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Innes K, Ahmed I, Hudson J, Hernández R, Gillies K, Bruce R, Bell V, Avenell A, Blazeby J, Brazzelli M, Cotton S, Croal B, Forrest M, MacLennan G, Murchie P, Wileman S, Ramsay C. Laparoscopic cholecystectomy versus conservative management for adults with uncomplicated symptomatic gallstones: the C-GALL RCT. Health Technol Assess 2024; 28:1-151. [PMID: 38943314 PMCID: PMC11228691 DOI: 10.3310/mnby3104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/01/2024] Open
Abstract
Background Gallstone disease is a common gastrointestinal disorder in industrialised societies. The prevalence of gallstones in the adult population is estimated to be approximately 10-15%, and around 80% remain asymptomatic. At present, cholecystectomy is the default option for people with symptomatic gallstone disease. Objectives To assess the clinical and cost-effectiveness of observation/conservative management compared with laparoscopic cholecystectomy for preventing recurrent symptoms and complications in adults presenting with uncomplicated symptomatic gallstones in secondary care. Design Parallel group, multicentre patient randomised superiority pragmatic trial with up to 24 months follow-up and embedded qualitative research. Within-trial cost-utility and 10-year Markov model analyses. Development of a core outcome set for uncomplicated symptomatic gallstone disease. Setting Secondary care elective settings. Participants Adults with symptomatic uncomplicated gallstone disease referred to a secondary care setting were considered for inclusion. Interventions Participants were randomised 1: 1 at clinic to receive either laparoscopic cholecystectomy or observation/conservative management. Main outcome measures The primary outcome was quality of life measured by area under the curve over 18 months using the Short Form-36 bodily pain domain. Secondary outcomes included the Otago gallstones' condition-specific questionnaire, Short Form-36 domains (excluding bodily pain), area under the curve over 24 months for Short Form-36 bodily pain domain, persistent symptoms, complications and need for further treatment. No outcomes were blinded to allocation. Results Between August 2016 and November 2019, 434 participants were randomised (217 in each group) from 20 United Kingdom centres. By 24 months, 64 (29.5%) in the observation/conservative management group and 153 (70.5%) in the laparoscopic cholecystectomy group had received surgery, median time to surgery of 9.0 months (interquartile range, 5.6-15.0) and 4.7 months (interquartile range 2.6-7.9), respectively. At 18 months, the mean Short Form-36 norm-based bodily pain score was 49.4 (standard deviation 11.7) in the observation/conservative management group and 50.4 (standard deviation 11.6) in the laparoscopic cholecystectomy group. The mean area under the curve over 18 months was 46.8 for both groups with no difference: mean difference -0.0, 95% confidence interval (-1.7 to 1.7); p-value 0.996; n = 203 observation/conservative, n = 205 cholecystectomy. There was no evidence of differences in quality of life, complications or need for further treatment at up to 24 months follow-up. Condition-specific quality of life at 24 months favoured cholecystectomy: mean difference 9.0, 95% confidence interval (4.1 to 14.0), p < 0.001 with a similar pattern for the persistent symptoms score. Within-trial cost-utility analysis found observation/conservative management over 24 months was less costly than cholecystectomy (mean difference -£1033). A non-significant quality-adjusted life-year difference of -0.019 favouring cholecystectomy resulted in an incremental cost-effectiveness ratio of £55,235. The Markov model continued to favour observation/conservative management, but some scenarios reversed the findings due to uncertainties in longer-term quality of life. The core outcome set included 11 critically important outcomes from both patients and healthcare professionals. Conclusions The results suggested that in the short term (up to 24 months) observation/conservative management may be a cost-effective use of National Health Service resources in selected patients, but subsequent surgeries in the randomised groups and differences in quality of life beyond 24 months could reverse this finding. Future research should focus on longer-term follow-up data and identification of the cohort of patients that should be routinely offered surgery. Trial registration This trial is registered as ISRCTN55215960. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 14/192/71) and is published in full in Health Technology Assessment; Vol. 28, No. 26. See the NIHR Funding and Awards website for further award information.
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Affiliation(s)
- Karen Innes
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Irfan Ahmed
- Department of Surgery, NHS Grampian, Aberdeen, UK
| | - Jemma Hudson
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Rodolfo Hernández
- Health Economics Research Unit, University of Aberdeen, Aberdeen, UK
| | - Katie Gillies
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Rebecca Bruce
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Victoria Bell
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Alison Avenell
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Jane Blazeby
- Center for Surgical Research, NIHR Bristol and Western Biomedical Research Centre, University of Bristol, Bristol, UK
| | - Miriam Brazzelli
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Seonaidh Cotton
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | | | - Mark Forrest
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Graeme MacLennan
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Peter Murchie
- Academic Primary Care, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
| | - Samantha Wileman
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Craig Ramsay
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
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Al P, Hey S, Weijer C, Gillies K, McCleary N, Yee ML, Inglis J, Presseau J, Brehaut J. Changing patient preferences toward better trial recruitment: an ethical analysis. Trials 2023; 24:233. [PMID: 36973759 PMCID: PMC10044713 DOI: 10.1186/s13063-023-07258-4] [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: 10/04/2022] [Accepted: 03/14/2023] [Indexed: 03/29/2023] Open
Abstract
While randomized controlled trials are essential to health research, many of these trials fail to recruit enough participants. Approaching recruitment through the lens of behavioral science can help trialists to understand influences on the decision to participate and use them to increase recruitment. Although this approach is promising, the use of behavioral influences during recruitment is in tension with the ethical principle of respect for persons, as at least some of these influences could be used to manipulate potential participants. In this paper, we examine this tension by discussing two types of behavioral influences: one example involves physician recommendations, and the other involves framing of information to exploit cognitive biases. We argue that despite the apparent tension with ethical principles, influencing trial participants through behavior change strategies can be ethically acceptable. However, we argue that trialists have a positive obligation to analyze their recruitment strategies for behavioral influences and disclose these upfront to the research ethics committee. But we also acknowledge that since neither trialists nor ethics committees are presently well equipped to perform these analyses, additional resources and guidance are needed. We close by outlining a path toward the development of such guidance.
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Affiliation(s)
- Pepijn Al
- Rotman Institute of Philosophy, Western University, London, ON, Canada.
| | - Spencer Hey
- Prism Analytic Technologies, Cambridge, MA, USA
| | - Charles Weijer
- Departments of Medicine, Epidemiology & Biostatistics, and Philosophy, Western University, London, ON, Canada
| | - Katie Gillies
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Nicola McCleary
- Centre for Implementation Research, Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
| | | | - Juliette Inglis
- Patient partner, Montreal, QC, Canada
- Patient partner, Edmonton, AB, Canada
| | - Justin Presseau
- Centre for Implementation Research, Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
| | - Jamie Brehaut
- Centre for Implementation Research, Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
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3
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Lawrie L, Duncan EM, Lendrum R, Lebrec V, Gillies K. Challenges and opportunities for conducting pre-hospital trauma trials: a behavioural investigation. Trials 2023; 24:157. [PMID: 36864520 PMCID: PMC9983243 DOI: 10.1186/s13063-023-07184-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Accepted: 02/17/2023] [Indexed: 03/04/2023] Open
Abstract
BACKGROUND Trials in pre-hospital trauma care are relatively uncommon. There are logistical and methodological challenges related to designing and delivering trials in this setting. Previous studies have assessed challenges reported in individual trials rather than across the pre-hospital trial landscape to identify over-arching factors. The aim of this study was to investigate the challenges and opportunities related to the set-up, design and conduct of pre-hospital trauma trials from across the pre-hospital trial landscape and a specific pre-hospital trauma feasibility study. METHODS Semi-structured interviews were conducted with two cohorts of participants: research personnel who had experience of pre-hospital trials, either through direct involvement in conduct or through strategic oversight of national initiatives (n = 7), and clinical staff (n = 16) involved in recruitment to a pre-hospital trauma feasibility study. Thematic analyses were used to assess the barriers and enablers of conducting pre-hospital trauma trials. Two frameworks (The Capability Opportunity Motivation-Behaviour and the Theoretical Domains Framework) were used to guide analyses. RESULTS The barriers and enablers reported were relevant to several TDF domains and COM-B components. Across both cohorts, challenges associated with opportunities were reported and included the lack of research experience amongst pre-hospital staff, team dynamics within a rotating shift schedule, and the involvement of external organisations with diverse institutional priorities and infrastructures (e.g. Air Ambulances). The infrequency of eligible cases was also reported to affect the trial design, set-up, and conduct. Other barriers reported related to clinical equipoise amongst staff and institutional pressures, which affected motivation. CONCLUSIONS This study has highlighted that pre-hospital trials face many context-specific but also generic challenges. Pre-hospital trauma trial teams could consider the findings to develop targeted, behaviourally focused, solutions to the challenges identified in order to enhance the set-up and conduct of trials in this setting. TRIAL REGISTRATION NCT04145271. Trial registration date: October 30, 2019. Note that this paper does not report results from a specific trial but does include participants who were involved in the conduct of a registered pre-hospital feasibility study.
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Affiliation(s)
- Louisa Lawrie
- Health Services Research Unit, 3Rd Floor Health Sciences Building, Institute of Applied Health Sciences, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Foresterhill, Aberdeen, AB25 2ZD, UK.
| | - Eilidh M Duncan
- Health Services Research Unit, 3Rd Floor Health Sciences Building, Institute of Applied Health Sciences, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Foresterhill, Aberdeen, AB25 2ZD, UK
| | - Robert Lendrum
- Barts Health NHS Trust, Royal London Hospital, St. Bartholomew's Hospital, London, England
| | - Victoria Lebrec
- Health Services Research Unit, 3Rd Floor Health Sciences Building, Institute of Applied Health Sciences, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Foresterhill, Aberdeen, AB25 2ZD, UK
| | - Katie Gillies
- Health Services Research Unit, 3Rd Floor Health Sciences Building, Institute of Applied Health Sciences, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Foresterhill, Aberdeen, AB25 2ZD, UK
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Zhou L, Wang J, Huang J, Song X, Wu Y, Chen X, Tan Y, Yang Q. The role of mesenchymal stem cell transplantation for ischemic stroke and recent research developments. Front Neurol 2022; 13:1000777. [PMID: 36468067 PMCID: PMC9708730 DOI: 10.3389/fneur.2022.1000777] [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: 07/22/2022] [Accepted: 10/03/2022] [Indexed: 09/08/2023] Open
Abstract
Ischemic stroke is a common cerebrovascular disease that seriously affects human health. However, most patients do not practice self-care and cannot rely on the current clinical treatment for guaranteed functional recovery. Stem cell transplantation is an emerging treatment studied in various central nervous system diseases. More importantly, animal studies show that transplantation of mesenchymal stem cells (MSCs) can alleviate neurological deficits and bring hope to patients suffering from ischemic stroke. This paper reviews the biological characteristics of MSCs and discusses the mechanism and progression of MSC transplantation to provide new therapeutic directions for ischemic stroke.
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Affiliation(s)
| | | | | | | | | | | | | | - Qin Yang
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
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Lawrie L, Duncan EM, Jansen JO, Campbell MK, Brunsdon D, Skea Z, Coffey T, Cochran C, Gillies K. Behavioural optimisation to address trial conduct challenges: case study in the UK-REBOA trial. Trials 2022; 23:398. [PMID: 35550599 PMCID: PMC9097042 DOI: 10.1186/s13063-022-06341-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 04/23/2022] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Clinical trials comprise multiple processes at various stages of the trial lifecycle. These processes often involve complex behaviours such as recruiting vulnerable patient populations and clinicians having to deliver complex trial interventions successfully. Few studies have utilised a behavioural framework to assess challenges and develop strategies for effective trial recruitment and delivery of trial interventions. This study reports the application of an innovative methodological approach to understand core trial processes, namely recruitment and intervention delivery, using a behavioural science approach to develop strategies designed to mitigate trial process problems. METHODS The UK-REBOA trial aims to evaluate the clinical and cost-effectiveness of resuscitative endovascular balloon occlusion of the aorta (a novel intervention) in injured patients with exsanguinating haemorrhage. A behavioural investigation ('diagnosis') was conducted using theory-informed (Theoretical Domains Framework, TDF) semi-structured interviews with site staff from the UK-REBOA trial to examine trial processes which could be improved in relation to trial recruitment and delivery of the intervention. Interviews were analysed using the TDF to identify influences on behaviour, which were then mapped to techniques for behaviour change and developed into potential solutions. RESULTS The behavioural diagnosis of the challenges experienced during trial processes highlighted factors relevant to a range of TDF domains: Skills, Environmental context and resources, Beliefs about capabilities, Beliefs about consequences, Social influences, and Memory, attention, and decision-making processes. Within the solution development phase, we identified 24 suitable behaviour change techniques that were developed into proposed solutions to target reported process problems with the aim of changing behaviour to improve recruitment and/or intervention delivery. Proposed solutions included targeted changes to trial training content, suggestions to restructure the environment (e.g. reinforced the purpose of the trial with information about the social and environmental consequences) and other strategies to reduce barriers to recruitment and intervention delivery. CONCLUSIONS This study demonstrates the feasibility of applying a behavioural approach to investigate ('diagnose') behavioural trial process problems and subsequently develop and implement targeted solutions ('treatment') in an active trauma trial. Understanding the factors that affected behaviour, attitudes and beliefs in this trauma trial allowed us to implement theoretically informed, evidence-based solutions designed to enhance trial practices. TRIAL REGISTRATION ISRCTN 16,184,981.
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Affiliation(s)
- Louisa Lawrie
- Institute of Applied Health Sciences, School of Medicine, Medical Sciences and Nutrition, Health Services Research Unit, 3Rd Floor Health Sciences Building, University of Aberdeen, Foresterhill, Aberdeen, AB25 2ZD, UK.
| | - Eilidh M Duncan
- Institute of Applied Health Sciences, School of Medicine, Medical Sciences and Nutrition, Health Services Research Unit, 3Rd Floor Health Sciences Building, University of Aberdeen, Foresterhill, Aberdeen, AB25 2ZD, UK
| | - Jan O Jansen
- Institute of Applied Health Sciences, School of Medicine, Medical Sciences and Nutrition, Health Services Research Unit, 3Rd Floor Health Sciences Building, University of Aberdeen, Foresterhill, Aberdeen, AB25 2ZD, UK
- Center for Injury Science, University of Alabama at Birmingham, Birmingham, AL, 35294, USA
| | - Marion K Campbell
- Institute of Applied Health Sciences, School of Medicine, Medical Sciences and Nutrition, Health Services Research Unit, 3Rd Floor Health Sciences Building, University of Aberdeen, Foresterhill, Aberdeen, AB25 2ZD, UK
| | - Dan Brunsdon
- Institute of Applied Health Sciences, School of Medicine, Medical Sciences and Nutrition, Health Services Research Unit, 3Rd Floor Health Sciences Building, University of Aberdeen, Foresterhill, Aberdeen, AB25 2ZD, UK
| | - Zoë Skea
- Institute of Applied Health Sciences, School of Medicine, Medical Sciences and Nutrition, Health Services Research Unit, 3Rd Floor Health Sciences Building, University of Aberdeen, Foresterhill, Aberdeen, AB25 2ZD, UK
| | - Taylor Coffey
- Institute of Applied Health Sciences, School of Medicine, Medical Sciences and Nutrition, Health Services Research Unit, 3Rd Floor Health Sciences Building, University of Aberdeen, Foresterhill, Aberdeen, AB25 2ZD, UK
| | - Claire Cochran
- Institute of Applied Health Sciences, School of Medicine, Medical Sciences and Nutrition, Health Services Research Unit, 3Rd Floor Health Sciences Building, University of Aberdeen, Foresterhill, Aberdeen, AB25 2ZD, UK
| | - Katie Gillies
- Institute of Applied Health Sciences, School of Medicine, Medical Sciences and Nutrition, Health Services Research Unit, 3Rd Floor Health Sciences Building, University of Aberdeen, Foresterhill, Aberdeen, AB25 2ZD, UK
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Understanding potential barriers and enablers to a perioperative early phase cell therapy trial. Cytotherapy 2022; 24:629-638. [PMID: 35396169 DOI: 10.1016/j.jcyt.2021.08.008] [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: 06/02/2021] [Revised: 08/23/2021] [Accepted: 08/25/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND AIMS Early-phase cell therapy clinical trials depend on patient and physician involvement, yet barriers can impede their participation. METHODS To optimize engagement for a planned cell therapy trial to prevent perioperative cardiac complications, the authors conducted semi-structured interviews with at-risk patients and physicians who could potentially be involved in the study. The authors used the theoretical domains framework to systematically identify potential barriers and enablers. RESULTS Forty-one interviews were conducted to reach data saturation, and four overall potential barriers to participation (themes) were identified. Theme 1 emphasizes that patients and physicians need accessible information to better understand the benefits and risks of the novel therapy and trial procedures and to address misconceptions. Theme 2 underscores the need for clarity on whether the trial's primary purpose is safety or efficacy, as this may influence patient and physician decisions. Theme 3 recognizes the resource and logistic realities for patients (e.g., convenient follow-up appointments) and physicians (e.g., personnel to assist in trial procedures, competing priorities). Theme 4 describes the importance of social influences (e.g., physicians and family, peers/colleagues) that may affect decisions to participate and the importance of patient preferences (e.g., availability of physicians to discuss the trial, including caregivers in discussions). CONCLUSIONS Prospectively addressing these issues may help optimize feasibility prior to conducting an expensive, resource-intensive trial.
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Schreiber S, Irving PM, Sharara AI, Martín-Arranz MD, Hébuterne X, Penchev P, Danese S, Anthopoulos P, Akhundova-Unadkat G, Baert F. Review article: randomised controlled trials in inflammatory bowel disease-common challenges and potential solutions. Aliment Pharmacol Ther 2022; 55:658-669. [PMID: 35132657 DOI: 10.1111/apt.16781] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Revised: 11/19/2021] [Accepted: 01/10/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND Recruitment rates for Crohn's disease and ulcerative colitis clinical trials continue to decrease annually. The inability to reach recruitment targets and complete trials has serious implications for stakeholders in the inflammatory bowel disease (IBD) community. Action is required to ensure patients with an unmet medical need have access to new therapies to improve the management of their IBD. AIMS Identify challenges contributing to recruitment decline in IBD clinical trials and propose potential solutions. METHODS PubMed and Google were used to identify literature, regulatory guidelines and conference proceedings related to IBD clinical trials and related concepts. Data on IBD clinical trials conducted between 1989 and 2020 were extracted from the Trialtrove database. RESULTS Key aspects that may improve recruitment rates were identified. An increasingly patient-centric approach should be taken to study design including improvements to the readability of key trial documentation and inclusion of patient representatives in trial planning. Placebo is unappealing to patients; approaches including platform trials should be explored to minimise placebo exposure. Non-invasive imaging, biomarkers and novel digital endpoints should continue to be examined to reduce the burden on patients. Reducing the administrative burden associated with trials via the use of electronic signatures, for example, may benefit study sites and investigators. Changes implemented to IBD trials during the COVID-19 pandemic provided examples of how trial conduct can be rapidly and constructively adapted. CONCLUSIONS To improve recruitment in Crohn's disease and ulcerative colitis trials, the IBD community should address a broad range of issues related to clinical trial conduct.
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Affiliation(s)
- Stefan Schreiber
- Department Internal Medicine I, University Hospital Schleswig-Holstein, Christian-Alrechts-Unversity, Kiel, Germany
| | | | - Ala I Sharara
- Division of Gastroenterology, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - María Dolores Martín-Arranz
- Department of Gastroenterology, La Paz University Hospital, Madrid, Spain.,School of Medicine, Universidad Autónoma de Madrid, Madrid, Spain.,Institute for Health Research, La Paz Hospital, Madrid, Spain
| | - Xavier Hébuterne
- Department of Gastroenterology and Clinical Nutrition, CHU of Nice and University Côte d'Azur, Nice, France
| | - Plamen Penchev
- Department of Gastroenterology, Medical University of Sofia, Sofia, Bulgaria
| | - Silvio Danese
- Gastroenterology and Endoscopy, IRCCS Ospedale San Raffaele and University Vita-Salute San Raffaele, Milan, Italy
| | | | | | - Filip Baert
- Department of Gastroenterology, AZ Delta, Roeselare, Belgium
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How can behavioural science help us design better trials? Trials 2021; 22:882. [PMID: 34863274 PMCID: PMC8643190 DOI: 10.1186/s13063-021-05853-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Accepted: 11/18/2021] [Indexed: 01/13/2023] Open
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Lawrie L, Duncan EM, Dunsmore J, Newlands R, Gillies K. Using a behavioural approach to explore the factors that affect questionnaire return within a clinical trial: a qualitative study based on the theoretical domains framework. BMJ Open 2021. [PMCID: PMC8039247 DOI: 10.1136/bmjopen-2020-048128] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
ObjectivesTo identify barriers and enablers to participant retention in trials requiring questionnaire return using the theoretical domains framework (TDF).Study design and settingWe identified and subsequently invited participants who did not return at least one questionnaire during their participation in a clinical trial for one-to-one semi-structured telephone interviews. We used a behavioural framework (TDF) to explore whether any of the behavioural domains (eg, beliefs about consequences, emotion) affected questionnaire return. Thereafter, we generated a series of belief statements which summarised the content of participants’ main responses and coded these under separate themes.ParticipantsWe distributed invites to 279 eligible individuals and subsequently interviewed 9 participants who took part in the C-Gall trial. The C-Gall trial required participants to complete five postal questionnaires during their participation.ResultsNine participants were interviewed. We developed 7 overarching themes which were relevant for returning postal questionnaires and identified both barriers and enablers from 11 core domains: knowledge; beliefs about consequences; environmental context and resources; reinforcement; emotion; beliefs about capabilities; behavioural regulation; social professional role and identity; skills; intentions and goals. Relevant content coded under these salient domains were categorised into seven key themes: unclear expectations of trial participation, personal attributes for questionnaire return, commitment to returning questionnaires given other priorities, sources of support in returning the questionnaires, individual preferences for presentation mode and timing of the questionnaires, internal and external strategies to encourage questionnaire return and the significance of questionnaire non-return.ConclusionWe demonstrate how a behavioural approach may be useful for clinical trials associated with significant participation burden (e.g. trials that require multiple questionnaire responses), acting as the essential groundwork for the development of appropriate evidence-based solutions to combat retention issues.Trial registration number55215960; Pre-results.
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Affiliation(s)
- Louisa Lawrie
- Health Services Research Unit, University of Aberdeen College of Life Sciences and Medicine, Aberdeen, UK
| | - Eilidh M Duncan
- Health Services Research Unit, University of Aberdeen College of Life Sciences and Medicine, Aberdeen, UK
| | - Jennifer Dunsmore
- Health Services Research Unit, University of Aberdeen College of Life Sciences and Medicine, Aberdeen, UK
| | - Rumana Newlands
- Health Services Research Unit, University of Aberdeen College of Life Sciences and Medicine, Aberdeen, UK
| | - Katie Gillies
- Health Services Research Unit, University of Aberdeen College of Life Sciences and Medicine, Aberdeen, UK
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Castillo G, Lalu M, Asad S, Foster M, Kekre N, Fergusson D, Hawrysh T, Atkins H, Thavorn K, Montroy J, Schwartz S, Holt R, Broady R, Presseau J. Hematologists' barriers and enablers to screening and recruiting patients to a chimeric antigen receptor (CAR) T cell therapy trial: a theory-informed interview study. Trials 2021; 22:230. [PMID: 33766105 PMCID: PMC7995587 DOI: 10.1186/s13063-021-05121-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Accepted: 02/11/2021] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Novel therapies often fail to reach the bedside due to low trial recruitment rates. Prior to conducting one of the first chimeric antigen receptor (CAR) T cell therapy trials in Canada, we used the Theoretical Domains Framework, a novel tool for identifying barriers and enablers to behavior change, to identify physician-related barriers and enablers to screening and recruiting patients for an early phase immunotherapy trial. METHODS We conducted interviews with hematologists across Canada and used a directed content analysis to identify relevant domains reflecting the key factors that may affect screening and recruitment. RESULTS In total, we interviewed 15 hematologists. Physicians expressed "cautious hope"; while expressing safety, feasibility, and screening criteria concerns, 14 out of 15 hematologists intended to screen for the trial (domains: knowledge, goals, beliefs about consequences, intentions). Physicians underscored the "challenging contexts," identifying resources, workload, forgetting, and patient wait times to receive CAR T cells as key practical barriers to screening (domains: environmental context and resources, memory, attention and decision-making, behavioral regulation). They also highlighted "variability in roles and procedures" that may lead to missed trial candidates (domain: social and professional role). Left unaddressed, these barriers may undermine trial recruitment. CONCLUSIONS This study is among the first to use the Theoretical Domains Framework from the physician perspective to identify recruitment challenges to early phase trials and demonstrates the value of this approach for identifying barriers to screening and recruitment that may not otherwise have been elicited. This approach can optimize trial procedures and may serve to inform future promising early phase cancer therapy trials. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT03765177 . Registered on December 5, 2018.
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Affiliation(s)
- Gisell Castillo
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, 501 Smyth Road, Ottawa, Ontario, K1H 8L6, Canada
- Blueprint Translational Research Group, Ottawa Hospital Research Institute, 501 Smyth Road, Ottawa, Ontario, K1H 8L6, Canada
| | - Manoj Lalu
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, 501 Smyth Road, Ottawa, Ontario, K1H 8L6, Canada
- Blueprint Translational Research Group, Ottawa Hospital Research Institute, 501 Smyth Road, Ottawa, Ontario, K1H 8L6, Canada
- Department of Anaesthesiology and Pain Medicine, University of Ottawa at the Ottawa Hospital General Campus, 501 Smyth Road, Ottawa, Ontario, K1H 8L6, Canada
| | - Sarah Asad
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, 501 Smyth Road, Ottawa, Ontario, K1H 8L6, Canada
- Blueprint Translational Research Group, Ottawa Hospital Research Institute, 501 Smyth Road, Ottawa, Ontario, K1H 8L6, Canada
| | - Madison Foster
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, 501 Smyth Road, Ottawa, Ontario, K1H 8L6, Canada
- Blueprint Translational Research Group, Ottawa Hospital Research Institute, 501 Smyth Road, Ottawa, Ontario, K1H 8L6, Canada
| | - Natasha Kekre
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, 501 Smyth Road, Ottawa, Ontario, K1H 8L6, Canada
- Blood and Marrow Transplant Program, The Ottawa Hospital, 501 Smyth Road, Ottawa, Ontario, K1H 8L6, Canada
| | - Dean Fergusson
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, 501 Smyth Road, Ottawa, Ontario, K1H 8L6, Canada
- Blueprint Translational Research Group, Ottawa Hospital Research Institute, 501 Smyth Road, Ottawa, Ontario, K1H 8L6, Canada
- School of Epidemiology and Public Health, University of Ottawa, 600 Peter Morand Crescent, Ottawa, Ontario, K1G 5Z3, Canada
| | | | - Harold Atkins
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, 501 Smyth Road, Ottawa, Ontario, K1H 8L6, Canada
- Blood and Marrow Transplant Program, The Ottawa Hospital, 501 Smyth Road, Ottawa, Ontario, K1H 8L6, Canada
| | - Kednapa Thavorn
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, 501 Smyth Road, Ottawa, Ontario, K1H 8L6, Canada
- School of Epidemiology and Public Health, University of Ottawa, 600 Peter Morand Crescent, Ottawa, Ontario, K1G 5Z3, Canada
- Institute for Clinical and Evaluative Sciences (ICES), University of Ottawa, 1053 Carling Ave., Ottawa, Ontario, K1Y 4E9, Canada
| | - Joshua Montroy
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, 501 Smyth Road, Ottawa, Ontario, K1H 8L6, Canada
- Blueprint Translational Research Group, Ottawa Hospital Research Institute, 501 Smyth Road, Ottawa, Ontario, K1H 8L6, Canada
| | | | - Robert Holt
- BC Cancer Genome Sciences Centre, 100-570 West 7th Avenue, Vancouver, British Columbia, V5Z 4S6, Canada
| | - Raewyn Broady
- Leukemia/BMT Program, Vancouver General Hospital, 2775 Laurel St - 10th floor, Vancouver, British Columbia, V5Z 1M9, Canada
| | - Justin Presseau
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, 501 Smyth Road, Ottawa, Ontario, K1H 8L6, Canada.
- Blueprint Translational Research Group, Ottawa Hospital Research Institute, 501 Smyth Road, Ottawa, Ontario, K1H 8L6, Canada.
- School of Epidemiology and Public Health, University of Ottawa, 600 Peter Morand Crescent, Ottawa, Ontario, K1G 5Z3, Canada.
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11
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Newlands R, Duncan E, Presseau J, Treweek S, Lawrie L, Bower P, Elliott J, Francis J, MacLennan G, Ogden M, Wells M, Witham MD, Young B, Gillies K. Why trials lose participants: A multitrial investigation of participants' perspectives using the theoretical domains framework. J Clin Epidemiol 2021; 137:1-13. [PMID: 33727134 DOI: 10.1016/j.jclinepi.2021.03.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2020] [Revised: 02/11/2021] [Accepted: 03/08/2021] [Indexed: 11/19/2022]
Abstract
OBJECTIVES To use the Theoretical Domains Framework (TDF) to identify barriers and enablers to participant retention in trials requiring questionnaire return and/or attendance at follow-up clinics. STUDY DESIGN AND SETTING We invited participants (n = 607) from five pragmatic effectiveness trials, who missed at least one follow-up time point (by not returning a questionnaire and/or not attending a clinic visit), to take part in semistructured telephone interviews. The TDF informed both data collection and analysis. To establish what barriers and enablers most likely influence the target behavior the domain relevance threshold was set at >75% of participants mentioning the domain. RESULTS Sixteen participants (out of 25 showing interest) were interviewed. Overall, seven theoretical domains were identified as both barriers and enablers to the target behaviors of attending clinic appointments and returning postal questionnaires. Barriers frequently reported in relation to both target behaviours stemmed from participants' knowledge, beliefs about their capabilities and the consequences of performing (or not performing) the behavior. Two domains were identified as salient for questionnaire return only: goals; and memory, attention and decision-making. Emotion was identified as relevant for clinic attendance only. CONCLUSION This is the first study informed by behavioural science to explore trial participants' accounts of trial retention. Findings will serve as a guiding framework when designing trials to limit barriers and enhance enablers of retention within clinical trials.
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Affiliation(s)
- Rumana Newlands
- Health Services Research Unit, Health Sciences Building, Foresterhill, Aberdeen AB25 2ZD, UK
| | - Eilidh Duncan
- Health Services Research Unit, Health Sciences Building, Foresterhill, Aberdeen AB25 2ZD, UK
| | - Justin Presseau
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada; School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada; School of Psychology, University of Ottawa, Ottawa, Canada
| | - Shaun Treweek
- Health Services Research Unit, Health Sciences Building, Foresterhill, Aberdeen AB25 2ZD, UK
| | - Louisa Lawrie
- Health Services Research Unit, Health Sciences Building, Foresterhill, Aberdeen AB25 2ZD, UK
| | - Peter Bower
- NIHR School for Primary Care Research, Centre for Primary Care and Health Services Research, Manchester Academic Health Science Centre, University of Manchester, UK
| | - Jim Elliott
- Health Services Research Unit, Health Sciences Building, Foresterhill, Aberdeen AB25 2ZD, UK; Public Partner
| | - Jill Francis
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada; Melbourne School of Health Sciences, The University of Melbourne, Melbourne, Australia
| | - Graeme MacLennan
- Health Services Research Unit, Health Sciences Building, Foresterhill, Aberdeen AB25 2ZD, UK
| | - Margaret Ogden
- Health Services Research Unit, Health Sciences Building, Foresterhill, Aberdeen AB25 2ZD, UK; Public Partner
| | - Mary Wells
- Faculty of Medicine, Department of Surgery and Cancer, Imperial College, London, UK; Imperial College Healthcare NHS Trust, London, UK
| | - Miles D Witham
- AGE Research Group, NIHR Newcastle Biomedical Research Centre, Newcastle University and Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle, UK
| | - Bridget Young
- Department of Public Health, Policy and Systems, Institute of Population Health, University of Liverpool, Liverpool, UK
| | - Katie Gillies
- Health Services Research Unit, Health Sciences Building, Foresterhill, Aberdeen AB25 2ZD, UK.
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12
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Brehaut JC, Carroll K, Presseau J, Richards DP, Gordon J, Bénard A, Hudek N, Graham ID, Fergusson DA, Marlin S. A patient-focused, theory-guided approach to survey design identified barriers to and drivers of clinical trial participation. J Clin Epidemiol 2020; 132:106-115. [PMID: 33338563 DOI: 10.1016/j.jclinepi.2020.12.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 11/16/2020] [Accepted: 12/08/2020] [Indexed: 12/27/2022]
Abstract
OBJECTIVES Despite clear evidence showing that many clinical trials fail or are delayed because of poor patient recruitment, there is surprisingly little empirically supported guidance for trialists seeking to optimize their trial recruitment strategies. We propose that the challenges of recruitment can be better understood and addressed by thinking of research participation as one or more behaviors, subject to the same forces as other human behaviors. In this article, we describe an adaptable, behavioral theory-driven approach for designing pretrial surveys of the barriers and drivers relevant to trial participation. Instead of proposing a single survey instrument intended to be used uniformly across many situations, we propose that tailored surveys be informed by a common comprehensive, theory-guided development approach that ensures all domains potentially guiding participation are considered. STUDY DESIGN AND SETTING We used the Theoretical Domains Framework (TDF), which organizes over 100 constructs known to be associated with behavior and behavior change into 14 domains that describe determinants of professional and patient health behaviors, to inform the development of tailored surveys about barriers to and drivers of clinical trial participation. After searching the literature for barriers and drivers to trial recruitment relevant to each of the TDF domains, we developed separate surveys for members of two national health charities (Canadian Breast Cancer Network, Huntington Society of Canada) to exemplify how the approach can be adapted across settings. We conducted think-aloud interviews with members of each group to maximize the clarity and usability of the surveys, elicited opinions about which barriers/drivers were relevant for each patient group, and identified additional barriers/drivers. Interviews proceeded iteratively with changes incorporated into subsequent interviews. Here, we describe our two target patient groups, as well as our process of modifying, adding, and deleting barrier/driver items for each group and across theoretical domains. RESULTS We interviewed 8 women with a history of breast cancer from the Canadian Breast Cancer Network (48-65 year old) and 11 Huntington Disease community members (9 women) from the Huntington Society of Canada (26-70 year old). After the iterative development interviews, the breast cancer group had identified 38 barriers/drivers thought relevant to their participation in clinical trials across 12 TDF domains. The Huntington group identified 47 items across 13 TDF domains. CONCLUSION Our patient-focused and theory-guided approach was able to identify a more comprehensive range of barriers to and drivers of trial participation than existing published tools. Our approach is also more broadly adaptable than such tools, in that it uses a theoretical framework and in-depth piloting to generate a set of items tailored to each specific clinical area, rather than a single set of items intended to be applicable to all situations. This theory-guided approach also enables more specific recruitment strategies to be developed once domain-specific barriers are known, potentially optimizing participation for a given trial and helping build a cumulative evidence of barriers/drivers and strategies for addressing them.
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Affiliation(s)
- Jamie C Brehaut
- Clinical Epidemiology Program, Ottawa Hospital Research Institute (OHRI), The Ottawa Hospital, General Campus, 501 Smyth Rd, Ottawa Ontario, Canada, K1H 8L6; Faculty of Medicine, School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada, K1G 5Z3.
| | - Kelly Carroll
- Clinical Epidemiology Program, Ottawa Hospital Research Institute (OHRI), The Ottawa Hospital, General Campus, 501 Smyth Rd, Ottawa Ontario, Canada, K1H 8L6
| | - Justin Presseau
- Clinical Epidemiology Program, Ottawa Hospital Research Institute (OHRI), The Ottawa Hospital, General Campus, 501 Smyth Rd, Ottawa Ontario, Canada, K1H 8L6; Faculty of Medicine, School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada, K1G 5Z3
| | - Dawn P Richards
- Clinical Trials Ontario, 661 University Avenue, Suite 460, MaRS Centre, West Tower, Toronto, Canada M5G 1M1
| | - Jenn Gordon
- Canadian Breast Cancer Network, 331 Cooper St. Suite 602, Ottawa, Canada, K2P 0G5
| | - Angèle Bénard
- Huntington Society of Canada (HSC), 20 Erb Street West, Suite 801, Waterloo, Ontario, N2L1T2
| | - Natasha Hudek
- Clinical Epidemiology Program, Ottawa Hospital Research Institute (OHRI), The Ottawa Hospital, General Campus, 501 Smyth Rd, Ottawa Ontario, Canada, K1H 8L6
| | - Ian D Graham
- Clinical Epidemiology Program, Ottawa Hospital Research Institute (OHRI), The Ottawa Hospital, General Campus, 501 Smyth Rd, Ottawa Ontario, Canada, K1H 8L6; Faculty of Medicine, School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada, K1G 5Z3
| | - Dean A Fergusson
- Clinical Epidemiology Program, Ottawa Hospital Research Institute (OHRI), The Ottawa Hospital, General Campus, 501 Smyth Rd, Ottawa Ontario, Canada, K1H 8L6; Faculty of Medicine, School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada, K1G 5Z3
| | - Susan Marlin
- Clinical Trials Ontario, 661 University Avenue, Suite 460, MaRS Centre, West Tower, Toronto, Canada M5G 1M1
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