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Nielsen AB, Holm M, Lindhard MS, Glenthøj JP, Borch L, Hartling U, Schmidt LS, Rytter MJH, Rasmussen AH, Damkjær M, Lemvik G, Petersen JJH, Søndergaard MJ, Thaarup J, Kristensen K, Jensen LH, Hansen LH, Lawaetz MC, Gottliebsen M, Horsager TH, Zaharov T, Hoffmann TU, Nygaard T, Justesen US, Stensballe LG, Vissing NH, Blanche P, Schmiegelow K, Nygaard U. Oral versus intravenous empirical antibiotics in children and adolescents with uncomplicated bone and joint infections: a nationwide, randomised, controlled, non-inferiority trial in Denmark. THE LANCET. CHILD & ADOLESCENT HEALTH 2024; 8:625-635. [PMID: 39025092 DOI: 10.1016/s2352-4642(24)00133-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/27/2024] [Revised: 05/26/2024] [Accepted: 05/27/2024] [Indexed: 07/20/2024]
Abstract
BACKGROUND Bone and joint infections (BJIs) are treated with intravenous antibiotics, which are burdensome and costly. No randomised controlled studies have compared if initial oral antibiotics are as effective as intravenous therapy. We aimed to investigate the efficacy and safety of initial oral antibiotics compared with initial intravenous antibiotics followed by oral antibiotics in children and adolescents with uncomplicated BJIs. METHODS From Sept 15, 2020, to June 30, 2023, this nationwide, randomised, non-inferiority trial included patients aged 3 months to 17 years with BJIs who presented to one of the 18 paediatric hospital departments in Denmark. Exclusion criteria were severe infection (ie, septic shock, the need for acute surgery, or substantial soft tissue involvement), prosthetic material, comorbidity, previous BJIs, or antibiotic therapy for longer than 24 h before inclusion. Patients were randomly assigned (1:1), stratified by C-reactive protein concentration (<35 mg/L vs ≥35 mg/L), to initially receive either high-dose oral antibiotics or intravenous ceftriaxone (100 mg/kg per day in one dose). High-dose oral antibiotics were coformulated amoxicillin (100 mg/kg per day) and clavulanic acid (12·5 mg/kg per day) in three doses for patients younger than 5 years or dicloxacillin (200 mg/kg per day) in four doses for patients aged 5 years or older. After a minimum of 3 days, and upon clinical improvement and decrease in C-reactive protein, patients in both groups received oral antibiotics in standard doses. The primary outcome was sequelae after 6 months in patients with BJIs, defined as any atypical mobility or function of the affected bone or joint, assessed blindly, in all randomised patients who were not terminated early due to an alternative diagnosis (ie, not BJI) and who attended the primary outcome assessment. A risk difference in sequelae after 6 months of less than 5% implied non-inferiority of the oral treatment. Safety outcomes were serious complications, the need for surgery after initiation of antibiotics, and treatment-related adverse events in the as-randomised population. This trial was registered with ClinicalTrials.gov, NCT04563325. FINDINGS 248 children and adolescents with suspected BJIs were randomly assigned to initial oral antibiotics (n=123) or initial intravenous antibiotics (n=125). After exclusion of patients without BJIs (n=54) or consent withdrawal (n=2), 101 patients randomised to oral treatment and 91 patients randomised to intravenous treatment were included. Ten patients did not attend the primary outcome evaluation. Sequelae after 6 months occurred in none of 98 patients with BJIs in the oral group and none of 84 patients with BJIs in the intravenous group (risk difference 0, one-sided 97·5% CI 0·0 to 3·8, pnon-inferiority=0·012). Surgery after randomisation was done in 12 (9·8%) of 123 patients in the oral group compared with seven (5·6%) of 125 patients in the intravenous group (risk difference 4·2%, 95% CI -2·7 to 11·5). We observed no serious complications. Rates of adverse events were similar across both treatment groups. INTERPRETATION In children and adolescents with uncomplicated BJIs, initial oral antibiotic treatment was non-inferior to initial intravenous antibiotics followed by oral therapy. The results are promising for oral treatment of uncomplicated BJIs, precluding the need for intravenous catheters and aligning with the principles of antimicrobial stewardship. FUNDING Innovation Fund Denmark and Rigshospitalets Forskningsfond.
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Affiliation(s)
- Allan Bybeck Nielsen
- Department of Paediatrics and Adolescent Medicine, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark; Department of Paediatrics and Adolescent Medicine, Copenhagen University Hospital, Hvidovre, Denmark
| | - Mette Holm
- Department of Paediatrics and Adolescent Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Morten S Lindhard
- Department of Pediatrics and Adolescent Medicine, Regional Hospital Randers, Randers, Denmark
| | - Jonathan P Glenthøj
- Department of Paediatrics and Adolescent Medicine, Hillerød University Hospital, Hillerød, Denmark
| | - Luise Borch
- Department of Paediatrics and Adolescent Medicine, Gødstrup Hospital, Gødstrup, Denmark; NIDO Centre for Research and Education, Gødstrup Hospital, Herning, Denmark
| | - Ulla Hartling
- Department of Paediatrics and Adolescent Medicine, Hans Christian Andersen Children's Hospital, Odense, Denmark
| | - Lisbeth S Schmidt
- Department of Paediatrics and Adolescent Medicine, Herlev University Hospital, Herlev, Denmark; Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Maren J H Rytter
- Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark; Department of Paediatrics and Adolescent Medicine, Slagelse Hospital, Slagelse, Denmark
| | - Annett H Rasmussen
- Department of Paediatrics and Adolescent Medicine, Hans Christian Andersen Children's Hospital, Odense, Denmark
| | - Mads Damkjær
- Department of Paediatrics and Adolescent Medicine, Lillebaelt Hospital, University Hospital of Southern Denmark, Kolding, Denmark; Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - Grethe Lemvik
- Department of Paediatrics and Adolescent Medicine, Viborg Regional Hospital, Viborg, Denmark
| | - Jens J H Petersen
- Department of Paediatrics and Adolescent Medicine, Esbjerg Central Hospital, Esbjerg, Denmark
| | - Mia J Søndergaard
- Department of Paediatrics and Adolescent Medicine, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Jesper Thaarup
- Department of Paediatrics and Adolescent Medicine, Aalborg University Hospital, Aalborg, Denmark
| | - Kim Kristensen
- Department of Paediatrics and Adolescent Medicine, Zealand University Hospital, Nykobing Falster, Denmark
| | - Lise H Jensen
- Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark; Department of Paediatrics and Adolescent Medicine, Zealand University Hospital, Roskilde, Denmark
| | - Lotte H Hansen
- Department of Paediatrics and Adolescent Medicine, Aabenraa Hospital, Aabenraa, Denmark
| | - Marie C Lawaetz
- Department of Paediatrics and Adolescent Medicine, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Martin Gottliebsen
- Department of Paediatric Orthopaedic Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Tanja H Horsager
- Department of Paediatrics and Adolescent Medicine, Aarhus University Hospital, Aarhus, Denmark; Department of Paediatrics and Adolescent Medicine, Viborg Regional Hospital, Viborg, Denmark
| | - Tatjana Zaharov
- Department of Paediatrics and Adolescent Medicine, Zealand University Hospital, Nykobing Falster, Denmark
| | - Thomas U Hoffmann
- Department of Paediatrics and Adolescent Medicine, Copenhagen University Hospital, Hvidovre, Denmark
| | - Tobias Nygaard
- Department of Paediatric Orthopaedic Surgery, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Ulrik S Justesen
- Department of Clinical Microbiology, Odense University Hospital, Odense, Denmark
| | - Lone G Stensballe
- Department of Paediatrics and Adolescent Medicine, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark; Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Nadja H Vissing
- Department of Paediatrics and Adolescent Medicine, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Paul Blanche
- Department of Biostatistics, University of Copenhagen, Copenhagen, Denmark
| | - Kjeld Schmiegelow
- Department of Paediatrics and Adolescent Medicine, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark; Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Ulrikka Nygaard
- Department of Paediatrics and Adolescent Medicine, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark; Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.
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Remiro-Azócar A, Gorst-Rasmussen A. Broad versus narrow research questions in evidence synthesis: A parallel to (and plea for) estimands. Res Synth Methods 2024. [PMID: 39118456 DOI: 10.1002/jrsm.1741] [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: 04/30/2024] [Revised: 05/24/2024] [Accepted: 07/08/2024] [Indexed: 08/10/2024]
Abstract
There has been a transition from broad to more specific research questions in the practice of network meta-analysis (NMA). Such convergence is also taking place in the context of individual registrational trials, following the recent introduction of the estimand framework, which is impacting the design, data collection strategy, analysis and interpretation of clinical trials. The language of estimands has much to offer to NMA, particularly given the "narrow" perspective of treatments and target populations taken in health technology assessment.
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Ades AE, Welton NJ, Dias S, Caldwell DM, Phillippo DM. Response to discussant comments on "NMA, the first 20 years". Res Synth Methods 2024. [PMID: 39054934 DOI: 10.1002/jrsm.1745] [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: 07/05/2024] [Accepted: 07/09/2024] [Indexed: 07/27/2024]
Abstract
We respond to discussant comments on our paper "Twenty years of network meta-analysis: Continuing controversies and recent developments" (https://doi.org/10.1002/jrsm.1700) and raise some additional points for consideration, including: the way in which methodological guidance is generated; integration of the estimand framework with evidence synthesis; and implications of the European Joint Clinical Assessment. We ask: what properties are required of population adjustment methods to enable transparent and consistent decision-making? We also ask why individual patient data is not routinely made available to re-imbursement authorities and clinical guideline developers.
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Affiliation(s)
- A E Ades
- Population Health Sciences, Bristol Medical School, Bristol, UK
| | - Nicky J Welton
- Population Health Sciences, Bristol Medical School, Bristol, UK
| | - Sofia Dias
- Centre for Reviews and Dissemination, University of York, York, UK
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De Silva AP, Leslie K, Braat S, Grobler AC. Application of the Estimand Framework to Anesthesia Trials. Anesthesiology 2024; 141:13-23. [PMID: 38743905 DOI: 10.1097/aln.0000000000004966] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/16/2024]
Abstract
SUMMARY Events occurring after randomization, such as use of rescue medication, treatment discontinuation, or death, are common in randomized trials. These events can change either the existence or interpretation of the outcome of interest. However, appropriate handling of these intercurrent events is often unclear. The International Council for Harmonisation of Technical Requirements for Pharmaceuticals for Human Use (ICH) E9(R1) addendum introduced the estimand framework, which aligns trial objectives with the design, conduct, statistical analysis, and interpretation of results. This article describes how the estimand framework can be used in anesthesia trials to precisely define the treatment effect to be estimated, key attributes of an estimand, common intercurrent events in anesthesia trials with strategies for handling them, and use of the estimand framework in a hypothetical anesthesia trial on postoperative delirium. When planning anesthesia trials, clearly defining the estimand is vital to ensure that what is being estimated is clearly understood, is clinically relevant, and helps answer the clinical questions of interest.
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Affiliation(s)
- Anurika P De Silva
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Australia; Methods and Implementation Support for Clinical and Health (MISCH) research Hub, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Australia
| | - Kate Leslie
- Department of Critical Care, Melbourne Medical School, University of Melbourne, Melbourne, Australia; Department of Anaesthesia and Pain Management, Royal Melbourne Hospital, Melbourne, Australia
| | - Sabine Braat
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Australia; Methods and Implementation Support for Clinical and Health (MISCH) research, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Australia
| | - Anneke C Grobler
- Department of Paediatrics, Melbourne Medical School, University of Melbourne, Melbourne, Australia; Murdoch Children's Research Institute, Melbourne, Australia
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Kahan BC, Blette BS, Harhay MO, Halpern SD, Jairath V, Copas A, Li F. Demystifying estimands in cluster-randomised trials. Stat Methods Med Res 2024:9622802241254197. [PMID: 38780480 DOI: 10.1177/09622802241254197] [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: 05/25/2024]
Abstract
Estimands can help clarify the interpretation of treatment effects and ensure that estimators are aligned with the study's objectives. Cluster-randomised trials require additional attributes to be defined within the estimand compared to individually randomised trials, including whether treatment effects are marginal or cluster-specific, and whether they are participant- or cluster-average. In this paper, we provide formal definitions of estimands encompassing both these attributes using potential outcomes notation and describe differences between them. We then provide an overview of estimators for each estimand, describe their assumptions, and show consistency (i.e. asymptotically unbiased estimation) for a series of analyses based on cluster-level summaries. Then, through a re-analysis of a published cluster-randomised trial, we demonstrate that the choice of both estimand and estimator can affect interpretation. For instance, the estimated odds ratio ranged from 1.38 (p = 0.17) to 1.83 (p = 0.03) depending on the target estimand, and for some estimands, the choice of estimator affected the conclusions by leading to smaller treatment effect estimates. We conclude that careful specification of the estimand, along with an appropriate choice of estimator, is essential to ensuring that cluster-randomised trials address the right question.
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Affiliation(s)
- Brennan C Kahan
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, UCL, London, UK
| | - Bryan S Blette
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, USA
| | - Michael O Harhay
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, UCL, London, UK
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
| | - Scott D Halpern
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
| | - Vipul Jairath
- Department of Medicine, Division of Gastroenterology, Schulich School of Medicine, Western University, London, ON, Canada
- Department of Epidemiology and Biostatistics, Western University, London, ON, Canada
| | - Andrew Copas
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, UCL, London, UK
| | - Fan Li
- Department of Biostatistics, Yale University School of Public Health, New Haven, CT, USA
- Center for Methods in Implementation and Prevention Science, Yale University School of Public Health, New Haven, CT, USA
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Kahan BC, Hindley J, Edwards M, Cro S, Morris TP. The estimands framework: a primer on the ICH E9(R1) addendum. BMJ 2024; 384:e076316. [PMID: 38262663 PMCID: PMC10802140 DOI: 10.1136/bmj-2023-076316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/07/2023] [Indexed: 01/25/2024]
Affiliation(s)
- Brennan C Kahan
- MRC Clinical Trials Unit at UCL, University College London, London WC1V 6LJ, UK
| | - Joanna Hindley
- MRC Clinical Trials Unit at UCL, University College London, London WC1V 6LJ, UK
| | - Mark Edwards
- Department of Anaesthesia, University Hospital Southampton NHS Foundation Trust, Southampton, UK
- Southampton NIHR Biomedical Research Centre, University of Southampton, Southampton, UK
| | - Suzie Cro
- Imperial Clinical Trials Unit, School of Public Health, Imperial College London, London, UK
| | - Tim P Morris
- MRC Clinical Trials Unit at UCL, University College London, London WC1V 6LJ, UK
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Ong SWX, Lee TC, Fowler RA, Mahar R, Pinto RL, Rishu A, Petrella L, Whiteway L, Cheng M, McDonald E, Johnstone J, Mertz D, Kandel C, Somayaji R, Davis JS, Tong SYC, Daneman N. Evaluating the impact of a SIMPlified LaYered consent process on recruitment of potential participants to the Staphylococcus aureus Network Adaptive Platform trial: study protocol for a multicentre pragmatic nested randomised clinical trial (SIMPLY-SNAP trial). BMJ Open 2024; 14:e083239. [PMID: 38238170 PMCID: PMC10806654 DOI: 10.1136/bmjopen-2023-083239] [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: 12/15/2023] [Accepted: 01/08/2024] [Indexed: 01/23/2024] Open
Abstract
INTRODUCTION Informed consent forms (ICFs) for randomised clinical trials (RCTs) can be onerous and lengthy. The process has the potential to overwhelm patients with information, leading them to miss elements of the study that are critical for an informed decision. Specifically, overly long and complicated ICFs have the potential to increase barriers to trial participation for patients with mild cognitive impairment, those who do not speak English as a first language or among those with lower medical literacy. In turn, this can influence trial recruitment, completion and external validity. METHODS AND ANALYSIS SIMPLY-SNAP is a pragmatic, multicentre, open-label, two-arm parallel-group superiority RCT, nested within a larger trial, the Staphylococcus aureus Network Adaptive Platform (SNAP) trial. We will randomise potentially eligible participants of the SNAP trial 1:1 to a full-length ICF or a SIMPlified LaYered (SIMPLY) consent process where basic information is summarised with embedded hyperlinks to supplemental information and videos. The primary outcome is recruitment into the SNAP trial. Secondary outcomes include patient understanding of the clinical trial, patient and research staff satisfaction with the consent process, and time taken for consent. As an exploratory outcome, we will also compare measures of diversity (eg, gender, ethnicity), according to the consent process randomised to. The planned sample size will be 346 participants. ETHICS AND DISSEMINATION The study has been approved by the ethics review board (Sunnybrook Health Sciences Research Ethics Board) at sites in Ontario. We will disseminate study results via the SNAP trial group and other collaborating clinical trial networks. TRIAL REGISTRATION NUMBER ClinicalTrials.gov Registry (NCT06168474; www. CLINICALTRIALS gov).
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Affiliation(s)
- Sean W X Ong
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Faculty of Medicine, Densitry and Health Sciences, Univesrity of Melbourne, Melbourne, Victoria, Australia
- Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Todd C Lee
- Clinical Practice Assessment Unit, McGill University Health Centre, Montréal, Quebec, Canada
- Division of Infectious Diseases, McGill Univesrity Health Centre, Montréal, Quebec, Canada
| | - Robert A Fowler
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Robert Mahar
- Centre for Epidemiology and Biostatistics, The University of Melbourne, Melbourne, Victoria, Australia
- Clinical Epidemiology and Biostatistics Unit, Murdoch Children's Research Institute, Parkville, Victoria, Australia
| | - Ruxandra L Pinto
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Asgar Rishu
- Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Lina Petrella
- Clinical Practice Assessment Unit, McGill University Health Centre, Montréal, Quebec, Canada
| | - Lyn Whiteway
- Freelance Health Consumer Advocate, Adelaide, South Australia, Australia
| | - Matthew Cheng
- Division of Infectious Diseases, McGill Univesrity Health Centre, Montréal, Quebec, Canada
| | - Emily McDonald
- Clinical Practice Assessment Unit, McGill University Health Centre, Montréal, Quebec, Canada
- Division of General Internal Medicine, McGill University Health Centre, Montréal, Quebec, Canada
| | - Jennie Johnstone
- Division of Infectious Diseases, Sinai Health, Toronto, Ontario, Canada
| | - Dominik Mertz
- Division of Infectious Diseases, McMaster University, Hamilton, Ontario, Canada
| | - Christopher Kandel
- Michael Garron Hospital, Toronto East Health Network, Toronto, Ontario, Canada
| | - Ranjani Somayaji
- Division of Infectious Diseases, University of Calgary, Calgary, Alberta, Canada
| | - Joshua S Davis
- School of Medicine and Public Health, The University of Newcastle, Callaghan, New South Wales, Australia
- Global and Tropical Health Division, Menzies School of Health Research, Darwin, Northern Territory, Australia
- Department of Immunology and Infectious Diseases, John Hunter Hospital, Newcastle, New South Wales, Australia
| | - Steven Y C Tong
- Department of Infectious Diseases, University of Melbourne, Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
- Victorian Infectious Diseases Service, Royal Melbourne Hospital, Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
| | - Nick Daneman
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
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Kahan BC, Li F, Blette B, Jairath V, Copas A, Harhay M. Informative cluster size in cluster-randomised trials: A case study from the TRIGGER trial. Clin Trials 2023; 20:661-669. [PMID: 37439089 PMCID: PMC10638852 DOI: 10.1177/17407745231186094] [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] [Indexed: 07/14/2023]
Abstract
BACKGROUND Recent work has shown that cluster-randomised trials can estimate two distinct estimands: the participant-average and cluster-average treatment effects. These can differ when participant outcomes or the treatment effect depends on the cluster size (termed informative cluster size). In this case, estimators that target one estimand (such as the analysis of unweighted cluster-level summaries, which targets the cluster-average effect) may be biased for the other. Furthermore, commonly used estimators such as mixed-effects models or generalised estimating equations with an exchangeable correlation structure can be biased for both estimands. However, there has been little empirical research into whether informative cluster size is likely to occur in practice. METHOD We re-analysed a cluster-randomised trial comparing two different thresholds for red blood cell transfusion in patients with acute upper gastrointestinal bleeding to explore whether estimates for the participant- and cluster-average effects differed, to provide empirical evidence for whether informative cluster size may be present. For each outcome, we first estimated a participant-average effect using independence estimating equations, which are unbiased under informative cluster size. We then compared this to two further methods: (1) a cluster-average effect estimated using either weighted independence estimating equations or unweighted cluster-level summaries, and (2) estimates from a mixed-effects model or generalised estimating equations with an exchangeable correlation structure. We then performed a small simulation study to evaluate whether observed differences between cluster- and participant-average estimates were likely to occur even if no informative cluster size was present. RESULTS For most outcomes, treatment effect estimates from different methods were similar. However, differences of >10% occurred between participant- and cluster-average estimates for 5 of 17 outcomes (29%). We also observed several notable differences between estimates from mixed-effects models or generalised estimating equations with an exchangeable correlation structure and those based on independence estimating equations. For example, for the EQ-5D VAS score, the independence estimating equation estimate of the participant-average difference was 4.15 (95% confidence interval: -3.37 to 11.66), compared with 2.84 (95% confidence interval: -7.37 to 13.04) for the cluster-average independence estimating equation estimate, and 3.23 (95% confidence interval: -6.70 to 13.16) from a mixed-effects model. Similarly, for thromboembolic/ischaemic events, the independence estimating equation estimate for the participant-average odds ratio was 0.43 (95% confidence interval: 0.07 to 2.48), compared with 0.33 (95% confidence interval: 0.06 to 1.77) from the cluster-average estimator. CONCLUSION In this re-analysis, we found that estimates from the various approaches could differ, which may be due to the presence of informative cluster size. Careful consideration of the estimand and the plausibility of assumptions underpinning each estimator can help ensure an appropriate analysis methods are used. Independence estimating equations and the analysis of cluster-level summaries (with appropriate weighting for each to correspond to either the participant-average or cluster-average treatment effect) are a desirable choice when informative cluster size is deemed possible, due to their unbiasedness in this setting.
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Affiliation(s)
| | - Fan Li
- Department of Biostatistics, Yale School of Public Health, Yale University, New Haven, CT, USA
| | - Bryan Blette
- Department of Biostatistics, Epidemiology & Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Vipul Jairath
- Division of Gastroenterology, Department of Medicine, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada
- Department of Epidemiology and Biostatistics, Western University, London, ON, Canada
| | | | - Michael Harhay
- Department of Biostatistics, Epidemiology & Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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Stevens J, Mills SD, Millett TJ, Lin FC, Leeman J. Design of a dual randomized trial in a type 2 hybrid effectiveness-implementation study. Implement Sci 2023; 18:64. [PMID: 37996884 PMCID: PMC10666326 DOI: 10.1186/s13012-023-01317-9] [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: 06/10/2023] [Accepted: 10/18/2023] [Indexed: 11/25/2023] Open
Abstract
BACKGROUND Dual randomized controlled trials (DRCT) are type 2 hybrid studies that include two randomized trials: one testing implementation strategies and one testing an intervention. We argue that this study design offers efficiency by providing rigorous investigation of both implementation and intervention in one study and has potential to accelerate generation of the evidence needed to translate interventions that work into real-world practice. Nevertheless, studies using this design are rare in the literature. MAIN TEXT We construct a paradigm that breaks down the components of the DRCT and provide a step-by-step explanation of features of the design and recommendations for use. A clear distinction is made between the dual strands that test the implementation versus the intervention, and a minimum of three randomized arms is advocated. We suggest an active treatment arm that includes both the implementation strategy and intervention that are hypothesized to be superior. We suggest two comparison/control arms: one to test the implementation strategy and the second to test the intervention. Further, we recommend selection criteria for the two control arms that place emphasis on maximizing the utility of the study design to advance public health practice. CONCLUSIONS On the surface, the design of a DRCT can appear simple, but actual application is complex. We believe it is that complexity that has limited its use in the literature. We hope that this paper will give both implementation scientists and trialists who are not familiar with implementation science a better understanding of the DRCT design and encouragement to use it.
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Affiliation(s)
- June Stevens
- Departments of Nutrition and Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, 27599, USA.
| | - Sarah Denton Mills
- Lineberger Comprehensive Cancer Center, Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, USA
| | - Thomas J Millett
- UTHealth Houston Institute for Implementation Science, University of Texas Health Science Center at Houston, Houston, TX, 77030, USA
| | - Feng-Chang Lin
- Department of Biostatistics, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, 27599, USA
| | - Jennifer Leeman
- School of Nursing, University of North Carolina at Chapel Hill, Chapel Hill, NC, 27599, USA
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Cumpston MS, McKenzie JE, Ryan R, Thomas J, Brennan SE. Critical elements of synthesis questions are incompletely reported: survey of systematic reviews of intervention effects. J Clin Epidemiol 2023; 163:79-91. [PMID: 37778736 DOI: 10.1016/j.jclinepi.2023.09.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Revised: 09/21/2023] [Accepted: 09/26/2023] [Indexed: 10/03/2023]
Abstract
OBJECTIVES To examine the characteristics of population, intervention and outcome groups and the extent to which they were completely reported for each synthesis in a sample of systematic reviews (SRs) of interventions. STUDY DESIGN AND SETTING We coded groups that were intended (or used) for comparisons in 100 randomly sampled SRs of public health and health systems interventions published in 2018 from the Health Evidence and Health Systems Evidence databases. RESULTS Authors commonly used population, intervention and outcome groups to structure comparisons, but these groups were often incompletely reported. For example, of 41 SRs that identified and/or used intervention groups for comparisons, 29 (71%) identified the groups in their methods description before reporting of the results (e.g., in the Background or Methods), 12 (29%) defined the groups in enough detail to replicate decisions about which included studies were eligible for each synthesis, 6 (15%) provided a rationale, and 24 (59%) stated that the groups would be used for comparisons. Sixteen (39%) SRs used intervention groups in their synthesis without any mention in the methods. Reporting for population, outcome and methodological groups was similarly incomplete. CONCLUSION Complete reporting of the groups used for synthesis would improve transparency and replicability of reviews, and help ensure that the synthesis is not driven by what is reported in the included studies. Although concerted effort is needed to improve reporting, this should lead to more focused and useful reviews for decision-makers.
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Affiliation(s)
- Miranda S Cumpston
- Methods in Evidence Synthesis Unit, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria 3004, Australia
| | - Joanne E McKenzie
- Methods in Evidence Synthesis Unit, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria 3004, Australia
| | - Rebecca Ryan
- Centre for Health Communication & Participation, La Trobe University, Melbourne, Victoria 3086, Australia
| | - James Thomas
- EPPI-Centre, UCL Social Research Institute, University College London, Gower St, London, WC1E 6BT, UK
| | - Sue E Brennan
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria 3004, Australia.
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Kang M, Price JC, Peters MG, Lewin SR, Sulkowski M. Design and analysis considerations for early phase clinical trials in hepatitis B (HBV) cure research: the ACTG A5394 study in persons with both HIV and HBV. J Virus Erad 2023; 9:100344. [PMID: 37744732 PMCID: PMC10514436 DOI: 10.1016/j.jve.2023.100344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Revised: 08/18/2023] [Accepted: 08/23/2023] [Indexed: 09/26/2023] Open
Abstract
With growing interest and efforts to achieve a hepatitis B (HBV) cure, HBV therapeutics have increasingly entered the clinical testing phase. In designing an early phase clinical trial aimed at HBV cure, the heterogeneity in participants and the choice of a biomarker endpoint that signals a cure requires careful consideration. We describe the key elements to consider during the development of HBV clinical trials aimed at a functional cure, and how we have addressed them in the design of a phase II AIDS Clinical Trials Group (ACTG) study, A5394 (NCT05551273). The trial we present is for persons with both HIV and HBV, a unique population that has much to gain from an HBV cure. Our decisions on the design elements are specific to the study agent and the targeted population, but our deliberations may be informative in the emerging field of early phase HBV trials aimed at cure.
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Affiliation(s)
- Minhee Kang
- Center for Biostatistics in AIDS Research in the Department of Biostatistics, Harvard T.H. Chan School of Public Health, United States
| | - Jennifer C. Price
- Division of Gastroenterology, University of California San Francisco School of Medicine, United States
| | - Marion G. Peters
- Department of Medicine, Feinberg School of Medicine, Northwestern University, United States
| | - Sharon R. Lewin
- Department of Infectious Diseases, The University of Melbourne, Australia
- Victorian Infectious Diseases Service, Royal Melbourne Hospital at the Peter Doherty Institute for Infection and Immunity, Australia
- Department of Infectious Diseases, Alfred Health and Monash University, Australia
| | - Mark Sulkowski
- Division of Infectious Diseases, Johns Hopkins University School of Medicine, United States
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12
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Harrer M, Cuijpers P, Schuurmans LKJ, Kaiser T, Buntrock C, van Straten A, Ebert D. Evaluation of randomized controlled trials: a primer and tutorial for mental health researchers. Trials 2023; 24:562. [PMID: 37649083 PMCID: PMC10469910 DOI: 10.1186/s13063-023-07596-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 08/18/2023] [Indexed: 09/01/2023] Open
Abstract
BACKGROUND Considered one of the highest levels of evidence, results of randomized controlled trials (RCTs) remain an essential building block in mental health research. They are frequently used to confirm that an intervention "works" and to guide treatment decisions. Given their importance in the field, it is concerning that the quality of many RCT evaluations in mental health research remains poor. Common errors range from inadequate missing data handling and inappropriate analyses (e.g., baseline randomization tests or analyses of within-group changes) to unduly interpretations of trial results and insufficient reporting. These deficiencies pose a threat to the robustness of mental health research and its impact on patient care. Many of these issues may be avoided in the future if mental health researchers are provided with a better understanding of what constitutes a high-quality RCT evaluation. METHODS In this primer article, we give an introduction to core concepts and caveats of clinical trial evaluations in mental health research. We also show how to implement current best practices using open-source statistical software. RESULTS Drawing on Rubin's potential outcome framework, we describe that RCTs put us in a privileged position to study causality by ensuring that the potential outcomes of the randomized groups become exchangeable. We discuss how missing data can threaten the validity of our results if dropouts systematically differ from non-dropouts, introduce trial estimands as a way to co-align analyses with the goals of the evaluation, and explain how to set up an appropriate analysis model to test the treatment effect at one or several assessment points. A novice-friendly tutorial is provided alongside this primer. It lays out concepts in greater detail and showcases how to implement techniques using the statistical software R, based on a real-world RCT dataset. DISCUSSION Many problems of RCTs already arise at the design stage, and we examine some avoidable and unavoidable "weak spots" of this design in mental health research. For instance, we discuss how lack of prospective registration can give way to issues like outcome switching and selective reporting, how allegiance biases can inflate effect estimates, review recommendations and challenges in blinding patients in mental health RCTs, and describe problems arising from underpowered trials. Lastly, we discuss why not all randomized trials necessarily have a limited external validity and examine how RCTs relate to ongoing efforts to personalize mental health care.
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Affiliation(s)
- Mathias Harrer
- Psychology and Digital Mental Health Care, Technical University Munich, Georg-Brauchle-Ring 60-62, Munich, 80992, Germany.
- Clinical Psychology and Psychotherapy, Institute for Psychology, Friedrich-Alexander-University Erlangen-Nuremberg, Erlangen, Germany.
| | - Pim Cuijpers
- Department of Clinical, Neuro and Developmental Psychology, Amsterdam Public Health Research Institute, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
- WHO Collaborating Centre for Research and Dissemination of Psychological Interventions, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Lea K J Schuurmans
- Psychology and Digital Mental Health Care, Technical University Munich, Georg-Brauchle-Ring 60-62, Munich, 80992, Germany
| | - Tim Kaiser
- Methods and Evaluation/Quality Assurance, Freie Universität Berlin, Berlin, Germany
| | - Claudia Buntrock
- Institute of Social Medicine and Health Systems Research (ISMHSR), Medical Faculty, Otto Von Guericke University Magdeburg, Magdeburg, Germany
| | - Annemieke van Straten
- Department of Clinical, Neuro and Developmental Psychology, Amsterdam Public Health Research Institute, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - David Ebert
- Psychology and Digital Mental Health Care, Technical University Munich, Georg-Brauchle-Ring 60-62, Munich, 80992, Germany
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Parker RA, Cook JA. The importance of clinical importance when determining the target difference in sample size calculations. Trials 2023; 24:495. [PMID: 37542276 PMCID: PMC10401796 DOI: 10.1186/s13063-023-07532-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Accepted: 07/20/2023] [Indexed: 08/06/2023] Open
Abstract
Recently, it was argued that clinically important differences should play no role in sample size calculations. Instead, it was proposed that sample size calculations should focus on setting realistic estimates of treatment benefit. We disagree, and argue in this article that considering the importance of a target difference is necessary in the context of randomised controlled trials of effectiveness, particularly definitive phase III trials. Ignoring clinical importance could have serious ethical and practical consequences.
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Affiliation(s)
- Richard A Parker
- Edinburgh Clinical Trials Unit, Usher Institute, University of Edinburgh, Edinburgh, UK.
| | - Jonathan A Cook
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
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14
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Cro S, Kahan BC, Patel A, Henley A, C J, Hellyer P, Kumar M, Rahman Y, Goulão B. Starting a conversation about estimands with public partners involved in clinical trials: a co-developed tool. Trials 2023; 24:443. [PMID: 37408080 PMCID: PMC10324181 DOI: 10.1186/s13063-023-07469-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 06/20/2023] [Indexed: 07/07/2023] Open
Abstract
BACKGROUND Clinical trials aim to draw conclusions about the effects of treatments, but a trial can address many different potential questions. For example, does the treatment work well for patients who take it as prescribed? Or does it work regardless of whether patients take it exactly as prescribed? Since different questions can lead to different conclusions on treatment benefit, it is important to clearly understand what treatment effect a trial aims to investigate-this is called the 'estimand'. Using estimands helps to ensure trials are designed and analysed to answer the questions of interest to different stakeholders, including patients and public. However, there is uncertainty about whether patients and public would like to be involved in defining estimands and how to do so. Public partners are patients and/or members of the public who are part of, or advise, the research team. We aimed to (i) co-develop a tool with public partners that helps explain what an estimand is and (ii) explore public partner's perspectives on the importance of discussing estimands during trial design. METHODS An online consultation meeting was held with 5 public partners of mixed age, gender and ethnicities, from various regions of the UK. Public partner opinions were collected and a practical tool describing estimands, drafted before the meeting by the research team, was developed. Afterwards, the tool was refined, and additional feedback sought via email. RESULTS Public partners want to be involved in estimand discussions. They found an introductory tool, to be presented and described to them by a researcher, helpful for starting a discussion about estimands in a trial design context. They recommended storytelling, analogies and visual aids within the tool. Four topics related to public partners' involvement in defining estimands were identified: (i) the importance of addressing questions that are relevant to patients and public in trials, (ii) involving public partners early on, (iii) a need for education and communication for all stakeholders and (iv) public partners and researchers working together. CONCLUSIONS We co-developed a tool for researchers and public partners to use to facilitate the involvement of public partners in estimand discussions.
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Affiliation(s)
- Suzie Cro
- Imperial Clinical Trials Unit, Imperial College London, London, UK.
| | | | - Akshaykumar Patel
- Critical Care and Perioperative Medicine Research Group, Queen Mary University, London, UK
| | - Ania Henley
- HEALTHY STATS Public Partner Co-Chair with Imperial Clinical Trials Unit, Imperial College London, London, UK
| | - Joanna C
- HEALTHY STATS Public Partner with Imperial Clinical Trials Unit, Imperial College London, London, UK
| | - Paul Hellyer
- HEALTHY STATS Public Partner with Imperial Clinical Trials Unit, Imperial College London, London, UK
| | - Manos Kumar
- HEALTHY STATS Public Partner with Imperial Clinical Trials Unit, Imperial College London, London, UK
| | - Yasmin Rahman
- HEALTHY STATS Public Partner with Imperial Clinical Trials Unit, Imperial College London, London, UK
| | - Beatriz Goulão
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
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15
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Kahan BC, Cro S, Li F, Harhay MO. Eliminating Ambiguous Treatment Effects Using Estimands. Am J Epidemiol 2023; 192:987-994. [PMID: 36790803 PMCID: PMC10236519 DOI: 10.1093/aje/kwad036] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Revised: 02/06/2023] [Accepted: 02/13/2023] [Indexed: 02/16/2023] Open
Abstract
Most reported treatment effects in medical research studies are ambiguously defined, which can lead to misinterpretation of study results. This is because most authors do not attempt to describe what the treatment effect represents, and instead require readers to deduce this based on the reported statistical methods. However, this approach is challenging, because many methods provide counterintuitive results. For example, some methods include data from all patients, yet the resulting treatment effect applies only to a subset of patients, whereas other methods will exclude certain patients while results will apply to everyone. Additionally, some analyses provide estimates pertaining to hypothetical settings in which patients never die or discontinue treatment. Herein we introduce estimands as a solution to the aforementioned problem. An estimand is a clear description of what the treatment effect represents, thus saving readers the necessity of trying to infer this from study methods and potentially getting it wrong. We provide examples of how estimands can remove ambiguity from reported treatment effects and describe their current use in practice. The crux of our argument is that readers should not have to infer what investigators are estimating; they should be told explicitly.
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Affiliation(s)
- Brennan C Kahan
- Correspondence to Dr. Brennan C. Kahan, MRC Clinical Trials Unit at UCL, University College London, 90 High Holborn, London WC1V 6LJ, United Kingdom (e-mail: )
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16
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Kahan BC, White IR, Edwards M, Harhay MO. Using modified intention-to-treat as a principal stratum estimator for failure to initiate treatment. Clin Trials 2023; 20:269-275. [PMID: 36916466 PMCID: PMC10262320 DOI: 10.1177/17407745231160074] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/15/2023]
Abstract
BACKGROUND A common intercurrent event affecting many trials is when some participants do not begin their assigned treatment. For example, in a double-blind drug trial, some participants may not receive any dose of study medication. Many trials use a 'modified intention-to-treat' approach, whereby participants who do not initiate treatment are excluded from the analysis. However, it is not clear (a) the estimand being targeted by such an approach and (b) the assumptions necessary for such an approach to be unbiased. METHODS Using potential outcome notation, we demonstrate that a modified intention-to-treat analysis which excludes participants who do not begin treatment is estimating a principal stratum estimand (i.e. the treatment effect in the subpopulation of participants who would begin treatment, regardless of which arm they were assigned to). The modified intention-to-treat estimator is unbiased for the principal stratum estimand under the assumption that the intercurrent event is not affected by the assigned treatment arm, that is, participants who initiate treatment in one arm would also do so in the other arm (i.e. if someone began the intervention, they would also have begun the control, and vice versa). RESULTS We identify two key criteria in determining whether the modified intention-to-treat estimator is likely to be unbiased: first, we must be able to measure the participants in each treatment arm who experience the intercurrent event, and second, the assumption that treatment allocation will not affect whether the participant begins treatment must be reasonable. Most double-blind trials will satisfy these criteria, as the decision to start treatment cannot be influenced by the allocation, and we provide an example of an open-label trial where these criteria are likely to be satisfied as well, implying that a modified intention-to-treat analysis which excludes participants who do not begin treatment is an unbiased estimator for the principal stratum effect in these settings. We also give two examples where these criteria will not be satisfied (one comparing an active intervention vs usual care, where we cannot identify which usual care participants would have initiated the active intervention, and another comparing two active interventions in an unblinded manner, where knowledge of the assigned treatment arm may affect the participant's choice to begin or not), implying that a modified intention-to-treat estimator will be biased in these settings. CONCLUSION A modified intention-to-treat analysis which excludes participants who do not begin treatment can be an unbiased estimator for the principal stratum estimand. Our framework can help identify when the assumptions for unbiasedness are likely to hold, and thus whether modified intention-to-treat is appropriate or not.
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Affiliation(s)
| | | | - Mark Edwards
- Department of Anaesthesia, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Michael O Harhay
- Clinical Trials Methods and Outcomes Lab, PAIR (Palliative and Advanced Illness Research) Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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Bybeck Nielsen A, Borch L, Damkjaer M, Glenthøj JP, Hartling U, Hoffmann TU, Holm M, Helleskov Rasmussen A, Schmidt LS, Schmiegelow K, Stensballe LG, Nygaard U. Oral-only antibiotics for bone and joint infections in children: study protocol for a nationwide randomised open-label non-inferiority trial. BMJ Open 2023; 13:e072622. [PMID: 37263683 DOI: 10.1136/bmjopen-2023-072622] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/03/2023] Open
Abstract
INTRODUCTION Children with bone and joint infections are traditionally treated with intravenous antibiotics for 3-10 days, followed by oral antibiotics. Oral-only treatment has not been tested in randomised trials. METHODS AND ANALYSIS Children (3 months to 18 years) will be randomised 1:1 with the experimental group receiving high-dose oral antibiotics and the control group receiving intravenous antibiotics with a shift in both groups to standard oral antibiotics after clinical and paraclinical improvement. Children in need of acute surgery or systemic features requiring intravenous therapy, including septic shock, are excluded. The primary outcome is defined as a normal blinded standardised clinical assessment 6 months after end of treatment. Secondary outcomes are non-acute treatment failure and recurrent infection. Outcomes will be compared by a non-inferiority assumption with an inferiority margin of 5%. ETHICS AND DISSEMINATION The trial has the potential to reduce unnecessary hospitalisation and use of intravenous antibiotics in children with bone or joint infections. Due to the close follow-up, exclusion of severely ill children and predefined criteria for discontinuation of the allocated therapy, we expect the risk of treatment failure to be minimal. TRIAL REGISTRATION NUMBER NCT04563325.
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Affiliation(s)
- Allan Bybeck Nielsen
- Department of Paediatrics and Adolescent Medicine, Copenhagen University Hospital, Kobenhavn, Denmark
| | - Luise Borch
- Department of Paediatrics and Adolescent Medicine, Gødstrup Hospital, Herning, Denmark
- NIDO - Centre for Research and Education, Gødstrup Hospital, Herning, Denmark
| | - Mads Damkjaer
- Department of Paediatrics and Adolescent Medicine, Lillebaelt Hospital - University Hospital of Southern Denmark, Kolding, Denmark
- Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - Jonathan Peter Glenthøj
- Department of Paediatrics and Adolescent Medicine, Copenhagen University Hospital, Hillerød, Denmark
| | - Ulla Hartling
- Department of Paediatrics and Adolescent Medicine, Odense University Hospital, Odense, Denmark
| | - Thomas Ulrik Hoffmann
- Department of Paediatrics and Adolescent Medicine, Copenhagen University Hospital, Hvidovre, Denmark
| | - Mette Holm
- Department of Paediatrics and Adolescent Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Annett Helleskov Rasmussen
- Department of Paediatrics and Adolescent Medicine, Lillebaelt Hospital - University Hospital of Southern Denmark, Kolding, Denmark
| | - Lisbeth Samsø Schmidt
- Department of Paediatrics and Adolescent Medicine, Copenhagen University Hospital, Herlev, Denmark
| | - Kjeld Schmiegelow
- Department of Paediatrics and Adolescent Medicine, Copenhagen University Hospital, Kobenhavn, Denmark
| | - Lone Graff Stensballe
- Department of Paediatrics and Adolescent Medicine, Copenhagen University Hospital, Kobenhavn, Denmark
| | - Ulrikka Nygaard
- Department of Paediatrics and Adolescent Medicine, Copenhagen University Hospital, Kobenhavn, Denmark
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Arundel CE, Welch C, Saramago P, Adderley U, Atkinson R, Chetter I, Cullum N, Davill T, Griffiths J, Hewitt C, Hirst C, Kletter M, Mullings J, Roberts G, Smart B, Soares M, Stather P, Strachan L, Stubbs N, Torgerson DJ, Watson J, Zahra S, Dumville J. A randomised controlled trial of compression therapies for the treatment of venous leg ulcers (VenUS 6): study protocol for a pragmatic, multicentre, parallel-group, three-arm randomised controlled trial. Trials 2023; 24:357. [PMID: 37237393 DOI: 10.1186/s13063-023-07349-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 05/05/2023] [Indexed: 05/28/2023] Open
Abstract
BACKGROUND Venous leg ulcer(s) are common, recurring, open wounds on the lower leg, resulting from diseased or damaged leg veins impairing blood flow. Wound healing is the primary treatment aim for venous leg ulceration, alongside the management of pain, wound exudate and infection. Full (high) compression therapy delivering 40 mmHg of pressure at the ankle is the recommended first-line treatment for venous leg ulcers. There are several different forms of compression therapy available including wraps, two-layer hosiery, and two-layer or four-layer bandages. There is good evidence for the clinical and cost-effectiveness of four-layer bandage and two-layer hosiery but more limited evidence for other treatments (two-layer bandage and compression wraps). Robust evidence is required to compare clinical and cost-effectiveness of these and to investigate which is the best compression treatment for reducing time to healing of venous leg ulcers whilst offering value for money. VenUS 6 will therefore investigate the clinical and cost-effectiveness of evidence-based compression, two-layer bandage and compression wraps for time to healing of venous leg ulcers. METHODS VenUS 6 is a pragmatic, multi-centre, three-arm, parallel-group, randomised controlled trial. Adult patients with a venous leg ulcer will be randomised to receive (1) compression wraps, (2) two-layer bandage or (3) evidence-based compression (two-layer hosiery or four-layer bandage). Participants will be followed up for between 4 and 12 months. The primary outcome will be time to healing (full epithelial cover in the absence of a scab) in days since randomisation. Secondary outcomes will include key clinical events (e.g. healing of the reference leg, ulcer recurrence, ulcer/skin deterioration, amputation, admission/discharge, surgery to close/remove incompetent superficial veins, infection or death), treatment changes, adherence and ease of use, ulcer related pain, health-related quality of life and resource use. DISCUSSION VenUS 6 will provide robust evidence on the clinical and cost-effectiveness of the different forms of compression therapies for venous leg ulceration. VenUS 6 opened to recruitment in January 2021 and is currently recruiting across 30 participating centres. TRIAL REGISTRATION ISRCTN67321719 . Prospectively registered on 14 September 2020.
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Affiliation(s)
- C E Arundel
- York Trials Unit, Department of Health Sciences, Faculty of Science, University of York, Lower Ground Floor ARRC Building, York, YO10 5DD, UK.
| | - C Welch
- York Trials Unit, Department of Health Sciences, Faculty of Science, University of York, Lower Ground Floor ARRC Building, York, YO10 5DD, UK
| | - P Saramago
- Centre for Health Economics, University of York, York, YO10 5DD, UK
| | - U Adderley
- Manchester University NHS Foundation Trust, Oxford Road, Manchester, M13 9WL, UK
| | - R Atkinson
- Division of Nursing, Midwifery and Social Work, Jean McFarlane Building, University of Manchester, Oxford Road, Manchester, M13 9PL, UK
| | - I Chetter
- University of Hull, Hull York Medical School and Hull University Teaching Hospitals NHS Trust, Hull, UK
| | - N Cullum
- Division of Nursing, Midwifery and Social Work, Jean McFarlane Building, University of Manchester, Oxford Road, Manchester, M13 9PL, UK
| | - T Davill
- York Trials Unit, Department of Health Sciences, Faculty of Science, University of York, Lower Ground Floor ARRC Building, York, YO10 5DD, UK
| | - J Griffiths
- Division of Nursing, Midwifery and Social Work, Jean McFarlane Building, University of Manchester, Oxford Road, Manchester, M13 9PL, UK
| | - C Hewitt
- York Trials Unit, Department of Health Sciences, Faculty of Science, University of York, Lower Ground Floor ARRC Building, York, YO10 5DD, UK
| | - C Hirst
- York Trials Unit, Department of Health Sciences, Faculty of Science, University of York, Lower Ground Floor ARRC Building, York, YO10 5DD, UK
| | - M Kletter
- Division of Nursing, Midwifery and Social Work, Jean McFarlane Building, University of Manchester, Oxford Road, Manchester, M13 9PL, UK
| | - J Mullings
- Manchester University NHS Foundation Trust, Oxford Road, Manchester, M13 9WL, UK
| | - G Roberts
- York Trials Unit, Department of Health Sciences, Faculty of Science, University of York, Lower Ground Floor ARRC Building, York, YO10 5DD, UK
| | - B Smart
- Division of Nursing, Midwifery and Social Work, Jean McFarlane Building, University of Manchester, Oxford Road, Manchester, M13 9PL, UK
| | - M Soares
- Centre for Health Economics, University of York, York, YO10 5DD, UK
| | - P Stather
- Norfolk and Norwich University Hospitals NHS Foundation Trust, Colney Lane, Norwich, NR4 7UY, UK
| | - L Strachan
- York Trials Unit, Department of Health Sciences, Faculty of Science, University of York, Lower Ground Floor ARRC Building, York, YO10 5DD, UK
| | - N Stubbs
- NCS Woundcare Consulting Limited, Cornmill Lane, Leeds, LS17 9EQ, UK
| | - D J Torgerson
- York Trials Unit, Department of Health Sciences, Faculty of Science, University of York, Lower Ground Floor ARRC Building, York, YO10 5DD, UK
| | - J Watson
- York Trials Unit, Department of Health Sciences, Faculty of Science, University of York, Lower Ground Floor ARRC Building, York, YO10 5DD, UK
| | - S Zahra
- York Trials Unit, Department of Health Sciences, Faculty of Science, University of York, Lower Ground Floor ARRC Building, York, YO10 5DD, UK
| | - J Dumville
- Division of Nursing, Midwifery and Social Work, Jean McFarlane Building, University of Manchester, Oxford Road, Manchester, M13 9PL, UK
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Paterson LM, Barker D, Cro S, Mozgunov P, Phillips R, Smith C, Nahar L, Paterson S, Lingford-Hughes AR. FORWARDS-1: an adaptive, single-blind, placebo-controlled ascending dose study of acute baclofen on safety parameters in opioid dependence during methadone-maintenance treatment-a pharmacokinetic-pharmacodynamic study. Trials 2022; 23:880. [PMID: 36258248 PMCID: PMC9579625 DOI: 10.1186/s13063-022-06821-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Accepted: 10/05/2022] [Indexed: 11/17/2022] Open
Abstract
Background Treatment of opiate addiction with opiate substitution treatment (e.g. methadone) is beneficial. However, some individuals desire or would benefit from abstinence but there are limited options to attenuate problems with opiate withdrawal. Preclinical and preliminary clinical evidence suggests that the GABA-B agonist, baclofen, has the desired properties to facilitate opiate detoxification and prevent relapse. This study aims to understand whether there are any safety issues in administering baclofen to opioid-dependent individuals receiving methadone. Methods Opiate-dependent individuals (DSM-5 severe opioid use disorder) maintained on methadone will be recruited from addiction services in northwest London (NHS and third sector providers). Participants will be medically healthy with no severe chronic obstructive pulmonary disease or type 2 respiratory failure, no current dependence on other substances (excluding nicotine), no current severe DSM-5 psychiatric disorders, and no contraindications for baclofen or 4800 IU vitamin D (placebo). Eligible participants will be randomised in a 3:1 ratio to receive baclofen or placebo in an adaptive, single-blind, ascending dose design. A Bayesian dose-escalation model will inform the baclofen dose (10, 30, 60, or 90 mg) based on the incidence of ‘dose-limiting toxicity’ (DLT) events and participant-specific methadone dose. A range of respiratory, cardiovascular, and sedative measures including the National Early Warning Score (NEWS2) and Glasgow Coma Scale will determine DLT. On the experimental day, participants will consume their usual daily dose of methadone followed by an acute dose of baclofen or placebo (vitamin D3) ~ 1 h later. Measures including oxygen saturation, transcutaneous CO2, respiratory rate, QTc interval, subjective effects (sedation, drug liking, craving), plasma levels (baclofen, methadone), and adverse events will be obtained using validated questionnaires and examinations periodically for 5 h after dosing. Discussion Study outcomes will determine what dose of baclofen is safe to prescribe to those receiving methadone, to inform a subsequent proof-of-concept trial of the efficacy baclofen to facilitate opiate detoxification. To proceed, the minimum acceptable dose is 30 mg of baclofen in patients receiving ≤ 60 mg/day methadone based on the clinical experience of baclofen’s use in alcoholism and guidelines for the management of opiate dependence. Trial registration Clinicaltrials.gov NCT05161351. Registered on 16 December 2021. Supplementary Information The online version contains supplementary material available at 10.1186/s13063-022-06821-9.
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Affiliation(s)
- L M Paterson
- Division of Psychiatry, Department of Brain Sciences, Imperial College London, London, UK.
| | - D Barker
- Division of Psychiatry, Department of Brain Sciences, Imperial College London, London, UK
| | - S Cro
- Imperial Clinical Trials Unit, Imperial College London, London, UK
| | - P Mozgunov
- MRC Biostatistics Unit, University of Cambridge, Cambridge, UK
| | - R Phillips
- Imperial Clinical Trials Unit, Imperial College London, London, UK
| | - C Smith
- Imperial Clinical Trials Unit, Imperial College London, London, UK
| | - L Nahar
- Toxicology Unit, Imperial College London, London, UK
| | - S Paterson
- Toxicology Unit, Imperial College London, London, UK
| | - A R Lingford-Hughes
- Division of Psychiatry, Department of Brain Sciences, Imperial College London, London, UK
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20
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Pham TM, Tweed CD, Carpenter JR, Kahan BC, Nunn AJ, Crook AM, Esmail H, Goodall R, Phillips PPJ, White IR. Rethinking intercurrent events in defining estimands for tuberculosis trials. Clin Trials 2022; 19:522-533. [PMID: 35850542 PMCID: PMC9523802 DOI: 10.1177/17407745221103853] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
BACKGROUND/AIMS Tuberculosis remains one of the leading causes of death from an infectious disease globally. Both choices of outcome definitions and approaches to handling events happening post-randomisation can change the treatment effect being estimated, but these are often inconsistently described, thus inhibiting clear interpretation and comparison across trials. METHODS Starting from the ICH E9(R1) addendum's definition of an estimand, we use our experience of conducting large Phase III tuberculosis treatment trials and our understanding of the estimand framework to identify the key decisions regarding how different event types are handled in the primary outcome definition, and the important points that should be considered in making such decisions. A key issue is the handling of intercurrent (i.e. post-randomisation) events (ICEs) which affect interpretation of or preclude measurement of the intended final outcome. We consider common ICEs including treatment changes and treatment extension, poor adherence to randomised treatment, re-infection with a new strain of tuberculosis which is different from the original infection, and death. We use two completed tuberculosis trials (REMoxTB and STREAM Stage 1) as illustrative examples. These trials tested non-inferiority of new tuberculosis treatment regimens versus a control regimen. The primary outcome was a binary composite endpoint, 'favourable' or 'unfavourable', which was constructed from several components. RESULTS We propose the following improvements in handling the above-mentioned ICEs and loss to follow-up (a post-randomisation event that is not in itself an ICE). First, changes to allocated regimens should not necessarily be viewed as an unfavourable outcome; from the patient perspective, the potential harms associated with a change in the regimen should instead be directly quantified. Second, handling poor adherence to randomised treatment using a per-protocol analysis does not necessarily target a clear estimand; instead, it would be desirable to develop ways to estimate the treatment effects more relevant to programmatic settings. Third, re-infection with a new strain of tuberculosis could be handled with different strategies, depending on whether the outcome of interest is the ability to attain culture negativity from infection with any strain of tuberculosis, or specifically the presenting strain of tuberculosis. Fourth, where possible, death could be separated into tuberculosis-related and non-tuberculosis-related and handled using appropriate strategies. Finally, although some losses to follow-up would result in early treatment discontinuation, patients lost to follow-up before the end of the trial should not always be classified as having an unfavourable outcome. Instead, loss to follow-up should be separated from not completing the treatment, which is an ICE and may be considered as an unfavourable outcome. CONCLUSION The estimand framework clarifies many issues in tuberculosis trials but also challenges trialists to justify and improve their outcome definitions. Future trialists should consider all the above points in defining their outcomes.
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Affiliation(s)
| | | | - James R Carpenter
- MRC Clinical Trials Unit at UCL, London, UK
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, UK
| | | | | | | | | | | | - Patrick PJ Phillips
- UCSF Center for Tuberculosis, University of California San Francisco, San Francisco, CA, USA
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21
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Cro S. Time to improve the clarity of clinical trial reports by including estimands. BMJ 2022; 378:o2108. [PMID: 36041772 DOI: 10.1136/bmj.o2108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Suzie Cro
- Imperial Clinical Trials Unit, School of Public Health, Imperial College London, London, UK
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22
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Fletcher C, Hefting N, Wright M, Bell J, Anzures-Cabrera J, Wright D, Lynggaard H, Schueler A. Marking 2-Years of New Thinking in Clinical Trials: The Estimand Journey. Ther Innov Regul Sci 2022; 56:637-650. [PMID: 35462609 PMCID: PMC9035309 DOI: 10.1007/s43441-022-00402-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Accepted: 04/04/2022] [Indexed: 11/30/2022]
Abstract
The ICH E9(R1) addendum on Estimands and Sensitivity Analyses in Clinical Trials has introduced a new estimand framework for the design, conduct, analysis, and interpretation of clinical trials. We share Pharmaceutical Industry experiences of implementing the estimand framework in the first two years since the final guidance became available with key lessons learned and highlight what else needs to be done to continue the journey in embedding the estimand framework in clinical trials. Emerging best practices and points to consider on strategies for implementing a new estimand thinking process are provided. Whilst much of the focus of implementing ICH E9(R1) to date has been on defining estimands, we highlight some of the important aspects relating to the choice of statistical analysis methods and sensitivity analyses to ensure estimands can be estimated robustly with minimal bias. In particular, we discuss the implications if complete follow-up is not possible when the treatment policy strategy is being used to handle intercurrent events. ICH E9(R1) was introduced just before the start of the COVID-19 pandemic, but a positive outcome from the pandemic has been an acceleration in the adoption of the estimand framework, including differentiating intercurrent events related or not related to the pandemic. In summary, much has been learned on the estimand journey and continued sharing of case studies will help to further advance the understanding and increase awareness across all clinical researchers of the estimand framework.
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Affiliation(s)
- C Fletcher
- Biostatistics, GlaxoSmithKline Plc, Stevenage, United Kingdom.
| | - N Hefting
- Clinical Development, Psychiatry, H. Lundbeck A/S, Valby, Denmark
| | - M Wright
- Analytics, Novartis Pharma AG, Basel, Switzerland
| | - J Bell
- Clinical Operations, Elderbrook Solutions GmbH, High Wycombe, United Kingdom
| | - J Anzures-Cabrera
- Data Sciences, Roche Products Ltd, Welywn Garden City, United Kingdom
| | - D Wright
- Statistical Innovation, DS&AI, BioPharma R&D, AstraZeneca, Cambridge, United Kingdom
| | - H Lynggaard
- Biostatistics, Data Science, Novo Nordisk A/S, Bagsværd, Denmark
| | - A Schueler
- Biostatistics, Epidemiology & Medical Writing, Merck Healthcare KGaA, Darmstadt, Germany
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