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Juffermans NP, Gözden T, Brohi K, Davenport R, Acker JP, Reade MC, Maegele M, Neal MD, Spinella PC. Transforming research to improve therapies for trauma in the twenty-first century. Crit Care 2024; 28:45. [PMID: 38350971 PMCID: PMC10865682 DOI: 10.1186/s13054-024-04805-6] [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: 12/31/2023] [Accepted: 01/11/2024] [Indexed: 02/15/2024] Open
Abstract
Improvements have been made in optimizing initial care of trauma patients, both in prehospital systems as well as in the emergency department, and these have also favorably affected longer term outcomes. However, as specific treatments for bleeding are largely lacking, many patients continue to die from hemorrhage. Also, major knowledge gaps remain on the impact of tissue injury on the host immune and coagulation response, which hampers the development of interventions to treat or prevent organ failure, thrombosis, infections or other complications of trauma. Thereby, trauma remains a challenge for intensivists. This review describes the most pressing research questions in trauma, as well as new approaches to trauma research, with the aim to bring improved therapies to the bedside within the twenty-first century.
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Affiliation(s)
- Nicole P Juffermans
- Department of Intensive Care, Erasmus Medical Center, Rotterdam, The Netherlands.
- Laboratory of Translational Intensive Care, Erasmus Medical Center, Rotterdam, The Netherlands.
| | - Tarik Gözden
- Laboratory of Translational Intensive Care, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Karim Brohi
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, London, UK
| | - Ross Davenport
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, London, UK
| | - Jason P Acker
- Canadian Blood Services, Innovation and Portfolio Management, Edmonton, AB, Canada
- Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, AB, Canada
| | - Michael C Reade
- Medical School, University of Queensland, Brisbane, QLD, Australia
- Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia
| | - Marc Maegele
- Department of Trauma and Orthopedic Surgery Cologne-Merheim Medical Center Institute of Research, Operative Medicine University Witten-Herdecke, Cologne, Germany
| | - Matthew D Neal
- Trauma and Transfusion Medicine Research Center, Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Philip C Spinella
- Trauma and Transfusion Medicine Research Center, Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
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2
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Chongwe G, Ali J, Kaye DK, Michelo C, Kass N. Ethics of Adaptive Designs for Randomized Controlled Trials. Ethics Hum Res 2023; 45:2-14. [PMID: 37777976 PMCID: PMC10739783 DOI: 10.1002/eahr.500178] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/03/2023]
Abstract
Over recent decades, adaptive trial designs have been used more and more often for clinical trials, including randomized controlled trials (RCTs). This rise in the use of adaptive RCTs has been accompanied by debates about whether such trials offer ethical and methodological advantages over traditional, fixed RCTs. This study examined how experts on clinical trial methods and ethics believe that adaptive RCTs, compared to fixed ones, affect the ethical character of clinical research. We conducted in-depth interviews with 17 researchers from bioethics, epidemiology, biostatistics, and/or medical backgrounds. While about half believed that adaptive trials are more complex and may thus threaten autonomy, these respondents also expressed that this challenge is not insurmountable. Most respondents expressed that efficiency and potential for participant benefit were the main justifications for adaptive trials. There was tension about whether adaptive randomization in response to increasing information disrupts clinical equipoise, with some respondents insisting that uncertainty still exists and therefore clinical equipoise is not disrupted. These findings suggest that further discussion is needed to increase the awareness and utility of these study designs.
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Affiliation(s)
- Gershom Chongwe
- School of Public Health, University of Zambia, Department
of Epidemiology and Biostatistics, Box 50110, Lusaka, Zambia
- Johns Hopkins University, Berman Institute of Bioethics,
1809 Ashland Avenue, Baltimore, MD, 21205, USA
- Tropical Diseases Research Centre, Box 71769, Ndola,
Zambia
| | - Joseph Ali
- Johns Hopkins University, Berman Institute of Bioethics,
1809 Ashland Avenue, Baltimore, MD, 21205, USA
| | - Daniel K. Kaye
- College of Health Sciences, Department of Obstetrics and
Gynaecology, Makerere University
| | - Charles Michelo
- School of Public Health, University of Zambia, Department
of Epidemiology and Biostatistics, Box 50110, Lusaka, Zambia
| | - Nancy Kass
- Johns Hopkins University, Berman Institute of Bioethics,
1809 Ashland Avenue, Baltimore, MD, 21205, USA
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3
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Robertson DS, Lee KM, López-Kolkovska BC, Villar SS. Response-adaptive randomization in clinical trials: from myths to practical considerations. Stat Sci 2023; 38:185-208. [PMID: 37324576 PMCID: PMC7614644 DOI: 10.1214/22-sts865] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
Response-Adaptive Randomization (RAR) is part of a wider class of data-dependent sampling algorithms, for which clinical trials are typically used as a motivating application. In that context, patient allocation to treatments is determined by randomization probabilities that change based on the accrued response data in order to achieve experimental goals. RAR has received abundant theoretical attention from the biostatistical literature since the 1930's and has been the subject of numerous debates. In the last decade, it has received renewed consideration from the applied and methodological communities, driven by well-known practical examples and its widespread use in machine learning. Papers on the subject present different views on its usefulness, and these are not easy to reconcile. This work aims to address this gap by providing a unified, broad and fresh review of methodological and practical issues to consider when debating the use of RAR in clinical trials.
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Affiliation(s)
- David S. Robertson
- MRC Biostatistics Unit, University of Cambridge, Forvie Site, Robinson Way, Cambridge CB2 0SR, United Kingdom
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4
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Wilson MG, Palmer E, Asselbergs FW, Harris SK. Integrated rapid-cycle comparative effectiveness trials using flexible point of care randomisation in electronic health record systems. J Biomed Inform 2023; 137:104273. [PMID: 36535604 DOI: 10.1016/j.jbi.2022.104273] [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: 05/10/2022] [Revised: 10/13/2022] [Accepted: 12/12/2022] [Indexed: 12/23/2022]
Abstract
Whilst the Randomised Controlled Trial remains the gold standard for deriving robust causal estimates of treatment efficacy, too often a traditional design proves prohibitively expensive or cumbersome when it comes to assessing questions regarding the comparative effectiveness of routinely used treatments. As a result, patients experience variation in practice as clinicians lack the evidence needed to personalise treatments effectively. This variation may be classified as unwarranted, where existing evidence is ignored, or legitimate where in the absence of evidence, clinicians rely on experience, expert opinion, and inferred principles from basic science to make decisions. We argue that within the right ethical and technological framework, legitimate variation can be transformed into a mechanism for evidence generation and learning. Learning Health Systems which harness existing variation in practice, represent a novel approach for generating evidence from everyday clinical practice. The development of these systems has gained traction due to the increased availability of modern Electronic Health Record Systems. However, despite their promise, overcoming hurdles to successfully integrating clinical trials within Learning Health Systems has proven challenging. This article describes the origins of integrated clinical trials and explores two main barriers to their further implementation - how best to obtain informed consent from patients to participate in routine comparative effectiveness research, and how to automate and integrate randomisation into a clinical workflow. Having described these barriers, we present a potential solution in the form of a research pipeline using a novel form of flexible point-of-care randomisation to allow clinicians and patients to participate in studies where there is clinical equipoise.
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Affiliation(s)
- Matthew G Wilson
- Institute of Health Informatics, Faculty of Population Health Sciences, University College London, UK.
| | - Edward Palmer
- Bloomsbury Institute of Intensive Care Medicine, University College London, UK; Whittington Hospital NHS Trust, UK
| | - Folkert W Asselbergs
- Institute of Cardiovascular Science and Institute of Health Informatics, Faculty of Population Health Sciences, University College London, UK; Department of Cardiology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands
| | - Steve K Harris
- Institute of Health Informatics, Faculty of Population Health Sciences, University College London, UK; Critical Care Department, University College London Hospital, UK
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5
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Grote T. Randomised controlled trials in medical AI: ethical considerations. JOURNAL OF MEDICAL ETHICS 2022; 48:899-906. [PMID: 33990429 DOI: 10.1136/medethics-2020-107166] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 03/30/2021] [Accepted: 04/08/2021] [Indexed: 06/12/2023]
Abstract
In recent years, there has been a surge of high-profile publications on applications of artificial intelligence (AI) systems for medical diagnosis and prognosis. While AI provides various opportunities for medical practice, there is an emerging consensus that the existing studies show considerable deficits and are unable to establish the clinical benefit of AI systems. Hence, the view that the clinical benefit of AI systems needs to be studied in clinical trials-particularly randomised controlled trials (RCTs)-is gaining ground. However, an issue that has been overlooked so far in the debate is that, compared with drug RCTs, AI RCTs require methodological adjustments, which entail ethical challenges. This paper sets out to develop a systematic account of the ethics of AI RCTs by focusing on the moral principles of clinical equipoise, informed consent and fairness. This way, the objective is to animate further debate on the (research) ethics of medical AI.
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Affiliation(s)
- Thomas Grote
- Ethics and Philosophy Lab, Cluster of Excellence "Machine Learning: New Perspectives for Science", University of Tübingen, Tübingen D-72076, Germany
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6
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Afolabi MO, Kelly LE. Non-static framework for understanding adaptive designs: an ethical justification in paediatric trials. JOURNAL OF MEDICAL ETHICS 2022; 48:825-831. [PMID: 34362828 PMCID: PMC9626916 DOI: 10.1136/medethics-2021-107263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Accepted: 06/25/2021] [Indexed: 06/13/2023]
Abstract
Many drugs used in paediatric medicine are off-label. There is a rising call for the use of adaptive clinical trial designs (ADs) in responding to the need for safe and effective drugs given their potential to offer efficiency and cost-effective benefits compared with traditional clinical trials. ADs have a strong appeal in paediatric clinical trials given the small number of available participants, limited understanding of age-related variability and the desire to limit exposure to futile or unsafe interventions. Although the ethical value of adaptive trials has increasingly come under scrutiny, there is a paucity of literature on the ethical dilemmas that may be associated with paediatric adaptive designs (PADs). This paper highlights some of these ethical concerns around safety, scientific/social value and caregiver/guardian comprehension of the trial design. Against this background, the paper develops a non-static conceptual lens for understanding PADs. It shows that ADs are epistemically open and reduce some of the knowledge-associated uncertainties inherent in clinical trials as well as fast-track the time to draw conclusions about the value of evaluated drugs/treatments. On this note, the authors argue that PADs are ethically justifiable given they (1) have multiple layers of safety, exposing enrolled children to lesser potential risks, (2) create social/scientific value generally and for paediatric populations in particular, (3) specifically foster the flourishing of paediatric populations and (4) can significantly improve paediatric trial efficiency when properly designed and implemented. However, because PADs are relatively new and their regulatory, ethical and logistical characteristics are yet to be clarified in some jurisdictions, the cooperation of various public and private stakeholders is required to ensure that the interests of children, their caregivers and parents/guardians are best served while exposing paediatric research subjects to the most minimal of risks when they are enrolled in paediatric trials that use ADs.
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Affiliation(s)
- Michael Os Afolabi
- Department of Pediatrics and Child Health, Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Lauren E Kelly
- Department of Pediatrics and Child Health, Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
- Children's Hospital Research Institute of Manitoba, Winnipeg, Manitoba, Canada
- George & Fay Yee Centre for Healthcare Innovation, Winnipeg, Manitoba, Canada
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7
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Wilson MG, Asselbergs FW, Miguel R, Brealey D, Harris SK. Embedded point of care randomisation for evaluating comparative effectiveness questions: PROSPECTOR-critical care feasibility study protocol. BMJ Open 2022; 12:e059995. [PMID: 36123103 PMCID: PMC9486229 DOI: 10.1136/bmjopen-2021-059995] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION Many routinely administered treatments lack evidence as to their effectiveness. When treatments lack evidence, patients receive varying care based on the preferences of clinicians. Standard randomised controlled trials are unsuited to comparisons of different routine treatment strategies, and there remains little economic incentive for change.Integrating clinical trial infrastructure into electronic health record systems offers the potential for routine treatment comparisons at scale, through reduced trial costs. To date, embedded trials have automated data collection, participant identification and eligibility screening, but randomisation and consent remain manual and therefore costly tasks.This study will investigate the feasibility of using computer prompts to allow flexible randomisation at the point of clinical decision making. It will compare the effectiveness of two prompt designs through the lens of a candidate research question-comparing liberal or restrictive magnesium supplementation practices for critical care patients. It will also explore the acceptability of two consent models for conducting comparative effectiveness research. METHODS AND ANALYSIS We will conduct a single centre, mixed-methods feasibility study, aiming to recruit 50 patients undergoing elective surgery requiring postoperative critical care admission. Participants will be randomised to either 'Nudge' or 'Preference' designs of electronic point-of-care randomisation prompt, and liberal or restrictive magnesium supplementation.We will judge feasibility through a combination of study outcomes. The primary outcome will be the proportion of prompts displayed resulting in successful randomisation events (compliance with the allocated magnesium strategy). Secondary outcomes will evaluate the acceptability of both prompt designs to clinicians and ascertain the acceptability of pre-emptive and opt-out consent models to patients. ETHICS AND DISSEMINATION This study was approved by Riverside Research Ethics Committee (Ref: 21/LO/0785) and will be published on completion. TRIAL REGISTRATION NUMBER NCT05149820.
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Affiliation(s)
- Matthew G Wilson
- Institute of Health Informatics, University College London, London, UK
| | - Folkert W Asselbergs
- Institute of Health Informatics, University College London, London, UK
- Department of Cardiology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Ruben Miguel
- Clinical Research Informatics Unit, Institute of Health Informatics, University College London, London, UK
| | - David Brealey
- Bloomsbury Institute for Intensive Care Medicine, University College London, London, UK
- Critical Care Department, University College London Hospitals NHS Foundation Trust, London, UK
| | - Steve K Harris
- Institute of Health Informatics, University College London, London, UK
- Critical Care Department, University College London Hospitals NHS Foundation Trust, London, UK
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8
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Tolles J, Beiling M, Schreiber MA, Del Junco DJ, McMullan JT, Guyette FX, Wang H, Jansen JO, Meurer WJ, Mainali S, Yadav K, Lewis RJ. An adaptive platform trial for evaluating treatments in patients with life-threatening hemorrhage from traumatic injuries: Rationale and proposal. Transfusion 2022; 62 Suppl 1:S231-S241. [PMID: 35732508 DOI: 10.1111/trf.16957] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Revised: 04/29/2022] [Accepted: 05/04/2022] [Indexed: 11/30/2022]
Affiliation(s)
- Juliana Tolles
- Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, California, USA.,Department of Emergency Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California, USA.,Berry Consultants, LLC, Austin, Texas, USA
| | - Marissa Beiling
- Division of Trauma, Critical Care & Acute Care Surgery, Department of Surgery, Oregon Health & Science University, Portland, Oregon, USA
| | - Martin A Schreiber
- Division of Trauma, Critical Care & Acute Care Surgery, Department of Surgery, Oregon Health & Science University, Portland, Oregon, USA
| | - Deborah J Del Junco
- Joint Trauma System, Defense Health Agency, Joint Base San Antonio Fort Sam Houston, San Antonio, Texas, USA.,Department of Emergency Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Jason T McMullan
- Department of Emergency Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Francis X Guyette
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Henry Wang
- Department of Emergency Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Jan O Jansen
- Center for Injury Science, University of Alabama at Birmingham, Birmingham, Alabama, USA.,Division of Trauma & Acute Care Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - William J Meurer
- Berry Consultants, LLC, Austin, Texas, USA.,Department of Emergency Medicine, University of Michigan, Ann Arbor, Michigan, USA.,Department of Neurology, University of Michigan, Ann Arbor, Michigan, USA
| | - Shraddha Mainali
- Department of Neurology, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Kabir Yadav
- Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, California, USA.,Department of Emergency Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Roger J Lewis
- Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, California, USA.,Department of Emergency Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California, USA.,Berry Consultants, LLC, Austin, Texas, USA
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9
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Harris S, Bonnici T, Keen T, Lilaonitkul W, White MJ, Swanepoel N. Clinical deployment environments: Five pillars of translational machine learning for health. Front Digit Health 2022; 4:939292. [PMID: 36060542 PMCID: PMC9437594 DOI: 10.3389/fdgth.2022.939292] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Accepted: 07/25/2022] [Indexed: 01/14/2023] Open
Abstract
Machine Learning for Health (ML4H) has demonstrated efficacy in computer imaging and other self-contained digital workflows, but has failed to substantially impact routine clinical care. This is no longer because of poor adoption of Electronic Health Records Systems (EHRS), but because ML4H needs an infrastructure for development, deployment and evaluation within the healthcare institution. In this paper, we propose a design pattern called a Clinical Deployment Environment (CDE). We sketch the five pillars of the CDE: (1) real world development supported by live data where ML4H teams can iteratively build and test at the bedside (2) an ML-Ops platform that brings the rigour and standards of continuous deployment to ML4H (3) design and supervision by those with expertise in AI safety (4) the methods of implementation science that enable the algorithmic insights to influence the behaviour of clinicians and patients and (5) continuous evaluation that uses randomisation to avoid bias but in an agile manner. The CDE is intended to answer the same requirements that bio-medicine articulated in establishing the translational medicine domain. It envisions a transition from "real-world" data to "real-world" development.
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Affiliation(s)
- Steve Harris
- Institute of Health Informatics, University College London, London, United Kingdom
- Department of Critical Care, University College London Hospital, London, United Kingdom
- Correspondence: Steve Harris
| | - Tim Bonnici
- Institute of Health Informatics, University College London, London, United Kingdom
- Department of Critical Care, University College London Hospital, London, United Kingdom
| | - Thomas Keen
- Institute of Health Informatics, University College London, London, United Kingdom
| | - Watjana Lilaonitkul
- Institute of Health Informatics, University College London, London, United Kingdom
| | - Mark J. White
- Digital Healthcare, University College London Hospital, London, United Kingdom
| | - Nel Swanepoel
- Centre for Advanced Research Computing, University College London, London, United Kingdom
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10
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Shah SK, London AJ, Mofenson L, Lavery JV, John-Stewart G, Flynn P, Theron G, Bangdiwala SI, Moodley D, Chinula L, Fairlie L, Sekoto T, Kakhu TJ, Violari A, Dadabhai S, McCarthy K, Fowler MG. Ethically designing research to inform multidimensional, rapidly evolving policy decisions: Lessons learned from the PROMISE HIV Perinatal Prevention Trial. Clin Trials 2021; 18:681-689. [PMID: 34524048 DOI: 10.1177/17407745211045734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Research in rapidly evolving policy contexts can lead to the following ethical challenges for sponsors and researchers: the study's standard of care can become different than what patients outside the study receive, there may be political or other pressure to move ahead with unproven interventions, and new findings or revised policies may decrease the relevance of ongoing studies. These ethical challenges are considerable, but not unprecedented. In this article, we review the case of a multinational, randomized, controlled perinatal HIV prevention trial, the "PROMISE" (Promoting Maternal Infant Survival Everywhere) study. PROMISE compared the relative efficacy and safety of interventions to prevent mother to child transmission of HIV. The sponsor engaged an independent international ethics panel to address controversy about the study's standard of care and relevance as national and international guidelines changed. This ethics panel concluded that continuing the PROMISE trial as designed was ethically permissible because: (1) participants in all arms received interventions that were effective, and there was insufficient evidence about whether one intervention was more effective or safer than the other, and (2) data from PROMISE could be useful for a diverse range of stakeholders. In general, trials designed to inform rapidly evolving policy issues should develop mechanisms to revisit social value while recognizing that the value of research varies for diverse stakeholders with legitimate reasons to weigh evidence differently. We conclude by providing four reasons that trials may depart from the standard of care after a change in policy, while remaining ethically justifiable, and by suggesting how to improve existing trial oversight mechanisms to address evolving social value.
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Affiliation(s)
- Seema K Shah
- Department of Pediatrics, Northwestern Feinberg School of Medicine, Mary Ann & J. Milburn Smith Child Health Outcomes, Research, and Evaluation (SCHORE) Center, Stanley Manne Children's Research Institute, Lurie Children's Hospital, Northwestern Pritzker School of Law, by courtesy, Chicago, IL, USA
| | - Alex John London
- Center for Ethics and Policy, Carnegie Mellon University, Pittsburgh, PA, USA
| | - Lynne Mofenson
- Elizabeth Glaser Pediatric AIDS Foundation, Washington, DC, USA
| | - James V Lavery
- Global Health Ethics, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | | | - Patricia Flynn
- Department of Infectious Diseases, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Gerhard Theron
- Department of Obstetrics and Gynaecology, Stellenbosch University, Cape Town, South Africa
| | | | - Dhayendre Moodley
- Centre for AIDS Research in South Africa and Department of Obstetrics and Gynecology, School of Clinical Medicine, University of KwaZulu Natal, Durban, South Africa
| | | | - Lee Fairlie
- Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, Johannesburg, South Africa
| | - Tumalano Sekoto
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Tebogo J Kakhu
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Avy Violari
- Perinatal HIV Research Unit, University of the Witwatersrand, Johannesburg, Johannesburg, South Africa
| | - Sufia Dadabhai
- Johns Hopkins Bloomberg School of Public Health, Blantyre, Malawi
| | | | - Mary Glenn Fowler
- Johns Hopkins University Research Collaboration, Makerere University, Kampala, Uganda
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11
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Sim J. Distinctive aspects of consent in pilot and feasibility studies. J Eval Clin Pract 2021; 27:657-664. [PMID: 33734529 DOI: 10.1111/jep.13556] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2020] [Revised: 01/21/2021] [Accepted: 02/24/2021] [Indexed: 11/29/2022]
Abstract
Prior to a main randomized clinical trial, investigators often carry out a pilot or feasibility study in order to test certain trial processes or estimate key statistical parameters, so as to optimize the design of the main trial and/or determine whether it can feasibly be run. Pilot studies reflect the design of the intended main trial, whereas feasibility studies may not do so, and may not involve allocation to different treatments. Testing relative clinical effectiveness is not considered an appropriate aim of pilot or feasibility studies. However, consent is no less important than in a main trial as a means of morally legitimizing the investigator's actions. Two misperceptions are central to consent in clinical studies-therapeutic misconception (a tendency to conflate research and therapy) and therapeutic misestimation (a tendency to overestimate possible benefits and/or underestimate possible harms associated with participation). These phenomena may take a distinctive form in pilot and feasibility studies, owing to potential participants' likely prior unfamiliarity with the nature and purposes of such studies. Thus, participants may confuse the aims of a pilot or feasibility study (developing or optimizing trial design and processes) with those of a main trial (testing treatment effectiveness) and base consent on this misconstrual. Similarly, a misunderstanding of the ability of pilot and feasibility studies to provide information that will inform clinical care, or the underdeveloped nature of interventions included in such studies, may lead to inaccurate assessments of the objective possibility of benefit, and weaken the epistemic basis of consent accordingly. Equipoise may also be particularly challenging to grasp in the context of a pilot study. The consent process in pilot and feasibility studies requires a particular focus, and careful communication, if it is to carry the appropriate moral weight. There are corresponding implications for the process of ethical approval.
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Affiliation(s)
- Julius Sim
- School of Medicine, Keele University, Staffordshire, UK
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12
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Lee KM, Brown LC, Jaki T, Stallard N, Wason J. Statistical consideration when adding new arms to ongoing clinical trials: the potentials and the caveats. Trials 2021; 22:203. [PMID: 33691748 PMCID: PMC7944243 DOI: 10.1186/s13063-021-05150-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Accepted: 02/24/2021] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Platform trials improve the efficiency of the drug development process through flexible features such as adding and dropping arms as evidence emerges. The benefits and practical challenges of implementing novel trial designs have been discussed widely in the literature, yet less consideration has been given to the statistical implications of adding arms. MAIN: We explain different statistical considerations that arise from allowing new research interventions to be added in for ongoing studies. We present recent methodology development on addressing these issues and illustrate design and analysis approaches that might be enhanced to provide robust inference from platform trials. We also discuss the implication of changing the control arm, how patient eligibility for different arms may complicate the trial design and analysis, and how operational bias may arise when revealing some results of the trials. Lastly, we comment on the appropriateness and the application of platform trials in phase II and phase III settings, as well as publicly versus industry-funded trials. CONCLUSION Platform trials provide great opportunities for improving the efficiency of evaluating interventions. Although several statistical issues are present, there are a range of methods available that allow robust and efficient design and analysis of these trials.
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Affiliation(s)
- Kim May Lee
- MRC Biostatistics Unit, School of Clinical Medicine, University of Cambridge, Cambridge, CB2 0SR, UK.
- Pragmatic Clinical Trials Unit, Queen Mary University of London, Yvonne Carter Building, 58 Turner Street, London, E1 2AB, UK.
| | - Louise C Brown
- MRC Clinical Trials Unit, University College London, 90 High Holborn 2nd Floor, London, WC1V 6LJ, UK
| | - Thomas Jaki
- MRC Biostatistics Unit, School of Clinical Medicine, University of Cambridge, Cambridge, CB2 0SR, UK
- Medical and Pharmaceutical Statistics Research Unit, Department of Mathematics and Statistics, Lancaster University, Lancaster, UK
| | - Nigel Stallard
- Statistics and Epidemiology, Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, CV4 7AL, UK
| | - James Wason
- MRC Biostatistics Unit, School of Clinical Medicine, University of Cambridge, Cambridge, CB2 0SR, UK
- Population Health Sciences Institute, Baddiley-Clark Building, Newcastle University, Richardson Road, Newcastle upon Tyne, UK
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13
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May Lee K, Lee JJ. Evaluating Bayesian adaptive randomization procedures with adaptive clip methods for multi-arm trials. Stat Methods Med Res 2021; 30:1273-1287. [DOI: 10.1177/0962280221995961] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Bayesian adaptive randomization is a heuristic approach that aims to randomize more patients to the putatively superior arms based on the trend of the accrued data in a trial. Many statistical aspects of this approach have been explored and compared with other approaches; yet only a limited number of works has focused on improving its performance and providing guidance on its application to real trials. An undesirable property of this approach is that the procedure would randomize patients to an inferior arm in some circumstances, which has raised concerns in its application. Here, we propose an adaptive clip method to rectify the problem by incorporating a data-driven function to be used in conjunction with Bayesian adaptive randomization procedure. This function aims to minimize the chance of assigning patients to inferior arms during the early time of the trial. Moreover, we propose a utility approach to facilitate the selection of a randomization procedure. A cost that reflects the penalty of assigning patients to the inferior arm(s) in the trial is incorporated into our utility function along with all patients benefited from the trial, both within and beyond the trial. We illustrate the selection strategy for a wide range of scenarios.
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Affiliation(s)
- Kim May Lee
- MRC Biostatistics Unit, University of Cambridge, Cambridge, UK
| | - J Jack Lee
- University of Texas MD Anderson Cancer Center, Houston, TX, USA
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14
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Burnett T, Mozgunov P, Pallmann P, Villar SS, Wheeler GM, Jaki T. Adding flexibility to clinical trial designs: an example-based guide to the practical use of adaptive designs. BMC Med 2020; 18:352. [PMID: 33208155 PMCID: PMC7677786 DOI: 10.1186/s12916-020-01808-2] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 10/07/2020] [Indexed: 12/18/2022] Open
Abstract
Adaptive designs for clinical trials permit alterations to a study in response to accumulating data in order to make trials more flexible, ethical, and efficient. These benefits are achieved while preserving the integrity and validity of the trial, through the pre-specification and proper adjustment for the possible alterations during the course of the trial. Despite much research in the statistical literature highlighting the potential advantages of adaptive designs over traditional fixed designs, the uptake of such methods in clinical research has been slow. One major reason for this is that different adaptations to trial designs, as well as their advantages and limitations, remain unfamiliar to large parts of the clinical community. The aim of this paper is to clarify where adaptive designs can be used to address specific questions of scientific interest; we introduce the main features of adaptive designs and commonly used terminology, highlighting their utility and pitfalls, and illustrate their use through case studies of adaptive trials ranging from early-phase dose escalation to confirmatory phase III studies.
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Affiliation(s)
- Thomas Burnett
- Department of Mathematics and Statistics, Lancaster University, Fylde College, Lancaster, LA1 4YF UK
| | - Pavel Mozgunov
- Department of Mathematics and Statistics, Lancaster University, Fylde College, Lancaster, LA1 4YF UK
| | - Philip Pallmann
- Centre for Trials Research, College of Biomedical & Life Sciences, Cardiff University, Cardiff, UK
| | - Sofia S. Villar
- MRC Biostatistics Unit, University of Cambridge School of Clinical Medicine, Cambridge Institute of Public Health, Forvie Site, Robinson Way, Cambridge Biomedical Campus, Cambridge, CB2 0SR UK
| | - Graham M. Wheeler
- Cancer Research UK & UCL Cancer Trials Centre, University College London, 90 Tottenham Court Road, London, W1T 4TJ UK
| | - Thomas Jaki
- Department of Mathematics and Statistics, Lancaster University, Fylde College, Lancaster, LA1 4YF UK
- MRC Biostatistics Unit, University of Cambridge School of Clinical Medicine, Cambridge Institute of Public Health, Forvie Site, Robinson Way, Cambridge Biomedical Campus, Cambridge, CB2 0SR UK
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15
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Dudi-Venkata NN, Wells CI. Changing landscape of surgical research: a trainee perspective. ANZ J Surg 2020; 90:2173-2174. [PMID: 33200523 DOI: 10.1111/ans.16085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Revised: 05/31/2020] [Accepted: 06/01/2020] [Indexed: 11/29/2022]
Affiliation(s)
- Nagendra N Dudi-Venkata
- South Australian Trainees Audit and Research Collaborative (STARC), Clinical Trials Network ANZ (CTANZ) Working Party Trainee Lead, Adelaide, South Australia, Australia.,Discipline of Surgery, Faculty of Health and Medical Sciences, School of Medicine, The University of Adelaide, Adelaide, South Australia, Australia
| | - Cameron I Wells
- Department of Surgery, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand.,Trials and Audit in Surgery by Medical Students in Australia and New Zealand (TASMAN) Collaborative, Auckland, New Zealand
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16
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Paul NW. [Studies on novel immune therapies: challenges from an ethical point of view]. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2020; 63:1424-1430. [PMID: 33067664 PMCID: PMC7647972 DOI: 10.1007/s00103-020-03232-6] [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: 05/08/2020] [Accepted: 09/29/2020] [Indexed: 11/23/2022]
Abstract
Neue Immuntherapien werden aufgrund der immer weiter reichenden molekularen Differenzierung von Erkrankungsmustern immer häufiger in sogenannten adaptiven, also fortlaufend an Ergebnisse angepassten Studiendesigns (Umbrella- oder Basket-Studien beziehungsweise Plattformstudien) klinisch erprobt. Der hier vorgelegte Beitrag diskutiert diese Studiendesigns jenseits der Feststellung von Regulierungsbedarf, um ausgehend von typischen Strukturmerkmalen ethische Probleme zu identifizieren und – wo möglich – Lösungsvorschläge zu machen. Neben dem Verhältnis von wissenschaftlichen und sozialen Werten in klinischen Studien werden insbesondere die wissenschaftliche Validität von Evidenz, Fragen des Einschlusses von Studienteilnehmern unter der Bedingung von relativer Unsicherheit, spezifische Herausforderungen für die ethische Bewertung adaptiver Studien sowie die ethischen und praktischen Herausforderungen im Bereich der Patientenaufklärung und -einwilligung in den Blick genommen.
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Affiliation(s)
- Norbert W Paul
- Institut für Geschichte, Theorie und Ethik der Medizin, Universitätsmedizin Mainz, Am Pulverturm 13, 55131, Mainz, Deutschland.
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17
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Opinion: It's ethical to test promising coronavirus vaccines against less-promising ones. Proc Natl Acad Sci U S A 2020; 117:18898-18901. [PMID: 32699147 DOI: 10.1073/pnas.2014154117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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18
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Crippa A, De Laere B, Discacciati A, Larsson B, Connor JT, Gabriel EE, Thellenberg C, Jänes E, Enblad G, Ullen A, Hjälm-Eriksson M, Oldenburg J, Ost P, Lindberg J, Eklund M, Grönberg H. The ProBio trial: molecular biomarkers for advancing personalized treatment decision in patients with metastatic castration-resistant prostate cancer. Trials 2020; 21:579. [PMID: 32586393 PMCID: PMC7318749 DOI: 10.1186/s13063-020-04515-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Accepted: 06/15/2020] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Multiple therapies exist for patients with metastatic castration-resistant prostate cancer (mCRPC). However, their improvement on progression-free survival (PFS) remains modest, potentially explained by tumor molecular heterogeneity. Several prognostic molecular biomarkers have been identified for mCRPC that may have predictive potential to guide treatment selection and prolong PFS. We designed a platform trial to test this hypothesis. METHODS The Prostate-Biomarker (ProBio) study is a multi-center, outcome-adaptive, multi-arm, biomarker-driven platform trial for tailoring treatment decisions for men with mCRPC. Treatment decisions in the experimental arms are based on biomarker signatures defined as mutations in certain genes/pathways suggested in the scientific literature to be important for treatment response in mCRPC. The biomarker signatures are determined by targeted sequencing of circulating tumor and germline DNA using a panel specifically designed for mCRPC. DISCUSSION Patients are stratified based on the sequencing results and randomized to either current clinical practice (control), where the treating physician decides treatment, or to molecularly driven treatment selection based on the biomarker profile. Outcome-adaptive randomization is implemented to early identify promising treatments for a biomarker signature. Biomarker signature-treatment combinations graduate from the platform when they demonstrate 85% probability of improving PFS compared to the control arm. Graduated combinations are further evaluated in a seamless confirmatory trial with fixed randomization. The platform design allows for new drugs and biomarkers to be introduced in the study. CONCLUSIONS The ProBio design allows promising treatment-biomarker combinations to quickly graduate from the platform and be confirmed for rapid implementation in clinical care. TRIAL REGISTRATION ClinicalTrials.gov Identifier NCT03903835. Date of registration: April 4, 2019. Status: Recruiting.
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Affiliation(s)
- Alessio Crippa
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden.
| | - Bram De Laere
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
- Department of Human Structure and Repair, Ghent University, Ghent, Belgium
| | - Andrea Discacciati
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Berit Larsson
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Jason T Connor
- University of Central Florida College of Medicine, Orlando, FL, USA
- Confluence Stat LLC, Orlando, FL, USA
| | - Erin E Gabriel
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Camilla Thellenberg
- Department of Radiation Sciences and Oncology, Umeå University, Umeå, Sweden
| | - Elin Jänes
- Länssjukhuset Sundsvall Härnösand, Sundsvall, Sweden
| | - Gunilla Enblad
- Department of Immunology, Genetics and Pathology, Uppsala Universitet, Uppsala, Sweden
| | - Anders Ullen
- Department of Oncology-Pathology, Karolinska Institutet, Stockholm, Sweden
| | | | - Jan Oldenburg
- Division of Medicine, University of Oslo, Oslo, Norway
| | - Piet Ost
- Department of Radiotherapy and Experimental Cancer Research, Ghent University, Ghent, Belgium
| | - Johan Lindberg
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Martin Eklund
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Henrik Grönberg
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
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19
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Hoffer LJ. Understanding Equipoise. Nutr Clin Pract 2020; 35:495-498. [PMID: 32347586 DOI: 10.1002/ncp.10492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Accepted: 12/10/2020] [Indexed: 11/07/2022] Open
Affiliation(s)
- L John Hoffer
- Lady Davis Institute for Medical Research, Jewish General Hospital, McGill University, Montreal, Quebec, Canada
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20
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Viele K, Saville BR, McGlothlin A, Broglio K. Comparison of response adaptive randomization features in multiarm clinical trials with control. Pharm Stat 2020; 19:602-612. [DOI: 10.1002/pst.2015] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Revised: 01/27/2020] [Accepted: 03/02/2020] [Indexed: 12/27/2022]
Affiliation(s)
- Kert Viele
- Berry Consultants Austin Texas USA
- Department of Biostatistics University of Kentucky Lexington Kentucky USA
| | - Benjamin R. Saville
- Berry Consultants Austin Texas USA
- Department of Biostatistics Vanderbilt University Nashville Tennessee USA
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21
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Scobie S, Castle‐Clarke S. Implementing learning health systems in the UK NHS: Policy actions to improve collaboration and transparency and support innovation and better use of analytics. Learn Health Syst 2019; 4:e10209. [PMID: 31989031 PMCID: PMC6971118 DOI: 10.1002/lrh2.10209] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Revised: 09/25/2019] [Accepted: 10/31/2019] [Indexed: 11/10/2022] Open
Abstract
Learning health systems (LHS) use digital health and care data to improve care, shorten the timeframe of improvement projects, and ensure these are based on real-world data. In the United Kingdom, policymakers are depending on digital innovation, driven by better use of data about current health service performance, to enable service transformation and a more sustainable health system. This paper examines what would be needed to develop LHS in the United Kingdom, considering national policy implications and actions, which local organisations and health systems could take. The paper draws on a seminar attended by academics, policymakers, and practitioners, a brief literature review, and feedback from policy experts and National Health Service (NHS) stakeholders. Although there are examples of some aspects of LHS in the UK NHS, it is hard to find examples where there is a continuous cycle of improvement driven by information and where analysis of data and implementing improvements is part of usual ways of working. The seminar and literature identified a number of barriers. Incentives and capacity to develop LHS are limited, and requires a shift in analytic capacity from regulation and performance, to quality improvement and transformation. The balance in priority given to research compared with implementation also needs to change. Policy initiatives are underway which address some barriers, including building analytical capacity, developing infrastructure, and data standards. The NHS and research partners are investing in infrastructure which could support LHS, although clinical buy in is needed to bring about improvement or address operational challenges. We identify a number of opportunities for local NHS organisations and systems to make better use of health data, and for ways that national policy could promote the collaboration and greater use of analytics which underpin the LHS concept.
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22
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King BT, Lawrence PD, Milling TJ, Warach SJ. Optimal delay time to initiate anticoagulation after ischemic stroke in atrial fibrillation (START): Methodology of a pragmatic, response-adaptive, prospective randomized clinical trial. Int J Stroke 2019; 14:977-982. [PMID: 31423922 PMCID: PMC7401695 DOI: 10.1177/1747493019870651] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
RATIONALE An estimated 15% of all strokes are associated with untreated atrial fibrillation. Long-term secondary stroke prevention in atrial fibrillation is anticoagulation, increasingly with non-vitamin K oral anticoagulants. The optimal time to initiate anticoagulation following an atrial fibrillation-related stroke that balances hemorrhagic conversion with recurrent stroke is not yet known. AIMS To determine if there is an optimal delay time to initiate anticoagulation after atrial fibrillation-related stroke that optimizes the composite outcome of hemorrhagic conversion and recurrent ischemic stroke. SAMPLE SIZE ESTIMATES The study will enroll 1500 total subjects split between a mild to moderate stroke cohort (1000) and a severe stroke cohort (500). METHODS AND DESIGN This study is a multi-center, prospective, randomized, pragmatic, adaptive trial that randomizes subjects to four arms of time to start of anticoagulation. The four arms for mild to moderate stroke are: Day 3, Day 6, Day 10, and Day 14. The time intervals for severe stroke are: Day 6, Day 10, Day 14, and Day 21. Allocation involves a response adaptive randomization via interim analyses to favor the arms that have a better risk-benefit profile. STUDY OUTCOMES The primary outcome event is the composite occurrence of an ischemic or hemorrhagic event within 30 days of the index stroke. Secondary outcomes are also collected at 30 and 90 days. DISCUSSION The optimal timing of direct oral anticoagulants post-ischemic stroke requires prospective randomized testing. A pragmatically designed trial with adaptive allocation and randomization to multiple time intervals such as the START trial is best suited to answer this question in order to directly inform current practice on this question.
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Affiliation(s)
- Benjamin T King
- Department of Neurology, University of Texas Dell Medical School, Austin, TX, USA
| | - Patrick D Lawrence
- Department of Neurology, University of Texas Dell Medical School, Austin, TX, USA
| | - Truman J Milling
- Department of Neurology, University of Texas Dell Medical School, Austin, TX, USA
- Seton Healthcare Family, Austin, TX, USA
- Department of Surgery and Perioperative Care, University of Texas Dell Medical School, Austin, TX, USA
| | - Steven J Warach
- Department of Neurology, University of Texas Dell Medical School, Austin, TX, USA
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23
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Viele K, Broglio K, McGlothlin A, Saville BR. Comparison of methods for control allocation in multiple arm studies using response adaptive randomization. Clin Trials 2019; 17:52-60. [PMID: 31630567 DOI: 10.1177/1740774519877836] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND/AIMS Response adaptive randomization has many polarizing properties in two-arm settings comparing control to a single treatment. The generalization of these features to the multiple arm setting has been less explored, and existing comparisons in the literature reach disparate conclusions. We investigate several generalizations of two-arm response adaptive randomization methods relating to control allocation in multiple arm trials, exploring how critiques of response adaptive randomization generalize to the multiple arm setting. METHODS We perform a simulation study to investigate multiple control allocation schemes within response adaptive randomization, comparing the designs on metrics such as power, arm selection, mean square error, and the treatment of patients within the trial. RESULTS The results indicate that the generalization of two-arm response adaptive randomization concerns is variable and depends on the form of control allocation employed. The concerns are amplified when control allocation may be reduced over the course of the trial but are mitigated in the methods considered when control allocation is maintained or increased during the trial. In our chosen example, we find minimal advantage to increasing, as opposed to maintaining, control allocation; however, this result reflects an extremely limited exploration of methods for increasing control allocation. CONCLUSION Selection of control allocation in multiple arm response adaptive randomization has a large effect on the performance of the design. Some disparate comparisons of response adaptive randomization to alternative paradigms may be partially explained by these results. In future comparisons, control allocation for multiple arm response adaptive randomization should be chosen to keep in mind the appropriate match between control allocation in response adaptive randomization and the metric or metrics of interest.
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Affiliation(s)
| | | | | | - Benjamin R Saville
- Berry Consultants LLC, Austin, TX, USA.,Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, TN, USA
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24
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Adaptive platform trials: definition, design, conduct and reporting considerations. Nat Rev Drug Discov 2019; 18:797-807. [DOI: 10.1038/s41573-019-0034-3] [Citation(s) in RCA: 141] [Impact Index Per Article: 28.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/25/2019] [Indexed: 11/08/2022]
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London AJ, Kimmelman J. Clinical Trial Portfolios: A Critical Oversight in Human Research Ethics, Drug Regulation, and Policy. Hastings Cent Rep 2019; 49:31-41. [DOI: 10.1002/hast.1034] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Sim J. Outcome-adaptive randomization in clinical trials: issues of participant welfare and autonomy. THEORETICAL MEDICINE AND BIOETHICS 2019; 40:83-101. [PMID: 30778720 PMCID: PMC6478640 DOI: 10.1007/s11017-019-09481-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Outcome-adaptive randomization (OAR) has been proposed as a corrective to certain ethical difficulties inherent in the traditional randomized clinical trial (RCT) using fixed-ratio randomization. In particular, it has been suggested that OAR redresses the balance between individual and collective ethics in favour of the former. In this paper, I examine issues of welfare and autonomy arising in relation to OAR. A central issue in discussions of welfare in OAR is equipoise, and the moral status of OAR is crucially influenced by the way in which this concept is construed. If OAR is based on a model of equipoise that demands strict indifference between competing interventions throughout the trial, such equipoise is disturbed by accruing data favouring one treatment over another; OAR seeks to redress this by weighting randomization to the seemingly superior treatment. However, this is a partial response, as patients continue to be allocated to the inferior therapy. Moreover, it rests upon considerations of aggregate harms and benefits, and does not therefore uphold individual ethics. Issues of fairness also arise, as early and late enrollees are randomized on a different basis. Fixed-ratio randomization represents a fuller and more consistent response to a loss of equipoise, as so construed. With regard to consent, the complexity of OAR poses challenges to adequate disclosure and comprehension. Additionally, OAR does not offer a remedy to the therapeutic misconception-participants' tendency to attribute treatment allocation in an RCT to individual clinical judgments, rather than to scientific considerations-and, if anything, accentuates rather than alleviates this misconception. In relation to these issues, OAR fails to offer ethical advantages over fixed-ratio randomization. More broadly, the ethical basis of OAR can be seen to lie more in collective than in individual ethics, and overall it fares worse in this territory than fixed-ratio randomization.
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Affiliation(s)
- Julius Sim
- Institute for Primary Care and Health Sciences, Keele University, Staffordshire, ST5 5BG, UK.
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27
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Dibao-Dina C, Caille A, Giraudeau B. Heterogeneous perception of the ethical legitimacy of unbalanced randomization by institutional review board members: a clinical vignette-based survey. Trials 2018; 19:440. [PMID: 30107812 PMCID: PMC6092831 DOI: 10.1186/s13063-018-2822-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2018] [Accepted: 07/27/2018] [Indexed: 12/03/2022] Open
Abstract
Background Institutional review boards must guarantee the ethical acceptability of a randomized controlled trial before it is conducted. However, some may regard an unbalanced randomization ratio as reflecting an absence of uncertainty between the groups being compared. The objective was to assess institutional review board members’ perceptions of whether unbalanced randomization in randomized controlled trials is justified and ethically acceptable. Methods Institutional review board members worldwide completed a survey involving clinical vignettes modeling situations classically advocated to explain the use of unbalanced randomization. Institutional review board members were asked whether unbalanced randomization was justified and ethically sound. Answers were collected by using visual analog scales. Data were analyzed by principal component analysis, and a hierarchical ascending classification was created. Verbatim answers were assessed by qualitative content analysis. Results We analyzed responses from 148 institutional review board members. Three classes of respondents were identified: class 1 (n = 58; 39.2%), mostly skeptics who disagreed with unbalanced randomization, whatever the justification; class 2 (n = 46; 31.1%), believers who considered that unbalanced randomization was acceptable whatever the justification, except cost; and class 3 (n = 44; 29.7%), circumstantial believers for whom unbalanced randomization may be justified for methodological and safety issues but not cost or ethical issues. When institutional review board members were asked whether unbalanced randomization respected the equipoise principle, the mean quotation was low (4.5 ± 3.3 out of 10), especially for class 1 members. Conclusions Institutional review board members perceive unbalanced randomization heterogeneously in terms of its justification and its ethical validity. Electronic supplementary material The online version of this article (10.1186/s13063-018-2822-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Clarisse Dibao-Dina
- Université de Tours, Université de Nantes, INSERM, SPHERE U1246, Tours, France. .,Département Universitaire de Médecine Générale, Faculté de Médecine - Université de Tours, 10 Boulevard Tonnellé, B.P. 3223, 37044, Tours, cedex 1, France.
| | - Agnès Caille
- Université de Tours, Université de Nantes, INSERM, SPHERE U1246, CHRU, CIC 1415, Tours, France
| | - Bruno Giraudeau
- Université de Tours, Université de Nantes, INSERM, SPHERE U1246, CHRU, CIC 1415, Tours, France
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London AJ, Omotade OO, Mello MM, Keusch GT. Ethics of randomized trials in a public health emergency. PLoS Negl Trop Dis 2018; 12:e0006313. [PMID: 29771907 PMCID: PMC5957337 DOI: 10.1371/journal.pntd.0006313] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Affiliation(s)
- Alex John London
- Department of Philosophy, Carnegie Mellon University, Pittsburgh, Pennsylvania, United States of America
| | | | - Michelle M. Mello
- School of Law and School of Medicine, Stanford University, Stanford, California, United States of America
| | - Gerald T. Keusch
- National Emerging Infectious Diseases Laboratory, Boston University, Boston, Massachusetts, United States of America
- * E-mail:
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