1
|
Goonasekera MA, Offer A, Karsan W, El-Nayir M, Mallorie AE, Parish S, Haynes RJ, Mafham MM. Accuracy of heart failure ascertainment using routinely collected healthcare data: a systematic review and meta-analysis. Syst Rev 2024; 13:79. [PMID: 38429771 PMCID: PMC10905869 DOI: 10.1186/s13643-024-02477-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 02/01/2024] [Indexed: 03/03/2024] Open
Abstract
BACKGROUND Ascertainment of heart failure (HF) hospitalizations in cardiovascular trials is costly and complex, involving processes that could be streamlined by using routinely collected healthcare data (RCD). The utility of coded RCD for HF outcome ascertainment in randomized trials requires assessment. We systematically reviewed studies assessing RCD-based HF outcome ascertainment against "gold standard" (GS) methods to study the feasibility of using such methods in clinical trials. METHODS Studies assessing International Classification of Disease (ICD) coded RCD-based HF outcome ascertainment against GS methods and reporting at least one agreement statistic were identified by searching MEDLINE and Embase from inception to May 2021. Data on study characteristics, details of RCD and GS data sources and definitions, and test statistics were reviewed. Summary sensitivities and specificities for studies ascertaining acute and prevalent HF were estimated using a bivariate random effects meta-analysis. Heterogeneity was evaluated using I2 statistics and hierarchical summary receiver operating characteristic (HSROC) curves. RESULTS A total of 58 studies of 48,643 GS-adjudicated HF events were included in this review. Strategies used to improve case identification included the use of broader coding definitions, combining multiple data sources, and using machine learning algorithms to search free text data, but these methods were not always successful and at times reduced specificity in individual studies. Meta-analysis of 17 acute HF studies showed that RCD algorithms have high specificity (96.2%, 95% confidence interval [CI] 91.5-98.3), but lacked sensitivity (63.5%, 95% CI 51.3-74.1) with similar results for 21 prevalent HF studies. There was considerable heterogeneity between studies. CONCLUSIONS RCD can correctly identify HF outcomes but may miss approximately one-third of events. Methods used to improve case identification should also focus on minimizing false positives.
Collapse
Affiliation(s)
- Michelle A Goonasekera
- Clinical Trial Service Unit and Epidemiological Studies Unit, Oxford Population Health, University of Oxford, Oxford, UK
| | - Alison Offer
- Clinical Trial Service Unit and Epidemiological Studies Unit, Oxford Population Health, University of Oxford, Oxford, UK
| | - Waseem Karsan
- Clinical Trial Service Unit and Epidemiological Studies Unit, Oxford Population Health, University of Oxford, Oxford, UK
| | - Muram El-Nayir
- Clinical Trial Service Unit and Epidemiological Studies Unit, Oxford Population Health, University of Oxford, Oxford, UK
| | - Amy E Mallorie
- Clinical Trial Service Unit and Epidemiological Studies Unit, Oxford Population Health, University of Oxford, Oxford, UK
| | - Sarah Parish
- Clinical Trial Service Unit and Epidemiological Studies Unit, Oxford Population Health, University of Oxford, Oxford, UK
- Nuffield Department of Population Health, MRC Population Health Research Unit, University of Oxford, Oxford, UK
| | - Richard J Haynes
- Clinical Trial Service Unit and Epidemiological Studies Unit, Oxford Population Health, University of Oxford, Oxford, UK
- Nuffield Department of Population Health, MRC Population Health Research Unit, University of Oxford, Oxford, UK
| | - Marion M Mafham
- Clinical Trial Service Unit and Epidemiological Studies Unit, Oxford Population Health, University of Oxford, Oxford, UK.
- Clinical Trial Service Unit and Epidemiological Studies Unit, Oxford Population Health, Richard Doll Building, Old Road Campus, Roosevelt Drive, Oxford, OX3 7LF, UK.
| |
Collapse
|
2
|
Xie CX, Sun L, Ingram E, De Simoni A, Eldridge S, Pinnock H, Relton C. Use of routine healthcare data in randomised implementation trials: a methodological mixed-methods systematic review. Implement Sci 2023; 18:47. [PMID: 37784099 PMCID: PMC10544368 DOI: 10.1186/s13012-023-01300-4] [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: 01/27/2023] [Accepted: 09/05/2023] [Indexed: 10/04/2023] Open
Abstract
BACKGROUND Routine data are increasingly used in randomised controlled trials evaluating healthcare interventions. They can aid participant identification, outcome assessment, and intervention delivery. Randomised implementation trials evaluate the effect of implementation strategies on implementation outcomes. Implementation strategies, such as reminders, are used to increase the uptake of evidence-based interventions into practice, while implementation outcomes, such as adoption, are key measures of the implementation process. The use of routine data in effectiveness trials has been explored; however, there are no reviews on implementation trials. We therefore aimed to describe how routine data have been used in randomised implementation trials and the design characteristics of these trials. METHODS We searched MEDLINE (Ovid) and Cochrane Central Register of Controlled Trials from Jan 2000 to Dec 2021 and manually searched protocols from trial registers. We included implementation trials and type II and type III hybrid effectiveness-implementation trials conducted using routine data. We extracted quantitative and qualitative data and narratively synthesised findings. RESULTS From 4206 titles, we included 80 trials, of which 22.5% targeted implementation of evidence-based clinical guidelines. Multicomponent implementation strategies were more commonly evaluated (70.0%) than single strategies. Most trials assessed adoption as the primary outcome (65.0%). The majority of trials extracted data from electronic health records (EHRs) (62.5%), and 91.3% used routine data for outcome ascertainment. Reported reasons for using routine data were increasing efficiency, assessing outcomes, reducing research burden, improving quality of care, identifying study samples, confirming findings, and assessing representativeness. Data quality, the EHR system, research governance, and external factors such as government policy could act either as facilitators or barriers. CONCLUSIONS Adherence to guidance on designing and reporting implementation studies, and specifically to harmonise the language used in describing implementation strategies and implementation outcomes, would aid identification of studies and data extraction. Routine healthcare data are widely used for participant identification, outcome assessment and intervention delivery. Researchers should familiarise themselves with the barriers and facilitators to using routine data, and efforts could be made to improve data quality to overcome some of the barriers. REGISTRATION PROSPERO CRD42022292321.
Collapse
Affiliation(s)
- Charis Xuan Xie
- Wolfson Institute of Population Health, Queen Mary University of London, London, England, UK.
| | - Lixin Sun
- School of Health and Related Research, University of Sheffield, Sheffield, England, UK
| | - Elizabeth Ingram
- Department of Applied Health Research, University College London, London, England, UK
| | - Anna De Simoni
- Wolfson Institute of Population Health, Queen Mary University of London, London, England, UK
| | - Sandra Eldridge
- Wolfson Institute of Population Health, Queen Mary University of London, London, England, UK
| | - Hilary Pinnock
- Asthma UK Centre for Applied Research, Usher Institute, The University of Edinburgh, Edinburgh, Scotland, UK
| | - Clare Relton
- Wolfson Institute of Population Health, Queen Mary University of London, London, England, UK
| |
Collapse
|
3
|
Ishani A, Leatherman SM, Woods P, Hau C, Klint A, Lew RA, Taylor AA, Glassman PA, Brophy MT, Fiore LD, Ferguson RE, Cushman WC. Design of a pragmatic clinical trial embedded in the Electronic Health Record: The VA's Diuretic Comparison Project. Contemp Clin Trials 2022; 116:106754. [PMID: 35390512 DOI: 10.1016/j.cct.2022.106754] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Revised: 04/01/2022] [Accepted: 04/01/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND Recent US guidelines recommend chlorthalidone over other thiazide-type diuretics for the treatment of hypertension based on its long half-life and proven ability to reduce CVD events. Despite recommendations most clinicians prescribe hydrochlorothiazide (HCTZ) over chlorthalidone (CTD). No randomized controlled data exist comparing these two diuretics on cardiovascular outcomes. METHODS The Diuretic Comparison Project (DCP) is a multicenter, two-arm, parallel, Prospective Randomized Open, Blinded End-point (PROBE) trial testing the primary hypothesis that CTD is superior to HCTZ in the prevention of non-fatal CVD events and non-cancer death. Patients with hypertension taking HCTZ 25 or 50 mg were randomly assigned to either continue their current HCTZ or switch to an equipotent dose of CTD. The primary outcome is time to the first occurrence of a composite outcome consisting of a non-fatal CVD event (stroke, myocardial infarction, urgent coronary revascularization because of unstable angina, or hospitalization for acute heart failure) or non-cancer death. The trial randomized 13,523 patients at 72 VA medical centers. The study is conducted by a centralized research team with site procedures embedded in the electronic health record and all data collected through administrative claims data, with no study related visits for participants. The trial will have 90% power to detect an absolute reduction in the composite event rate of 2.4%. RESULTS Enrollment ended in November 2021. There are 4128 participting primary care providers and 16,595 patients individually consented to participate, 13,523 of whom were randomized. CONCLUSIONS DCP should provide much needed evidence as to whether CTD is superior to HCTZ in preventing cardiovascular events in hypertensive patients. CLINICAL TRIAL REGISTRATION NCT02185417 [https://clinicaltrials.gov/ct2/show/NCT02185417].
Collapse
Affiliation(s)
- Areef Ishani
- Minneapolis VA Health Care System, Department of Medicine, University of Minnesota, Minneapolis, MN, United States of America
| | - Sarah M Leatherman
- Boston Cooperative Studies Program Coordinating Center, VA Boston Healthcare System, Boston, MA, United States of America.
| | - Patricia Woods
- Boston Cooperative Studies Program Coordinating Center, VA Boston Healthcare System, Boston, MA, United States of America
| | - Cynthia Hau
- Boston Cooperative Studies Program Coordinating Center, VA Boston Healthcare System, Boston, MA, United States of America
| | - Alison Klint
- Boston Cooperative Studies Program Coordinating Center, VA Boston Healthcare System, Boston, MA, United States of America
| | - Robert A Lew
- Boston Cooperative Studies Program Coordinating Center, VA Boston Healthcare System, Boston University School of Public Health, Boston, MA, United States of America
| | - Addison A Taylor
- Michael E. DeBakey VA Medical Center, Baylor College of Medicine, Houston, TX, United States of America
| | - Peter A Glassman
- Pharmacy Benefits Management Services, Department of Veterans Affairs, VA Greater Los Angeles Healthcare System, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States of America
| | - Mary T Brophy
- Boston Cooperative Studies Program Coordinating Center, VA Boston Healthcare System, Boston University School of Medicine, Boston, MA, United States of America
| | - Louis D Fiore
- Boston Cooperative Studies Program Coordinating Center, VA Boston Healthcare System, Boston University School of Medicine, Boston, MA, United States of America
| | - Ryan E Ferguson
- Boston Cooperative Studies Program Coordinating Center, VA Boston Healthcare System, Boston University School of Medicine, Boston, MA, United States of America
| | - William C Cushman
- Department of Preventive Medicine, University of Tennessee Health Science Center, United States of America
| |
Collapse
|
4
|
Hay AD, Moore MV, Taylor J, Turner N, Noble S, Cabral C, Horwood J, Prasad V, Curtis K, Delaney B, Damoiseaux R, Domínguez J, Tapuria A, Harris S, Little P, Lovering A, Morris R, Rowley K, Sadoo A, Schilder A, Venekamp R, Wilkes S, Curcin V. Immediate oral versus immediate topical versus delayed oral antibiotics for children with acute otitis media with discharge: the REST three-arm non-inferiority electronic platform-supported RCT. Health Technol Assess 2021; 25:1-76. [PMID: 34816795 DOI: 10.3310/hta25670] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Acute otitis media is a painful infection of the middle ear that is commonly seen in children. In some children, the eardrum spontaneously bursts, discharging visible pus (otorrhoea) into the outer ear. OBJECTIVE To compare the clinical effectiveness of immediate topical antibiotics or delayed oral antibiotics with the clinical effectiveness of immediate oral antibiotics in reducing symptom duration in children presenting to primary care with acute otitis media with discharge and the economic impact of the alternative strategies. DESIGN This was a pragmatic, three-arm, individually randomised (stratified by age < 2 vs. ≥ 2 years), non-inferiority, open-label trial, with economic and qualitative evaluations, supported by a health-record-integrated electronic trial platform [TRANSFoRm (Translational Research and Patient Safety in Europe)] with an internal pilot. SETTING A total of 44 English general practices. PARTICIPANTS Children aged ≥ 12 months and < 16 years whose parents (or carers) were seeking medical care for unilateral otorrhoea (ear discharge) following recent-onset (≤ 7 days) acute otitis media. INTERVENTIONS (1) Immediate ciprofloxacin (0.3%) solution, four drops given three times daily for 7 days, or (2) delayed 'dose-by-age' amoxicillin suspension given three times daily (clarithromycin twice daily if the child was penicillin allergic) for 7 days, with structured delaying advice. All parents were given standardised information regarding symptom management (paracetamol/ibuprofen/fluids) and advice to complete the course. COMPARATOR Immediate 'dose-by-age' oral amoxicillin given three times daily (or clarithromycin given twice daily) for 7 days. Parents received standardised symptom management advice along with advice to complete the course. MAIN OUTCOME MEASURE Time from randomisation to the first day on which all symptoms (pain, fever, being unwell, sleep disturbance, otorrhoea and episodes of distress/crying) were rated 'no' or 'very slight' problem (without need for analgesia). METHODS Participants were recruited from routine primary care appointments. The planned sample size was 399 children. Follow-up used parent-completed validated symptom diaries. RESULTS Delays in software deployment and configuration led to small recruitment numbers and trial closure at the end of the internal pilot. Twenty-two children (median age 5 years; 62% boys) were randomised: five, seven and 10 to immediate oral, delayed oral and immediate topical antibiotics, respectively. All children received prescriptions as randomised. Seven (32%) children fully adhered to the treatment as allocated. Symptom duration data were available for 17 (77%) children. The median (interquartile range) number of days until symptom resolution in the immediate oral, delayed oral and immediate topical antibiotic arms was 6 (4-9), 4 (3-7) and 4 (3-6), respectively. Comparative analyses were not conducted because of small numbers. There were no serious adverse events and six reports of new or worsening symptoms. Qualitative clinician interviews showed that the trial question was important. When the platform functioned as intended, it was liked. However, staff reported malfunctioning software for long periods, resulting in missed recruitment opportunities. Troubleshooting the software placed significant burdens on staff. LIMITATIONS The over-riding weakness was the failure to recruit enough children. CONCLUSIONS We were unable to answer the main research question because of a failure to reach the required sample size. Our experience of running an electronic platform-supported trial in primary care has highlighted challenges from which we have drawn recommendations for the National Institute for Health Research (NIHR) and the research community. These should be considered before such a platform is used again. TRIAL REGISTRATION Current Controlled Trials ISRCTN12873692 and EudraCT 2017-003635-10. FUNDING This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 67. See the NIHR Journals Library website for further project information.
Collapse
Affiliation(s)
- Alastair D Hay
- Centre for Academic Primary Care, Department of Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Michael V Moore
- Primary Care and Population Sciences, University of Southampton, Southampton, UK
| | - Jodi Taylor
- Bristol Randomised Trials Collaboration, Department of Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Nicholas Turner
- Bristol Randomised Trials Collaboration, Department of Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Sian Noble
- Bristol Randomised Trials Collaboration, Department of Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Christie Cabral
- Centre for Academic Primary Care, Department of Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Jeremy Horwood
- Centre for Academic Primary Care, Department of Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Vibhore Prasad
- School of Population Health and Environmental Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Kathryn Curtis
- Bristol Randomised Trials Collaboration, Department of Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Brendan Delaney
- Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK
| | - Roger Damoiseaux
- Julius Center for Health Sciences and Primary Care & Department of Otorhinolaryngology, UMC Utrecht, Utrecht, the Netherlands
| | - Jesús Domínguez
- School of Population Health and Environmental Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Archana Tapuria
- School of Population Health and Environmental Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Sue Harris
- Bristol Randomised Trials Collaboration, Department of Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Paul Little
- Primary Care and Population Sciences, University of Southampton, Southampton, UK
| | - Andrew Lovering
- Department of Medical Microbiology, North Bristol NHS Trust, Bristol, UK
| | - Richard Morris
- Bristol Randomised Trials Collaboration, Department of Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Kate Rowley
- Bristol Randomised Trials Collaboration, Department of Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Annie Sadoo
- Bristol Randomised Trials Collaboration, Department of Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Anne Schilder
- Ear Institute, University College London, London, UK
| | - Roderick Venekamp
- Julius Center for Health Sciences and Primary Care & Department of Otorhinolaryngology, UMC Utrecht, Utrecht, the Netherlands
| | - Scott Wilkes
- School of Medicine, University of Sunderland, Sunderland, UK
| | - Vasa Curcin
- School of Population Health and Environmental Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| |
Collapse
|
5
|
Dhond R, Elbers D, Majahalme N, Dipietro S, Goryachev S, Acher R, Leatherman S, Anglin-Foote T, Liu Q, Su S, Seerapu R, Hall R, Ferguson R, Brophy MT, Ferraro J, DuVall SL, Do NV. ProjectFlow: a configurable workflow management application for point of care research. JAMIA Open 2021; 4:ooab074. [PMID: 34485848 DOI: 10.1093/jamiaopen/ooab074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Revised: 05/21/2021] [Accepted: 08/16/2021] [Indexed: 11/12/2022] Open
Abstract
Objective To best meet our point-of-care research (POC-R) needs, we developed ProjectFlow, a configurable, clinical research workflow management application. In this article, we describe ProjectFlow and how it is used to manage study processes for the Diuretic Comparison Project (DCP) and the Research Precision Oncology Program (RePOP). Materials and methods The Veterans Health Administration (VHA) is the largest integrated health care system in the United States. ProjectFlow is a flexible web-based workflow management tool specifically created to facilitate conduct of our clinical research initiatives within the VHA. The application was developed using the Grails web framework and allows researchers to create custom workflows using Business Process Model and Notation. Results As of January 2021, ProjectFlow has facilitated management of study recruitment, enrollment, randomization, and drug orders for over 10 000 patients for the DCP clinical trial. It has also helped us evaluate over 3800 patients for recruitment and enroll over 370 of them into RePOP for use in data sharing partnerships and predictive analytics aimed at optimizing cancer treatment in the VHA. Discussion The POC-R study design embeds research processes within day-to-day clinical care and leverages longitudinal electronic health record (EHR) data for study recruitment, monitoring, and outcome reporting. Software that allows flexibility in study workflow creation and integrates with enterprise EHR systems is critical to the success of POC-R. Conclusions We developed a flexible web-based informatics solution called ProjectFlow that supports custom research workflow configuration and has ability to integrate data from existing VHA EHR systems.
Collapse
Affiliation(s)
- Rupali Dhond
- VA Boston Healthcare System, Boston, Massachusetts, USA
| | - Danne Elbers
- VA Boston Healthcare System, Boston, Massachusetts, USA
| | | | | | | | - Ryan Acher
- VA Boston Healthcare System, Boston, Massachusetts, USA
| | | | | | - Qingzhu Liu
- VA Salt Lake City Healthcare System, Salt Lake City, Utah, USA
| | - Shaoyu Su
- VA Salt Lake City Healthcare System, Salt Lake City, Utah, USA
| | - Ramana Seerapu
- VA Salt Lake City Healthcare System, Salt Lake City, Utah, USA
| | - Robert Hall
- VA Boston Healthcare System, Boston, Massachusetts, USA
| | - Ryan Ferguson
- VA Boston Healthcare System, Boston, Massachusetts, USA
| | - Mary T Brophy
- VA Boston Healthcare System, Boston, Massachusetts, USA
| | - Jeff Ferraro
- VA Salt Lake City Healthcare System, Salt Lake City, Utah, USA
| | - Scott L DuVall
- VA Salt Lake City Healthcare System, Salt Lake City, Utah, USA
| | - Nhan V Do
- VA Boston Healthcare System, Boston, Massachusetts, USA
| |
Collapse
|
6
|
Osborne V, Lane S, Shakir SAW. The Role of the Contextual Cohort to Resolve Some Challenges and Limitations of Comparisons in Pharmacoepidemiology. Drug Saf 2021; 44:835-841. [PMID: 33961212 PMCID: PMC8279980 DOI: 10.1007/s40264-021-01074-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/20/2021] [Indexed: 12/12/2022]
Abstract
In pharmacoepidemiology, comparison studies can provide a useful estimate of the level of increased or decreased risk of specific events with a medication (through a measure of effect). A key focus of pharmacoepidemiological studies is the safety and effectiveness of medicines in their real-world use, and adequate comparisons of effect estimates are critical. However, consideration of guidelines, pharmacoeconomic assessments, and policies for reimbursement have made comparisons in pharmacoepidemiological studies far more difficult to conduct in recent years. Where certain subject characteristics influence the probability of being exposed to a treatment, this can introduce issues of selection bias and confounding. Methodologies are available to minimise selection bias (through case-only and randomised study designs) and deal with confounding (such as regression modelling or propensity score matching methods), however these each have their own limitations. Where prescribing guidelines are present, conducting comparisons in pharmacoepidemiology produces many challenges and not all of these can be easily overcome. Patient channelling can be more frequent with adherence to clinical guidelines compared with when prescribing decisions by doctors are based predominantly on their clinical judgement. Use of a contextual cohort could be considered as an option to characterise the adoption of new medications into clinical practice and describe the prevalence of clinical characteristics and risk factors in the two cohorts, rather than compare event rates and produce an estimate of effect.
Collapse
Affiliation(s)
- Vicki Osborne
- Drug Safety Research Unit, Bursledon Hall, Blundell Lane, Southampton, SO31 1AA, UK. .,School of Pharmacy and Biomedical Sciences, University of Portsmouth, Portsmouth, UK.
| | - Samantha Lane
- Drug Safety Research Unit, Bursledon Hall, Blundell Lane, Southampton, SO31 1AA, UK.,School of Pharmacy and Biomedical Sciences, University of Portsmouth, Portsmouth, UK
| | - Saad A W Shakir
- Drug Safety Research Unit, Bursledon Hall, Blundell Lane, Southampton, SO31 1AA, UK.,School of Pharmacy and Biomedical Sciences, University of Portsmouth, Portsmouth, UK
| |
Collapse
|
7
|
Concordance in the recording of stroke across UK primary and secondary care datasets: a population-based cohort study. BJGP Open 2020; 5:BJGPO.2020.0117. [PMID: 33234512 PMCID: PMC8170615 DOI: 10.3399/bjgpo.2020.0117] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Accepted: 08/27/2020] [Indexed: 12/02/2022] Open
Abstract
Background Previous work has demonstrated that the recording of acute health outcomes, such as myocardial infarction (MI), may be suboptimal in primary healthcare databases. Aim To assess the completeness and accuracy of the recording of stroke in UK primary care. Design & setting A population-based longitudinal cohort study. Method Cases of stroke were identified separately in Clinical Practice Research Datalink (CPRD) primary care records and linked Hospital Episode Statistics (HES). The recording of events in the same patient across the two datasets was compared. The reliability of strategies to identify fatal strokes in primary care and hospital records was also assessed. Results Of the 75 674 stroke events that were identified in either CPRD or HES data during the period of the study, 54 929 (72.6%) were recorded in CPRD and 51 013 (67.4%) were recorded in HES. Two-fifths (n = 30 268) of all recorded strokes were found in both datasets (allowing for a time window of 120 days). Among these 'matched' strokes the subtype was recorded accurately in approximately 75% of CPRD records (compared with coding in HES); however, 43.5% of ischaemic strokes in HES were coded as 'non-specific' strokes in CPRD data. Furthermore, 48.2% had same-day recordings, and 56.2% were date-matched within ±1 day. Conclusion The completeness and accuracy of stroke recording is improved by the use of linked hospital and primary care records. For studies that have a time-sensitive research question, the use of linked, as opposed to stand-alone, CPRD data is strongly recommended.
Collapse
|
8
|
Mintz HP, Dosanjh A, Parsons HM, Hughes A, Jakeman A, Pope AM, Bryan RT, James ND, Patel P. Development and validation of a follow-up methodology for a randomised controlled trial, utilising routine clinical data as an alternative to traditional designs: a pilot study to assess the feasibility of use for the BladderPath trial. Pilot Feasibility Stud 2020; 6:165. [PMID: 33292682 PMCID: PMC7599120 DOI: 10.1186/s40814-020-00713-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Accepted: 10/20/2020] [Indexed: 01/19/2023] Open
Abstract
Background Bladder cancer outcomes have not changed significantly in 30 years; the BladderPath trial (Image Directed Redesign of Bladder Cancer Treatment Pathway, ISRCTN35296862) proposes to evaluate a modified pathway for diagnosis and treatment ensuring appropriate pathways are undertaken earlier to improve outcomes. We are piloting a novel data collection technique based on routine National Health Service (NHS) data, with no traditional patient-Health Care Professional contact after recruitment, where trial data are traditionally collected on case report forms. Data will be collected from routine administrative sources and validated via data queries to sites. We report here the feasibility and pre-trial methodological development and validation of the schema proposed for BladderPath. Methods Locally treated patient cohorts were utilised for routine data validation (hospital interactions data (HID) and administrative radiotherapy department data (RTD)). Single site events of interest were algorithmically extracted from the 2008–2018 HID and validated against reference datasets to determine detection sensitivity. Survival analysis was performed using RTD and HID data. Hazard ratios and survival statistics were calculated estimating treatment effects and further validating and assessing the scope of routine data. Results Overall, 829/1042 (sensitivity 0.80) events of interest were identified in the HID, with varying levels of sensitivity; identifying, 202/206 (sensitivity 0.98; PPV 0.96) surgical events but only 391/568 (sensitivity 0.69; PPV 0.95) radiotherapy regimens. An overall temporal quality improvement trend was present: detecting 41/117 events (35%) in 2011 to 104/109 (95%) in 2017 (all event types). Using the RTD, 5-year survival rates were 43% (95% CI 25–59%) in the chemoradiotherapy group and 30% (95% CI 23–36%) in the radiotherapy group; using the HID, the 5-year radical cystectomy survival rate was 57% (95% CI 50–63%). Conclusions Routine data are a feasible method for trial data collection. As long as events of interest are pre-validated, very high sensitivities for trial conduct can be achieved and further improved with targeted data queries. Outcomes can also be produced comparable to clinical trial and national dataset results. Given the real-time, obligatory nature of the HID, which forms the Hospital Episode Statistics (HES) data, alongside other datasets, we believe routine data extraction and validation is a robust way of rapidly collecting datasets for trials. Supplementary Information Supplementary information accompanies this paper at 10.1186/s40814-020-00713-y.
Collapse
Affiliation(s)
- Harriet P Mintz
- Warwick Medical School, University of Warwick, Coventry, CV4 7AL, UK.,University Hospitals Birmingham NHS Foundation Trust, Edgbaston, Birmingham, B15 2GW, UK
| | - Amandeep Dosanjh
- University Hospitals Birmingham NHS Foundation Trust, Edgbaston, Birmingham, B15 2GW, UK.,Institute of Cancer and Genomic Sciences, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK
| | - Helen M Parsons
- Warwick Medical School, University of Warwick, Coventry, CV4 7AL, UK
| | - Ana Hughes
- Institute of Cancer and Genomic Sciences, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK
| | - Alicia Jakeman
- University Hospitals Birmingham NHS Foundation Trust, Edgbaston, Birmingham, B15 2GW, UK
| | - Ann M Pope
- Institute of Cancer and Genomic Sciences, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK
| | - Richard T Bryan
- Institute of Cancer and Genomic Sciences, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK
| | | | - Nicholas D James
- The Institute of Cancer Research, 237 Fulham Road, London, SW3 6JB, UK.,The Royal Marsden NHS foundation Trust, Fulham Road, Chelsea, London, SW3 6JJ, UK
| | - Prashant Patel
- University Hospitals Birmingham NHS Foundation Trust, Edgbaston, Birmingham, B15 2GW, UK. .,Institute of Cancer and Genomic Sciences, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK.
| |
Collapse
|
9
|
Frampton GK, Shepherd J, Pickett K, Griffiths G, Wyatt JC. Digital tools for the recruitment and retention of participants in randomised controlled trials: a systematic map. Trials 2020; 21:478. [PMID: 32498690 PMCID: PMC7273688 DOI: 10.1186/s13063-020-04358-3] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Accepted: 04/28/2020] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Recruiting and retaining participants in randomised controlled trials (RCTs) is challenging. Digital tools, such as social media, data mining, email or text-messaging, could improve recruitment or retention, but an overview of this research area is lacking. We aimed to systematically map the characteristics of digital recruitment and retention tools for RCTs, and the features of the comparative studies that have evaluated the effectiveness of these tools during the past 10 years. METHODS We searched Medline, Embase, other databases, the Internet, and relevant web sites in July 2018 to identify comparative studies of digital tools for recruiting and/or retaining participants in health RCTs. Two reviewers independently screened references against protocol-specified eligibility criteria. Included studies were coded by one reviewer with 20% checked by a second reviewer, using pre-defined keywords to describe characteristics of the studies, populations and digital tools evaluated. RESULTS We identified 9163 potentially relevant references, of which 104 articles reporting 105 comparative studies were included in the systematic map. The number of published studies on digital tools has doubled in the past decade, but most studies evaluated digital tools for recruitment rather than retention. The key health areas investigated were health promotion, cancers, circulatory system diseases and mental health. Few studies focussed on minority or under-served populations, and most studies were observational. The most frequently-studied digital tools were social media, Internet sites, email and tv/radio for recruitment; and email and text-messaging for retention. One quarter of the studies measured efficiency (cost per recruited or retained participant) but few studies have evaluated people's attitudes towards the use of digital tools. CONCLUSIONS This systematic map highlights a number of evidence gaps and may help stakeholders to identify and prioritise further research needs. In particular, there is a need for rigorous research on the efficiency of the digital tools and their impact on RCT participants and investigators, perhaps as studies-within-a-trial (SWAT) research. There is also a need for research into how digital tools may improve participant retention in RCTs which is currently underrepresented relative to recruitment research. REGISTRATION Not registered; based on a pre-specified protocol, peer-reviewed by the project's Advisory Board.
Collapse
Affiliation(s)
- Geoff K. Frampton
- Southampton Health Technology Assessments Centre (SHTAC), Wessex Institute, Faculty of Medicine, University of Southampton, Alpha House, Southampton Science Park, Southampton, SO16 7NS UK
- Wessex Institute, Faculty of Medicine, University of Southampton, Alpha House, Southampton Science Park, Southampton, SO16 7NS UK
| | - Jonathan Shepherd
- Southampton Health Technology Assessments Centre (SHTAC), Wessex Institute, Faculty of Medicine, University of Southampton, Alpha House, Southampton Science Park, Southampton, SO16 7NS UK
- Wessex Institute, Faculty of Medicine, University of Southampton, Alpha House, Southampton Science Park, Southampton, SO16 7NS UK
| | - Karen Pickett
- Southampton Health Technology Assessments Centre (SHTAC), Wessex Institute, Faculty of Medicine, University of Southampton, Alpha House, Southampton Science Park, Southampton, SO16 7NS UK
- Wessex Institute, Faculty of Medicine, University of Southampton, Alpha House, Southampton Science Park, Southampton, SO16 7NS UK
| | - Gareth Griffiths
- Southampton Clinical Trials Unit, University of Southampton and Southampton University Hospital NHS Foundation Trust, Southampton General Hospital, Southampton, SO16 6YD UK
| | - Jeremy C. Wyatt
- Wessex Institute, Faculty of Medicine, University of Southampton, Alpha House, Southampton Science Park, Southampton, SO16 7NS UK
| |
Collapse
|
10
|
Shi W, Kelsey T, Sullivan F. Efficient identification of patients eligible for clinical studies using case-based reasoning on Scottish Health Research register (SHARE). BMC Med Inform Decis Mak 2020; 20:70. [PMID: 32306964 PMCID: PMC7169032 DOI: 10.1186/s12911-020-1091-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Accepted: 04/12/2020] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND Trials often struggle to achieve their target sample size with only half doing so. Some researchers have turned to Electronic Health Records (EHRs), seeking a more efficient way of recruitment. The Scottish Health Research Register (SHARE) obtained patients' consent for their EHRs to be used as a searching base from which researchers can find potential participants. However, due to the fact that EHR data is not complete, sufficient or accurate, a database search strategy may not generate the best case-finding result. The current study aims to evaluate the performance of a case-based reasoning method in identifying participants for population-based clinical studies recruiting through SHARE, and assess the difference between its resultant cohort and the original one deriving from searching EHRs. METHODS A case-based reasoning framework was applied to 119 participants in nine projects using two-fold cross-validation, with records from a further 86,292 individuals used for testing. A prediction score for study participation was derived from the diagnosis, procedure, pharmaceutical prescription, and laboratory test results attributes of each participant. Evaluation was conducted by calculating Area Under the ROC Curve and information retrieval metrics for the ranking list of the test set by prediction score. We compared the most likely participants as identified by searching a database to those ranked highest by our model. RESULTS The average ROCAUC for nine projects was 81% indicating strong predictive ability for these data. However, the derived ranking lists showed lower predictive performance, with only 21% of the persons ranked within top 50 positions being the same as identified by searching databases. CONCLUSIONS Case-based reasoning is may be more effective than a database search strategy for participant identification for clinical studies using population EHRs. The lower performance of ranking lists derived from case-based reasoning means that patients identified as highly suitable for study participation may still not be recruited. This suggests that further study is needed into improvements in the collection and curation of population EHRs, such as use of free text data to aid reliable identification of people more likely to be recruited to clinical trials.
Collapse
Affiliation(s)
- Wen Shi
- School of Medicine, University of St. Andrews, North Haugh, St. Andrews, Scotland, KY16 9TF, UK
| | - Tom Kelsey
- School of Computer Science, University of St. Andrews, North Haugh, St. Andrews, Scotland, KY16 9SX, UK.
| | - Frank Sullivan
- School of Medicine, University of St. Andrews, North Haugh, St. Andrews, Scotland, KY16 9TF, UK
| |
Collapse
|
11
|
Abstract
Clinical trials embedded in health systems can randomize large populations using automated data sources to determine trial eligibility and assess outcomes. The suicide prevention outreach trial used real-world data for trial design and randomized 18,868 individuals in four health systems using patient-reported thoughts of death or self-harm (Patient Health Questionnaire item 9). This took 3.5 years. We consider if using predictive analytics, that is, suicide risk estimates based on prediction models, could improve trial "efficiency." We used data on mental health outpatient visits between 1 January 2009 and 30 September 2017 in seven health systems (HealthPartners; Henry Ford Health System; and Colorado, Hawaii, Northwest, Southern California, and Washington Kaiser Permanente regions). We used a suicide risk prediction model developed in these same systems. We compared five trial designs with different eligibility criteria: a response of a 2 or 3 on Patient Health Questionnaire item 9, a response of a 3, suicide risk score above 90th, 95th, or 99th percentile. We compared the sample that met each criterion, 90-day suicide attempt rate following first eligible visit, and necessary sample sizes to detect a 15%, 25%, and 35% relative reduction in the suicide attempt rate, assuming 90% power, for each eligibility criterion. Our sample included 24,355,599 outpatient visits. Despite wide-spread use of Patient Health Questionnaire, 21,026,985 (86.3%) visits did not have a recorded Patient Health Questionnaire. Of the 2,928,927 individuals in our sample, 109,861 had a recorded Patient Health Questionnaire item 9 response of a 2 or 3 over the study years with a 1.40% 90-day suicide attempt rate and 50,047 had a response of a 3 (suicide attempt rate 1.98%). More patients met criteria requiring a certain risk score or higher: 331,273 had a 90th percentile risk score or higher (suicide attempt rate: 1.36%); 182,316 a 95th percentile or higher (suicide attempt rate 2.16%), and 78,655 a 99th percentile or higher (suicide attempt rate: 3.95%). Eligibility criterion of a Patient Health Questionnaire item 9 response of a 2 or 3 would require randomizing 44,081 individuals (40.2% of eligible population in our sample); eligibility criterion of a 3 would require 31,024 individuals (62.0% of eligible population). Eligibility criterion of a suicide risk score of 90th percentile or higher would require 45,675 individuals (13.8% of eligible population), 95th percentile 28,699 individuals (15.7% of eligible population), and 99th percentile 15,509 (19.7% of eligible population). A suicide risk prediction calculator could improve trial "efficiency"; identifying more individuals at increased suicide risk than relying on patient-report. It is an open scientific question if individuals identified using predictive analytics would respond differently to interventions than those identified by more traditional means.
Collapse
Affiliation(s)
- Susan M Shortreed
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA.,Department of Biostatistics, University of Washington, Seattle, WA, USA
| | - Gregory E Simon
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
| |
Collapse
|
12
|
Quality improvement and practice-based research in sleep medicine using structured clinical documentation in the electronic medical record. SLEEP SCIENCE AND PRACTICE 2020; 4:1. [PMID: 32395635 PMCID: PMC7213673 DOI: 10.1186/s41606-019-0038-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background: We developed and implemented a structured clinical documentation support (SCDS) toolkit within the electronic medical record, to optimize patient care, facilitate documentation, and capture data at office visits in a sleep medicine/neurology clinic for patient care and research collaboration internally and with other centers. Methods: To build our SCDS toolkit, physicians met frequently to develop content, define the cohort, select outcome measures, and delineate factors known to modify disease progression. We assigned tasks to the care team and mapped data elements to the progress note. Programmer analysts built and tested the SCDS toolkit, which included several score tests. Auto scored and interpreted tests included the Generalized Anxiety Disorder 7-item, Center for Epidemiological Studies Depression Scale, Epworth Sleepiness Scale, Pittsburgh Sleep Quality Index, Insomnia Severity Index, and the International Restless Legs Syndrome Study Group Rating Scale. The SCDS toolkits also provided clinical decision support (untreated anxiety or depression) and prompted enrollment of patients in a DNA biobank. Results: The structured clinical documentation toolkit captures hundreds of fields of discrete data at each office visit. This data can be displayed in tables or graphical form. Best practice advisories within the toolkit alert physicians when a quality improvement opportunity exists. As of May 1, 2019, we have used the toolkit to evaluate 18,105 sleep patients at initial visit. We are also collecting longitudinal data on patients who return for annual visits using the standardized toolkits. We provide a description of our development process and screenshots of our toolkits. Conclusions: The electronic medical record can be structured to standardize Sleep Medicine office visits, capture data, and support multicenter quality improvement and practice-based research initiatives for sleep patients at the point of care.
Collapse
|
13
|
Seki T, Aki M, Kawashima H, Miki T, Tanaka S, Kawakami K, Furukawa TA. Electronic health record nested pragmatic randomized controlled trial of a reminder system for serum lithium level monitoring in patients with mood disorder: KONOTORI study protocol. Trials 2019; 20:706. [PMID: 31829279 PMCID: PMC6907204 DOI: 10.1186/s13063-019-3847-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2019] [Accepted: 10/25/2019] [Indexed: 11/12/2022] Open
Abstract
Background The weaknesses of classical explanatory randomized controlled trials (RCTs) include limited generalizability, high cost, and time burden. Pragmatic RCTs nested within electronic health records (EHRs) can be useful to overcome such limitations. Serum lithium monitoring has often been underutilized in real-world practice in Japan. This trial aims to evaluate the effectiveness of the EHR-nested reminder system for serum lithium level monitoring in the maintenance of therapeutic lithium concentration and in the improvement of the quality of care for patients on lithium maintenance therapy. Methods The Kyoto Toyooka nested controlled trial of reminders (KONOTORI trial) is an EHR-nested, parallel-group, superiority, stratified, permuted block-randomized controlled trial. Screening, random allocation, reminder output, and outcome collection will be conducted automatically by the EHR-nested trial program. Patients with a mood disorder taking lithium carbonate for maintenance therapy will be randomly allocated to the two-step reminder system for serum lithium monitoring or to usual care. The primary outcome is the achievement of therapeutic serum lithium concentration between 0.4 and 1.0 mEq/L at 18 months after informed consent. Discussion The KONOTORI trial uses EHRs to enable the efficient conduct of a pragmatic trial of the reminder system for lithium monitoring. This may contribute to improved quality of care for patients on lithium maintenance therapy. Trial registration University Hospital Medical Information Network (UMIN) Clinical Trials Registry, UMIN000033633. Registered on 3 July 2018.
Collapse
Affiliation(s)
- Tomotsugu Seki
- Department of Pharmacoepidemiology, Graduate School of Medicine/School of Public Health, Kyoto University, Kyoto, Japan
| | - Morio Aki
- Department of Psychiatry, Toyooka Hospital, Toyooka, Hyogo, Japan
| | - Hirotsugu Kawashima
- Department of Psychiatry, Toyooka Hospital, Toyooka, Hyogo, Japan.,Department of Psychiatry, Kyoto University Hospital, Kyoto, Japan
| | - Tomotaka Miki
- Department of Psychiatry, Toyooka Hospital, Toyooka, Hyogo, Japan.,Department of Psychiatry, Kyoto University Hospital, Kyoto, Japan
| | - Shiro Tanaka
- Department of Clinical Biostatistics, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Koji Kawakami
- Department of Pharmacoepidemiology, Graduate School of Medicine/School of Public Health, Kyoto University, Kyoto, Japan
| | - Toshi A Furukawa
- Department of Health Promotion and Human Behavior, Graduate School of Medicine/School of Public Health, Kyoto University, Kyoto, Japan.
| |
Collapse
|
14
|
Naar S, Hudgens MG, Brookmeyer R, Idalski Carcone A, Chapman J, Chowdhury S, Ciaranello A, Comulada WS, Ghosh S, Horvath KJ, Ingram L, LeGrand S, Reback CJ, Simpson K, Stanton B, Starks T, Swendeman D. Improving the Youth HIV Prevention and Care Cascades: Innovative Designs in the Adolescent Trials Network for HIV/AIDS Interventions. AIDS Patient Care STDS 2019; 33:388-398. [PMID: 31517525 DOI: 10.1089/apc.2019.0095] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Dramatic decreases in HIV transmission are achievable with currently available biomedical and behavioral interventions, including antiretroviral therapy and pre-exposure prophylaxis. However, such decreases have not yet been realized among adolescents and young adults. The Adolescent Medicine Trials Network (ATN) for HIV/AIDS interventions is dedicated to research addressing the needs of youth at high risk for HIV acquisition as well as youth living with HIV. This article provides an overview of an array of efficient and effective designs across the translational spectrum that are utilized within the ATN. These designs maximize methodological rigor and real-world applicability of findings while minimizing resource use. Implementation science and cost-effectiveness methods are included. Utilizing protocol examples, we demonstrate the feasibility of such designs to balance rigor and relevance to shorten the science-to-practice gap and improve the youth HIV prevention and care continua.
Collapse
Affiliation(s)
- Sylvie Naar
- Center for Translational Behavioral Science, Florida State University, Tallahassee, Florida
| | - Michael G. Hudgens
- Department of Biostatistics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Ron Brookmeyer
- Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - April Idalski Carcone
- Department of Family Medicine and Public Health Sciences, Wayne State University School of Medicine, Detroit, Michigan
| | | | - Shrabanti Chowdhury
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Andrea Ciaranello
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts
| | - W. Scott Comulada
- Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Samiran Ghosh
- Department of Family Medicine and Public Health Sciences, Wayne State University School of Medicine, Detroit, Michigan
| | - Keith J. Horvath
- Department of Psychology, San Diego State University, San Diego, California
| | - LaDrea Ingram
- Arnold School of Public Health, University of South Carolina, Columbia, South Carolina
| | - Sara LeGrand
- Duke Global Health Institute, Duke University, Durham, North Carolina
| | | | - Kit Simpson
- Department of Healthcare Leadership and Management, Medical University of South Carolina, Charleston, South Carolina
| | - Bonita Stanton
- Hackensack Meridian School of Medicine, Seton Hall University, Newark, New Jersey
| | - Tyrel Starks
- Department of Psychology, City University of New York–Hunter College, New York, New York
| | - Dallas Swendeman
- Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine at UCLA, Los Angeles, California
| |
Collapse
|
15
|
Close J, Fosh B, Wheat H, Horrell J, Lee W, Byng R, Bainbridge M, Blackwell R, Witts L, Hall L, Lloyd H. Longitudinal evaluation of a countywide alternative to the Quality and Outcomes Framework in UK General Practice aimed at improving Person Centred Coordinated Care. BMJ Open 2019; 9:e029721. [PMID: 31337661 PMCID: PMC6661675 DOI: 10.1136/bmjopen-2019-029721] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Revised: 05/23/2019] [Accepted: 05/30/2019] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVES To evaluate a county-wide deincentivisation of the Quality and Outcomes Framework (QOF) payment scheme for UK General Practice (GP). SETTING In 2014, National Health Service England signalled a move towards devolution of QOF to Clinical Commissioning Groups. Fifty-five GPs in Somerset established the Somerset Practice Quality Scheme (SPQS)-a deincentivisation of QOF-with the goal of redirecting resources towards Person Centred Coordinated Care (P3C), especially for those with long-term conditions (LTCs). We evaluated the impact on processes and outcomes of care from April 2016 to March 2017. PARTICIPANTS AND DESIGN The evaluation used data from 55 SPQS practices and 17 regional control practices for three survey instruments. We collected patient experiences ('P3C-EQ'; 2363 returns from patients with 1+LTC; 36% response rate), staff experiences ('P3C-practitioner'; 127 professionals) and organisational data ('P3C-OCT'; 36 of 55 practices at two time points, 65% response rate; 17 control practices). Hospital Episode Statistics emergency admission data were analysed for 2014-2017 for ambulatory-sensitive conditions across Somerset using interrupted time series. RESULTS Patient and practitioner experiences were similar in SPQS versus control practices. However, discretion from QOF incentives resulted in time savings in the majority of practices, and SPQS practice data showed a significant increase in P3C oriented organisational processes, with a moderate effect size (Wilcoxon signed rank test; p=0.01; r=0.42). Analysis of transformation plans and organisational data suggested stronger federation-level agreements and informal networks, increased multidisciplinary working, reallocation of resources for other healthcare professionals and changes to the structure and timings of GP appointments. No disbenefits were detected in admission data. CONCLUSION The SPQS scheme leveraged time savings and reduced administrative burden via discretionary removal of QOF incentives, enabling practices to engage actively in a number of schemes aimed at improving care for people with LTCs. We found no differences in the experiences of patients or healthcare professionals between SPQS and control practices.
Collapse
Affiliation(s)
- James Close
- Community and Primary Care Research Group, University of Plymouth, Plymouth, UK
| | - Ben Fosh
- Community and Primary Care Research Group, University of Plymouth, Plymouth, UK
| | - Hannah Wheat
- Sociology, Philosophy and Anthropology Department, University of Exeter, Exeter, UK
| | - Jane Horrell
- Community and Primary Care Research Group, University of Plymouth, Plymouth, UK
| | - William Lee
- Community and Primary Care Research Group, University of Plymouth, Plymouth, UK
| | - Richard Byng
- Peninsula Schools of Medicine and Dentistry, University of Plymouth, Plymouth, UK
| | | | | | - Louise Witts
- South West Academic Health Science Network, Exeter, UK
| | - Louise Hall
- South West Academic Health Science Network, Exeter, UK
| | - Helen Lloyd
- Psychology, University of Plymouth, Plymouth, UK
| |
Collapse
|
16
|
Makady A, van Acker S, Nijmeijer H, de Boer A, Hillege H, Klungel O, Goettsch W. Conditional Financing of Drugs in the Netherlands: Past, Present, and Future-Results From Stakeholder Interviews. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2019; 22:399-407. [PMID: 30975390 DOI: 10.1016/j.jval.2018.11.016] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/15/2018] [Revised: 11/26/2018] [Accepted: 11/27/2018] [Indexed: 06/09/2023]
Abstract
BACKGROUND Conditional financing (CF) of hospital drugs was implemented in the Netherlands as a form of managed entry agreements between 2006 and 2012. CF was a 4-year process comprising 3 stages: initial health technology assessment of the drug (T = 0), conduct of outcomes research studies, and reassessment of the drug (T = 4). OBJECTIVES To analyze stakeholder experiences in implementing CF in practice. METHODS Public and private stakeholders were approached for participation in stakeholder interviews through standardized email invitations. An interview guide was developed to guide discussions that covered the following topics: perceived aims of CF, functioning of CF, impact of CF, and conclusions and future perspectives. Extensive summaries were generated for each interview and subsequently used for directed content analysis. RESULTS Thirty stakeholders were interviewed. Differences emerged among the stakeholders on the perceived aims of CF. Conversely, there was some agreement among stakeholders on the shortcomings in the functioning of CF, the positive impact of CF on the Dutch healthcare setting, and improvement points for CF. CONCLUSIONS Despite stakeholders' belief that CF either did not meet its aims or only partially did so, there was agreement on the need for new policy to address the same aims of CF in the future. Nevertheless, stakeholders diverged on whether CF should be improved on the basis of learnings identified and reintroduced into practice or replaced with new policy schemes.
Collapse
Affiliation(s)
- Amr Makady
- The National Healthcare Institute, Diemen, The Netherlands; Department of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht, The Netherlands.
| | | | - Hugo Nijmeijer
- Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Anthonius de Boer
- Department of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht, The Netherlands
| | - Hans Hillege
- Department of Epidemiology, University Medical Centre Groningen, Groningen, The Netherlands
| | - Olaf Klungel
- Department of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht, The Netherlands
| | - Wim Goettsch
- The National Healthcare Institute, Diemen, The Netherlands; Department of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht, The Netherlands
| |
Collapse
|
17
|
Shortreed SM, Rutter CM, Cook AJ, Simon GE. Improving pragmatic clinical trial design using real-world data. Clin Trials 2019; 16:273-282. [PMID: 30866672 DOI: 10.1177/1740774519833679] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Pragmatic clinical trials often use automated data sources such as electronic health records, claims, or registries to identify eligible individuals and collect outcome information. A specific advantage that this automated data collection often yields is having data on potential participants when design decisions are being made. We outline how this data can be used to inform trial design. METHODS Our work is motivated by a pragmatic clinical trial evaluating the impact of suicide-prevention outreach interventions on fatal and non-fatal suicide attempts in the 18 months after randomization. We illustrate our recommended approaches for designing pragmatic clinical trials using historical data from the health systems participating in this study. Specifically, we illustrate how electronic health record data can be used to inform the selection of trial eligibility requirements, to estimate the distribution of participant characteristics over the course of the trial, and to conduct power and sample size calculations. RESULTS Data from 122,873 people with patient health questionnaire (PHQ) responses, recorded in their electronic health records between 1 July 2010 and 31 March 2012, were used to show that the suicide attempt rate in the 18 months following completion of the questionnaire varies by response to item nine of the PHQ. We estimated that the proportion of individuals with a prior recorded elevated PHQ (i.e. history of suicidal ideation) would decrease from approximately 50% at the beginning of a trial to about 5%, 50 weeks later. Using electronic health record data, we conducted simulations to estimate the power to detect a 25% reduction in suicide attempts. Simulation-based power calculations estimated that randomizing 8000 participants per randomization arm would allow 90% power to detect a 25% reduction in the suicide attempt rate in the intervention arm compared to usual care at an alpha rate of 0.05. CONCLUSIONS Historical data can be used to inform the design of pragmatic clinical trials, a strength of trials that use automated data collection for randomizing participants and assessing outcomes. In particular, realistic sample size calculations can be conducted using real-world data from the health systems in which the trial will be conducted. Data-informed trial design should yield more realistic estimates of statistical power and maximize efficiency of trial recruitment.
Collapse
Affiliation(s)
- Susan M Shortreed
- 1 Biostatistics Unit, Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA.,2 Department of Biostatistics, University of Washington, Seattle, WA, USA
| | | | - Andrea J Cook
- 1 Biostatistics Unit, Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA.,2 Department of Biostatistics, University of Washington, Seattle, WA, USA
| | - Gregory E Simon
- 4 Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
| |
Collapse
|
18
|
Odgers-Jewell K, Isenring EA, Thomas R, Reidlinger DP. Group-based education for patients with type 2 diabetes: a survey of Australian dietitians. Aust J Prim Health 2019; 23:364-372. [PMID: 28566113 DOI: 10.1071/py16156] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2016] [Accepted: 02/28/2017] [Indexed: 12/24/2022]
Abstract
Group-based education has the potential to substantially improve the outcomes of individuals with type 2 diabetes mellitus (T2DM) and reduce the enormous burden that chronic diseases place on healthcare systems worldwide. Despite this proven effectiveness, the utilisation of group services for the management of T2DM by Australian dietitians is surprisingly low. This study surveyed a sample of 263 Australian dietitians to explore the utilisation of group-based education for T2DM, as well as dietitians' preferences for practice and training. The results of this study indicate that Australian dietitians are currently under-utilising group-based education programs for the management of T2DM, with the primary reasons identified as a lack of training provided to dietitians in the area, limited access to facilities suitable for conducting group education, the perceived poor cost-effectiveness of these programs, and the lack of evidence-based practice guidelines for the group-based management of persons with T2DM. Additionally, the majority of preferences for further training were for either face-to-face or web-based formal training conducted over 3-6h. Clear, evidence-based practice guidelines and training resources for group education for the management of T2DM are needed in order to encourage better utilisation of group-based education by Australian dietitians.
Collapse
Affiliation(s)
- Kate Odgers-Jewell
- Bond University, Faculty of Health Sciences and Medicine, 14 University Drive, Gold Coast, Qld 4229, Australia
| | - Elisabeth A Isenring
- Bond University, Faculty of Health Sciences and Medicine, 14 University Drive, Gold Coast, Qld 4229, Australia
| | - Rae Thomas
- Bond University, Faculty of Health Sciences and Medicine, 14 University Drive, Gold Coast, Qld 4229, Australia
| | - Dianne P Reidlinger
- Bond University, Faculty of Health Sciences and Medicine, 14 University Drive, Gold Coast, Qld 4229, Australia
| |
Collapse
|
19
|
Affiliation(s)
- Anushka Patel
- From The George Institute for Global Health, University of New South Wales, Sydney, Australia.
| | - Laurent Billot
- From The George Institute for Global Health, University of New South Wales, Sydney, Australia
| |
Collapse
|
20
|
Franklin M, Thorn J. Self-reported and routinely collected electronic healthcare resource-use data for trial-based economic evaluations: the current state of play in England and considerations for the future. BMC Med Res Methodol 2019; 19:8. [PMID: 30626337 PMCID: PMC6325715 DOI: 10.1186/s12874-018-0649-9] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2017] [Accepted: 12/20/2018] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Randomised controlled trials (RCTs) are generally regarded as the "gold standard" for providing quantifiable evidence around the effectiveness and cost-effectiveness of new healthcare technologies. In order to perform the economic evaluations associated with RCTs, there is a need for accessible and good quality resource-use data; for the purpose of discussion here, data that best reflect the care received. Traditionally, researchers have developed questionnaires for resource-use data collection. However, the evolution of routinely collected electronic data within care services provides new opportunities for collecting data without burdening patients or caregivers (e.g. clinicians). This paper describes the potential strengths and limitations of each data collection method and then discusses aspects for consideration before choosing which method to use. MAIN TEXT We describe electronic data sources (large observational datasets, commissioning data, and raw data extraction) that may be suitable data sources for informing clinical trials and the current status of self-reported instruments for measuring resource-use. We assess the methodological risks and benefits, and compare the two methodologies. We focus on healthcare resource-use; however, many of the considerations have relevance to clinical questions. Patient self-report forms a pragmatic and cheap method that is largely under the control of the researcher. However, there are known issues with the validity of the data collected, loss to follow-up may be high, and questionnaires suffer from missing data. Routinely collected electronic data may be more accurate and more practical if large numbers of patients are involved. However, datasets often incur a cost and researchers are bound by the time for data approval and extraction by the data holders. CONCLUSIONS Owing to the issues associated with electronic datasets, self-reported methods may currently be the preferred option. However, electronic hospital data are relatively more accessible, informative, standardised, and reliable. Therefore in trials where secondary care constitutes a major driver of patient care, detailed electronic data may be considered superior to self-reported methods; with the caveat of requiring data sharing agreements with third party providers and potentially time-consuming extraction periods. Self-reported methods will still be required when a 'societal' perspective (e.g. quantifying informal care) is desirable for the intended analysis.
Collapse
Affiliation(s)
- Matthew Franklin
- School of Health and Related Research (ScHARR), University of Sheffield West Court, 1 Mappin Street, Sheffield, S1 4DT UK
| | - Joanna Thorn
- School of Social and Community Medicine, University of Bristol Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS UK
| |
Collapse
|
21
|
Thompson W, Reeve E, Moriarty F, Maclure M, Turner J, Steinman MA, Conklin J, Dolovich L, McCarthy L, Farrell B. Deprescribing: Future directions for research. Res Social Adm Pharm 2018; 15:801-805. [PMID: 30241876 DOI: 10.1016/j.sapharm.2018.08.013] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Accepted: 08/29/2018] [Indexed: 01/11/2023]
Abstract
A World Café workshop was held at the Bruyère Evidence-Based Deprescribing Guidelines Symposium in March 2018 with 30 participants (researchers, clinicians, policy makers, stakeholders). This workshop explored priorities for future work in the field of deprescribing and deprescribing guidelines through group discussion. The discussions were guided by the following questions: (1) What are deprescribing research priorities (to inform guideline development), (2) What outcome measures are important for developing deprescribing guidelines, and (3) How do we evaluate the implementation and effectiveness of deprescribing guidelines? Discussion from all 3 questions identified 6 main priority areas: (1) conducting high-quality and long-term clinical trials that measure patient-important outcomes, (2) focusing on patient involvement and perspectives, (3) investigating the pharmacoeconomics of deprescribing interventions, (4) understanding deprescribing interventions in different populations, (5) generating evidence on clinical management during deprescribing (e.g. managing adverse drug withdrawal effects, subsequent re-prescribing), and (6) implementing interventions in clinical practice. These topics represent what a group of experienced researchers, clinicians, and stakeholders in the field collectively felt was important to consider for design and implementation of future deprescribing studies. The aim is for these findings to stimulate future discussions and be considered by granting agencies, policy makers, deprescribing research networks, and individual researchers planning future deprescribing studies.
Collapse
Affiliation(s)
- Wade Thompson
- Research Unit of General Practice, Department of Public Health, University of Southern Denmark, JB Winsløwsvej 9A, 5000C, Odense, Denmark.
| | - Emily Reeve
- NHMRC Cognitive Decline Partnership Centre, Kolling Institute of Medical Research, Northern Clinical School, Faculty of Medicine and Health, University of Sydney, Royal North Shore Hospital, St Leonards, NSW, 2065, Australia; Geriatric Medicine Research, Faculty of Medicine and College of Pharmacy, Dalhousie University and Nova Scotia Health Authority, NS, Canada.
| | - Frank Moriarty
- HRB Centre for Primary Care Research, Royal College of Surgeons in Ireland, 123 St Stephen's Green, D02 YN77, Dublin, Ireland.
| | - Malcolm Maclure
- Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, 2775 Laurel Street, V5Z 1M9, Vancouver, British Columbia, Canada.
| | - Justin Turner
- University of Montreal, Centre de recherche, Institut Universitaire de Gériatrie de Montréal, 4545 Chemin Queen Mary, H3W 1W4, Montréal, Quebec, Canada.
| | - Michael A Steinman
- Division of Geriatrics, Department of Medicine, University of California San Francisco, 4150 Clement St., Box 181G, 94121, San Francisco, USA.
| | - James Conklin
- Bruyère Research Institute, Ottawa, Ontario, Canada; Concordia University, Montreal, Quebec, Canada.
| | - Lisa Dolovich
- Leslie Dan Faculty of Pharmacy, University of Toronto, 144 College Street, M5S 3M2, Toronto, Ontario, Canada; Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada.
| | - Lisa McCarthy
- Women's College Research Institute, Women's College Hospital, 76 Grenville St., M5S 1B2, Toronto, Ontario, Canada; Leslie Dan Faculty of Pharmacy, University of Toronto, 144 College Street, M5S 3M2, Toronto, Ontario, Canada; Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada.
| | - Barbara Farrell
- Bruyère Research Institute, Ottawa, Ontario, Canada; Department of Family Medicine, University of Ottawa, Ottawa, Ontario, Canada; School of Pharmacy, University of Waterloo, Kitchener, Ontario, Canada.
| |
Collapse
|
22
|
Usage of glaucoma-specific patient-reported outcome measures (PROMs) in the Singapore context: a qualitative scoping exercise. BMC Ophthalmol 2018; 18:197. [PMID: 30107834 PMCID: PMC6092864 DOI: 10.1186/s12886-018-0803-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2017] [Accepted: 05/30/2018] [Indexed: 11/15/2022] Open
Abstract
Background Despite the increasing emphasis on the role of glaucoma-specific patient-reported outcome measures (PROMs) as relevant outcome measures for the impact of glaucoma and its intervention on patients' daily lives, the feasibility of implementing PROMs in the routine clinical setting in Singapore remains undefined. We aim to evaluate the comprehensibility, acceptability, and relevance of four glaucoma-specific PROMs at healthcare professionals' and patients' level in a Singapore context. Methods Sixteen ophthalmic healthcare professionals and 24 glaucoma patients, with average age 60 years (SD = 15), were invited from a tertiary hospital in Singapore. Semi-structured interviews were conducted to explore participants’ perceptions on the content and administration of four glaucoma-specific PROMs - the Glaucoma Quality of Life-15, Glaucoma Symptom Identifier, Independent Mobility Questionnaire and Treatment Satisfaction Survey of Intra-ocular Pressure. Semi-structured interviews were hand transcribed, and analysed thematically. Each participant filled out a feasibility survey at the end of interview. Results 79% of glaucoma patients and 94% of glaucoma healthcare professionals felt selected PROMs relevant to patients. 63% of glaucoma patients and 50% of healthcare professionals felt that selected PROMs were sufficiently comprehensive for clinical use. 46% of glaucoma patients and 56% of healthcare professionals felt selected PROMs were user-friendly. Conclusions Using PROMs in the Singapore clinical setting receives promising support from both healthcare professionals and patients. The identified potential barriers tailored to Singapore clinical setting will help successful implementation of PROMs into routine clinical care.
Collapse
|
23
|
Fanning L, Vo L, Ilomäki J, Bell JS, Elliott RA, Dārziņš P. Validity of electronic hospital discharge prescription records as a source of medication data for pharmacoepidemiological research. Ther Adv Drug Saf 2018; 9:425-438. [PMID: 30364834 PMCID: PMC6199684 DOI: 10.1177/2042098618776598] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2017] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND The advent of hospital electronic medical records (EMRs) with electronic prescribing provides considerable opportunity for pharmacoepidemiological research. However, validity of EMR prescribing data for research purposes is not well established. Validity concerns the percentage of cases in which medications and characteristics (name, type, formulation, dose) are true when verified with an independent data source. This study evaluated the validity of EMR discharge prescription data within the Eastern Health hospital network in Melbourne, Australia. METHODS A random sample of patients were selected who had a diagnosis of atrial fibrillation (AF) and were prescribed at least five medications. Prescription records from 2012 to 2015 were compared with pharmacy dispensing and hospital medical records (reference standards). Medication name, dose, directions and route of administration were compared. Discrepancies between data sources were categorized as omissions, additions, discrepancies in dose, medication form or route of administration or discrepancies in reordering. Sensitivities and 95% confidence intervals (CIs) for intended medication exposure were estimated for therapeutic classes. RESULTS A total of 5724 prescription orders for 479 patients for whom reference standards were available were included. There were 163 discrepancies (2.8%) between prescription records and reference standards. Additions were the most common data discrepancy (n = 65; ~1.1% of total prescriptions evaluated), followed by discrepancies in reordering (n = 34; 0.59%). Sensitivities for intended patient exposure to a medication for each therapeutic class at the first level of the Anatomical Therapeutic Chemical (ATC) classification system were between 97% and 100%. The genitourinary system and sex hormone level of the ATC system demonstrated the lowest sensitivity, (97.3%; 95% CI 92.0%-100%) and the cardiovascular system level demonstrated the highest sensitivity (99.9%; 95% CI 99.7%-100%). CONCLUSION EMR discharge prescription records for patients with AF are a valid information source for conducting pharmacoepidemiological research within Eastern Health in Melbourne, Australia. Further studies in different regions, countries and patient cohorts are required to establish validity of hospital EMR prescription records for pharmacoepidemiological research.
Collapse
Affiliation(s)
- Laura Fanning
- Eastern Health Clinical School, Level 2, 5
Arnold Street, Box Hill, 3128, Victoria, Australia
| | - Lilian Vo
- Centre for Medicine Use and Safety, Faculty of
Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne,
Australia
| | - Jenni Ilomäki
- Centre for Medicine Use and Safety, Faculty of
Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne,
Australia
- School of Public Health and Preventive Medicine,
Monash University, Melbourne, Australia
| | - J. Simon Bell
- Centre for Medicine Use and Safety, Faculty of
Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne,
Australia
- School of Public Health and Preventive Medicine,
Monash University, Melbourne, Australia
- Sansom Institute, School of Pharmacy and Medical
Sciences, University of South Australia, Adelaide, Australia
| | - Rohan A. Elliott
- Centre for Medicine Use and Safety, Faculty of
Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne,
Australia
- Pharmacy Department, Austin Health, Melbourne,
Australia
| | - Pēteris Dārziņš
- Eastern Health Clinical School, Faculty of
Medicine Nursing and Health Sciences, Monash University, Melbourne,
Australia
- Geriatric Medicine, Eastern Health, Melbourne,
Australia
| |
Collapse
|
24
|
Harris M, Marti J, Watt H, Bhatti Y, Macinko J, Darzi AW. Explicit Bias Toward High-Income-Country Research: A Randomized, Blinded, Crossover Experiment Of English Clinicians. Health Aff (Millwood) 2018; 36:1997-2004. [PMID: 29137509 DOI: 10.1377/hlthaff.2017.0773] [Citation(s) in RCA: 59] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Unconscious bias may interfere with the interpretation of research from some settings, particularly from lower-income countries. Most studies of this phenomenon have relied on indirect outcomes such as article citation counts and publication rates; few have addressed or proven the effect of unconscious bias in evidence interpretation. In this randomized, blinded crossover experiment in a sample of 347 English clinicians, we demonstrate that changing the source of a research abstract from a low- to a high-income country significantly improves how it is viewed, all else being equal. Using fixed-effects models, we measured differences in ratings for strength of evidence, relevance, and likelihood of referral to a peer. Having a high-income-country source had a significant overall impact on respondents' ratings of relevance and recommendation to a peer. Unconscious bias can have far-reaching implications for the diffusion of knowledge and innovations from low-income countries.
Collapse
Affiliation(s)
- Matthew Harris
- Matthew Harris ( ) is a clinical senior lecturer in public health at the Institute of Global Health Innovation, Imperial College London, in the United Kingdom
| | - Joachim Marti
- Joachim Marti is a lecturer in health economics at the Institute of Global Health Innovation, Imperial College London
| | - Hillary Watt
- Hillary Watt is a statistician in the Department of Primary Care and Public Health, Imperial College London
| | - Yasser Bhatti
- Yasser Bhatti is a research fellow in frugal innovation, Institute of Global Health Innovation, Imperial College London
| | - James Macinko
- James Macinko is a professor in the Fielding School of Public Health, University of California, Los Angeles
| | - Ara W Darzi
- Ara W. Darzi is director of the Institute for Global Health Innovation, Imperial College London
| |
Collapse
|
25
|
Cornelius VR, McDermott L, Forster AS, Ashworth M, Wright AJ, Gulliford MC. Automated recruitment and randomisation for an efficient randomised controlled trial in primary care. Trials 2018; 19:341. [PMID: 29945656 PMCID: PMC6020316 DOI: 10.1186/s13063-018-2723-3] [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: 12/29/2017] [Accepted: 06/06/2018] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND/AIMS Use of electronic health records and information technology to deliver more efficient clinical trials is attracting the attention of research funders and researchers. We report on methodological issues and data quality for a comparison of 'automated' and manual (or 'in-practice') methods for recruitment and randomisation in a large randomised controlled trial, with individual patient allocation in primary care. METHODS We conducted a three-arm randomised controlled trial in primary care to evaluate interventions to improve the uptake of invited NHS health checks for cardiovascular risk assessment. Eligible participants were identified using a borough-wide health check management information system. An in-practice recruitment and randomisation method used at 12 general practices required the research team to complete monthly visits to each general practice. For the fully automated method, employed for six general practices, randomisation of eligible participants was performed automatically and remotely using a bespoke algorithm embedded in the health check management information system. RESULTS There were 8588 and 4093 participants recruited for the manual and automated methods, respectively. The in-practice method was ready for implementation 3 months sooner than the automated method and the in-practice method allowed for full control and documentation of the randomisation procedure. However the in-practice approach was labour intensive and the requirement for participant records to be stored locally resulted in the loss of data for 10 practice months. No records for participants allocated using the automated method were lost. A fixed-effects meta-analysis showed that effect estimates for the primary outcome were consistent for the two allocation methods. CONCLUSIONS This trial demonstrated the feasibility of automated recruitment and randomisation methods into a randomised controlled trial performed in primary care. Future research should explore the application of these techniques in other clinical contexts and health care settings. TRIAL REGISTRATION Current Controlled Trials, ID: ISRCTN42856343 . Registered on 21 March 2013.
Collapse
Affiliation(s)
- Victoria R Cornelius
- Department of Primary Care and Public Health Sciences, King's College, London, UK.
- Imperial Clinical Trials Unit, Imperial College London, 68 Wood Lane, London, W12 7RH, UK.
| | - Lisa McDermott
- Department of Primary Care and Public Health Sciences, King's College, London, UK
| | - Alice S Forster
- Department of Primary Care and Public Health Sciences, King's College, London, UK
- Department of Behavioural Science and Health, University College, London, UK
| | - Mark Ashworth
- Department of Primary Care and Public Health Sciences, King's College, London, UK
| | - Alison J Wright
- Department of Primary Care and Public Health Sciences, King's College, London, UK
- NIHR Biomedical Research Centre at Guy's and St Thomas' Hospital, London, UK
| | - Martin C Gulliford
- Department of Primary Care and Public Health Sciences, King's College, London, UK
- NIHR Biomedical Research Centre at Guy's and St Thomas' Hospital, London, UK
| |
Collapse
|
26
|
Simon KC, Tideman S, Hillman L, Lai R, Jathar R, Ji Y, Bergman-Bock S, Castle J, Franada T, Freedom T, Marcus R, Mark A, Meyers S, Rubin S, Semenov I, Yucus C, Pham A, Garduno L, Szela M, Frigerio R, Maraganore DM. Design and implementation of pragmatic clinical trials using the electronic medical record and an adaptive design. JAMIA Open 2018; 1:99-106. [PMID: 30386852 PMCID: PMC6207187 DOI: 10.1093/jamiaopen/ooy017] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Objectives To demonstrate the feasibility of pragmatic clinical trials comparing the effectiveness of treatments using the electronic medical record (EMR) and an adaptive assignment design. Methods We have designed and are implementing pragmatic trials at the point-of-care using custom-designed structured clinical documentation support and clinical decision support tools within our physician's typical EMR workflow. We are applying a subgroup based adaptive design (SUBA) that enriches treatment assignments based on baseline characteristics and prior outcomes. SUBA uses information from a randomization phase (phase 1, equal randomization, 120 patients), to adaptively assign treatments to the remaining participants (at least 300 additional patients total) based on a Bayesian hierarchical model. Enrollment in phase 1 is underway in our neurology clinical practices for 2 separate trials using this method, for migraine and mild cognitive impairment (MCI). Results We are successfully collecting structured data, in the context of the providers' clinical workflow, necessary to conduct our trials. We are currently enrolling patients in 2 point-of-care trials of non-inferior treatments. As of March 1, 2018, we have enrolled 36% of eligible patients into our migraine study and 63% of eligible patients into our MCI study. Enrollment is ongoing and validation of outcomes has begun. Discussion This proof of concept article demonstrates the feasibility of conducting pragmatic trials using the EMR and an adaptive design. Conclusion The demonstration of successful pragmatic clinical trials based on a customized EMR and adaptive design is an important next step in achieving personalized medicine and provides a framework for future studies of comparative effectiveness.
Collapse
Affiliation(s)
- Kelly Claire Simon
- Northshore Neurological Institute, NorthShore University Health System, Evanston, Illinois, USA
| | - Samuel Tideman
- Clinical Analytics, NorthShore University Health System, Evanston, Illinois, USA
| | - Laura Hillman
- Health Information Technology, NorthShore University Health System, Evanston, Illinois, USA
| | - Rebekah Lai
- Health Information Technology, NorthShore University Health System, Evanston, Illinois, USA
| | - Raman Jathar
- Health Information Technology, NorthShore University Health System, Evanston, Illinois, USA
| | - Yuan Ji
- Research Institute, NorthShore University Health System, Evanston, Illinois, USA
| | - Stuart Bergman-Bock
- Northshore Neurological Institute, NorthShore University Health System, Evanston, Illinois, USA
| | - James Castle
- Northshore Neurological Institute, NorthShore University Health System, Evanston, Illinois, USA
| | - Tiffani Franada
- Northshore Neurological Institute, NorthShore University Health System, Evanston, Illinois, USA
| | - Thomas Freedom
- Northshore Neurological Institute, NorthShore University Health System, Evanston, Illinois, USA
| | - Revital Marcus
- Northshore Neurological Institute, NorthShore University Health System, Evanston, Illinois, USA
| | - Angela Mark
- Northshore Neurological Institute, NorthShore University Health System, Evanston, Illinois, USA
| | - Steven Meyers
- Northshore Neurological Institute, NorthShore University Health System, Evanston, Illinois, USA
| | - Susan Rubin
- Northshore Neurological Institute, NorthShore University Health System, Evanston, Illinois, USA
| | - Irene Semenov
- Northshore Neurological Institute, NorthShore University Health System, Evanston, Illinois, USA
| | - Chad Yucus
- Northshore Neurological Institute, NorthShore University Health System, Evanston, Illinois, USA
| | - Anna Pham
- Northshore Neurological Institute, NorthShore University Health System, Evanston, Illinois, USA
| | - Lisette Garduno
- Northshore Neurological Institute, NorthShore University Health System, Evanston, Illinois, USA
| | - Monika Szela
- Northshore Neurological Institute, NorthShore University Health System, Evanston, Illinois, USA
| | - Roberta Frigerio
- Northshore Neurological Institute, NorthShore University Health System, Evanston, Illinois, USA
| | - Demetrius M Maraganore
- Northshore Neurological Institute, NorthShore University Health System, Evanston, Illinois, USA
| |
Collapse
|
27
|
Abstract
This article looks at the use of large health records datasets, typically linked with other data sources, and their use in mental health research. The most comprehensive examples of this kind of big data are typically found in Scandinavian countries however there are also many useful sources in the UK. There are a number of promising methodological innovations from studies using big data in UK mental health research, including: hybrid study designs, examples of data linkage and enhanced study recruitment. It is, though, important to be aware of the limitations of research using big data, particularly the various analysis pitfalls. We therefore caution against throwing out the methodological baby with the bathwater and argue that other data sources are equally valuable and ideally research should incorporate a range of data.
Collapse
|
28
|
Wallach JD, Ross JS, Naci H. The US Food and Drug Administration’s expedited approval programs: Evidentiary standards, regulatory trade-offs, and potential improvements. Clin Trials 2018; 15:219-229. [DOI: 10.1177/1740774518770648] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
The US Food and Drug Administration has several regulatory programs and pathways to expedite the development and approval of therapeutic agents aimed at treating serious or life-debilitating conditions. A common feature of these programs is the regulatory flexibility, which allows for a customized approval approach that enables market authorization on the basis of less rigorous evidence, in exchange for requiring postmarket evidence generation. An increasing share of therapeutic agents approved by the Food and Drug Administration in recent years are associated with expedited programs. In this article, we provide an overview of the evidentiary standards required by the Food and Drug Administration’s expedited development and review programs, summarize the findings of the recent academic literature demonstrating some of the limitations of these programs, and outline potential opportunities to address these limitations. Recent evidence suggests that therapeutic agents in the Food and Drug Administration’s expedited programs are approved on the basis of fewer and smaller studies that may lack comparator groups and random allocation, and rather than focusing on clinical outcomes for study endpoints, rely instead on surrogate markers of disease. Once on the market, agents receiving expedited approvals are often quickly incorporated into clinical practice, and evidence generated in the postmarket period may not necessarily address the evidentiary limitations at the time of market entry. Furthermore, not all pathways require additional postmarket studies. Evidence suggests that drugs in expedited approval programs are associated with a greater likelihood that the Food and Drug Administration will take a safety action following market entry. There are several opportunities to improve the timeliness, information value, and validity of the pre- and postmarket studies of therapeutic agents receiving expedited approvals. When use of nonrandomized and uncontrolled studies cannot be avoided prior to market entry, randomized trials should be mandatory in the postmarket period, unless there are strong justifications for not carrying out such studies. In the premarket period, validity of the surrogate markers can be improved by more rigorously evaluating their correlation with patient-relevant clinical outcomes. Opportunities to reduce the duration, complexity, and cost of postmarket randomized trials should not compromise their validity and instead incorporate pragmatic “real-world” design elements. Despite recent enthusiasm for widely using real-world evidence, adaptive designs, and pragmatic trials in the regulatory setting, caution is warranted until large-scale empirical evaluations demonstrate their validity compared to more traditional trial designs.
Collapse
Affiliation(s)
- Joshua D Wallach
- Collaboration for Research Integrity and Transparency, Yale School of Medicine, New Haven, CT, USA
| | - Joseph S Ross
- Section of General Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Huseyin Naci
- LSE Health, Department of Health Policy, London School of Economics and Political Science, London, UK
| |
Collapse
|
29
|
Hills T, Semprini A, Beasley R. Pragmatic randomised clinical trials using electronic health records: general practitioner views on a model of a priori consent. Trials 2018; 19:278. [PMID: 29769088 PMCID: PMC5956547 DOI: 10.1186/s13063-018-2658-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2017] [Accepted: 05/02/2018] [Indexed: 11/30/2022] Open
Abstract
Pragmatic randomised clinical trials could use existing electronic health records (EHRs) to identify trial participants, perform randomisation, and to collect follow-up data. Achieving adequate informed consent in routine care and clinician recruitment have been identified as key barriers to this approach to clinical trials. We propose a model where written informed consent for a pragmatic comparative effectiveness trial is obtained in advance by the research team, recorded in the EHR, and then confirmed by the general practitioner (GP) at the time of enrolment. The EHR software then randomly assigns a patient to one of two treatments. Follow-up data is collected in the EHR. Twenty-two of 23 GPs surveyed (96%) were ‘definitely’ or ‘probably’ comfortable with confirming consent. Twenty-one out of 23 GPs (91%) were ‘definitely’ or ‘probably’ comfortable with a patient being randomised to one of two comparable drugs during a routine consultation. Twenty-two out of 23 GPs (96%) were ‘definitely’ or ‘probably’ comfortable with allowing the electronic system to randomise a patient to drug A or drug B and generate a prescription. Ten out of 23 GPs (43%) identified time constraints as the main hurdle to conducting this sort of research in the primary care setting. On average, it was felt that 6.5 min, in addition to a usual consult, would be acceptable to complete enrolment. Our survey found this model of a comparative effectiveness trial to be acceptable to the majority of GPs.
Collapse
Affiliation(s)
- Thomas Hills
- Medical Research Institute of New Zealand, Private Bag 7902, Wellington, 6242, New Zealand.
| | - Alex Semprini
- Medical Research Institute of New Zealand, Private Bag 7902, Wellington, 6242, New Zealand
| | - Richard Beasley
- Medical Research Institute of New Zealand, Private Bag 7902, Wellington, 6242, New Zealand
| |
Collapse
|
30
|
Davies G, Jordan S, Brooks CJ, Thayer D, Storey M, Morgan G, Allen S, Garaiova I, Plummer S, Gravenor M. Long term extension of a randomised controlled trial of probiotics using electronic health records. Sci Rep 2018; 8:7668. [PMID: 29769554 PMCID: PMC5955897 DOI: 10.1038/s41598-018-25954-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2017] [Accepted: 04/09/2018] [Indexed: 12/12/2022] Open
Abstract
Most randomised controlled trials (RCTs) are relatively short term and, due to costs and available resources, have limited opportunity to be re-visited or extended. There is no guarantee that effects of treatments remain unchanged beyond the study. Here, we illustrate the feasibility, benefits and cost-effectiveness of enriching standard trial design with electronic follow up. We completed a 5-year electronic follow up of a RCT investigating the impact of probiotics on asthma and eczema in children born 2005–2007, with traditional fieldwork follow up to two years. Participants and trial outcomes were identified and analysed after five years using secure, routine, anonymised, person-based electronic health service databanks. At two years, we identified 93% of participants and compared fieldwork with electronic health records, highlighting areas of agreement and disagreement. Retention of children from lower socio-economic groups was improved, reducing volunteer bias. At 5 years we identified a reduced 82% of participants. These data allowed the trial’s first robust analysis of asthma endpoints. We found no indication that probiotic supplementation to pregnant mothers and infants protected against asthma or eczema at 5 years. Continued longer-term follow up is technically straightforward.
Collapse
Affiliation(s)
- Gareth Davies
- Swansea University Medical School, Singleton Park, Swansea, UK
| | - Sue Jordan
- Department of Nursing, The College of Human and Health Sciences, Swansea University, Singleton Park, Swansea, UK.
| | | | - Daniel Thayer
- Swansea University Medical School, Singleton Park, Swansea, UK
| | - Melanie Storey
- Department of Nursing, The College of Human and Health Sciences, Swansea University, Singleton Park, Swansea, UK
| | - Gareth Morgan
- The Children's Trust, Tadworth, Surrey, UK.,The Harley Street Clinic Children's Hospital, London, UK
| | - Stephen Allen
- Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, UK
| | - Iveta Garaiova
- Research Department, Cultech Limited, Baglan Industrial Park, Port Talbot, UK
| | - Sue Plummer
- Research Department, Cultech Limited, Baglan Industrial Park, Port Talbot, UK
| | - Mike Gravenor
- Swansea University Medical School, Singleton Park, Swansea, UK
| |
Collapse
|
31
|
Dal-Ré R, Janiaud P, Ioannidis JPA. Real-world evidence: How pragmatic are randomized controlled trials labeled as pragmatic? BMC Med 2018; 16:49. [PMID: 29615035 PMCID: PMC5883397 DOI: 10.1186/s12916-018-1038-2] [Citation(s) in RCA: 138] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Accepted: 03/15/2018] [Indexed: 01/29/2023] Open
Abstract
INTRODUCTION Pragmatic randomized controlled trials (RCTs) mimic usual clinical practice and they are critical to inform decision-making by patients, clinicians and policy-makers in real-world settings. Pragmatic RCTs assess effectiveness of available medicines, while explanatory RCTs assess efficacy of investigational medicines. Explanatory and pragmatic are the extremes of a continuum. This debate article seeks to evaluate and provide recommendation on how to characterize pragmatic RCTs in light of the current landscape of RCTs. It is supported by findings from a PubMed search conducted in August 2017, which retrieved 615 RCTs self-labeled in their titles as "pragmatic" or "naturalistic". We focused on 89 of these trials that assessed medicines (drugs or biologics). DISCUSSION 36% of these 89 trials were placebo-controlled, performed before licensing of the medicine, or done in a single-center. In our opinion, such RCTs overtly deviate from usual care and pragmatism. It follows, that the use of the term 'pragmatic' to describe them, conveys a misleading message to patients and clinicians. Furthermore, many other trials among the 615 coined as 'pragmatic' and assessing other types of intervention are plausibly not very pragmatic; however, this is impossible for a reader to tell without access to the full protocol and insider knowledge of the trial conduct. The degree of pragmatism should be evaluated by the trial investigators themselves using the PRECIS-2 tool, a tool that comprises 9 domains, each scored from 1 (very explanatory) to 5 (very pragmatic). CONCLUSIONS To allow for a more appropriate characterization of the degree of pragmatism in clinical research, submissions of RCTs to funders, research ethics committees and to peer-reviewed journals should include a PRECIS-2 tool assessment done by the trial investigators. Clarity and accuracy on the extent to which a RCT is pragmatic will help understand how much it is relevant to real-world practice.
Collapse
Affiliation(s)
- Rafael Dal-Ré
- Epidemiology Unit, Health Research Institute-Fundación Jiménez Díaz University Hospital, Universidad Autónoma de Madrid, E-28040, Madrid, Spain
| | - Perrine Janiaud
- Meta-Research Innovation Center at Stanford (METRICS), Stanford University, Stanford, CA, 94305, USA
| | - John P A Ioannidis
- Departments of Medicine, Health Research and Policy, Biomedical Data Science, Statistics, and Meta-Research Innovation Center at Stanford (METRICS), Stanford University, Stanford, CA, 94305, USA.
| |
Collapse
|
32
|
Wright-Hughes A, Graham E, Cottrell D, Farrin A. Routine hospital data - is it good enough for trials? An example using England's Hospital Episode Statistics in the SHIFT trial of Family Therapy vs. Treatment as Usual in adolescents following self-harm. Clin Trials 2018; 15:197-206. [PMID: 29498542 PMCID: PMC5901065 DOI: 10.1177/1740774517751381] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Use of routine data sources within clinical research is increasing and is endorsed by the National Institute for Health Research to increase trial efficiencies; however there is limited evidence for its use in clinical trials, especially in relation to self-harm. One source of routine data, Hospital Episode Statistics, is collated and distributed by NHS Digital and contains details of admissions, outpatient, and Accident and Emergency attendances provided periodically by English National Health Service hospitals. We explored the reliability and accuracy of Hospital Episode Statistics, compared to data collected directly from hospital records, to assess whether it would provide complete, accurate, and reliable means of acquiring hospital attendances for self-harm - the primary outcome for the SHIFT (Self-Harm Intervention: Family Therapy) trial evaluating Family Therapy for adolescents following self-harm. METHODS Participant identifiers were linked to Hospital Episode Statistics Accident and Emergency, and Admissions data, and episodes combined to describe participants' complete hospital attendance. Attendance data were initially compared to data previously gathered by trial researchers from pre-identified hospitals. Final comparison was conducted of subsequent attendances collected through Hospital Episode Statistics and researcher follow-up. Consideration was given to linkage rates; number and proportion of attendances retrieved; reliability of Accident and Emergency, and Admissions data; percentage of self-harm episodes recorded and coded appropriately; and percentage of required data items retrieved. RESULTS Participants were first linked to Hospital Episode Statistics with an acceptable match rate of 95%, identifying a total of 341 complete hospital attendances, compared to 139 reported by the researchers at the time. More than double the proportion of Hospital Episode Statistics Accident and Emergency episodes could not be classified in relation to self-harm (75%) compared to 34.9% of admitted episodes, and of overall attendances, 18% were classified as self-harm related and 20% not related, while ambiguity or insufficient information meant 62% were unclassified. Of 39 self-harm-related attendances reported by the researchers, Hospital Episode Statistics identified 24 (62%) as self-harm related while 15 (38%) were unclassified. Based on final data received, 1490 complete hospital attendances were identified and comparison to researcher follow-up found Hospital Episode Statistics underestimated the number of self-harm attendances by 37.2% (95% confidence interval 32.6%-41.9%). CONCLUSION Advantages of routine data collection via NHS Digital included the acquisition of more comprehensive and timely trial outcome data, identifying more than double the number of hospital attendances than researchers. Disadvantages included ambiguity in the classification of self-harm relatedness. Our resulting primary outcome data collection strategy used routine data to identify hospital attendances supplemented by targeted researcher data collection for attendances requiring further self-harm classification.
Collapse
Affiliation(s)
- Alexandra Wright-Hughes
- 1 Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Elizabeth Graham
- 1 Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - David Cottrell
- 2 Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Amanda Farrin
- 1 Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| |
Collapse
|
33
|
Goldstein CE, Weijer C, Brehaut JC, Fergusson DA, Grimshaw JM, Horn AR, Taljaard M. Ethical issues in pragmatic randomized controlled trials: a review of the recent literature identifies gaps in ethical argumentation. BMC Med Ethics 2018; 19:14. [PMID: 29482537 PMCID: PMC5827974 DOI: 10.1186/s12910-018-0253-x] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2017] [Accepted: 02/19/2018] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND Pragmatic randomized controlled trials (RCTs) are designed to evaluate the effectiveness of interventions in real-world clinical conditions. However, these studies raise ethical issues for researchers and regulators. Our objective is to identify a list of key ethical issues in pragmatic RCTs and highlight gaps in the ethics literature. METHODS We conducted a scoping review of articles addressing ethical aspects of pragmatic RCTs. After applying the search strategy and eligibility criteria, 36 articles were included and reviewed using content analysis. RESULTS Our review identified four major themes: 1) the research-practice distinction; 2) the need for consent; 3) elements that must be disclosed in the consent process; and 4) appropriate oversight by research ethics committees. 1) Most authors reject the need for a research-practice distinction in pragmatic RCTs. They argue that the distinction rests on the presumptions that research participation offers patients less benefit and greater risk than clinical practice, but neither is true in the case of pragmatic RCTs. 2) Most authors further conclude that pragmatic RCTs may proceed without informed consent or with simplified consent procedures when risks are low and consent is infeasible. 3) Authors who endorse the need for consent assert that information need only be disclosed when research participation poses incremental risks compared to clinical practice. Authors disagree as to whether randomization must be disclosed. 4) Finally, all authors view regulatory oversight as burdensome and a practical impediment to the conduct of pragmatic RCTs, and argue that oversight procedures ought to be streamlined when risks to participants are low. CONCLUSION The current ethical discussion is framed by the assumption that the function of research oversight is to protect participants from risk. As pragmatic RCTs commonly involve usual care interventions, the risks may be minimal. This leads many to reject the research-practice distinction and question the need for informed consent. But the function of oversight should be understood broadly as protecting the liberty and welfare interest of participants and promoting public trust in research. This understanding, we suggest, will focus discussion on questions about appropriate ethical review for pragmatic RCTs.
Collapse
Affiliation(s)
- Cory E Goldstein
- Rotman Institute of Philosophy, Western University, 1151 Richmond St., London, ON, N6A 5B7, Canada.
| | - Charles Weijer
- Rotman Institute of Philosophy, Western University, 1151 Richmond St., London, ON, N6A 5B7, Canada
| | - Jamie C Brehaut
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Dean A Fergusson
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Jeremy M Grimshaw
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Austin R Horn
- Rotman Institute of Philosophy, Western University, 1151 Richmond St., London, ON, N6A 5B7, Canada
| | - Monica Taljaard
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| |
Collapse
|
34
|
McDermott L, Wright AJ, Cornelius V, Burgess C, Forster AS, Ashworth M, Khoshaba B, Clery P, Fuller F, Miller J, Dodhia H, Rudisill C, Conner MT, Gulliford MC. Enhanced invitation methods and uptake of health checks in primary care: randomised controlled trial and cohort study using electronic health records. Health Technol Assess 2018; 20:1-92. [PMID: 27846927 DOI: 10.3310/hta20840] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND A national programme of health checks to identify risk of cardiovascular disease (CVD) is being rolled out but is encountering difficulties because of low uptake. OBJECTIVE To evaluate the effectiveness of an enhanced invitation method using the question-behaviour effect (QBE), with or without the offer of a financial incentive to return the QBE questionnaire, at increasing the uptake of health checks. The research went on to evaluate the reasons for the low uptake of invitations and compare the case mix for invited and opportunistic health checks. DESIGN Three-arm randomised trial and cohort study. PARTICIPANTS All participants invited for a health check from 18 general practices. Individual participants were randomised. INTERVENTIONS (1) Standard health check invitation only; (2) QBE questionnaire followed by a standard invitation; and (3) QBE questionnaire with offer of a financial incentive to return the questionnaire, followed by a standard invitation. MAIN OUTCOME MEASURES The primary outcome was completion of the health check within 6 months of invitation. A p-value of 0.0167 was used for significance. In the cohort study of all health checks completed during the study period, the case mix was compared for participants responding to invitations and those receiving 'opportunistic' health checks. Participants were not aware that several types of invitation were in use. The research team were blind to trial arm allocation at outcome data extraction. RESULTS In total, 12,459 participants were included in the trial and health check uptake was evaluated for 12,052 participants for whom outcome data were collected. Health check uptake was as follows: standard invitation, 590 out of 4095 (14.41%); QBE questionnaire, 630 out of 3988 (15.80%); QBE questionnaire and financial incentive, 629 out of 3969 (15.85%). The increase in uptake associated with the QBE questionnaire was 1.43% [95% confidence interval (CI) -0.12% to 2.97%; p = 0.070] and the increase in uptake associated with the QBE questionnaire and offer of financial incentive was 1.52% (95% CI -0.03% to 3.07%; p = 0.054). The difference in uptake associated with the offer of an incentive to return the QBE questionnaire was -0.01% (95% CI -1.59% to 1.58%; p = 0.995). During the study period, 58% of health check cardiovascular risk assessments did not follow a trial invitation. People who received an 'opportunistic' health check had greater odds of a ≥ 10% CVD risk than those who received an invited health check (adjusted odds ratio 1.70, 95% CI 1.45 to 1.99; p < 0.001). CONCLUSIONS Uptake of a health check following an invitation letter is low and is not increased through an enhanced invitation method using the QBE. The offer of a £5 incentive did not increase the rate of return of the QBE questionnaire. A high proportion of all health checks are performed opportunistically and not in response to a standard invitation letter. Participants receiving opportunistic checks are at higher risk of CVD than those responding to standard invitations. Future research should aim to increase the accessibility of preventative medical interventions to increase uptake. Research should also explore the wider use of electronic health records in delivering efficient trials. TRIAL REGISTRATION Current Controlled Trials ISRCTN42856343. FUNDING This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 20, No. 84. See the NIHR Journals Library website for further project information.
Collapse
Affiliation(s)
- Lisa McDermott
- Department of Primary Care and Public Health Sciences, King's College London, London, UK
| | - Alison J Wright
- Department of Primary Care and Public Health Sciences, King's College London, London, UK
| | - Victoria Cornelius
- Department of Primary Care and Public Health Sciences, King's College London, London, UK
| | - Caroline Burgess
- Department of Primary Care and Public Health Sciences, King's College London, London, UK
| | - Alice S Forster
- Department of Primary Care and Public Health Sciences, King's College London, London, UK
| | - Mark Ashworth
- Department of Primary Care and Public Health Sciences, King's College London, London, UK
| | - Bernadette Khoshaba
- Department of Primary Care and Public Health Sciences, King's College London, London, UK
| | - Philippa Clery
- Department of Primary Care and Public Health Sciences, King's College London, London, UK
| | - Frances Fuller
- Public Health Directorate, Lewisham Borough Council, London, UK
| | - Jane Miller
- Public Health Directorate, Lewisham Borough Council, London, UK
| | - Hiten Dodhia
- Public Health Directorate, Lambeth Borough Council, London, UK
| | - Caroline Rudisill
- Department of Social Policy, London School of Economics and Political Science, London, UK
| | - Mark T Conner
- School of Psychology, University of Leeds, Leeds, UK
| | - Martin C Gulliford
- Department of Primary Care and Public Health Sciences, King's College London, London, UK.,NIHR Biomedical Research Centre at Guy's and St Thomas' Hospitals, Guy's Hospital, London, UK
| |
Collapse
|
35
|
Dal-Ré R. Could phase 3 medicine trials be tagged as pragmatic? A case study: The Salford COPD trial. J Eval Clin Pract 2018; 24:258-261. [PMID: 28685913 DOI: 10.1111/jep.12796] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2017] [Accepted: 06/13/2017] [Indexed: 11/29/2022]
Abstract
Randomized clinical trials (RCTs) can be classified as explanatory or pragmatic. Currently, explanatory and pragmatic are considered to be the extremes of a continuum: Many trials have some features of both explanatory and pragmatic RCTs. The Salford Chronic Obstructive Respiratory Disease (COPD) trial was an open-label phase 3 RCT assessing an experimental product (fluticasone furoate-vilanterol) vs usual care. The Salford investigators labelled it as "the world's first phase 3 pragmatic RCT" in COPD patients. The evaluation of the Salford trial by means of the PRECIS-2 tool, yielded a mix of both extremes (explanatory and pragmatic) with several of the 9 domains close to the explanatory extreme and few to the pragmatic one. A number of the features could not be considered as being minimal changes over usual clinical practice. Hence, it would be difficult to accept that the Salford COPD trial was a pragmatic RCT. In addition, all trial participants could have been subject to the Hawthorne effect. The scientific community needs to be rigorous enough when using certain terms related to RCT. It is clear that the Salford COPD trial had particular features-sharing some of explanatory phase 3 RCTs and some of pragmatic RCTs. This, however, is not enough to tag it as a "pragmatic" RCT providing "real-world" data. These words should not be used when referring to prelicensed RCT, unless they really describe how was the trial conducted and the type of data gathered-something that with the current clinical trial regulations will only occur in very rare circumstances.
Collapse
Affiliation(s)
- Rafael Dal-Ré
- Epidemiology Unit, Health Research Institute-Fundación Jiménez Díaz University Hospital, Universidad Autónoma de Madrid, Madrid, Spain
| |
Collapse
|
36
|
Kim SY. Ethical issues in pragmatic trials of "standard-of-care" interventions in learning health care systems. Learn Health Syst 2018; 2:e10045. [PMID: 31245574 PMCID: PMC6508815 DOI: 10.1002/lrh2.10045] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2017] [Revised: 09/07/2017] [Accepted: 10/12/2017] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION Learning health care systems (LHS) hold the promise of improving medical care by systematically and continuously integrating the delivery of medical services with clinical research. One important type of integration would involve embedding trials that compare interventions that are already commonly in use (as "accepted" or "standard of care") into the clinical setting-trials that could cost-effectively improve care. But the traditional requirement of informed consent for clinical trials stands in tension with the conduct of such trials. METHOD Narrative analysis. RESULTS Although some have suggested that the idea of LHS makes the distinction between research and ordinary clinical care obsolete, the distinction remains ethically relevant even when it comes to randomized clinical trials (RCTs) that compare standard-of-care interventions. This paper presents an ethical framework for analyzing standard-of-care RCTs in resolving the tension between such trials and traditional requirements of research ethics. CONCLUSION It is important not to treat all standard-of-care RCTs as a monolithic category of special ethical status. Close attention to ethical issues in specific standard-of-care RCTs is crucial if the LHS movement is to avoid ethical lapses that could be counterproductive to its long term vision.
Collapse
Affiliation(s)
- Scott Y.H. Kim
- Department of BioethicsClinical Center, National Institutes of HealthBethesdaMaryland
| |
Collapse
|
37
|
Maxwell AE, Parker RA, Drever J, Rudd A, Dennis MS, Weir CJ, Al-Shahi Salman R. Promoting Recruitment using Information Management Efficiently (PRIME): a stepped-wedge, cluster randomised trial of a complex recruitment intervention embedded within the REstart or Stop Antithrombotics Randomised Trial. Trials 2017; 18:623. [PMID: 29282142 PMCID: PMC5745698 DOI: 10.1186/s13063-017-2355-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2017] [Accepted: 11/17/2017] [Indexed: 11/18/2022] Open
Abstract
Background Few interventions are proven to increase recruitment in clinical trials. Recruitment to RESTART, a randomised controlled trial of secondary prevention after stroke due to intracerebral haemorrhage, has been slower than expected. Therefore, we sought to investigate an intervention to boost recruitment to RESTART. Methods/design We conducted a stepped-wedge, cluster randomised trial of a complex intervention to increase recruitment, embedded within the RESTART trial. The primary objective was to investigate if the PRIME complex intervention (a recruitment co-ordinator who conducts a recruitment review, provides access to bespoke stroke audit data exports, and conducts a follow-up review after 6 months) increases the recruitment rate to RESTART. We included 72 hospital sites located in England, Wales, or Scotland that were active in RESTART in June 2015. All sites began in the control state and were allocated using block randomisation stratified by hospital location (Scotland versus England/Wales) to start the complex intervention in one of 12 different months. The primary outcome was the number of patients randomised into RESTART per month per site. We quantified the effect of the complex intervention on the primary outcome using a negative binomial, mixed model adjusting for site, December/January months, site location, and background time trends in recruitment rate. Results We recruited and randomised 72 sites and recorded their monthly recruitment to RESTART over 24 months (March 2015 to February 2017 inclusive), providing 1728 site-months of observations for the primary analysis. The adjusted rate ratio for the number of patients randomised per month after allocation to the PRIME complex intervention versus control time before allocation to the PRIME complex intervention was 1.06 (95% confidence interval 0.55 to 2.03, p = 0.87). Although two thirds of respondents to the 6-month follow-up questionnaire agreed that the audit reports were useful, only six patients were reported to have been randomised using the audit reports. Respondents frequently reported resource and time pressures as being key barriers to running the audit reports. Conclusion The PRIME complex intervention did not significantly improve the recruitment rate to RESTART. Further research is needed to establish if PRIME might be beneficial at an earlier stage in a prevention trial or for prevention dilemmas that arise more often in clinical practice. Electronic supplementary material The online version of this article (doi:10.1186/s13063-017-2355-z) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Amy E Maxwell
- Centre for Clinical Brain Sciences, University of Edinburgh, Chancellor's Building, 49 Little France Crescent, Edinburgh, EH16 4SB, UK
| | - Richard A Parker
- Edinburgh Clinical Trials Unit and Centre for Population Health Sciences, Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
| | - Jonathan Drever
- Centre for Clinical Brain Sciences, University of Edinburgh, Chancellor's Building, 49 Little France Crescent, Edinburgh, EH16 4SB, UK
| | - Anthony Rudd
- St Thomas' Hospital, Westminster Bridge Road, London, UK
| | - Martin S Dennis
- Centre for Clinical Brain Sciences, University of Edinburgh, Chancellor's Building, 49 Little France Crescent, Edinburgh, EH16 4SB, UK
| | - Christopher J Weir
- Edinburgh Clinical Trials Unit and Centre for Population Health Sciences, Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
| | - Rustam Al-Shahi Salman
- Centre for Clinical Brain Sciences, University of Edinburgh, Chancellor's Building, 49 Little France Crescent, Edinburgh, EH16 4SB, UK.
| |
Collapse
|
38
|
Agweyu A, Oliwa J, Gathara D, Muinga N, Allen E, Lilford RJ, English M. Comparable outcomes among trial and nontrial participants in a clinical trial of antibiotics for childhood pneumonia: a retrospective cohort study. J Clin Epidemiol 2017; 94:1-7. [PMID: 29097339 PMCID: PMC5808926 DOI: 10.1016/j.jclinepi.2017.10.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2016] [Revised: 05/13/2017] [Accepted: 10/25/2017] [Indexed: 11/17/2022]
Abstract
OBJECTIVES We compared characteristics and outcomes of children enrolled in a randomized controlled trial (RCT) comparing oral amoxicillin and benzyl penicillin for the treatment of chest indrawing pneumonia vs. children who received routine care to determine the external validity of the trial results. STUDY DESIGN AND SETTING A retrospective cohort study was conducted among children aged 2-59 months admitted in six Kenyan hospitals. Data for nontrial participants were extracted from inpatient records upon conclusion of the RCT. Mortality among trial vs. nontrial participants was compared in multivariate models. RESULTS A total of 1,709 children were included, of whom 527 were enrolled in the RCT and 1,182 received routine care. History of a wheeze was more common among trial participants (35.4% vs. 11.2%; P < 0.01), while dehydration was more common among nontrial participants (8.6% vs. 5.9%; P = 0.05). Other patient characteristics were balanced between the two groups. Among those with available outcome data, 14/1,140 (1.2%) nontrial participants died compared to 4/527 (0.8%) enrolled in the trial (adjusted odds ratio, 0.7; 95% confidence interval: 0.2-2.1). CONCLUSION Patient characteristics were similar, and mortality was low among trial and nontrial participants. These findings support the revised World Health Organization treatment recommendations for chest indrawing pneumonia.
Collapse
Affiliation(s)
- Ambrose Agweyu
- Department of Public Health Research, Health Services Unit, KEMRI-Wellcome Trust Research Programme, P.O. Box 43640, 00100 Nairobi, Kenya.
| | - Jacquie Oliwa
- Department of Public Health Research, Health Services Unit, KEMRI-Wellcome Trust Research Programme, P.O. Box 43640, 00100 Nairobi, Kenya
| | - David Gathara
- Department of Public Health Research, Health Services Unit, KEMRI-Wellcome Trust Research Programme, P.O. Box 43640, 00100 Nairobi, Kenya
| | - Naomi Muinga
- Department of Public Health Research, Health Services Unit, KEMRI-Wellcome Trust Research Programme, P.O. Box 43640, 00100 Nairobi, Kenya
| | - Elizabeth Allen
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK
| | - Richard J Lilford
- Department of Health Sciences, Warwick Medical School, University of Warwick, Medical School Building, Coventry CV4 7AL, UK
| | - Mike English
- Department of Public Health Research, Health Services Unit, KEMRI-Wellcome Trust Research Programme, P.O. Box 43640, 00100 Nairobi, Kenya; Nuffield Department of Medicine, University of Oxford, Old Road Campus, Headington, Oxford OX3 7BN, UK
| |
Collapse
|
39
|
|
40
|
Baum A, Scarpa J, Bruzelius E, Tamler R, Basu S, Faghmous J. Targeting weight loss interventions to reduce cardiovascular complications of type 2 diabetes: a machine learning-based post-hoc analysis of heterogeneous treatment effects in the Look AHEAD trial. Lancet Diabetes Endocrinol 2017; 5:808-815. [PMID: 28711469 PMCID: PMC5815373 DOI: 10.1016/s2213-8587(17)30176-6] [Citation(s) in RCA: 69] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2017] [Revised: 04/21/2017] [Accepted: 04/27/2017] [Indexed: 02/08/2023]
Abstract
BACKGROUND The Action for Health in Diabetes (Look AHEAD) trial investigated whether long-term cardiovascular disease morbidity and mortality could be reduced through a weight loss intervention among people with type 2 diabetes. Despite finding no significant reduction in cardiovascular events on average, it is possible that some subpopulations might have derived benefit. In this post-hoc analysis, we test the hypothesis that the overall neutral average treatment effect in the trial masked important heterogeneous treatment effects (HTEs) from intensive weight loss interventions. METHODS We used causal forest modelling, which identifies HTEs, using a random half of the trial data (the training set). We applied Cox proportional hazards models to test the potential HTEs on the remaining half of the data (the testing set). The analysis was deemed exempt from review by the Columbia University Institutional Review Board, Protocol ID# AAAO3003. FINDINGS Between Aug 22, 2001, and April 30, 2004, 5145 patients with type 2 diabetes were enrolled in the Look AHEAD randomised controlled trial, of whom 4901 were included in the The National Institute of Diabetes and Digestive and Kidney Diseases Repository and included in our analyses: 2450 for model development and 2451 in the testing dataset. Baseline HbA1c and self-reported general health distinguished participants who differentially benefited from the intervention. Cox models for the primary composite cardiovascular outcome revealed a number needed to treat of 28·9 to prevent 1 event over 9·6 years among participants with HbA1c 6·8% or higher, or both HbA1c less than 6·8% and Short Form Health Survey (SF-36) general health score of 48 or more (2101 [86%] of 2451 participants in the testing dataset; 167 [16%] of 1046 primary outcome events for intervention vs 205 [19%] of 1055 for control, absolute risk reduction of 3·46%, 95% CI 0·21-6·73%, p=0·038) By contrast, participants with HbA1c less than 6·8% and baseline SF-36 general health score of less than 48 (350 [14%] of 2451 participants in the testing data; 27 [16%] of 171 primary outcome events for intervention vs 15 [8%] of 179 primary outcome events for control) had an absolute risk increase of the primary outcome of 7·41% (0·60 to 14·22, p=0·003). INTERPRETATION Look AHEAD participants with moderately or poorly controlled diabetes (HbA1c 6·8% or higher) and subjects with well controlled diabetes (HbA1c less than 6·8%) and good self-reported health (85% of the overall study population) averted cardiovascular events from a behavioural intervention aimed at weight loss. However, 15% of participants with well controlled diabetes and poor self-reported general health experienced negative effects that rendered the overall study outcome neutral. HbA1c and a short questionnaire on general health might identify people with type 2 diabetes likely to derive benefit from an intensive lifestyle intervention aimed at weight loss. FUNDING None.
Collapse
Affiliation(s)
- Aaron Baum
- Department of Health System Design and Global Health, Arnhold Institute for Global Health, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
| | - Joseph Scarpa
- Department of Health System Design and Global Health, Arnhold Institute for Global Health, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Emilie Bruzelius
- Department of Health System Design and Global Health, Arnhold Institute for Global Health, Icahn School of Medicine at Mount Sinai, New York, NY, USA; Department of Epidemiology, Joseph L Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Ronald Tamler
- Division of Endocrinology, Diabetes, and Bone Disease, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Sanjay Basu
- Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - James Faghmous
- Department of Health System Design and Global Health, Arnhold Institute for Global Health, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| |
Collapse
|
41
|
Dal-Ré R, Carcas AJ, Carné X, Wendler D. Patients' beliefs regarding informed consent for low-risk pragmatic trials. BMC Med Res Methodol 2017; 17:145. [PMID: 28923007 PMCID: PMC5604493 DOI: 10.1186/s12874-017-0424-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Accepted: 09/10/2017] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND The requirement to obtain written informed consent may undermine the potential of pragmatic randomized clinical trials (pRCTs) to improve evidence-based care. This requirement could compromise trials statistical power or even force it to close them down prematurely. However, recent data from the U.S. and Spain suggest that a majority of the public endorses written consent for low-risk pRCTs. The present manuscript assesses whether this view is shared by patients. METHODS This was a cross-sectional, probability-based survey, with a 2 × 2 factorial design, assessing support for written informed consent versus verbal consent or general notification for two low-risk pRCTs in hypertension, one comparing 2 drugs with similar risk/benefit profiles and the other comparing the same drug being taken in the morning or at night. This web-based survey was conducted in May 2016. Two-thousand and eight adults who were representative of the Spanish population participated in the survey (response rate: 61%). Of these 2008 respondents, 338 indicated that they had been diagnosed with hypertension and were being treated with prescription medicines for this condition at the time of responding to the survey. The primary outcome measures were respondents' personal preference and recommendation to a research ethics committee regarding the use of written informed consent versus verbal consent or general notification. RESULTS Overall, 74% of the 338 patient respondents endorsed written consent. In both scenarios, general notification received significantly more support (30.6%-44.7%) than verbal consent (13.3%-17.6%). 43% of respondents preferred and/or recommended general notification rather than written consent. CONCLUSIONS As in the survey of the general public, more patients endorsed written consent than the alternative option. However, two factors suggest that a different approach to written consent should be investigated for low-risk pRCTs: a) a substantial minority of respondents supported general notification, b) data from the US have shown that most patients who prefer written consent are willing to forego it if obtaining written consent makes the trial too difficult to be conducted; and c) 2016 CIOMS guidelines endorse waivers of consent when the trial fulfills specific conditions. Surveys in other EU countries are needed to assess what patients believe towards pRCTs. If similar results to that reported in this study are found, it is foreseeable that with educational efforts, general notification could be an acceptable and widespread approach to the conduct of low-risk pRCTs.
Collapse
Affiliation(s)
- Rafael Dal-Ré
- Clinical Research, BUC (Biosciences UAM+CSIC) Program, International Campus of Excellence, Universidad Autónoma de Madrid, Ciudad Universitaria de Cantoblanco, Einstein 3, 28049, Madrid, Spain.
- Chair on Bioethics "Grifols Foundation", University of Vic - Central University of Catalonia, Miquel Martí i Pol 1, Campus Miramarges, E-08500, Vic, Barcelona, Spain.
- Epidemiology Unit, Health Research Institute-Fundación Jiménez Díaz University Hospital, Universidad Autónoma de Madrid, Avda. Reyes Católicos 2, E-28040, Madrid, Spain.
| | - Antonio J Carcas
- Clinical Pharmacology Department, La Paz University Hospital, IdiPaz, School of Medicine, Universidad Autónoma de Madrid, Paseo de la Castellana 261, 28046, Madrid, Spain
| | - Xavier Carné
- Chair on Bioethics "Grifols Foundation", University of Vic - Central University of Catalonia, Miquel Martí i Pol 1, Campus Miramarges, E-08500, Vic, Barcelona, Spain
- Clinical Pharmacology Department, Clínic Hospital, August Pi i Sunyer Biomedical Research Institute (IDIBAPS); Clinical Fundamentals Department, Universidad de Barcelona, Carrer de Villarroel 170, 08036, Barcelona, Spain
| | - David Wendler
- Section on Research Ethics, Department of Bioethics, NIH Clinical Center, 10 Center Dr, Bethesda, MD, 20814, USA
| |
Collapse
|
42
|
Boeckhout M, Scheltens P, Manders P, Smit C, Bredenoord AL, Zielhuis GA. Patients to learn from: on the need for systematic integration of research and care in academic health care. J Clin Transl Res 2017; 3:401-406. [PMID: 30873488 PMCID: PMC6412601] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Patients suffering from rare, extreme or extremely complex sets of symptoms have something to expect from efforts to improve care through research. Biomedical research and care have often been approached as distinct worlds which are and should be only loosely connected. For observational research focusing on data drawn from real-world settings, however, that approach is found wanting. Integrating research and care responsibly is the main challenge instead. Integrated IT infrastructures facilitating Personalized medicine and Big Data are crucial components of a learning health care system, in which patients regularly play a double role: as individuals to be treated and as cases to learn from. Drawing on the example of the Dutch Parelsnoer Institute (PSI), a national biobanking and IT infrastructure integrated with clinical care procedures, this article outlines the reforms that are needed. Systematic integration of research and care offers a promising avenue, provided that a number of conditions are met: data and IT infrastructures will require overhauls in order to facilitate secure, high-quality data integration between research and care; institutional focus is needed to bring patient populations and expertise together; ethical frameworks and approaches for integrating research and care responsibly require further elaboration; clinical procedures and professional responsibilities may need to be adapted in order to accommodate research requirements in clinical processes; and involvement of patients and other stakeholders in design and research priority setting is needed to further the goals of real-world and patient relevance. RELEVANCE FOR PATIENTS Integrating research and care in academic medicine in a more systematic fashion offers a promising perspective to current and future patients. In order to live up to these promises, research and care should be integrated more systematically in academic health science, with patients being included as research participants by default. Data and tissue infrastructures and facilities can provide a platform for doing so. At the same time, many issues remain to be settled. New ethical ways and means for protecting and respecting patient-participants in such a double role are also needed in this respect. In this way a deeper transformation is at stake as well: a change towards a setting in which patients fully take center stage in debate and action on the future of biomedicine.
Collapse
Affiliation(s)
- Martin Boeckhout
- 1BBMRI-NL, University Medical Centre Groningen, the Netherlands,2Julius Center for Health Sciences and Primary Care, Department of Medical Humanities, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Philip Scheltens
- 3Alzheimer Center, VU University Medical Center, Amsterdam, the Netherlands
| | - Peggy Manders
- 4Radboud Biobank, Radboud university medical center, Nijmegen, the Netherlands,5Department for Human Genetics, Radboud university medical center, Nijmegen, the Netherlands,6Department for Health Evidence, Radboud university medical center, Nijmegen, the Netherlands
| | - Cees Smit
- 4Radboud Biobank, Radboud university medical center, Nijmegen, the Netherlands,7Patient advocate, VSOP, Soestdijk, the Netherlands
| | - Annelien L Bredenoord
- 2Julius Center for Health Sciences and Primary Care, Department of Medical Humanities, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Gerhard A Zielhuis
- 4Radboud Biobank, Radboud university medical center, Nijmegen, the Netherlands,6Department for Health Evidence, Radboud university medical center, Nijmegen, the Netherlands
| |
Collapse
|
43
|
Atkins S, Ojajärvi U, Talola N, Viljamaa M, Nevalainen J, Uitti J. Impact of improved recording of work-relatedness in primary care visits at occupational health services on sickness absences: study protocol for a randomised controlled trial. Trials 2017; 18:352. [PMID: 28747193 PMCID: PMC5530531 DOI: 10.1186/s13063-017-2076-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2016] [Accepted: 06/30/2017] [Indexed: 11/25/2022] Open
Abstract
Background Employment protects and fosters health. Occupational health services, particularly in Finland, have a central role in protecting employee health and preventing work ability problems. However, primary care within occupational health services is currently underused in informing preventive activities. This study was designed to assess whether the recording of work ability problems and improvement of follow-up of work-related primary care visits can reduce sickness absences and work disability pensions after 1 year. Methods/design A pragmatic trial will be conducted using patient electronic registers and registers of the central pensions agency in Finland. Twenty-two occupational health centres will be randomised to intervention and control groups. Intervention units will receive training to improve recording of work ability illnesses in the primary care setting and improved follow-up procedures. The intervention impact will be assessed through examining rates of sickness absence across intervention and control clinics as well as before and after the intervention. Discussion The trial will develop knowledge of the intervention potential of primary care for preventing work disability pensions and sickness absence. The use of routine patient registers and pensions registers to assess the outcomes of a randomised controlled trial will bring forward trial methodology, particularly when using register-based data. If successful, the intervention will improve the quality of occupational health care primary care and contribute to reducing work disability. Trial registration ISRCTN Registry reference number ISRCTN45728263. Registered on 18 April 2016. Electronic supplementary material The online version of this article (doi:10.1186/s13063-017-2076-3) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Salla Atkins
- Faculty of Medicine and Life Sciences, University of Tampere, Tampere, Finland. .,Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden.
| | | | - Nina Talola
- Faculty of Medicine and Life Sciences, University of Tampere, Tampere, Finland
| | | | | | - Jukka Uitti
- Faculty of Medicine and Life Sciences, University of Tampere, Tampere, Finland
| |
Collapse
|
44
|
Kalkman S, Kim SYH, van Thiel GJMW, Grobbee DE, van Delden JJM. Ethics of Informed Consent for Pragmatic Trials with New Interventions. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2017; 20:902-908. [PMID: 28712619 DOI: 10.1016/j.jval.2017.04.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/21/2016] [Revised: 03/30/2017] [Accepted: 04/03/2017] [Indexed: 06/07/2023]
Abstract
OBJECTIVES Pragmatic trials evaluate the comparative benefits, risks, and burdens of health care interventions in real-world conditions. Such studies are now recognized as valuable to the perimarketing stage of drug development and evaluation, with early pragmatic trials (EPTs) being explored as a means to generate real-world evidence at the time of regulatory market approval. In this article, we present an analysis of the ethical issues involved in informed consent for EPTs, in light of the generally recognized concern that traditional ethical rules governing randomized clinical trials, such as lengthy informed consent procedures, could threaten the "real world" nature of such trials. Specifically, we examine to what extent modifications (waivers or alterations) to regulatory consent for EPTs would be ethical. METHODS We first identify broadly accepted necessary conditions for modifications of informed consent (namely, the research involves no more than minimal risk of harm, the research is impracticable with regulatory consent, and the alternative to regulatory consent does not violate legitimate patient expectations) and then apply those criteria to the premarket and early postmarket contexts. RESULTS AND CONCLUSIONS The analysis shows that neither waivers nor alterations of regulatory consent for premarket EPTs will be ethically permissible. For postmarket EPTs with newly approved interventions, waivers of consent will be ethically problematic, but some studies might be conducted in an ethical manner with alterations to regulatory consent.
Collapse
Affiliation(s)
- Shona Kalkman
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands.
| | - Scott Y H Kim
- Department of Bioethics, Clinical Center, National Institutes of Health, Bethesda, MD, USA
| | - Ghislaine J M W van Thiel
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Diederick E Grobbee
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Johannes J M van Delden
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| |
Collapse
|
45
|
Dal-Ré R, Carcas AJ, Carné X, Wendler D. Public preferences on written informed consent for low-risk pragmatic clinical trials in Spain. Br J Clin Pharmacol 2017; 83:1921-1931. [PMID: 28419518 PMCID: PMC5582372 DOI: 10.1111/bcp.13305] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2016] [Revised: 04/06/2017] [Accepted: 04/08/2017] [Indexed: 01/29/2023] Open
Abstract
Aims Pragmatic randomized clinical trials (pRCTs) collect data that have the potential to improve medical care significantly. However, these trials may be undermined by the requirement to obtain written informed consent, which can decrease accrual and increase selection bias. Recent data suggest that the majority of the US public endorses written consent for low‐risk pRCTs. The present study was designed to assess whether this view is specific to the US. Methods The study took the form of a cross‐sectional, probability‐based survey, with a 2 × 2 factorial design, assessing support for written informed consent vs. verbal consent or general notification for two low‐risk pRCTs in hypertension, one comparing two drugs with similar risk/benefit profiles and the other comparing the same drug being taken in the morning or at night. The primary outcome measures were respondents' personal preference and hypothetical recommendation to a research ethics committee regarding the use of written informed consent vs. the alternatives. Results A total of 2008 adults sampled from a probability‐based online panel responded to the web‐based survey conducted in May 2016 (response rate: 61%). Overall, 77% of respondents endorsed written consent. In both scenarios, the alternative of general notification received significantly more support (28.7–37.1%) than the alternative of verbal consent (12.7–14.0%) (P = 0.001). Forty per cent of respondents preferred and/or recommended general notification rather than written consent. Conclusions The results suggested that, rather than attempting to waive written consent, current pRCTs should focus on developing ways to implement written consent that provide sufficient information without undermining recruitment or increasing selection bias. The finding that around 40% of respondents endorsed general notification over written consent raises the possibility that, with educational efforts, the majority of Spaniards might accept general notification for low‐risk pRCTs.
Collapse
Affiliation(s)
- Rafael Dal-Ré
- Clinical Research, BUC (Biosciences UAM+CSIC) Program, International Campus of Excellence, Universidad Autónoma de Madrid, Ciudad Universitaria de Cantoblanco, Einstein 3, 28049, Madrid, Spain.,Chair on Bioethics 'Grifols Foundation', University of Vic-Central University of Catalonia, Miquel Martí i Pol 1, Campus Miramarges, 08500, Vic, Barcelona, Spain
| | - Antonio J Carcas
- Clinical Pharmacology Department, La Paz University Hospital, IdiPaz, School of Medicine, Universidad Autónoma de Madrid, Paseo de la Castellana 261, 28046, Madrid, Spain
| | - Xavier Carné
- Chair on Bioethics 'Grifols Foundation', University of Vic-Central University of Catalonia, Miquel Martí i Pol 1, Campus Miramarges, 08500, Vic, Barcelona, Spain.,Clinical Pharmacology Department, Clínic Hospital, August Pi i Sunyer Biomedical Research Institute (IDIBAPS); Clinical Fundamentals Department, Universidad de Barcelona, Carrer de Villarroel 170, 08036, Barcelona, Spain.,Chair on Bioethics 'Grifols Foundation', University of Vic-Central University of Catalonia, Miquel Martí i Pol 1, Campus Miramarges, E-08500, Vic, Barcelona, Spain
| | - David Wendler
- Section on Research Ethics, Department of Bioethics, NIH Clinical Center, 10 Center Drive, Bethesda, MD, 20814,, USA
| |
Collapse
|
46
|
Huang H, Turner M, Raju S, Reich J, Leatherman S, Armstrong K, Woods P, Ferguson RE, Fiore LD, Lederle FA. Identification of Acute Decompensated Heart Failure Hospitalizations Using Administrative Data. Am J Cardiol 2017; 119:1791-1796. [PMID: 28395889 DOI: 10.1016/j.amjcard.2017.03.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2016] [Revised: 03/01/2017] [Accepted: 03/01/2017] [Indexed: 11/15/2022]
Abstract
Hospitalization for acute decompensated heart failure (ADHF) is an important outcome in clinical trials and heart failure registries; however, the optimal strategy to identify these hospitalizations using International Classification of Diseases, Ninth Revision (ICD-9) codes is uncertain. We sought to identify diagnostic codes that improve ascertainment of ADHF hospitalizations. Heart failure-related ICD-9 principal discharge codes were used to identify 2,202 hospitalizations within the Minneapolis Veterans Affairs Medical Center from 2009 to 2014. Two independent reviewers adjudicated 447 of these hospitalizations to determine the accuracy of each code. We then applied our findings to an unadjusted nationwide sample containing the same ICD-9 codes of interest, from which overall positive predictive value (PPV), sensitivity, and accuracy were calculated. Use of 428.x alone resulted in a PPV of 91.3% (95% confidence interval [CI] 91.0 to 91.7), sensitivity of 97.5% (95% CI 97.3 to 97.6), and accuracy of 89.7% (95% CI 89.4 to 90.0). Combining 428.x with 402.x1, 404.x1, 415, and 518.4 resulted in improved sensitivity (99.2%; 95% CI 99.0 to 99.3) and accuracy (90.7%; 95% CI 90.4 to 91.1) while maintaining a PPV of 91.1% (95% CI 90.7 to 91.4). Excluding chronic heart failure codes (428.22, 428.32, and 428.42) from the proposed strategy resulted in an improvement of PPV to 92.3% (95% CI 92.0 to 92.6), although sensitivity and accuracy decreased to 96.6% (95% CI 96.3 to 96.8) and 90.0% (95% CI 89.6 to 90.3), respectively. In conclusion, a combination of codes including 428.x, 402.x1, 404.x1, 415, and 518.4 improves sensitivity and overall accuracy in ascertaining ADHF events compared with 428.x alone. This strategy could be further improved by manual adjudication of chronic heart failure codes.
Collapse
Affiliation(s)
- Hans Huang
- Department of Medicine, University of Minnesota Medical Center, Minneapolis, Minnesota
| | - Matthew Turner
- Department of Medicine, University of Minnesota Medical Center, Minneapolis, Minnesota
| | - Srihari Raju
- Department of Medicine, Center for Chronic Disease Outcomes Research, VA Health Care System, Minneapolis, Minnesota
| | - Jon Reich
- Department of Medicine, University of Minnesota Medical Center, Minneapolis, Minnesota
| | - Sarah Leatherman
- Massachusetts Veterans Epidemiology Research and Information Center (MAVERIC), Cooperative Studies Coordinating Center, VA Boston Healthcare System, Jamaica Plain, Massachusetts
| | - Katherine Armstrong
- Massachusetts Veterans Epidemiology Research and Information Center (MAVERIC), Cooperative Studies Coordinating Center, VA Boston Healthcare System, Jamaica Plain, Massachusetts
| | - Patricia Woods
- Massachusetts Veterans Epidemiology Research and Information Center (MAVERIC), Cooperative Studies Coordinating Center, VA Boston Healthcare System, Jamaica Plain, Massachusetts
| | - Ryan E Ferguson
- Massachusetts Veterans Epidemiology Research and Information Center (MAVERIC), Cooperative Studies Coordinating Center, VA Boston Healthcare System, Jamaica Plain, Massachusetts; Department of Epidemiology, School of Public Health, Boston University, Boston, Massachusetts; Department of Medicine, School of Medicine, Boston University, Boston, Massachusetts
| | - Louis D Fiore
- Massachusetts Veterans Epidemiology Research and Information Center (MAVERIC), Cooperative Studies Coordinating Center, VA Boston Healthcare System, Jamaica Plain, Massachusetts; Department of Epidemiology, School of Public Health, Boston University, Boston, Massachusetts; Department of Medicine, School of Medicine, Boston University, Boston, Massachusetts
| | - Frank A Lederle
- Department of Medicine, Center for Chronic Disease Outcomes Research, VA Health Care System, Minneapolis, Minnesota.
| |
Collapse
|
47
|
Landray MJ, Bax JJ, Alliot L, Buyse M, Cohen A, Collins R, Hindricks G, James SK, Lane S, Maggioni AP, Meeker-O'Connell A, Olsson G, Pocock SJ, Rawlins M, Sellors J, Shinagawa K, Sipido KR, Smeeth L, Stephens R, Stewart MW, Stough WG, Sweeney F, Van de Werf F, Woods K, Casadei B. Improving public health by improving clinical trial guidelines and their application. Eur Heart J 2017; 38:1632-1637. [PMID: 28329235 PMCID: PMC5837481 DOI: 10.1093/eurheartj/ehx086] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2016] [Revised: 12/16/2016] [Accepted: 02/10/2017] [Indexed: 11/12/2022] Open
Abstract
Evidence generated from randomized controlled trials forms the foundation of cardiovascular therapeutics and has led to the adoption of numerous drugs and devices that prolong survival and reduce morbidity, as well as the avoidance of interventions that have been shown to be ineffective or even unsafe. Many aspects of cardiovascular research have evolved considerably since the first randomized trials in cardiology were conducted. In order to be large enough to provide reliable evidence about effects on major outcomes, cardiovascular trials may now involve thousands of patients recruited from hundreds of clinical sites in many different countries. Costly infrastructure has developed to meet the increasingly complex organizational and operational requirements of these clinical trials. Concerns have been raised that this approach is unsustainable, inhibiting the reliable evaluation of new and existing treatments, to the detriment of patient care. These issues were considered by patients, regulators, funders, and trialists at a meeting of the European Society of Cardiology Cardiovascular Roundtable in October 2015. This paper summarizes the key insights and discussions from the workshop, highlights subsequent progress, and identifies next steps to produce meaningful change in the conduct of cardiovascular clinical research.
Collapse
Affiliation(s)
- Martin J. Landray
- Clinical Trial Service Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Jeroen J. Bax
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Marc Buyse
- IDDI and CluePoints, Louvain-la-Neuve, Belgium
- University of Hasselt, Hasselt, Belgium
| | - Adam Cohen
- Centre for Human Drug Research, Leiden, The Netherlands
| | - Rory Collins
- Clinical Trial Service Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Gerhard Hindricks
- Department of Electrophysiology, Heart Center, University of Leipzig, Leipzig, Germany
| | - Stefan K. James
- Department of Medical Sciences, Cardiology, Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | | | | | | | - Gunnar Olsson
- Board Member (advisory) of European Society of Cardiology, Sweden
| | - Stuart J. Pocock
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, UK
| | - Michael Rawlins
- Medicines and Healthcare products Regulatory Agency, London, UK
| | | | | | - Karin R. Sipido
- Department of Cardiovascular Sciences, Experimental Cardiology, KU Leuven, University of Leuven, Leuven, Belgium
| | - Liam Smeeth
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, UK
| | | | | | - Wendy Gattis Stough
- Campbell University College of Pharmacy and Health Sciences, North Carolina, USA
| | | | - Frans Van de Werf
- Department of Cardiovascular Sciences, University Hospitals, Leuven, Belgium
| | - Kerrie Woods
- National Institute for Health Research, National Health Service, London, UK
| | - Barbara Casadei
- Radcliffe Department of Medicine, Division of Cardiovascular Medicine, John Radcliffe Hospital, University of Oxford, Level 6, West Wing, Oxford, OX3 9DU, UK
| |
Collapse
|
48
|
Series: Pragmatic trials and real world evidence: Paper 4. Informed consent. J Clin Epidemiol 2017; 89:181-187. [PMID: 28502809 DOI: 10.1016/j.jclinepi.2017.03.019] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2016] [Revised: 01/17/2017] [Accepted: 03/20/2017] [Indexed: 11/22/2022]
Abstract
The GetReal consortium of the Innovative Medicines Initiative aims to develop strategies to incorporate real-world evidence earlier into the drug life cycle to better inform health care decision makers on the comparative risks and benefits of new drugs. Pragmatic trials are currently explored as a means to generate such evidence in routine care settings. The traditional informed consent model for randomized clinical trials has been argued to pose substantial hurdles to the practicability of pragmatic trials: it would lead to recruitment difficulties, reduced generalizability of the results, and selection bias. The present article analyzes these challenges and discusses four proposed alternative informed consent models: integrated consent, targeted consent, broadcast consent, and a waiver of consent. These alternative consent models each aim at overcoming operational and methodological challenges, while still providing patients all the relevant information they need to make informed decisions. Each consent model, however, relies on different attitudes toward the principle of respect for persons and the related duty to inform patients as well as represents different views on whether the common good demands moral duties from patients. Such normative consequences of modifying consent requirements should be at least acknowledged and ought to be assessed in light of the validity of empirical claims.
Collapse
|
49
|
Worsley SD, Oude Rengerink K, Irving E, Lejeune S, Mol K, Collier S, Groenwold RHH, Enters-Weijnen C, Egger M, Rhodes T. Series: Pragmatic trials and real world evidence: Paper 2. Setting, sites, and investigator selection. J Clin Epidemiol 2017; 88:14-20. [PMID: 28502811 DOI: 10.1016/j.jclinepi.2017.05.003] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2016] [Revised: 08/22/2016] [Accepted: 05/03/2017] [Indexed: 11/16/2022]
Abstract
This second article in the series on pragmatic trials describes the challenges in selection of sites for pragmatic clinical trials and the impact on validity, precision, and generalizability of the results. The selection of sites is an important factor for the successful execution of a pragmatic trial and impacts the extent to which the results are applicable to future patients in clinical practice. The first step is to define usual care and understand the heterogeneity of sites, patient demographics, disease prevalence and country choice. Next, specific site characteristics are important to consider such as interest in the objectives of the trial, the level of research experience, availability of resources, and the expected number of eligible patients. It can be advisable to support the sites with implementing the trial-related activities and minimize the additional burden that the research imposes on routine clinical practice. Health care providers should be involved in an early phase of protocol development to generate engagement and ensure an appropriate selection of sites with patients who are representative of the future drug users.
Collapse
Affiliation(s)
- Sally D Worsley
- Real World Evidence, GSK R&D, Gunnels Wood Road, Stevenage, Hertfordshire SG12NY, UK.
| | - Katrien Oude Rengerink
- Julius Center for Health Sciences and Primary Care, Universiteitsweg 100, 3584 CG, Utrecht, The Netherlands
| | - Elaine Irving
- Real World Evidence, GSK R&D, Gunnels Wood Road, Stevenage, Hertfordshire SG12NY, UK
| | - Stephane Lejeune
- European Organisation for Research and Treatment of Cancer, 83 Avenue Mounier, Brussels 1200, Belgium
| | - Koen Mol
- EMEA Medical Affairs, Janssen Pharmaceutica NV, Turnhoutseweg 30, Beerse 2340, Belgium
| | - Sue Collier
- Respiratory Therapeutic Area, GSK R&D, Stockley Park West, 1-3 Ironbridge Road, Uxbridge, Middlesex UB11 1BT, UK
| | - Rolf H H Groenwold
- Julius Center for Health Sciences and Primary Care, Universiteitsweg 100, 3584 CG, Utrecht, The Netherlands
| | - Catherine Enters-Weijnen
- Julius Center for Health Sciences and Primary Care, Universiteitsweg 100, 3584 CG, Utrecht, The Netherlands; Department of Primary Care Research, Julius Clinical, Zeist 3703 CD, The Netherlands
| | - Matthias Egger
- Institute of Social and Preventive Medicine & Department of Clinical Research, Clinical Trials Unit, University of Bern, Finkenhubelweg 11, Bern CH-3012, Switzerland
| | - Thomas Rhodes
- Center for Observational and Real-world Evidence (CORE) - Pharmacoepidemiology, MSD, 351N. Sumneytown Pike, North Wales, PA 19454, USA
| |
Collapse
|
50
|
Antimicrobial resistance in human populations: challenges and opportunities. GLOBAL HEALTH EPIDEMIOLOGY AND GENOMICS 2017; 2:e4. [PMID: 29276617 PMCID: PMC5732576 DOI: 10.1017/gheg.2017.4] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/17/2016] [Revised: 01/05/2017] [Accepted: 03/30/2017] [Indexed: 12/24/2022]
Abstract
Antimicrobial resistance (AMR) is a global public health threat. Emergence of AMR occurs naturally, but can also be selected for by antimicrobial exposure in clinical and veterinary medicine. Despite growing worldwide attention to AMR, there are substantial limitations in our understanding of the burden, distribution and determinants of AMR at the population level. We highlight the importance of population-based approaches to assess the association between antimicrobial use and AMR in humans and animals. Such approaches are needed to improve our understanding of the development and spread of AMR in order to inform strategies for the prevention, detection and management of AMR, and to support the sustainable use of antimicrobials in healthcare.
Collapse
|