental Health Sciences, University of Minnesota School of Public Health, Minneapolis
| | | | - Ida Sim
- Open mHealth, New York, New York.,Department of General Internal Medicine, University of California, San Francisco, San Francisco
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Wordsworth S, Doble B, Payne K, Buchanan J, Marshall DA, McCabe C, Regier DA. Using "Big Data" in the Cost-Effectiveness Analysis of Next-Generation Sequencing Technologies: Challenges and Potential Solutions. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2018; 21:1048-1053. [PMID: 30224108 DOI: 10.1016/j.jval.2018.06.016] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Accepted: 06/27/2018] [Indexed: 05/27/2023]
Abstract
Next-generation sequencing (NGS) is considered to be a prominent example of "big data" because of the quantity and complexity of data it produces and because it presents an opportunity to use powerful information sources that could reduce clinical and health economic uncertainty at a patient level. One obstacle to translating NGS into routine health care has been a lack of clinical trials evaluating NGS technologies, which could be used to populate cost-effectiveness analyses (CEAs). A key question is whether big data can be used to partially support CEAs of NGS. This question has been brought into sharp focus with the creation of large national sequencing initiatives. In this article we summarize the main methodological and practical challenges of using big data as an input into CEAs of NGS. Our focus is on the challenges of using large observational datasets and cohort studies and linking these data to the genomic information obtained from NGS, as is being pursued in the conduct of large genomic sequencing initiatives. We propose potential solutions to these key challenges. We conclude that the use of genomic big data to support and inform CEAs of NGS technologies holds great promise. Nevertheless, health economists face substantial challenges when using these data and must be cognizant of them before big data can be confidently used to produce evidence on the cost-effectiveness of NGS.
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Affiliation(s)
- Sarah Wordsworth
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK; Oxford National Institute for Health Research, Biomedical Research Centre, Oxford, UK.
| | - Brett Doble
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK; Oxford National Institute for Health Research, Biomedical Research Centre, Oxford, UK
| | - Katherine Payne
- Manchester Centre for Health Economics, Division of Population Health, Health Services Research & Primary Care, School of Health Sciences, The University of Manchester, Manchester, UK
| | - James Buchanan
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK; Oxford National Institute for Health Research, Biomedical Research Centre, Oxford, UK
| | | | - Christopher McCabe
- Institute of Health Economics, Alberta, Canada; Faculty of Medicine and Dentistry, University of Alberta, Alberta, Canada
| | - Dean A Regier
- Canadian Centre for Applied Research in Cancer Control (ARCC), Cancer Control Research, BC Cancer, Vancouver, Canada; School of Population and Public Health, University of British Columbia, Vancouver, Canada
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Kronish IM, Hampsey M, Falzon L, Konrad B, Davidson KW. Personalized (N-of-1) Trials for Depression: A Systematic Review. J Clin Psychopharmacol 2018; 38:218-225. [PMID: 29596148 PMCID: PMC5904006 DOI: 10.1097/jcp.0000000000000864] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
PURPOSE/BACKGROUND Personalized (N-of-1) trials are single-patient, crossover-design trials that may be useful for personalizing the selection of depression treatments. We conducted a systematic review of published N-of-1 trials for depression to determine the feasibility and suitability of this methodology for personalizing depression care. METHODS/PROCEDURES Electronic databases were searched from database inception through October 2016. Studies were selected if they enrolled depressed patients, included a within-subject crossover design, and systematically assessed depressive symptoms during the N-of-1 trial. FINDINGS/RESULTS Five eligible studies reporting on 47 depressed patients (range, 1-18 patients) were identified. Two studies were conducted among adults with treatment-resistant depression, 1 study among depressed inpatients, and 2 studies among patients from special populations (geriatric nursing home, human immunodeficiency virus-associated encephalopathy). All studies evaluated the effects of pharmacologic treatments (methylphenidate, D-amphetamine, ketamine, and sulpiride). Three studies compared an off-label treatment with placebo, 1 study compared 2 off-label treatments, and 1 study compared escalating doses of an off-label treatment with placebo. All 4 studies with more than 1 participant demonstrated heterogeneous treatment effects. All studies produced data that could personalize treatment selection for individual patients. No studies reported on recruitment challenges, compliance with self-tracking, or satisfaction with participation. IMPLICATIONS/CONCLUSIONS The feasibility of N-of-1 trials for depression was demonstrated for a limited number of second-line pharmacologic treatments in treatment-resistant patients or in patients with comorbidities that would have excluded them from conventional randomized controlled trials. Additional research is needed to determine whether N-of-1 trials are suitable for improving the selection of depression treatments in clinical practice.
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Affiliation(s)
- Ian M. Kronish
- Center for Behavioral Cardiovascular Health, Columbia University Medical Center, 622 W. 168 St. New York, NY 10032
| | - Meghan Hampsey
- Center for Behavioral Cardiovascular Health, Columbia University Medical Center, 622 W. 168 St. New York, NY 10032
| | - Louise Falzon
- Center for Behavioral Cardiovascular Health, Columbia University Medical Center, 622 W. 168 St. New York, NY 10032
| | - Beatrice Konrad
- Center for Behavioral Cardiovascular Health, Columbia University Medical Center, 622 W. 168 St. New York, NY 10032
| | - Karina W. Davidson
- Center for Behavioral Cardiovascular Health, Columbia University Medical Center, 622 W. 168 St. New York, NY 10032
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Moise N, Wood D, Cheung YKK, Duan N, Onge TS, Duer-Hefele J, Pu T, Davidson KW, Kronish IM. Patient preferences for personalized (N-of-1) trials: a conjoint analysis. J Clin Epidemiol 2018; 102:12-22. [PMID: 29859242 DOI: 10.1016/j.jclinepi.2018.05.020] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2017] [Revised: 04/18/2018] [Accepted: 05/24/2018] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Despite their promise for increasing treatment precision, Personalized Trials (i.e., N-of-1 trials) have not been widely adopted. We aimed to ascertain patient preferences for Personalized Trials. STUDY DESIGN AND SETTING We recruited 501 adults with ≥2 common chronic conditions from Harris Poll Online. We used Sawtooth Software to generate 45 plausible Personalized Trial designs comprising combinations of eight key attributes (treatment selection, treatment type, clinician involvement, blinding, time commitment, self-monitoring frequency, duration, and cost) at different levels. Conditional logistic regression was used to assess relative importance of different attributes using a random utility maximization model. RESULTS Overall, participants preferred Personalized Trials with no costs vs. $100 cost (utility difference 1.52 [standard error 0.07], P < 0.001) and with less vs. more time commitment/day (0.16 [0.07], P < 0.015) but did not hold preferences for the other six attributes. In subgroup analyses, participants ≥65 years, white, and with income ≤$50,000 were more averse to costs than their counterparts (P all <0.05). CONCLUSION To optimize dissemination, Personalized Trial designers should seek to minimize out-of-pocket costs and time burden of self-monitoring. They should also consider adaptive designs that can accommodate subgroup differences in design preferences.
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Affiliation(s)
| | - Dallas Wood
- RTI International, Research Triangle Park, NC, USA
| | | | - Naihua Duan
- Columbia University Medical Center, New York, NY, USA
| | - Tara St Onge
- Columbia University Medical Center, New York, NY, USA
| | | | | | | | - Ian M Kronish
- Columbia University Medical Center, New York, NY, USA
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Alemayehu C, Nikles J, Mitchell G. N-of-1 trials in the clinical care of patients in developing countries: a systematic review. Trials 2018; 19:246. [PMID: 29685163 PMCID: PMC5914018 DOI: 10.1186/s13063-018-2596-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2017] [Accepted: 03/16/2018] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND N-of-1 trials have a potential role in promoting patient-centered medicine in developing countries. However, there is limited academic literature regarding the use of N-of-1 trials in the clinical care of patients in resource-poor settings. OBJECTIVE To assess the extent of use, purpose and treatment outcome of N-of-1 trials in developing countries. METHOD A systematic review of clinical N-of-1 trials was conducted between 1985 and September 2015 using PubMed, Embase, CINAHL, Web of Science and the Cochrane Central Register of Controlled Trials. Grey literature databases and clinical trial registers were also searched. This review included randomized, multi-cycle, crossover within individual patient trials involving drug intervention. Quality assessment and data extraction were conducted by two independent reviewers. RESULT Out of 131 N-of-1 trials identified, only 6 (4.5%) were conducted in developing countries. The major reason that N-of-1 trials were used was to provide evidence on feasibility, effectiveness and safety of therapies. A total of 72 participants were involved in these trials. Five of the studies were conducted in China and all evaluated Chinese traditional medicine. The remaining study was conducted in Brazil. The completion rate was 93%. More than half, 46 (69%) of subjects made medication changes consistent with trial results after trial completion. A number of threats to the validity of the included evidence limited the validity of the evidence. In particular, the estimated overall effect in four of the included studies could have been affected by the "carry over" of the previous treatment effect as no adequate pharmacokinetic evidence regarding traditional medicines was presented. CONCLUSION The prevalence and scope of N-of-1 trials in developing countries is low. A coordinated effort among government, clinicians, researchers and sponsor organizations is needed to increase their uptake and quality in developing countries. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42015026841 .
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McCallum C, Rooksby J, Gray CM. Evaluating the Impact of Physical Activity Apps and Wearables: Interdisciplinary Review. JMIR Mhealth Uhealth 2018; 6:e58. [PMID: 29572200 PMCID: PMC5889496 DOI: 10.2196/mhealth.9054] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2017] [Revised: 01/01/2018] [Accepted: 01/07/2018] [Indexed: 01/02/2023] Open
Abstract
Background Although many smartphone apps and wearables have been designed to improve physical activity, their rapidly evolving nature and complexity present challenges for evaluating their impact. Traditional methodologies, such as randomized controlled trials (RCTs), can be slow. To keep pace with rapid technological development, evaluations of mobile health technologies must be efficient. Rapid alternative research designs have been proposed, and efficient in-app data collection methods, including in-device sensors and device-generated logs, are available. Along with effectiveness, it is important to measure engagement (ie, users’ interaction and usage behavior) and acceptability (ie, users’ subjective perceptions and experiences) to help explain how and why apps and wearables work. Objectives This study aimed to (1) explore the extent to which evaluations of physical activity apps and wearables: employ rapid research designs; assess engagement, acceptability, as well as effectiveness; use efficient data collection methods; and (2) describe which dimensions of engagement and acceptability are assessed. Method An interdisciplinary scoping review using 8 databases from health and computing sciences. Included studies measured physical activity, and evaluated physical activity apps or wearables that provided sensor-based feedback. Results were analyzed using descriptive numerical summaries, chi-square testing, and qualitative thematic analysis. Results A total of 1829 abstracts were screened, and 858 articles read in full. Of 111 included studies, 61 (55.0%) were published between 2015 and 2017. Most (55.0%, 61/111) were RCTs, and only 2 studies (1.8%) used rapid research designs: 1 single-case design and 1 multiphase optimization strategy. Other research designs included 23 (22.5%) repeated measures designs, 11 (9.9%) nonrandomized group designs, 10 (9.0%) case studies, and 4 (3.6%) observational studies. Less than one-third of the studies (32.0%, 35/111) investigated effectiveness, engagement, and acceptability together. To measure physical activity, most studies (90.1%, 101/111) employed sensors (either in-device [67.6%, 75/111] or external [23.4%, 26/111]). RCTs were more likely to employ external sensors (accelerometers: P=.005). Studies that assessed engagement (52.3%, 58/111) mostly used device-generated logs (91%, 53/58) to measure the frequency, depth, and length of engagement. Studies that assessed acceptability (57.7%, 64/111) most often used questionnaires (64%, 42/64) and/or qualitative methods (53%, 34/64) to explore appreciation, perceived effectiveness and usefulness, satisfaction, intention to continue use, and social acceptability. Some studies (14.4%, 16/111) assessed dimensions more closely related to usability (ie, burden of sensor wear and use, interface complexity, and perceived technical performance). Conclusions The rapid increase of research into the impact of physical activity apps and wearables means that evaluation guidelines are urgently needed to promote efficiency through the use of rapid research designs, in-device sensors and user-logs to assess effectiveness, engagement, and acceptability. Screening articles was time-consuming because reporting across health and computing sciences lacked standardization. Reporting guidelines are therefore needed to facilitate the synthesis of evidence across disciplines.
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Affiliation(s)
- Claire McCallum
- Institute of Health and Wellbeing, University of Glasgow, Glasgow, United Kingdom
| | - John Rooksby
- School of Computing Science, University of Glasgow, Glasgow, United Kingdom
| | - Cindy M Gray
- Institute of Health and Wellbeing, University of Glasgow, Glasgow, United Kingdom
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Davidson KW, Cheung YK. Envisioning a future for precision health psychology: innovative applied statistical approaches to N-of-1 studies. Health Psychol Rev 2018. [PMID: 28651455 DOI: 10.1080/17437199.2017.1347514] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Karina W Davidson
- a Columbia University Irving Medical Center , New York , NY , USA.,b NewYork Presbyterian Hospital , New York , NY , USA
| | - Ying Kuen Cheung
- c Columbia University Mailman School of Public Health , New York , NY , USA
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Daza EJ. Causal Analysis of Self-tracked Time Series Data Using a Counterfactual Framework for N-of-1 Trials. Methods Inf Med 2018; 57:e10-e21. [PMID: 29621835 PMCID: PMC6087468 DOI: 10.3414/me16-02-0044] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2016] [Accepted: 08/16/2017] [Indexed: 11/11/2022]
Abstract
Many of an individual's historically recorded personal measurements vary over time, thereby forming a time series (e.g., wearable-device data, self-tracked fitness or nutrition measurements, regularly monitored clinical events or chronic conditions). Statistical analyses of such n-of-1 (i.e., single-subject) observational studies (N1OSs) can be used to discover possible cause-effect relationships to then self-test in an n-of-1 randomized trial (N1RT). However, a principled way of determining how and when to interpret an N1OS association as a causal effect (e.g., as if randomization had occurred) is needed.Our goal in this paper is to help bridge the methodological gap between risk-factor discovery and N1RT testing by introducing a basic counterfactual framework for N1OS design and personalized causal analysis.We introduce and characterize what we call the average period treatment effect (APTE), i.e., the estimand of interest in an N1RT, and build an analytical framework around it that can accommodate autocorrelation and time trends in the outcome, effect carryover from previous treatment periods, and slow onset or decay of the effect. The APTE is loosely defined as a contrast (e.g., difference, ratio) of averages of potential outcomes the individual can theoretically experience under different treatment levels during a given treatment period. To illustrate the utility of our framework for APTE discovery and estimation, two common causal inference methods are specified within the N1OS context. We then apply the framework and methods to search for estimable and interpretable APTEs using six years of the author's self-tracked weight and exercise data, and report both the preliminary findings and the challenges we faced in conducting N1OS causal discovery.Causal analysis of an individual's time series data can be facilitated by an N1RT counterfactual framework. However, for inference to be valid, the veracity of certain key assumptions must be assessed critically, and the hypothesized causal models must be interpretable and meaningful.
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Affiliation(s)
- Eric J. Daza
- Stanford Prevention Research Center, Stanford University School of Medicine, Stanford, CA, USA
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Affiliation(s)
- RD Mirza
- Faculty of Health Sciences, McMaster University, Hamilton, ON L8S 4L8 Ontario, Canada
| | - S Punja
- Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB T6G 2R3 Alberta, Canada
| | - S Vohra
- Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB T6G 2R3 Alberta, Canada
| | - G Guyatt
- Faculty of Health Sciences, McMaster University, Hamilton, ON L8S 4L8 Ontario, Canada
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Porcino AJ, Punja S, Chan AW, Kravitz R, Orkin A, Ravaud P, Schmid CH, Vohra S. Protocol for a systematic review of N-of-1 trial protocol guidelines and protocol reporting guidelines. Syst Rev 2017; 6:132. [PMID: 28679407 PMCID: PMC5498872 DOI: 10.1186/s13643-017-0525-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2016] [Accepted: 06/16/2017] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND N-of-1 trials are multiple cross-over trials done in individual participants, generating individual treatment effect information. While reporting guidelines for the CONSORT Extension for N-of-1 trials (CENT) and the Standard Protocol Items: Recommendations for Interventional Trials (SPIRIT) already exist, there is no standardized recommendation for the reporting of N-of-1 trial protocols. OBJECTIVE The objective of this study is to evaluate current literature on N-of-1 design and reporting to identify key elements of rigorous N-of-1 protocol design. METHODS We will conduct a systematic search for all N-of-1 trial guidelines and protocol-reporting guidelines published in peer-reviewed literature. We will search Medline, Embase, PsycINFO, CINAHL, the Cochrane Methodology Register, CENTRAL, and the NHS Economic Evaluation Database. Eligible articles will contain explicit guidance on N-of-1 protocol construction or reporting. Two reviewers will independently screen all titles and abstracts and then undertake full-text reviews of potential articles to determine eligibility. One reviewer will perform data extraction of selected articles, checked by the second reviewer. Data analysis will ascertain common features of N-of-1 trial protocols and compare them to the SPIRIT and CENT items. DISCUSSION This systematic review assesses recommendations on the design and reporting of N-of-1 trial protocols. These findings will inform an international Delphi development process for an N-of-1 trial protocol reporting guideline. The development of this guideline is critical for improving the quality of N-of-1 protocols, leading to improvements in the quality of published N-of-1 trial research.
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Affiliation(s)
- Antony J Porcino
- CARE Program, Department of Pediatrics, Faculty of Medicine and Dentistry, and Integrative Health Institute, University of Alberta, Suite #1702, College Plaza 8215 112 St. NW, Edmonton, AB, T6G 2C8, Canada
| | - Salima Punja
- CARE Program, Department of Pediatrics, Faculty of Medicine and Dentistry, and Integrative Health Institute, University of Alberta, Suite #1702, College Plaza 8215 112 St. NW, Edmonton, AB, T6G 2C8, Canada
| | - An-Wen Chan
- Women's College Research Institute, Women's College Hospital, Department of Medicine, University of Toronto, 76 Grenville St, Toronto, ON, M5S 1B1, Canada
| | - Richard Kravitz
- UC Davis Department of Internal Medicine, 4150 V St., Sacramento, CA, 95817, USA
| | - Aaron Orkin
- Dalla Lana School of Public Health, University of Toronto, 155 College Street, Toronto, ON, M5T 1P8, Canada
| | - Philippe Ravaud
- EQUATOR France, Centre d'épidémiologie clinique, Hôpital Hôtel-Dieu, 1 place du Parvis Notre-Dame, Paris, 75004, France
| | - Christopher H Schmid
- Center for Evidence Based Medicine, School of Public Health, Brown University, 121 South Main Street, 8th Floor, Providence, RI, 02903, USA
| | - Sunita Vohra
- CARE Program, Department of Pediatrics, Faculty of Medicine and Dentistry, and Integrative Health Institute, University of Alberta, Suite #1702, College Plaza 8215 112 St. NW, Edmonton, AB, T6G 2C8, Canada.
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Kronish IM, Alcántara C, Duer-Hefele J, St Onge T, Davidson KW, Carter EJ, Medina V, Cohn E, Moise N. Patients and primary care providers identify opportunities for personalized (N-of-1) trials in the mobile health era. J Clin Epidemiol 2017. [PMID: 28648833 DOI: 10.1016/j.jclinepi.2017.06.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Ian M Kronish
- Department of Medicine, Center for Behavioral Cardiovascular Health, Columbia University Medical Center, 622 W. 168th Street, PH9-311, New York, NY 10032, USA.
| | - Carmela Alcántara
- School of Social Work, Columbia University, 1255 Amsterdam Avenue Room 810, MC 4600, New York, NY 10027, USA
| | - Joan Duer-Hefele
- Department of Medicine, Center for Behavioral Cardiovascular Health, Columbia University Medical Center, 622 W. 168th Street, PH9-316, New York, NY 10032, USA
| | - Tara St Onge
- Department of Medicine, Center for Behavioral Cardiovascular Health, Columbia University Medical Center, 622 W. 168th Street, PH9-316, New York, NY 10032, USA
| | - Karina W Davidson
- Department of Medicine, Center for Behavioral Cardiovascular Health, Columbia University Medical Center, 622 W. 168th Street, PH9-314, New York, NY 10032, USA
| | - Eileen J Carter
- Department of Nursing, Columbia University Medical Center, 617 W. 168th Street New York, NY 10032, USA
| | - Vivian Medina
- Department of Medicine, Center for Behavioral Cardiovascular Health, Columbia University Medical Center, 622 W. 168th Street, PH9-311, New York, NY 10032, USA
| | - Elizabeth Cohn
- Center for Health Innovation, Adelphi University and Irving Institute for Clinical and Translation Research, Columbia University, 617 W. 168th Street New York, NY 10032, USA
| | - Nathalie Moise
- Department of Medicine, Center for Behavioral Cardiovascular Health, Columbia University Medical Center, 622 W. 168th Street, PH9-321, New York, NY 10032, USA
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Brábek J, Rosel D, Fernandes M. Pragmatic medicine in solid cancer: a translational alternative to precision medicine. Onco Targets Ther 2016; 9:1839-55. [PMID: 27103822 PMCID: PMC4827419 DOI: 10.2147/ott.s103832] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
The precision medicine (PM) initiative is a response to the dismal outlook in solid cancer. Despite heterogeneity, common mechanistic denominators may exist across the spectrum of solid cancer. A shift from conventional research and development (R&D) toward PM will require conceptual and structural change. As individuals and as a society, we welcome innovation, but question change. We ask: In solid cancer, does PM identify and address the causes of prior failures, and, if so, are the proposed solutions feasible? And, when may we expect safer, more effective and affordable drugs in the clinic? Considerations that prompt a pragmatic rethink include a failure analysis of translational R&D in solid cancer suggesting that trials and regulations need to be aligned with the natural history of the disease. In successful therapeutic interventions in chronic, complex disease, surrogate markers and endpoints should be consistent with the Prentice's criteria. In solid cancer, drug induced tumor shrinkage, is a drug effect and not a disease response; tumor shrinkage does not reflect nor predict interruption of the disease. Overall, we support a pragmatic, multidisciplinary, and collaborative R&D, and suggest that direction be set by clinical need and utility, and by questions, not answers. PM will prove worthwhile if it could improve clinical outcomes. The lag in therapeutics relative to diagnostics is a cause for confusion. Overdiagnosis adds to fear and harm, especially in the absence of effective interventions. A revised initiative that prioritizes metastasis research could replicate the successful HIV/AIDS model in solid cancer. A pragmatic approach may further translational efforts toward meaningfully effective, generally available, and affordable solutions.
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Affiliation(s)
- Jan Brábek
- Department of Cell Biology, Faculty of Science, Charles University in Prague, Prague 2, Czech Republic
| | - Daniel Rosel
- Department of Cell Biology, Faculty of Science, Charles University in Prague, Prague 2, Czech Republic
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Zhai J, Cao H, Ren M, Mu W, Lv S, Si J, Wang H, Chen J, Shang H. Reporting of core items in hierarchical Bayesian analysis for aggregating N-of-1 trials to estimate population treatment effects is suboptimal. J Clin Epidemiol 2016; 76:99-107. [PMID: 26946040 DOI: 10.1016/j.jclinepi.2016.02.023] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2015] [Revised: 02/16/2016] [Accepted: 02/24/2016] [Indexed: 10/22/2022]
Abstract
OBJECTIVES N-of-1 trials can be aggregated to estimate population treatment effects using hierarchical Bayesian models. It is very important to report core items in hierarchical Bayesian analysis. In this study, we assessed reporting of items in hierarchical Bayesian analysis for aggregating N-of-1 trials to estimate population treatment effects. STUDY DESIGN AND SETTING This was a systematic literature review of aggregating N-of-1 trials by hierarchical Bayesian models to estimate population treatment effects. A comprehensive search was performed to collect eligible articles. Pilot studies, formal N-of-1 trials and reports in which the data were reanalyzed using hierarchical Bayesian methods, were included. The information of reported items related with hierarchical Bayesian analysis was extracted by two independent reviewers. The guideline "ROBUST," developed for reporting Bayesian analysis of clinical studies, was published in Journal of Clinical Epidemiology in 2005. We assessed the included reports using ROBUST criteria and 18 other important items. RESULTS After careful screening, 11 studies were identified to be eligible for inclusion. There were three pilot studies, four formal trials, and four reports in which the data were reanalyzed using hierarchical Bayesian methods. The number of reported items in ROBUST criteria ranged from six to seven, with a median number of six. Five of eleven included articles reported all items of the ROBUST criteria. But for justification and sensitivity analysis in prior distribution items, other items were reported in all of the included articles. Software and analysis data set items were reported the most frequently in additional items excluded from the ROBUST criteria. Less than half of the studies reported the other additional items. CONCLUSION Reporting of core items in hierarchical Bayesian analysis for aggregating N-of-1 trials to estimate population treatment effects is suboptimal. A PRISMA-like guidance on reviews of Bayesian N-of-1 trials may be required in the future.
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Affiliation(s)
- Jingbo Zhai
- Research Institute of Traditional Chinese Medicine, Tianjin University of Traditional Chinese Medicine, 88 Yuquan Street, Nankai District, Tianjin 300193, China
| | - Hongbo Cao
- Research Institute of Traditional Chinese Medicine, Tianjin University of Traditional Chinese Medicine, 88 Yuquan Street, Nankai District, Tianjin 300193, China
| | - Ming Ren
- Baokang Hospital, Tianjin University of Traditional Chinese Medicine, 88 Yuquan Street, Nankai District, Tianjin 300193, China
| | - Wei Mu
- Second Affiliated Hospital, Tianjin University of Traditional Chinese Medicine, 816 Zhenli Street, Hebei District, Tianjin 300150, China
| | - Sisi Lv
- Modern Educational Technology and Information Center, Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Jinhua Si
- Library of Tianjin University of Traditional Chinese Medicine, 88 Yuquan Street, Nankai District, Tianjin 300193, China
| | - Hui Wang
- Research Institute of Traditional Chinese Medicine, Tianjin University of Traditional Chinese Medicine, 88 Yuquan Street, Nankai District, Tianjin 300193, China
| | - Jing Chen
- Baokang Hospital, Tianjin University of Traditional Chinese Medicine, 88 Yuquan Street, Nankai District, Tianjin 300193, China.
| | - Hongcai Shang
- Key Laboratory of Chinese Internal Medicine of Ministry of Education and Beijing, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing 100700, China.
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Farrugia A, Noone D, Schlenkrich U, Schlenkrich S, O’Mahony B, Cassar J. Issues in assessing products for the treatment of hemophilia - the intersection between efficacy, economics, and ethics. J Blood Med 2015; 6:185-95. [PMID: 26124687 PMCID: PMC4476485 DOI: 10.2147/jbm.s79091] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Following the obviation of the pathogen safety threats posed by previous generations of clotting factor concentrates for the treatment of hemophilia, the principal issue facing the patient community is timely access to adequate supplies of continuously improving therapies. The application of evidence-based medicine has enhanced the basis of hemophilia therapy, while resulting in some challenges to patient care. Increasingly, the criteria used for the approval and payment of treatment products by regulatory and reimbursement agencies, respectively, are becoming inflexible and unrealistic. This is occurring particularly in the requirements for demonstrating product efficacy. Concurrently, emerging evidence of the interpatient variability in the clinical response to therapy has led to the proposed personalization of therapeutic regimens. Possible impediments to optimal care include competitive tensions among suppliers who seek to gain label claims for reimbursement purposes, which result in clinical trial designs of, arguably, unethical design, carried out in poor countries. We synthesize these converging developments to suggest some changes to the current hemophilia treatment paradigm, which should make it more patient-centric and enable speedier access to new therapies.
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Affiliation(s)
- Albert Farrugia
- School of Surgery, QEII Medical Centre, The University of Western Australia (M509), Crawley, WA, Australia
- College of Medicine, Medicine and Environment, Australian National University, Canberra, WA, Australia
| | | | | | | | | | - Josephine Cassar
- Faculty of Health, University of Canberra, Canberra, WA, Australia
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Weisner TS, Hay MC. Practice to research: integrating evidence-based practices with culture and context. Transcult Psychiatry 2015; 52:222-43. [PMID: 25416746 DOI: 10.1177/1363461514557066] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
There are ways to integrate culturally competent services (CCS) and evidence-based practices (EBP) which can improve the experiences of patients and their families and communities when faced with health problems, as well as the effectiveness and positive experiences of practitioners. CCS and EBP evidence should be jointly deployed for helping patients and clinicians. Partnership research models are useful for achieving the integration of CCS and EBP, since they involve close observation of and participation by clinicians and practitioners in the research process, and often use integrated qualitative and quantitative mixed methods. We illustrate this with 3 examples of work that can help integrate CCS and EBP: ongoing collection of information from patients, clinicians and staff, or "evidence farming"; close study and continuous improvement of activities and accommodations; and use of evidence of tacit, implicit cultural scripts and norms, such as being "productive," as well as explicit scripts. From a research practice point of view, collaborative partnerships will likely produce research with culture and context bracketed in, and will contribute stronger research models, methods, and units of analysis.
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Barr C, Marois M, Sim I, Schmid CH, Wilsey B, Ward D, Duan N, Hays RD, Selsky J, Servadio J, Schwartz M, Dsouza C, Dhammi N, Holt Z, Baquero V, MacDonald S, Jerant A, Sprinkle R, Kravitz RL. The PREEMPT study - evaluating smartphone-assisted n-of-1 trials in patients with chronic pain: study protocol for a randomized controlled trial. Trials 2015; 16:67. [PMID: 25881274 PMCID: PMC4367894 DOI: 10.1186/s13063-015-0590-8] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2014] [Accepted: 02/05/2015] [Indexed: 11/10/2022] Open
Abstract
Background Chronic pain is prevalent, costly, and clinically vexatious. Clinicians typically use a trial-and-error approach to treatment selection. Repeated crossover trials in a single patient (n-of-1 trials) may provide greater therapeutic precision. N-of-1 trials are the most direct way to estimate individual treatment effects and are useful in comparing the effectiveness and toxicity of different analgesic regimens. The goal of the PREEMPT study is to test the ‘Trialist’ mobile health smartphone app, which has been developed to make n-of-1 trials easier to accomplish, and to provide patients and clinicians with tools for individualizing treatments for chronic pain. Methods/design A randomized controlled trial is being conducted to test the feasibility and effectiveness of the Trialist app. A total of 244 participants will be randomized to either the Trialist app intervention group (122 patients) or a usual care control group (122 patients). Patients assigned to the Trialist app will work with their clinicians to set up an n-of-1 trial comparing two pain regimens, selected from a menu of flexible options. The Trialist app provides treatment reminders and collects data entered daily by the patient on pain levels and treatment side effects. Upon completion of the n-of-1 trial, patients review results with their clinicians and develop a long-term treatment plan. The primary study outcome (comparing Trialist to usual care patients) is pain-related interference with daily functioning at 26 weeks. Discussion Trialist will allow patients and clinicians to conduct personalized n-of-1 trials. In prior studies, n-of-1 trials have been shown to encourage greater patient involvement with care, which has in turn been associated with better health outcomes. mHealth technology implemented using smartphones may offer an efficient means of facilitating n-of-1 trials so that more patients can benefit from this approach. Trial registration ClinicalTrials.gov: NCT02116621, first registered 15 April 2014. Electronic supplementary material The online version of this article (doi:10.1186/s13063-015-0590-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Colin Barr
- Center for Health Care Policy and Research, University of California Davis, 2103 Stockton Blvd, Suite 2224, Sacramento, CA, 95817, USA.
| | - Maria Marois
- Center for Health Care Policy and Research, University of California Davis, 2103 Stockton Blvd, Suite 2224, Sacramento, CA, 95817, USA.
| | - Ida Sim
- Department of General Internal Medicine, University of California San Francisco, 1545 Divisadero St, Suite 308, San Francisco, CA, 94118, USA. .,Open mHealth, 412 Broadway, Floor 2, New York, NY, 10013, USA.
| | - Christopher H Schmid
- Department of Biostatistics and Center for Evidence Based Medicine, Brown University School of Public Health, 121 South Main Street, Providence, RI, 02912, USA.
| | - Barth Wilsey
- Department of Physical Medicine & Rehabilitation, 4150 V Street, Suite 1200, Sacramento, CA, 95817, USA. .,VA Northern California Health Care System, 10535 Hospital Way, Mather, CA, 95655, USA.
| | - Deborah Ward
- Betty Irene Moore School of Nursing, University of California Davis, 4610 X Street, Sacramento, CA, 95817, USA.
| | - Naihua Duan
- Department of Psychiatry, Columbia University, 1051 Riverside Drive, Unit 48, New York, NY, 10032, USA.
| | - Ron D Hays
- Division of General Internal Medicine & Health Services Research, Department of Medicine, University of California Los Angeles, 911 Broxton Avenue, Los Angeles, CA, 90024, USA.
| | - Joshua Selsky
- Open mHealth, 412 Broadway, Floor 2, New York, NY, 10013, USA. .,Cornell Tech, 111 8th Avenue, Number 302, New York, NY, 10011, USA.
| | - Joseph Servadio
- Department of Biostatistics and Center for Evidence Based Medicine, Brown University School of Public Health, 121 South Main Street, Providence, RI, 02912, USA.
| | - Marc Schwartz
- 2Know, Inc, 257 Gold Street #1408, Brooklyn, NY, 11201, USA.
| | - Clyde Dsouza
- Center for Health Care Policy and Research, University of California Davis, 2103 Stockton Blvd, Suite 2224, Sacramento, CA, 95817, USA.
| | - Navjot Dhammi
- Center for Health Care Policy and Research, University of California Davis, 2103 Stockton Blvd, Suite 2224, Sacramento, CA, 95817, USA.
| | - Zachary Holt
- Department of Internal Medicine, University of California Davis, 4150 V Street, Suite 3100, Sacramento, CA, 95817, USA.
| | - Victor Baquero
- University of California Davis Medical Group - Folsom, 1370 Prairie City Road, Folsom, CA, 95630, USA.
| | - Scott MacDonald
- University of California Davis Medical Group - Sacramento, 2825 J Street, Suite 300, Sacramento, CA, 95816, USA.
| | - Anthony Jerant
- Department of Family and Community Medicine, University of California Davis, 4860 Y Street, Suite 2300, Sacramento, CA, 95817, USA.
| | - Ron Sprinkle
- University of California Davis Medical Group - Davis, 2660 West Covell Boulevard, Suites A, B and C, Davis, CA, 95616, USA.
| | - Richard L Kravitz
- Center for Health Care Policy and Research, University of California Davis, 2103 Stockton Blvd, Suite 2224, Sacramento, CA, 95817, USA. .,Department of Internal Medicine, University of California Davis, 4150 V Street, Suite 3100, Sacramento, CA, 95817, USA.
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50
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Peyvandi F, Farrugia A, Iorio A, Key NS, Srivastava A. Joint WFH-ISTH session: issues in clinical trial design. Haemophilia 2014; 20 Suppl 4:137-44. [PMID: 24762289 DOI: 10.1111/hae.12415] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/24/2014] [Indexed: 11/28/2022]
Abstract
Haemophilia therapy is experiencing an unprecedented expansion in the number and novelty of clotting factor concentrates. Every product must be licensed by regulatory authorities, primarily on the basis of its safety and efficacy profiles. The low prevalence of haemophilia, and other inherited bleeding disorders, presents a significant challenge to patient recruitment for preauthorization clinical trials, especially given the low frequency of inhibitory antibodies, the major adverse event related to clotting factor exposure. Other challenges include a lack of harmonization between the major regulatory authorities in certain key areas, the selection of laboratory monitoring methodologies and the difficulty in obtaining high-quality phase IV safety data following authorization. These aspects will be reviewed in this session, which will also highlight the roles played by the World Federation of Hemophilia and International Society on Thrombosis and Haemostasis in the promotion of these discussions.
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Affiliation(s)
- F Peyvandi
- Department of Pathophysiology and Transplantation, Angelo Bianchi Bonomi Haemophilia and Thrombosis Center, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Università degli Studi di Milano, Luigi Villa Foundation, Milan, Italy
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