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Eisenstein EL, Hill KD, Wood N, Kirchner JL, Anstrom KJ, Granger CB, Rao SV, Baldwin HS, Jacobs JP, Jacobs ML, Kannankeril PJ, Graham EM, O'Brien SM, Li JS. Evaluating registry-based trial economics: Results from the STRESS clinical trial. Contemp Clin Trials Commun 2024; 38:101257. [PMID: 38298917 PMCID: PMC10826145 DOI: 10.1016/j.conctc.2024.101257] [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: 08/29/2023] [Revised: 12/18/2023] [Accepted: 01/08/2024] [Indexed: 02/02/2024] Open
Abstract
Background Registry-based trials have the potential to reduce randomized clinical trial (RCT) costs. However, observed cost differences also may be achieved through pragmatic trial designs. A systematic comparison of trial costs across different designs has not been previously performed. Methods We conducted a study to compare the current Steroids to Reduce Systemic inflammation after infant heart surgery (STRESS) registry-based RCT vs. two established designs: pragmatic RCT and explanatory RCT. The primary outcome was total RCT design costs. Secondary outcomes included: RCT duration and personnel hours. Costs were estimated using the Duke Clinical Research Institute's pricing model. Results The Registry-Based RCT estimated duration was 31.9 weeks greater than the other designs (259.5 vs. 227.6 weeks). This delay was caused by the Registry-Based design's periodic data harvesting that delayed site closing and statistical reporting. Total personnel hours were greatest for the Explanatory design followed by the Pragmatic design and the Registry-Based design (52,488 vs 29,763 vs. 24,480 h, respectively). Total costs were greatest for the Explanatory design followed by the Pragmatic design and the Registry-Based design ($10,140,263 vs. $4,164,863 vs. $3,268,504, respectively). Thus, Registry-Based total costs were 32 % of the Explanatory and 78 % of the Pragmatic design. Conclusion Total costs for the STRESS RCT with a registry-based design were less than those for a pragmatic design and much less than an explanatory design. Cost savings reflect design elements and leveraging of registry resources to improve cost efficiency, but delays to trial completion should be considered.
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Affiliation(s)
| | - Kevin D. Hill
- Duke Clinical Research Institute, Durham, NC, USA
- Duke Pediatric and Congenital Heart Center, Durham, NC, USA
| | - Nancy Wood
- Duke Clinical Research Institute, Durham, NC, USA
| | | | - Kevin J. Anstrom
- Collaborative Studies Coordinating Center, Chapel Hill, NC, USA
- Department of Biostatistics, University of North Carolina, Chapel Hill, NC, USA
| | | | | | - H. Scott Baldwin
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, USA
| | | | | | | | - Eric M. Graham
- Medical University of South Carolina, Charleston, SC, USA
| | | | - Jennifer S. Li
- Duke Clinical Research Institute, Durham, NC, USA
- Duke Pediatric and Congenital Heart Center, Durham, NC, USA
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2
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Hey SP, Dellapina M, Lindquist K, Hartog B, LaRoche J. Digital Health Technologies in Clinical Trials: An Ontology-Driven Analysis to Inform Digital Sustainability Policies. Ther Innov Regul Sci 2023; 57:1269-1278. [PMID: 37544966 PMCID: PMC10579130 DOI: 10.1007/s43441-023-00560-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Accepted: 07/24/2023] [Indexed: 08/08/2023]
Abstract
BACKGROUND Digital health technologies (DHTs) can facilitate the execution of de-centralized trials that can offer opportunities to reduce the burden on participants, collect outcome data in a real-world setting, and potentially make trial populations more diverse and inclusive. However, DHTs can also be a significant source of electronic waste (e-waste). In recognition of the potential health and environmental impact from DHT use in trials, private and public institutions have recently launched initiatives to help measure and manage this e-waste. But in order to develop sound e-waste management policies, it will be necessary to first estimate the current volume of e-waste that results from the use of DHTs in trials. MATERIALS AND METHODS A Web Ontology Language (OWL)-compliant ontology of DHTs was created using a list of 500 DHT device names derived from a mixture of public and private sources. The U.S. clinical trials registry, ClinicalTrials.gov, was then queried to identify and classify trials using any of the devices in the ontology. The ClinicalTrials.gov records from this search were then analyzed to characterize the volume and properties of trials using DHTs, as well as estimating the total volume of individual DHT units that have been provisioned (or are planned to be provisioned) for clinical research. RESULTS Our ontology-driven search identified 2326 unique clinical trials with a reported "actual" enrollment of 200,947 participants and a "planned" enrollment of an additional 4,094,748 participants. The most-used class of DHTs in our ontology was "wearables," (1852 trials), largely driven by the use of smart watches and other wrist-worn sensors (estimated to involve 149,391 provisioned devices). The most-used subtype of DHTs in trials was "subcutaneous" devices (367 trials), driven by the prevalent use and testing of glucose monitors (estimated to involve 17,666 provisioned devices). CONCLUSION Thousands of trials, involving hundreds of thousands of devices, have already been completed, and many more trials (potentially involving millions more devices) are planned. Despite the great opportunities that are afforded by DHTs to the clinical trial enterprise, if the industry lacks the ability to track DHT use with sufficient resolution, the result is likely to be a great deal of e-waste. A new ontology of DHTs, combined with rigorous data science methods like those described in this paper, can be used to provide better information across the industry, and in turn, help create a more sustainable and equitable clinical trials enterprise.
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Affiliation(s)
| | - Maria Dellapina
- Prism Analytic Technologies, 245 Main St., Cambridge, MA, 02142, USA
| | - Kristin Lindquist
- Prism Analytic Technologies, 245 Main St., Cambridge, MA, 02142, USA
| | - Bert Hartog
- Janssen-Cilag B.V., 4837 DS, Breda, The Netherlands
| | - Jason LaRoche
- Janssen Research & Development, LLC, Raritan, NJ, 08869, USA
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3
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Harmon DM, Noseworthy PA, Yao X. The Digitization and Decentralization of Clinical Trials. Mayo Clin Proc 2023; 98:1568-1578. [PMID: 36669937 DOI: 10.1016/j.mayocp.2022.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 08/23/2022] [Accepted: 10/06/2022] [Indexed: 01/20/2023]
Abstract
Now, more than ever, digital technology has made its way into the daily lives of billions across the globe, and the widespread use of this technology has also allowed a digital window into consumers' and patients' daily lives, respectively. In a similar way, the practice of medicine has digitally evolved with the application of electronic health records and development of wearable/portable consumer-based medical devices (eg, Apple Watch ECG and Kardia Mobile by AliveCor). Alongside the increased use of digital technology in clinical care (eg, telehealth and wearable arrhythmia detection), clinical investigators have harnessed this powerful stockpile of data to gain insight into what happens to patients beyond the clinic walls. In this thematic review, we show the impact of digital advancements on the clinical trial process from recruitment and enrollment to interventions and data collection. We also show the pragmatism of this decentralized process and how it will mitigate the limitations of conventional randomized controlled trials. Finally, while pushing the boundaries of tech, we also describe a few limitations of this rapidly growing field to understand better what gaps need to be bridged in the future.
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Affiliation(s)
- David M Harmon
- Department of Internal Medicine, Mayo Clinic School of Graduate Medical Education, Mayo Clinic, Rochester, MN, USA; Department of Cardiovascular Medicine, Mayo Clinic College of Medicine, Mayo Clinic, Rochester, MN, USA.
| | - Peter A Noseworthy
- Department of Cardiovascular Medicine, Mayo Clinic College of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Xiaoxi Yao
- Department of Cardiovascular Medicine, Mayo Clinic College of Medicine, Mayo Clinic, Rochester, MN, USA; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
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4
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Razaghizad A, McKee T, Malhamé I, Friedrich MG, Giannetti N, Coristine A, Johnson A, Ashley EA, Hershman SG, Struck B, Krastev S, Pilat D, Sharma A. Mobile Health Fitness Interventions: Impact of Features on Routine Use and Data Sharing Acceptability. JACC. ADVANCES 2023; 2:100613. [PMID: 38938369 PMCID: PMC11198255 DOI: 10.1016/j.jacadv.2023.100613] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Revised: 06/29/2023] [Accepted: 07/16/2023] [Indexed: 06/29/2024]
Abstract
Background Mobile health (mHealth) interventions are increasingly being used for cardiovascular research and physical activity promotion. Objectives As a result, the authors aimed to evaluate which features facilitate and impede routine engagement with mobile fitness applications. Methods We distributed a pan-Canadian online questionnaire via the behavioral research platform Prolific.co to evaluate what features are associated with the use and routine engagement (ie, daily or weekly use) of mHealth fitness applications and attitudes about data sharing. Binary logistic regression was used to quantify the association between these endpoints and exploratory factors such as the perceived utility of various mHealth application features. Results The survey received 694 responses. Most people were women (62%), the median age was 28 years (range: 18-78 years), and most people reported current use of an mHealth fitness application (48%). The perceived importance of personal health (OR: 2.40; 95% CI: 1.34-4.50) was the factor most associated with the current use of an mHealth fitness application. The feature most associated with routine engagement was the ability to track progress toward a goal (OR: 5.10; 95% CI: 2.73-9.61) while the most significant barrier was the absence of goal customization features (OR: 0.44; 95% CI: 0.25-0.81). The acceptance of sharing health data for research was high (56%), and privacy concerns did not significantly affect routine engagement (OR: 0.81; 95% CI: 0.40-1.77). Results were consistent across race and gender. Conclusions mHealth interventions have the potential to be scaled across populations. Optimizing applications to improve self-monitoring and personalization could increase routine engagement and, thus, user retention and intervention effectiveness.
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Affiliation(s)
- Amir Razaghizad
- Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
- DREAM-CV Lab, McGill University Health Centre, McGill University, Montreal, Quebec, Canada
- Division of Cardiology, McGill University Health Centre, McGill University, Montreal, Quebec, Canada
| | | | - Isabelle Malhamé
- Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
- Division of General Internal Medicine, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
| | - Matthias G. Friedrich
- Division of Cardiology, McGill University Health Centre, McGill University, Montreal, Quebec, Canada
- Courtois Cardiovascular Signature Program, Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Nadia Giannetti
- Division of Cardiology, McGill University Health Centre, McGill University, Montreal, Quebec, Canada
- Courtois Cardiovascular Signature Program, Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Andrew Coristine
- Division of Cardiology, McGill University Health Centre, McGill University, Montreal, Quebec, Canada
| | - Anders Johnson
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University, Stanford, California, USA
| | - Euan A. Ashley
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University, Stanford, California, USA
| | - Steven G. Hershman
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University, Stanford, California, USA
| | | | | | - Dan Pilat
- The Decision Lab, Montreal, Quebec, Canada
| | - Abhinav Sharma
- Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
- DREAM-CV Lab, McGill University Health Centre, McGill University, Montreal, Quebec, Canada
- Division of Cardiology, McGill University Health Centre, McGill University, Montreal, Quebec, Canada
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5
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Nebie EI, Sawadogo HN, van Eeuwijk P, Signorell A, Reus E, Utzinger J, Burri C. Opportunities and challenges for decentralised clinical trials in sub-Saharan Africa: a qualitative study. BMJ Open 2023; 13:e075903. [PMID: 37739467 PMCID: PMC10533674 DOI: 10.1136/bmjopen-2023-075903] [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: 05/22/2023] [Accepted: 09/04/2023] [Indexed: 09/24/2023] Open
Abstract
INTRODUCTION Digital health has gained traction in research and development, and clinical decision support systems. The COVID-19 pandemic accelerated the adoption of decentralised clinical trials (DCTs) as a mitigation and efficiency improvement strategy. We assessed the opportunities and challenges of a digital transformation in clinical research in sub-Saharan Africa from different stakeholders' perspectives. METHODS A qualitative study, including 40 in-depth semi structured interviews, was conducted with investigators of three leading research institutions in sub-Saharan Africa and Switzerland, contract research organisations and sponsors managing clinical trials in sub-Saharan Africa. A thematic approach was used for the analysis. RESULTS Interviewees perceived DCTs as an opportunity for trial efficiency improvement, quality improvement and reducing the burden of people participating in clinical trials. However, to gain and maintain an optimal quality of clinical trials, a transition period is necessary to tackle contextual challenges before DCTs are being implemented. The main challenges are categorised into four themes: (1) usability and practicability of the technology; (2) paradigm shift and trial data quality; (3) ethical and regulatory hurdles and (4) contextual factors (site-specific research environment and sociocultural aspects). CONCLUSION The transformation from a site to a patient-centric model with an increased responsibility of participants should be context adapted. The transformation requires substantial investment, training of the various stakeholders and an efficient communication. Additionally, commitment of sponsors, investigators, ethics and regulatory authorities and the buy-in of the communities are essential for this change.
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Affiliation(s)
- Eric I Nebie
- University of Basel, Basel, Switzerland
- Swiss Tropical and Public Health Institute, Allschwil, Switzerland
- Centre de Recherche en Santé de Nouna, Nouna, Burkina Faso
| | | | - Peter van Eeuwijk
- University of Basel, Basel, Switzerland
- Swiss Tropical and Public Health Institute, Allschwil, Switzerland
| | - Aita Signorell
- University of Basel, Basel, Switzerland
- Swiss Tropical and Public Health Institute, Allschwil, Switzerland
| | - Elisabeth Reus
- University of Basel, Basel, Switzerland
- Swiss Tropical and Public Health Institute, Allschwil, Switzerland
| | - Juerg Utzinger
- University of Basel, Basel, Switzerland
- Swiss Tropical and Public Health Institute, Allschwil, Switzerland
| | - Christian Burri
- University of Basel, Basel, Switzerland
- Swiss Tropical and Public Health Institute, Allschwil, Switzerland
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6
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Moons P, Norekvål TM, Arbelo E, Borregaard B, Casadei B, Cosyns B, Cowie MR, Fitzsimons D, Fraser AG, Jaarsma T, Kirchhof P, Mauri J, Mindham R, Sanders J, Schiele F, Torbica A, Zwisler AD. Placing patient-reported outcomes at the centre of cardiovascular clinical practice: implications for quality of care and management. Eur Heart J 2023; 44:3405-3422. [PMID: 37606064 DOI: 10.1093/eurheartj/ehad514] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Revised: 05/01/2023] [Accepted: 07/25/2023] [Indexed: 08/23/2023] Open
Abstract
Patient-reported outcomes (PROs) provide important insights into patients' own perspectives about their health and medical condition, and there is evidence that their use can lead to improvements in the quality of care and to better-informed clinical decisions. Their application in cardiovascular populations has grown over the past decades. This statement describes what PROs are, and it provides an inventory of disease-specific and domain-specific PROs that have been developed for cardiovascular populations. International standards and quality indices have been published, which can guide the selection of PROs for clinical practice and in clinical trials and research; patients as well as experts in psychometrics should be involved in choosing which are most appropriate. Collaborations are needed to define criteria for using PROs to guide regulatory decisions, and the utility of PROs for comparing and monitoring the quality of care and for allocating resources should be evaluated. New sources for recording PROs include wearable digital health devices, medical registries, and electronic health record. Advice is given for the optimal use of PROs in shared clinical decision-making in cardiovascular medicine, and concerning future directions for their wider application.
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Affiliation(s)
- Philip Moons
- KU Leuven Department of Public Health and Primary Care, KU Leuven - University of Leuven, Kapucijnenvoer 35 PB7001, 3000 Leuven, Belgium
- Institute of Health and Care Sciences, University of Gothenburg, Arvid Wallgrens backe 1, 413 46 Gothenburg, Sweden
- Department of Paediatrics and Child Health, University of Cape Town, Klipfontein Rd, Rondebosch, 7700 Cape Town, South Africa
| | - Tone M Norekvål
- Department of Heart Disease, Haukeland University Hospital, Haukelandsveien 22, 5009 Bergen, Norway
- Department of Clinical Science, Faculty of Medicine, University of Bergen, Jonas Lies veg, 875021 Bergen, Norway
| | - Elena Arbelo
- Cardiology Department, Hospital Clínic, Universitat de Barcelona, C/Villarroel 170, 08036 Barcelona, Spain
- Institut d'Investigació August Pi i Sunyer (IDIBAPS). Rosselló 149-153, 08036 Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Av. Monforte de Lemos, 3-5. Pabellón 11. Planta 0, 28029 Madrid, Spain
| | - Britt Borregaard
- Department of Cardiology, Odense University Hospital, J.B. Winsløws Vej 4, 5000 Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, J.B. Winsløws Vej 19, 5000 Odense, Denmark
| | - Barbara Casadei
- Division of Cardiovascular Medicine, RDM, University of Oxford; Headley Way, Headington Oxford OX3 9DU, UK
- NIHR Biomedical Research Centre, Headley Way, Headington Oxford OX3 9DU, UK
| | - Bernard Cosyns
- Department of Cardiology, University Hospital Brussels, Laarbeeklaan 101, 1090 Jette, Belgium
| | - Martin R Cowie
- Royal Brompton Hospital & School of Cardiovascular Medicine, Faculty of Medicine & Lifesciences, King's College London, Sydney St, London SW3 6NP, UK
| | - Donna Fitzsimons
- School of Nursing & Midwifery, Queens University Belfast, 97 Lisburn Road, Belfast | BT9 7BL, Northern Ireland
| | - Alan G Fraser
- School of Medicine, Cardiff University, Heath Park, Cardiff CF14 4XW, UK
| | - Tiny Jaarsma
- Department of Medicine, Health and Caring Sciences, Linköping University, Campus Norrköping, 601 74 Norrköping, Sweden
- Nursing Science, Julius Center, University Medical Centre Utrecht, Universiteitsweg 100, 3584 CG Utrecht, The Netherlands
| | - Paulus Kirchhof
- Department of Cardiology, University Heart and Vascular Center Hamburg, Martinistrasse 52, D-20246 Hamburg, Germany
- German Center for Cardiovascular Research (DZHK), partner site Hamburg/Kiel/Lübeck, Martinistrasse 52, D-20246 Hamburg, Germany
- Institute of Cardiovascular Sciences, College of Medical and Dental Sciences, University of Birmingham, Edgbaston Birmingham B15 2TT, UK
| | - Josepa Mauri
- Department of Cardiology, Hospital Universitari Germans Trias i Pujol, Carretera de Canyet, s/n, 08916 Badalona, Barcelona, Spain
| | - Richard Mindham
- European Society of Cardiology (ESC) Patient Forum, 2035 route des colles, CS 80179 Biot, 06903 Sophia Antipolis Cedex, France
| | - Julie Sanders
- St Bartholomew's Hospital, Barts Health NHS Trust, West Smithfield, London EC1A 7BE, UK
- William Harvey Research Institute, Charterhouse Square, Queen Mary University of London, London EC1M 6BQ, UK
| | - Francois Schiele
- Department of Cardiology, University Hospital Besancon, 3 Bd Alexandre Fleming, 25030 Besançon, France
| | - Aleksandra Torbica
- Centre for Research on Health and Social Care Management (CERGAS), Bocconi University, Via Sarfatti, 10 20136 Milan, Italy
| | - Ann Dorthe Zwisler
- Department of Cardiology, Odense University Hospital, J.B. Winsløws Vej 4, 5000 Odense, Denmark
- REHPA, The Danish Knowledge Centre for Rehabilitation and Palliative Care, Odense University Hospital, Vestergade 17, 5800 Nyborg, Denmark
- Department of Clinical Research, University of Southern Denmark, Campusvej 55, DK-5230 Odense, Denmark
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7
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Gelis L, Stoeckert I, Podhaisky HP. Digital Tools-Regulatory Considerations for Application in Clinical Trials. Ther Innov Regul Sci 2023; 57:769-782. [PMID: 37195515 DOI: 10.1007/s43441-023-00535-z] [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: 01/27/2023] [Accepted: 04/28/2023] [Indexed: 05/18/2023]
Abstract
During the last few years, the pharmaceutical industry has adopted digital technologies/digital health technology (DHT) to improve the drug development process and the commercialization of new products. Technological advances are strongly supported by both the US-FDA and the EMA, but the regulatory landscape in the US seems to be more suitable to promote innovation in the digital health sector (e.g. Cures Act). In contrast, the new Medical Device Regulation sets high hurdles for Medical Device software to pass regulatory scrutiny.On both sides of the Atlantic, a digital tool must be fit-for-purpose for the intended use in the clinical drug trial. Irrespective of its status as a Medical Device, at least the basic safety and performance requirements according to local regulations should be met, quality system and surveillance requirements should be fulfilled, and the sponsor must ensure conformity with GxP and the local data privacy and cybersecurity legislations.There is an overlap in technical and clinical validation for drug development tool qualification in both regions to ensure that the digital tools deliver reliable data with tangible clinical benefits. Based on an analysis of the regulatory framework of the FDA and the EMA, this study proposes regulatory strategies for a global pharma company: It would be prudent for drug development companies to a) use approved solutions or b) consider qualification of drug development tools early and in parallel to clinical development. Early engagement with the FDA and the EMA/CA is recommended to define evidentiary standards and corresponding regulatory pathways for different contexts-of-use and to clarify regulator's expectations as to what extent data collected by digital tools are acceptable to support marketing authorization applications (MAA).Hence a harmonization of the partly disparate regulatory requirements in the US and the EU accompanied by further development of the regulatory landscape in the EU, could further foster the use of digital tools in drug clinical development. The outlook for the use of digital tools in clinical trials is hopeful.
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Affiliation(s)
- Lian Gelis
- Bayer AG, Research & Development, Pharmaceuticals, Project Management 1, Wuppertal, Germany
| | - Isabelle Stoeckert
- Bayer AG, Research & Development, Pharmaceuticals, Regulatory Affairs, EMEA, Wuppertal, Germany
| | - Hans-Peter Podhaisky
- Bayer AG, Research & Development, Pharmaceuticals, Regulatory Affairs, MD, Berlin, Germany.
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8
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Betcheva L, Kim JY, Erhun F, Oraiopoulos N, Getz K. Applying Systems Thinking to Inform Decentralized Clinical Trial Planning and Deployment. Ther Innov Regul Sci 2023:10.1007/s43441-023-00540-2. [PMID: 37389795 PMCID: PMC10400692 DOI: 10.1007/s43441-023-00540-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Accepted: 05/23/2023] [Indexed: 07/01/2023]
Abstract
Recently, there has been a growing interest in understanding how decentralized clinical trial (DCT) solutions can mitigate existing challenges in clinical development, particularly participant burden and access, and the collection, management, and quality of clinical data. This paper examines DCT deployments, emphasizing how they are integrated and how they may impact clinical trial oversight, management, and execution. We propose a conceptual framework that employs systems thinking to evaluate the impact on key stakeholders through a reiterative assessment of pain points. We conclude that decentralized solutions should be customized to meet patient needs and preferences and the unique requirements of each clinical trial. We discuss how DCT elements introduce new demands and pressures within the existing system and reflect on enablers that can overcome DCT implementation challenges. As stakeholders look for ways to make clinical research more relevant and accessible to a larger and more diverse patient population, further robust and granular research is needed to quantify the impact of DCTs empirically.
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Affiliation(s)
- Lidia Betcheva
- Judge Business School, University of Cambridge, Cambridge, CB2 1AG, UK.
| | - Jennifer Y Kim
- Tufts Center for the Study of Drug Development, Tufts University, Boston, MA, 02111, USA
| | - Feryal Erhun
- Judge Business School, University of Cambridge, Cambridge, CB2 1AG, UK
| | | | - Kenneth Getz
- Tufts Center for the Study of Drug Development, Tufts University, Boston, MA, 02111, USA
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9
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Khan MS, Usman MS, Talha KM, Van Spall HGC, Greene SJ, Vaduganathan M, Khan SS, Mills NL, Ali ZA, Mentz RJ, Fonarow GC, Rao SV, Spertus JA, Roe MT, Anker SD, James SK, Butler J, McGuire DK. Leveraging electronic health records to streamline the conduct of cardiovascular clinical trials. Eur Heart J 2023; 44:1890-1909. [PMID: 37098746 DOI: 10.1093/eurheartj/ehad171] [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: 04/17/2022] [Revised: 02/05/2023] [Accepted: 03/07/2023] [Indexed: 04/27/2023] Open
Abstract
Conventional randomized controlled trials (RCTs) can be expensive, time intensive, and complex to conduct. Trial recruitment, participation, and data collection can burden participants and research personnel. In the past two decades, there have been rapid technological advances and an exponential growth in digitized healthcare data. Embedding RCTs, including cardiovascular outcome trials, into electronic health record systems or registries may streamline screening, consent, randomization, follow-up visits, and outcome adjudication. Moreover, wearable sensors (i.e. health and fitness trackers) provide an opportunity to collect data on cardiovascular health and risk factors in unprecedented detail and scale, while growing internet connectivity supports the collection of patient-reported outcomes. There is a pressing need to develop robust mechanisms that facilitate data capture from diverse databases and guidance to standardize data definitions. Importantly, the data collection infrastructure should be reusable to support multiple cardiovascular RCTs over time. Systems, processes, and policies will need to have sufficient flexibility to allow interoperability between different sources of data acquisition. Clinical research guidelines, ethics oversight, and regulatory requirements also need to evolve. This review highlights recent progress towards the use of routinely generated data to conduct RCTs and discusses potential solutions for ongoing barriers. There is a particular focus on methods to utilize routinely generated data for trials while complying with regional data protection laws. The discussion is supported with examples of cardiovascular outcome trials that have successfully leveraged the electronic health record, web-enabled devices or administrative databases to conduct randomized trials.
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Affiliation(s)
- Muhammad Shahzeb Khan
- Division of Cardiology, Duke University School of Medicine, 2301 Erwin Rd., Durham, NC 27705, USA
| | - Muhammad Shariq Usman
- Department of Medicine, University of Mississippi Medical Center, 2500 N State St, Jackson, MS 39216, USA
| | - Khawaja M Talha
- Department of Medicine, University of Mississippi Medical Center, 2500 N State St, Jackson, MS 39216, USA
| | - Harriette G C Van Spall
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- Population Health Research Institute, Hamilton, ON, Canada
| | - Stephen J Greene
- Division of Cardiology, Duke University School of Medicine, 2301 Erwin Rd., Durham, NC 27705, USA
- Duke Clinical Research Institute, Durham, NC, USA
| | - Muthiah Vaduganathan
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Sadiya S Khan
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Nicholas L Mills
- BHF Centre for Cardiovascular Science, University of Edinburgh, Chancellors Building, Royal Infirmary of Edinburgh, Edinburgh, Scotland, UK
- Usher Institute, University of Edinburgh, Edinburgh, Scotland, UK
| | - Ziad A Ali
- DeMatteis Cardiovascular Institute, St Francis Hospital and Heart Center, Roslyn, NY, USA
| | - Robert J Mentz
- Division of Cardiology, Duke University School of Medicine, 2301 Erwin Rd., Durham, NC 27705, USA
- Duke Clinical Research Institute, Durham, NC, USA
| | - Gregg C Fonarow
- Division of Cardiology, University of California Los Angeles, Los Angeles, CA, USA
| | - Sunil V Rao
- Division of Cardiology, New York University Langone Health System, New York, NY, USA
| | - John A Spertus
- Department of Cardiology, Saint Luke's Mid America Heart Institute, Kansas City, MO, USA
- Kansas City's Healthcare Institute for Innovations in Quality, University of Missouri, Kansas, MO, USA
| | - Matthew T Roe
- Division of Cardiology, Duke University School of Medicine, 2301 Erwin Rd., Durham, NC 27705, USA
- Duke Clinical Research Institute, Durham, NC, USA
| | - Stefan D Anker
- Department of Cardiology (CVK), Berlin Institute of Health Center for Regenerative Therapies (BCRT), and German Centre for Cardiovascular Research (DZHK) Partner Site Berlin, Charité Universitätsmedizin, Berlin, Germany
| | - Stefan K James
- Department of Medical Sciences, Scientific Director UCR, Uppsala University, Uppsala, Uppland, Sweden
| | - Javed Butler
- Department of Medicine, University of Mississippi Medical Center, 2500 N State St, Jackson, MS 39216, USA
- Baylor Scott & White Research Institute, Dallas, TX, USA
| | - Darren K McGuire
- Division of Cardiology, Department of Internal Medicine, UT Southwestern Medical Center and Parkland Health and Hospital System, Dallas, TX, USA
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10
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Eisenstein EL, Zozus MN, Garza MY, Lanham HJ, Adagarla B, Walden A, Benjamin DK, Zimmerman KO, Kumar KR. Assessing clinical site readiness for electronic health record (EHR)-to-electronic data capture (EDC) automated data collection. Contemp Clin Trials 2023; 128:107144. [PMID: 36898625 PMCID: PMC10164080 DOI: 10.1016/j.cct.2023.107144] [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: 12/19/2022] [Revised: 02/13/2023] [Accepted: 03/05/2023] [Indexed: 03/11/2023]
Abstract
BACKGROUND eSource software is used to automatically copy a patient's electronic health record data into a clinical study's electronic case report form. However, there is little evidence to assist sponsors in identifying the best sites for multi-center eSource studies. METHODS We developed an eSource site readiness survey. The survey was administered to principal investigators, clinical research coordinators, and chief research information officers at Pediatric Trial Network sites. RESULTS A total of 61 respondents were included in this study (clinical research coordinator, 22; principal investigator, 20; and chief research information officer, 19). Clinical research coordinators and principal investigators ranked medication administration, medication orders, laboratory, medical history, and vital signs data as having the highest priority for automation. While most organizations used some electronic health record research functions (clinical research coordinator, 77%; principal investigator, 75%; and chief research information officer, 89%), only 21% of sites were using Fast Healthcare Interoperability Resources standards to exchange patient data with other institutions. Respondents generally gave lower readiness for change ratings to organizations that did not have a separate research information technology group and where researchers practiced in hospitals not operated by their medical schools. CONCLUSIONS Site readiness to participate in eSource studies is not merely a technical problem. While technical capabilities are important, organizational priorities, structure, and the site's support of clinical research functions are equally important considerations.
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Affiliation(s)
| | - Meredith N Zozus
- University of Texas Health Science Center at San Antonio, San Antonio, TX 78229, USA.
| | - Maryam Y Garza
- University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA.
| | - Holly J Lanham
- University of Texas Health Science Center at San Antonio, San Antonio, TX 78229, USA.
| | | | - Anita Walden
- Oregon Health & Science University, Portland, OR 97239, USA..
| | | | | | - Karan R Kumar
- Duke Clinical Research Institute, Durham, NC 27701, USA.
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11
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Brooksbank JA, Faulkenberg KD, Tang WHW, Martyn T. Novel Strategies to Improve Prescription of Guideline-Directed Medical Therapy in Heart Failure. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2023; 25:93-110. [PMID: 37077616 PMCID: PMC10073621 DOI: 10.1007/s11936-023-00979-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/22/2023] [Indexed: 04/07/2023]
Abstract
PURPOSE OF REVIEW To examine the emerging data for novel strategies being studied to improve use and dose titration of guideline-directed medical therapy (GDMT) for patients with heart failure (HF). RECENT FINDINGS There is mounting evidence to employ novel multi-pronged strategies to address HF implementation gaps. SUMMARY Despite high-level randomized evidence and clear national society recommendations, a large gap persists in use and dose titration of guideline-directed medical therapy (GDMT) in patients with heart failure (HF). Accelerating the safe implementation of GDMT has proven to reduce the morbidity and mortality associated with HF but remains an ongoing challenge for patients, clinicians, and health systems. In this review, we examine the emerging data for novel strategies to improve the use of GDMT including the use of multidisciplinary team-based approaches, nontraditional patient encounters, patient messaging/engagement, remote patient monitoring, and electronic health record (EHR)-based clinical alerts. While societal guidelines and implementation studies have focused on heart failure with reduced ejection fraction (HFrEF), expanding indications and evidence for the use of sodium glucose cotransporter2 (SGLT2i) will necessitate implementation efforts across the LVEF spectrum.
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Affiliation(s)
- Jeremy A. Brooksbank
- Robert and Suzanne Tomsich Department of Cardiovascular Medicine, Sydell and Arnold Miller Family Heart and Vascular Institute, Cleveland Clinic, Euclid Ave, Cleveland, OH USA
| | | | - W. H. Wilson Tang
- Robert and Suzanne Tomsich Department of Cardiovascular Medicine, Sydell and Arnold Miller Family Heart and Vascular Institute, Cleveland Clinic, Euclid Ave, Cleveland, OH USA
- George M. and Linda H. Kaufman Center for Heart Failure and Recovery, Cleveland Clinic, Cleveland, OH USA
| | - Trejeeve Martyn
- Robert and Suzanne Tomsich Department of Cardiovascular Medicine, Sydell and Arnold Miller Family Heart and Vascular Institute, Cleveland Clinic, Euclid Ave, Cleveland, OH USA
- George M. and Linda H. Kaufman Center for Heart Failure and Recovery, Cleveland Clinic, Cleveland, OH USA
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12
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Marquis-Gravel G, Faulkner M, Merritt G, Farrehi P, Zemon N, Robertson HR, Jones WS, Kraschnewski J. Importance of patient engagement in the conduct of pragmatic multicenter randomized controlled trials: The ADAPTABLE experience. Clin Trials 2023; 20:31-35. [PMID: 35999816 DOI: 10.1177/17407745221118559] [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: 11/16/2022]
Abstract
BACKGROUND/AIMS Actively engaging patient partners in the conduct of trials is crucial to ensure the studies answer genuine, patient-centered, unmet clinical needs, and to facilitate participant recruitment and retention. The aim of this article is to demonstrate the feasibility of patient engagement within a large pragmatic multicenter randomized controlled trial, specifically for the purposes of dissemination of study information/updates and to favorize recruitment and retention. METHODS In the patient-centric, pragmatic ADAPTABLE randomized trial, transparent and timely dissemination of information on the study updates to the trial participants was undertaken to create meaningful engagement and to facilitate retention. A national panel of patient partners, the Adaptors, were directly involved in this information dissemination strategy, and study participants were engaged both nationally and locally to design recruitment methods iteratively during the conduct of the trial. All Adaptors had a lived experience with cardiovascular disease. RESULTS Adaptors attended bi-weekly meetings facilitated by the director of the study's patient-powered research network. They drafted and/or edited newsletters and ad hoc educational information written in a lay-friendly manner for study participants, which were regularly distributed to the ADAPTABLE community, in addition to online forums where participants could share their experience of their involvement in ADAPTABLE. To spur recruitment, a patient-driven initiative was to draft letters sharing their story, which were distributed by the local study teams. Patient partners thought that using patients' voice to provide their perspectives on why they believed this project was important would be more engaging for prospective participants than traditional approaches. CONCLUSIONS ADAPTABLE's experience has demonstrated the feasibility of engaging patients as partners in the conduct of a large-scale, multi-center, pragmatic randomized controlled trial. Future trials should embrace and iteratively improve this model by engaging patient partners as early as study protocol development and funding applications, and quantify its impact on the effectiveness and value of the trial.
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Affiliation(s)
| | - Madelaine Faulkner
- Department of Epidemiology and Biostatistics, University of California, San Francisco, CA, USA
| | | | - Peter Farrehi
- University of Michigan Medical School, Ann Arbor, MI, USA
| | | | | | - W Schuyler Jones
- Duke Clinical Research Institute, Durham, NC, USA.,Duke University Medical Center, Durham, NC, USA
| | - Jennifer Kraschnewski
- Departments of Medicine and Public Health Sciences, Penn State College of Medicine, Hershey, PA, USA
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13
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Gerhalter T, Müller C, Maron E, Thielen M, Schätzl T, Mähler A, Schütte T, Boschmann M, Herzer R, Spuler S, Gazzerro E. "suMus," a novel digital system for arm movement metrics and muscle energy expenditure. Front Physiol 2023; 14:1057592. [PMID: 36776973 PMCID: PMC9909604 DOI: 10.3389/fphys.2023.1057592] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Accepted: 01/11/2023] [Indexed: 01/27/2023] Open
Abstract
Objective: In the field of non-treatable muscular dystrophies, promising new gene and cell therapies are being developed and are entering clinical trials. Objective assessment of therapeutic effects on motor function is mandatory for economical and ethical reasons. Main shortcomings of existing measurements are discontinuous data collection in artificial settings as well as a major focus on walking, neglecting the importance of hand and arm movements for patients' independence. We aimed to create a digital tool to measure muscle function with an emphasis on upper limb motility. Methods: suMus provides a custom-made App running on smartwatches. Movement data are sent to the backend of a suMus web-based platform, from which they can be extracted as CSV data. Fifty patients with neuromuscular diseases assessed the pool of suMus activities in a first orientation phase. suMus performance was hence validated in four upper extremity exercises based on the feedback of the orientation phase. We monitored the arm metrics in a cohort of healthy volunteers using the suMus application, while completing each exercise at low frequency in a metabolic chamber. Collected movement data encompassed average acceleration, rotation rate as well as activity counts. Spearman rank tests correlated movement data with energy expenditure from the metabolic chamber. Results: Our novel application "suMus," sum of muscle activity, collects muscle movement data plus Patient-Related-Outcome-Measures, sends real-time feedback to patients and caregivers and provides, while ensuring data protection, a long-term follow-up of disease course. The application was well received from the patients during the orientation phase. In our pilot study, energy expenditure did not differ between overnight fasted and non-fasted participants. Acceleration ranged from 1.7 ± 0.7 to 3.2 ± 0.5 m/sec2 with rotation rates between 0.9 ± 0.5 and 2.0 ± 3.4 rad/sec. Acceleration and rotation rate as well as derived activity counts correlated with energy expenditure values measured in the metabolic chamber for one exercise (r = 0.58, p < 0.03). Conclusion: In the analysis of slow frequency movements of upper extremities, the integration of the suMus application with smartwatch sensors characterized motion parameters, thus supporting a use in clinical trial outcome measures. Alternative methodologies need to complement indirect calorimetry in validating accelerometer-derived energy expenditure data.
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Affiliation(s)
- Teresa Gerhalter
- Muscle Research Unit, Charité-Universitätsmedizin Berlin, Berlin, Germany,Experimental and Clinical Research Center, a joint Cooperation between the Max Delbrück Center for Molecular Medicine in the Helmholtz Association and the Charité-Universitätsmedizin Berlin, Berlin, Germany,Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | | | | | | | - Teresa Schätzl
- Muscle Research Unit, Charité-Universitätsmedizin Berlin, Berlin, Germany,Experimental and Clinical Research Center, a joint Cooperation between the Max Delbrück Center for Molecular Medicine in the Helmholtz Association and the Charité-Universitätsmedizin Berlin, Berlin, Germany,Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Anja Mähler
- Experimental and Clinical Research Center, a joint Cooperation between the Max Delbrück Center for Molecular Medicine in the Helmholtz Association and the Charité-Universitätsmedizin Berlin, Berlin, Germany,Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany,Max Delbrück Center for Molecular Medicine in the Helmholtz Association (MDC), Berlin, Germany
| | - Till Schütte
- Experimental and Clinical Research Center, a joint Cooperation between the Max Delbrück Center for Molecular Medicine in the Helmholtz Association and the Charité-Universitätsmedizin Berlin, Berlin, Germany,Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany,Max Delbrück Center for Molecular Medicine in the Helmholtz Association (MDC), Berlin, Germany,Clinical Study Center (CSC), Berlin Institute of Health at Charité–Universitätsmedizin Berlin, Berlin, Germany
| | - Michael Boschmann
- Experimental and Clinical Research Center, a joint Cooperation between the Max Delbrück Center for Molecular Medicine in the Helmholtz Association and the Charité-Universitätsmedizin Berlin, Berlin, Germany,Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany,Max Delbrück Center for Molecular Medicine in the Helmholtz Association (MDC), Berlin, Germany
| | | | - Simone Spuler
- Muscle Research Unit, Charité-Universitätsmedizin Berlin, Berlin, Germany,Experimental and Clinical Research Center, a joint Cooperation between the Max Delbrück Center for Molecular Medicine in the Helmholtz Association and the Charité-Universitätsmedizin Berlin, Berlin, Germany,Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany,Max Delbrück Center for Molecular Medicine in the Helmholtz Association (MDC), Berlin, Germany,*Correspondence: Simone Spuler, ; Elisabetta Gazzerro,
| | - Elisabetta Gazzerro
- Muscle Research Unit, Charité-Universitätsmedizin Berlin, Berlin, Germany,Experimental and Clinical Research Center, a joint Cooperation between the Max Delbrück Center for Molecular Medicine in the Helmholtz Association and the Charité-Universitätsmedizin Berlin, Berlin, Germany,Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany,Max Delbrück Center for Molecular Medicine in the Helmholtz Association (MDC), Berlin, Germany,*Correspondence: Simone Spuler, ; Elisabetta Gazzerro,
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14
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Conducting CNS trials during a public health emergency – Lessons learned from the COVID-19 pandemic: A joint ISCTM/ECNP working group consensus paper. NEUROSCIENCE APPLIED 2023; 2:101129. [PMCID: PMC10275769 DOI: 10.1016/j.nsa.2023.101129] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Revised: 05/27/2023] [Accepted: 06/09/2023] [Indexed: 12/11/2023]
Abstract
A joint working group between the International Society of CNS Clinical Trials and Methodology (ISCTM) and the European College of Neuropsychopharmacology (ECNP) was formed in the latter part of 2020 to explore possible ways to mitigate the impact of Coronavirus disease-19 (COVID-19) in clinical trials while attempting to advance approaches and capabilities to bring new therapeutics to patients. The working group was tasked with developing guidelines for trial design modifications to assist sponsor companies in minimizing risks to data integrity, with a focus on regulatory, technological, operational, and methodological issues related to COVID-19. To facilitate focused and transferable recommendations, three disease categories were selected as examples to demonstrate the breadth of solutions implemented across CNS clinical trials, as well as ongoing challenges. The categories studied reflected the interests and expertise of the working group, and included neurodegenerative diseases and dementia, mental health disorders, and rare/pediatric diseases. Herein, we describe interim recommendations from the working group as well as priorities for future public health emergencies, to inform permanent adoption in CNS clinical trial development and conduct.
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15
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Coleman KM, Lam B, George D, Brennan C, Mountantonakis SE. Leveraging electronic health record query to streamline adverse event reporting and protocol compliance. Contemp Clin Trials 2022; 121:106901. [PMID: 36041676 DOI: 10.1016/j.cct.2022.106901] [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: 04/14/2022] [Revised: 08/18/2022] [Accepted: 08/24/2022] [Indexed: 01/27/2023]
Abstract
Electronic medical records are increasingly being leveraged to improve the efficiency and effectiveness of clinical trials. Reporting safety data and adhering to follow-up schedules are two challenges faced by study centers conducting a large number of clinical trials led by a single principal investigator. The Lenox Hill Electrophysiology Research Department collaborated with Northwell Health's informatics department to develop a live query accessing both inpatient and outpatient data. To demonstrate the efficacy of this approach we compared the compliance rate of adverse event reporting and patient follow-up visits between a clinical trial run using this approach and a clinical trial conducted prior to use. We compared the number of out of window visits, missed visits, missed assessments, subject drop out and number of late reported adverse events between both studies. The trial run using the described query method had a marked reduction in these categories. Leveraging available informatics resources have allowed for improved efficiency, accurate adverse even reporting and improved follow-up scheduling.
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Affiliation(s)
- Kristie M Coleman
- Department of Cardiac Electrophysiology, Northwell Health - Lenox Hill Heart and Lung, 100 East 77th Street, New York, NY 10075, United States of America
| | - Betty Lam
- Department of Cardiac Electrophysiology, Northwell Health - Lenox Hill Heart and Lung, 100 East 77th Street, New York, NY 10075, United States of America.
| | - Deepika George
- Quantitative Intelligence - Feinstein Institutes for Medical Research, 350 Community Drive, Manhasset, NY 11030, United States of America
| | - Christina Brennan
- Office of Clinical Research (OCR) - Feinstein Institutes for Medical Research, 1981 Marcus Ave, Manhasset, NY 11030, United States of America
| | - Stavros E Mountantonakis
- Department of Cardiac Electrophysiology, Northwell Health - Lenox Hill Heart and Lung, 100 East 77th Street, New York, NY 10075, United States of America
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16
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Ethics review of decentralized clinical trials (DCTs): Results of a mock ethics review. Drug Discov Today 2022; 27:103326. [PMID: 35870693 DOI: 10.1016/j.drudis.2022.07.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 07/11/2022] [Accepted: 07/19/2022] [Indexed: 11/03/2022]
Abstract
Decentralized clinical trials (DCTs) can be a valuable addition to the clinical trial landscape. However, the practice of DCTs is dependent on a regulatory system designed for conventional (site-based) trials. This study provides insight into the ethics review of DCTs. A 'mock ethics review' was performed in which members of European ethics committees (ECs) and national competent authorities (NCAs) discussed and reviewed a DCT protocol. Respondents expressed hesitancy toward DCTs and focused on potential risks and burdens. We advise to address these aspects explicitly when submitting a DCT protocol. We propose that both the benefits and risks of DCTs should be carefully monitored to advance the review and practice of this innovative approach to ethically optimize drug development.
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17
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Duda SN, Kennedy N, Conway D, Cheng AC, Nguyen V, Zayas-Cabán T, Harris PA. HL7 FHIR-based tools and initiatives to support clinical research: a scoping review. J Am Med Inform Assoc 2022; 29:1642-1653. [PMID: 35818340 DOI: 10.1093/jamia/ocac105] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Revised: 05/23/2022] [Accepted: 06/20/2022] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES The HL7® fast healthcare interoperability resources (FHIR®) specification has emerged as the leading interoperability standard for the exchange of healthcare data. We conducted a scoping review to identify trends and gaps in the use of FHIR for clinical research. MATERIALS AND METHODS We reviewed published literature, federally funded project databases, application websites, and other sources to discover FHIR-based papers, projects, and tools (collectively, "FHIR projects") available to support clinical research activities. RESULTS Our search identified 203 different FHIR projects applicable to clinical research. Most were associated with preparations to conduct research, such as data mapping to and from FHIR formats (n = 66, 32.5%) and managing ontologies with FHIR (n = 30, 14.8%), or post-study data activities, such as sharing data using repositories or registries (n = 24, 11.8%), general research data sharing (n = 23, 11.3%), and management of genomic data (n = 21, 10.3%). With the exception of phenotyping (n = 19, 9.4%), fewer FHIR-based projects focused on needs within the clinical research process itself. DISCUSSION Funding and usage of FHIR-enabled solutions for research are expanding, but most projects appear focused on establishing data pipelines and linking clinical systems such as electronic health records, patient-facing data systems, and registries, possibly due to the relative newness of FHIR and the incentives for FHIR integration in health information systems. Fewer FHIR projects were associated with research-only activities. CONCLUSION The FHIR standard is becoming an essential component of the clinical research enterprise. To develop FHIR's full potential for clinical research, funding and operational stakeholders should address gaps in FHIR-based research tools and methods.
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Affiliation(s)
- Stephany N Duda
- Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Department of Biomedical Informatics, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Nan Kennedy
- Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Douglas Conway
- Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Alex C Cheng
- Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Department of Biomedical Informatics, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Viet Nguyen
- Stratametrics LLC, Salt Lake City, Utah, USA.,HL7 Da Vinci Project, Ann Arbor, Michigan, USA
| | - Teresa Zayas-Cabán
- National Library of Medicine, National Institutes of Health, Bethesda, Maryland, USA
| | - Paul A Harris
- Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Department of Biomedical Informatics, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
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18
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Use of Digital Health Technology in Heart Failure and Diabetes: a Scoping Review. J Cardiovasc Transl Res 2022:10.1007/s12265-022-10273-6. [PMID: 35639339 PMCID: PMC9153219 DOI: 10.1007/s12265-022-10273-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Accepted: 05/05/2022] [Indexed: 11/23/2022]
Abstract
Use of digital health technologies (DHT) in chronic disease management is rising. We aim to evaluate the impact of DHT on clinical outcomes from randomized controlled trials (RCTs) of patients with heart failure (HF) and diabetes mellitus (DM). Electronic databases were searched for DHT RCTs in patients with HF and DM until February 2021. Patient characteristics and outcomes were analyzed. One published (N = 519) and 6 registered (N = 3423) eligible studies were identified, with one study exclusively including HF and DM patients. Median DHT monitoring was 12 months, with six studies using mobile platforms as their key exposure. Clinical outcomes included quality-of-life or self-care surveys (n = 1 each), physical activity metrics, changes in biomarkers, and other clinical endpoints (n = 3). Limited data exist on RCTs evaluating DHT in patients with concomitant HF and DM. Further work should define standardized clinical endpoints and platforms that can manage patients with multiple comorbidities.
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Abstract
The majority of cardiovascular randomized controlled trials (RCTs) test interventions in selected patient populations under explicitly protocol-defined settings. Although these ‘explanatory’ trial designs optimize conditions to test the efficacy and safety of an intervention, they limit the generalizability of trial findings in broader clinical settings. The concept of ‘pragmatism’ in RCTs addresses this concern by providing counterbalance to the more idealized situation underpinning explanatory RCTs and optimizing effectiveness over efficacy. The central tenets of pragmatism in RCTs are to test interventions in routine clinical settings, with patients who are representative of broad clinical practice, and to reduce the burden on investigators and participants by minimizing the number of trial visits and the intensity of trial-based testing. Pragmatic evaluation of interventions is particularly important in cardiovascular diseases, where the risk of death among patients has remained fairly stable over the past few decades despite the development of new therapeutic interventions. Pragmatic RCTs can help to reveal the ‘real-world’ effectiveness of therapeutic interventions and elucidate barriers to their implementation. In this Review, we discuss the attributes of pragmatism in RCT design, conduct and interpretation as well as the general need for increased pragmatism in cardiovascular RCTs. We also summarize current challenges and potential solutions to the implementation of pragmatism in RCTs and highlight selected ongoing and completed cardiovascular RCTs with pragmatic trial designs. In this Review, Khan and colleagues discuss the benefits and challenges of including pragmatism in the design, conduct and interpretation of randomized controlled trials (RCTs) for cardiovascular disease and highlight selected ongoing and completed cardiovascular RCTs that incorporate a pragmatic design. Most cardiovascular randomized controlled trials (RCTs) conducted to date have been ‘explanatory’, that is, designed to study the intervention in optimized conditions with selected patient populations and frequent protocolized assessments. Although explanatory RCT designs increase validity, they limit the generalizability of trial findings, whereas a ‘pragmatic’ approach to RCTs yields findings more relevant to real-world practice. In pragmatic RCTs, interventions are tested in patients who are broadly representative of the condition being studied, and the study is aligned with routine clinical care to reduce costs and organizational burden. Although pragmatic RCTs tend to attenuate estimates of treatment effects, they do provide a more realistic understanding of population-level effectiveness and costs than explanatory trials. Pragmatic trials can highlight barriers to the implementation of therapies and are better suited than explanatory RCTs to assessing the effects of implementation strategies and health-care policies at the population level. Widespread implementation of pragmatic trials would require the development of technological infrastructure to collect and share data as well as regulatory guidelines amenable to findings derived from routinely collected data.
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20
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Sharma A, Avram R. Opportunities and Challenges of Mobile Health Tools to Promote Health Behaviors. Circulation 2022; 145:1456-1459. [PMID: 35533217 DOI: 10.1161/circulationaha.122.059715] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Abhinav Sharma
- DREAM-CV Lab, McGill University Health Centre, Montreal, QC, Canada (A.S.).,Division of Cardiology, Department of Medicine, McGill University, Montreal, QC, Canada (A.S.)
| | - Robert Avram
- Division of Cardiology, Department of Medicine, Montreal Heart Institute, University of Montreal, QC, Canada (R.A.)
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21
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de Jong AJ, van Rijssel TI, Zuidgeest MGP, van Thiel GJMW, Askin S, Fons-Martínez J, De Smedt T, de Boer A, Santa-Ana-Tellez Y, Gardarsdottir H. Opportunities and Challenges for Decentralized Clinical Trials: European Regulators' Perspective. Clin Pharmacol Ther 2022; 112:344-352. [PMID: 35488483 PMCID: PMC9540149 DOI: 10.1002/cpt.2628] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Accepted: 03/20/2022] [Indexed: 01/07/2023]
Abstract
Decentralized clinical trials (DCTs) have the potential to improve accessibility, diversity, and retention in clinical trials by moving trial activities to participants’ homes and local surroundings. In this study, we conducted semi‐structured interviews with 20 European regulators to identify regulatory challenges and opportunities for the implementation of DCTs in the European Union. The key opportunities for DCTs that were recognized by regulators include a reduced participation burden, which could facilitate the participation of underserved patients. In addition, regulators indicated that data collected in DCTs are expected to be more representative of the real world. Key challenges recognized by regulators for DCTs include concerns regarding investigator oversight and participants’ safety when physical examinations and face‐to‐face contact are limited. To facilitate future learning, hybrid clinical trials with both on‐site and decentralized elements are proposed by the respondents.
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Affiliation(s)
- Amos J de Jong
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
| | - Tessa I van Rijssel
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Mira G P Zuidgeest
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Ghislaine J M W van Thiel
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Scott Askin
- Regulatory Affairs Innovation, Novartis Pharma AG, Basel, Switzerland
| | - Jaime Fons-Martínez
- The Foundation for the Promotion of Health and Biomedical Research of Valencia Region, Valencia, Spain
| | - Tim De Smedt
- Global Regulatory Affairs, UCB Pharma, Brussels, Belgium
| | - Anthonius de Boer
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands.,Dutch Medicines Evaluation Board, Utrecht, The Netherlands
| | - Yared Santa-Ana-Tellez
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
| | - Helga Gardarsdottir
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands.,Department of Clinical Pharmacy, Division Laboratory and Pharmacy, University Medical Center Utrecht, Utrecht, The Netherlands.,Faculty of Pharmaceutical Sciences, University of Iceland, Reykjavik, Iceland
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Fulford-Smith A, Leah E, Azroyan A, De Abadal M, Loew D, Hildemann S. Medical Affairs Transformation in Specialty Pharma: Next-Level Collaboration at the Core. Pharmaceut Med 2022; 36:63-69. [PMID: 35249212 PMCID: PMC8898556 DOI: 10.1007/s40290-022-00419-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/23/2022] [Indexed: 11/29/2022]
Abstract
Pharmaceutical companies with a medical mindset and an empowered Medical Affairs function are well equipped to meet the needs and expectations of patients and society. Yet, as capacity to understand and serve those needs accelerates, so too do expectations. Evidence-based practice, without delay, is expected throughout the development and delivery of medicine, healthcare, and information, and potential sources of evidence are legion. To keep pace and go beyond, to innovate, requires efficiencies. Not the disguised cutbacks of political language, but the collaborative constructive efficiencies of shared learning, forming new evidence bases for further progress. Here, we describe the first year of a medical transformation process at a global mid-sized pharmaceutical company. Beginning with a broad review designed to leverage collective intelligence and focus on meaningful outcomes for patients, this process examined and reshaped the structure, culture, and tools of the medical organization and its interactions within and outside the company. We report the findings of the diagnostic phase, outline the solutions implemented to date, and anticipate the next steps in this dynamic evolving journey.
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Khedraki R, Srivastava AV, Bhavnani SP. Framework for Digital Health Phenotypes in Heart Failure. Heart Fail Clin 2022; 18:223-244. [DOI: 10.1016/j.hfc.2021.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Lang T, Reeder J, Moorthy V, Trindade Lima N, Gray G, Kaleebu P, Ihekweazu C, Nsanzimana S, Kang G, Makanga M, Swaminathan S. Creating equity in health research to drive more and better evidence. Wellcome Open Res 2022; 7:15. [PMID: 38031536 PMCID: PMC10685064 DOI: 10.12688/wellcomeopenres.17287.1] [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] [Accepted: 12/08/2021] [Indexed: 12/01/2023] Open
Abstract
Health research is rapidly changing with evidence being gathered through new agile methods. This evolution is critical but must be globally equitable so the poorest nations do not lose out. We must harness this change to better tackle the daily burden of diseases that affect the most impoverished populations and bring research capabilities to every corner of the world so that rapid and fair responses to new pathogen are possible; anywhere they appear. We must seize this opportunity to make research easier, better and more equitable. Currently too many nations are unable to generate the evidence or translate it to directly change health outcomes in their own communities. It is essential to act and harness this emerging change in how research data can be generated and shared, so that all nations sustainably gain from this development. There are positive examples to draw on from COVID-19, but we now need to act. Here we present an initiative to develop a new framework that can guide researchers in the design and execution of their studies. This highly agile system will work by adapting to risk and complexity in any given study, whilst generating quality, safe and ethical data.
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Affiliation(s)
- Trudie Lang
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, OX3 7FZ, UK
| | - John Reeder
- Department of Research for Health, World Health Organization, Geneva, Switzerland
- Special Programme for Research and Training in Tropical Diseases (TDR), World Health Organization, Geneva, Switzerland
| | - Vasee Moorthy
- Department of Research for Health, World Health Organization, Geneva, Switzerland
| | | | - Glenda Gray
- South African Medical Research Council, Western Cape, South Africa
| | - Pontiano Kaleebu
- Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine Uganda Research Unit, Entebbe, Uganda
| | - Chikwe Ihekweazu
- Nigeria Centre for Disease Control (NCDC), Federal Ministry of Health, Abuja, Nigeria
| | | | - Gagandeep Kang
- The Wellcome Trust Research Laboratory, Division of Gastrointestinal Sciences, Christian Medical College, Vellore, India
| | - Michael Makanga
- European & Developing Countries Clinical Trials Partnership (EDCTP), The Hague, The Netherlands
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Rogers A, De Paoli G, Subbarayan S, Copland R, Harwood K, Coyle J, Mitchell L, MacDonald TM, Mackenzie IS. A Systematic Review of Methods used to Conduct Decentralised Clinical Trials. Br J Clin Pharmacol 2021; 88:2843-2862. [PMID: 34961991 PMCID: PMC9306873 DOI: 10.1111/bcp.15205] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Revised: 12/15/2021] [Accepted: 12/17/2021] [Indexed: 12/02/2022] Open
Abstract
Aims To evaluate, using quantitative and qualitative approaches, published data on the design and conduct of decentralised clinical trials (DCTs). Methods We searched MEDLINE, EMBASE, CENTRAL, PsycINFO, ProQuest Dissertations and Theses, ClinicalTrials.gov, OpenGrey and Google Scholar for publications reporting, discussing, or evaluating decentralised clinical research methods. Reports of randomised clinical trials using decentralised methods were included in a focused quantitative analysis with a primary outcome of number of randomised participants. All publications discussing or evaluating DCTs were included in a wider qualitative analysis to identify advantages, disadvantages, facilitators, barriers and stakeholder opinions of decentralised clinical trials. Quantitative data were summarised using descriptive statistics, and qualitative data analysed using a thematic approach. Results Initial searches identified 19 704 articles. After removal of duplicates, 18 553 were screened, resulting in 237 eligible for full‐text assessment. Forty‐five trials were included in the quantitative analysis; 117 documents were included in the qualitative analysis. Trials were widely heterogeneous in design and reporting, precluding meta‐analysis of the effect of DCT methods on the primary recruitment outcome. Qualitative analysis formulated 4 broad themes: value, burden, safety and equity. Participant and stakeholder experiences of DCTs were incompletely represented. Conclusion DCTs are developing rapidly. However, there is insufficient evidence to confirm which methods are most effective in trial recruitment, retention, or overall cost. The identified advantages, disadvantages, facilitators and barriers should inform the development of DCT methods. We recommend further research on how DCTs are experienced and perceived by participants and stakeholders to maximise potential benefits.
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Affiliation(s)
- Amy Rogers
- MEMO Research, Division of Molecular and Clinical Medicine, University of Dundee, Dundee, UK
| | - Giorgia De Paoli
- MEMO Research, Division of Molecular and Clinical Medicine, University of Dundee, Dundee, UK
| | - Selvarani Subbarayan
- MEMO Research, Division of Molecular and Clinical Medicine, University of Dundee, Dundee, UK
| | - Rachel Copland
- MEMO Research, Division of Molecular and Clinical Medicine, University of Dundee, Dundee, UK
| | - Kate Harwood
- MEMO Research, Division of Molecular and Clinical Medicine, University of Dundee, Dundee, UK
| | - Joanne Coyle
- MEMO Research, Division of Molecular and Clinical Medicine, University of Dundee, Dundee, UK
| | - Lyn Mitchell
- MEMO Research, Division of Molecular and Clinical Medicine, University of Dundee, Dundee, UK
| | - Thomas M MacDonald
- MEMO Research, Division of Molecular and Clinical Medicine, University of Dundee, Dundee, UK
| | - Isla S Mackenzie
- MEMO Research, Division of Molecular and Clinical Medicine, University of Dundee, Dundee, UK
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Marquis-Gravel G, Hammill BG, Mulder H, Roe MT, Robertson HR, Wruck LM, Sharlow A, Harris DF, Pohlman FW, Hernandez AF, Jones WS. Validation of Cardiovascular End Points Ascertainment Leveraging Multisource Electronic Health Records Harmonized Into a Common Data Model in the ADAPTABLE Randomized Clinical Trial. Circ Cardiovasc Qual Outcomes 2021; 14:e008190. [PMID: 34886680 DOI: 10.1161/circoutcomes.121.008190] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND The ADAPTABLE trial (Aspirin Dosing: A Patient-Centric Trial Assessing Benefits and Long-Term Effectiveness) is the first randomized trial conducted within the National Patient-Centered Clinical Research Network to use the electronic health record data formatted into a common data model as the primary source of end point ascertainment, without confirmation by standard adjudication. The objective of this prespecified study is to assess the validity of nonfatal end points captured from the National Patient-Centered Clinical Research Network, using traditional blinded adjudication as the gold standard. METHODS A total of 15 076 participants with established atherosclerotic cardiovascular disease were randomized to two doses of aspirin (81 mg and 325 mg once daily). Nonfatal end points (hospitalization for nonfatal myocardial infarction, nonfatal stroke, and major bleeding requiring transfusion of blood products) were captured with the use of programming algorithms applied to National Patient-Centered Clinical Research Network data. A random subset of end points was independently reviewed by a disease-specific expert adjudicator. The positive predictive value of the programming algorithms were calculated separately for end points listed as primary and as nonprimary diagnoses. RESULTS A total of 225 end points were identified (91 myocardial infarction events, 89 stroke events, and 45 bleeding events), including 142 (63%) that were listed as primary diagnoses. Complete source documents were missing for 14% of events. The positive predictive value were 90%, 72%, and 93% for hospitalizations for myocardial infarction, stroke, and major bleeding, respectively, as compared to adjudication. When only primary diagnoses were considered, positive predictive value were 93%, 91%, and 97%, respectively. When only nonprimary diagnoses were considered, positive predictive value were 82%, 36%, and 71%. CONCLUSIONS As compared with blinded adjudication, clinical end point ascertainment from queries of the National Patient-Centered Clinical Research Network distributed harmonized data was valid to identify hospitalizations for myocardial infarction in ADAPTABLE. The proportion of contradicted events was high for hospitalizations for bleeding and strokes when nonprimary diagnoses were analyzed, but not when only primary diagnoses were considered.
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Affiliation(s)
- Guillaume Marquis-Gravel
- Duke Clinical Research Institute, Durham, NC (G.M.-G., B.G.H., H.M., M.T.R., H.R.R., L.M.W., A.S., D.F.H., F.W.P., A.F.H., W.S.J.)
| | - Bradley G Hammill
- Duke Clinical Research Institute, Durham, NC (G.M.-G., B.G.H., H.M., M.T.R., H.R.R., L.M.W., A.S., D.F.H., F.W.P., A.F.H., W.S.J.)
| | - Hillary Mulder
- Duke Clinical Research Institute, Durham, NC (G.M.-G., B.G.H., H.M., M.T.R., H.R.R., L.M.W., A.S., D.F.H., F.W.P., A.F.H., W.S.J.)
| | - Matthew T Roe
- Duke Clinical Research Institute, Durham, NC (G.M.-G., B.G.H., H.M., M.T.R., H.R.R., L.M.W., A.S., D.F.H., F.W.P., A.F.H., W.S.J.).,Duke University Medical Center, Durham, NC (M.T.R., F.W.P., A.F.H., W.S.J.)
| | - Holly R Robertson
- Duke Clinical Research Institute, Durham, NC (G.M.-G., B.G.H., H.M., M.T.R., H.R.R., L.M.W., A.S., D.F.H., F.W.P., A.F.H., W.S.J.)
| | - Lisa M Wruck
- Duke Clinical Research Institute, Durham, NC (G.M.-G., B.G.H., H.M., M.T.R., H.R.R., L.M.W., A.S., D.F.H., F.W.P., A.F.H., W.S.J.)
| | - Amber Sharlow
- Duke Clinical Research Institute, Durham, NC (G.M.-G., B.G.H., H.M., M.T.R., H.R.R., L.M.W., A.S., D.F.H., F.W.P., A.F.H., W.S.J.)
| | - Debra F Harris
- Duke Clinical Research Institute, Durham, NC (G.M.-G., B.G.H., H.M., M.T.R., H.R.R., L.M.W., A.S., D.F.H., F.W.P., A.F.H., W.S.J.)
| | - F Will Pohlman
- Duke Clinical Research Institute, Durham, NC (G.M.-G., B.G.H., H.M., M.T.R., H.R.R., L.M.W., A.S., D.F.H., F.W.P., A.F.H., W.S.J.).,Duke University Medical Center, Durham, NC (M.T.R., F.W.P., A.F.H., W.S.J.)
| | - Adrian F Hernandez
- Duke Clinical Research Institute, Durham, NC (G.M.-G., B.G.H., H.M., M.T.R., H.R.R., L.M.W., A.S., D.F.H., F.W.P., A.F.H., W.S.J.).,Duke University Medical Center, Durham, NC (M.T.R., F.W.P., A.F.H., W.S.J.)
| | - W Schuyler Jones
- Duke Clinical Research Institute, Durham, NC (G.M.-G., B.G.H., H.M., M.T.R., H.R.R., L.M.W., A.S., D.F.H., F.W.P., A.F.H., W.S.J.).,Duke University Medical Center, Durham, NC (M.T.R., F.W.P., A.F.H., W.S.J.)
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Gaudelet T, Day B, Jamasb AR, Soman J, Regep C, Liu G, Hayter JBR, Vickers R, Roberts C, Tang J, Roblin D, Blundell TL, Bronstein MM, Taylor-King JP. Utilizing graph machine learning within drug discovery and development. Brief Bioinform 2021; 22:bbab159. [PMID: 34013350 PMCID: PMC8574649 DOI: 10.1093/bib/bbab159] [Citation(s) in RCA: 48] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Revised: 04/01/2021] [Accepted: 04/05/2021] [Indexed: 12/15/2022] Open
Abstract
Graph machine learning (GML) is receiving growing interest within the pharmaceutical and biotechnology industries for its ability to model biomolecular structures, the functional relationships between them, and integrate multi-omic datasets - amongst other data types. Herein, we present a multidisciplinary academic-industrial review of the topic within the context of drug discovery and development. After introducing key terms and modelling approaches, we move chronologically through the drug development pipeline to identify and summarize work incorporating: target identification, design of small molecules and biologics, and drug repurposing. Whilst the field is still emerging, key milestones including repurposed drugs entering in vivo studies, suggest GML will become a modelling framework of choice within biomedical machine learning.
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Affiliation(s)
| | - Ben Day
- Relation Therapeutics, London, UK
- The Computer Laboratory, University of Cambridge, UK
| | - Arian R Jamasb
- Relation Therapeutics, London, UK
- The Computer Laboratory, University of Cambridge, UK
- Department of Biochemistry, University of Cambridge, UK
| | | | | | | | | | | | | | - Jian Tang
- Mila, the Quebec AI Institute, Canada
- HEC Montreal, Canada
| | - David Roblin
- Relation Therapeutics, London, UK
- Juvenescence, London, UK
- The Francis Crick Institute, London, UK
| | | | - Michael M Bronstein
- Relation Therapeutics, London, UK
- Department of Computing, Imperial College London, UK
- Twitter, UK
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Keenoy KE, Lenze EJ, Nicol GE. Going remote: Implementing digital research methods at an academic medical center during COVID-19. J Clin Transl Sci 2021; 5:e189. [PMID: 34812289 PMCID: PMC8593367 DOI: 10.1017/cts.2021.865] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Revised: 09/29/2021] [Accepted: 09/29/2021] [Indexed: 02/06/2023] Open
Abstract
COVID-19 has forced medical research institutions to conduct clinical research remotely. Here, we describe how a university's mHealth Research Core helped facilitate the shift to remote research during the COVID-19 pandemic. In 2019 (pre-pandemic), we conducted stakeholder interviews and leadership group sessions to identify, create, and implement resources and core functions to support investigator-initiated mHealth research. Between April 2019 and February 2020, we identified four investigator needs: 1) a seminar series on trends in mHealth research, 2) mHealth case consultation services, 3) liaison services with institutional regulatory compliance groups, and 4) online navigation tools for implementation of mHealth methods (e.g., eConsent) and for building partnerships with technology vendors. To date, the mHealth Research Core has held seven seminars, completed 71 case consultations, assisted four COVID-related clinical studies, advised the IRB on shifting to remote research, and widely disseminated eConsent navigation tools. Although pre-pandemic stakeholder and investigator needs led to the creation of the mHealth Research Core, this institutional resource played a critical role in continuing clinical research during the pandemic by assisting investigators in rapidly shifting to remote study methodology.
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Affiliation(s)
- Katie E. Keenoy
- Washington University School of Medicine, St. Louis, MO, USA
- happyMedium | healthyMedium, LLC, St. Louis, MO, USA
| | - Eric J. Lenze
- Washington University School of Medicine, St. Louis, MO, USA
| | - Ginger E. Nicol
- Washington University School of Medicine, St. Louis, MO, USA
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Kua KP, Lee DSWH. Home environmental interventions for prevention of respiratory tract infections: a systematic review and meta-analysis. REVIEWS ON ENVIRONMENTAL HEALTH 2021; 36:297-307. [PMID: 33544536 DOI: 10.1515/reveh-2020-0169] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Accepted: 01/10/2021] [Indexed: 06/12/2023]
Abstract
OBJECTIVES Poor housing conditions have been associated with increased risks of respiratory infections. This review aims to determine whether modifying the physical environment of the home has benefits in reducing respiratory infections. CONTENT We performed a systematic review and meta-analysis of the effectiveness of home environmental interventions for preventing respiratory tract infections. Ten electronic databases were searched to identify randomized controlled trials published from inception to July 31, 2020. Random-effects meta-analyses were used to assess the study outcomes. Our search identified 14 eligible studies across 12 countries, which comprised 87,428 households in total. The type of interventions on home environment included kitchen appliance and design, water supply and sanitation, house insulation, and home heating. Meta-analysis indicated a potential benefit of home environmental interventions in preventing overall respiratory tract infections (Absolute RR=0.89, 95% CI=0.78-1.01, p=0.07; Pooled adjusted RR=0.72, 95% CI=0.63-0.84, p<0.0001). Subgroup analyses depicted that home environmental interventions had no significant impact on lower respiratory tract infections, pneumonia, and severe pneumonia. A protective effect against respiratory infections was observed in high income country setting (RR=0.82, 95% CI=0.78-0.87, p<0.00001). SUMMARY AND OUTLOOK Home environmental interventions have the potential to reduce morbidity of respiratory tract infections. The lack of significant impact from stand-alone housing interventions suggests that multicomponent interventions should be implemented in tandem with high-quality health systems.
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Affiliation(s)
- Kok Pim Kua
- Puchong Health Clinic, Petaling District Health Office, Ministry of Health Malaysia, Petaling, Malaysia
| | - Dr Shaun Wen Huey Lee
- School of Pharmacy, Monash University, Bandar Sunway, 47500 Subang Jaya, Selangor, Malaysia
- Asian Centre for Evidence Synthesis in Population, Implementation, and Clinical Outcomes (PICO), Health and Well-being Cluster, Global Asia in the 21st Century (GA21) Platform, Monash University, Bandar Sunway, 47500 Subang Jaya, Selangor, Malaysia
- Gerontechnology Laboratory, Global Asia in the 21st Century (GA21) Platform, Monash University, Bandar Sunway, 47500 Subang Jaya, Selangor, Malaysia
- Faculty of Health and Medical Sciences, Taylor's University, Lakeside Campus, 47500 Subang Jaya, Selangor, Malaysia
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Kadakia KT, Halperin DM, Offodile AC. Operationalizing Virtual Trials in Oncology-From Aspiration to Action. JCO Clin Cancer Inform 2021; 5:953-957. [PMID: 34516277 DOI: 10.1200/cci.21.00073] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Affiliation(s)
| | - Daniel M Halperin
- Department of Gastrointestinal Medical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Anaeze C Offodile
- Department of Plastic and Reconstructive Surgery, University of Texas MD Anderson Cancer Center, Houston, TX.,Institute for Cancer Care Innovation, University of Texas MD Anderson Cancer Center, Houston, TX.,Baker Institute for Public Policy, Rice University, Houston, TX
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Permission to prescribe: do cardiologists need permission to prescribe diabetes medications that afford cardiovascular benefit? Curr Opin Cardiol 2021; 36:672-681. [PMID: 34173772 DOI: 10.1097/hco.0000000000000892] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE OF REVIEW Antihyperglycemic therapies including sodium glucose contransporter-2 inhibitors (SGLT2i) and glucagon-like peptide-1 receptor agonists (GLP-1 RA) have been demonstrated to confer significant cardiovascular benefit and reduce future events in patients with type 2 diabetes mellitus (T2DM). However, despite positive data from cardiovascular outcome trials, these therapies remain underutilized in a large proportion of patients who have clinical indications and meet coverage guidelines for their initiation. One of the causes of the observed gap between scientific evidence and clinical cardiology practice is therapeutic hesitancy (otherwise known as therapeutic inertia). The purpose of this review is to discuss the contributors to therapeutic hesitancy in the implementation of these evidence-based therapies and, more importantly, provide pragmatic solutions to address these barriers. RECENT FINDINGS Recent studies have demonstrated that clinicians may not initiate cardiovascular protective therapies due to a reluctance to overstep perceived interdisciplinary boundaries, concerns about causing harm due to medication side effects, and a sense of unfamiliarity with the optimal choice of therapy amidst a rapidly evolving landscape of T2DM therapies. SUMMARY Herein, we describe a multifaceted approach aimed at creating a 'permission to prescribe' culture, developing integrated multidisciplinary models of care, enhancing trainees' experiences in cardiovascular disease prevention, and utilizing technology to motivate change. Taken together, these interventions should increase the implementation of evidence-based therapies and improve the quality of life and cardiovascular outcomes of individuals with T2DM.
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Anchouche K, Elharram M, Oulousian E, Razaghizad A, Avram R, Marquis-Gravel G, Randhawa VK, Nkulikiyinka R, Ni W, Fiuzat M, O'Connor C, Psotka MA, Fox J, Tyl B, Kao D, Sharma A. Use of Actigraphy (Wearable Digital Sensors to Monitor Activity) in Heart Failure Randomized Clinical Trials: A Scoping Review. Can J Cardiol 2021; 37:1438-1449. [PMID: 34256087 DOI: 10.1016/j.cjca.2021.07.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2021] [Revised: 07/05/2021] [Accepted: 07/05/2021] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Actigraphy-based measurements of physiologic parameters may enable design of patient-centric heart failure (HF) clinical trials. Recently, the Heart Failure Collaboratory focused on recommendations for meaningful change and use of actigraphy as an end point in HF clinical trials. We aimed to evaluate randomized controlled trials (RCTs) that have quantified the impact of HF interventions using actigraphy. METHODS Using a scoping review strategy, we evaluated the use of actigraphy in HF RCTs. Studies were identified through electronic searches of Embase, OVID Medline, PubMed, and Cochrane Review. Data on trial characteristics and results were collected. RESULTS We identified 11 RCTs with a total of 1,455 participants. The risk of bias across the included trials was high overall. All trials had the primary outcomes reflecting measures of either physical activity (n = 8), sleep (n = 2), or both (n = 1). Five trials evaluated response to pharmacologic therapies compared with placebo, 3 evaluated physical activity interventions, 2 evaluated group or cognitive therapy, and 1 evaluated sleep-ventilation strategy. Sample sizes ranged from 30 to 619 participants. There was significant heterogeneity relating to device type, body placement site, and handling of missing actigraphy data. Duration of monitoring ranged from 48 hours to 12 weeks. None of the studies evaluating pharmacologic therapies (n = 5) demonstrated a significant improvement of actigraphy-based primary end point measurements. CONCLUSIONS There is significant heterogeneity in the use, methodology, and results of actigraphy-based HF RCTs. Our results highlight the need to develop, standardize, and validate actigraphy-specific outcomes for use in HF clinical trials.
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Affiliation(s)
- Khalil Anchouche
- Division of Cardiology, McGill University Health Centre, McGill University, Montréal, Québec, Canada; DREAM-CV Lab, McGill University Health Centre, McGill University, Montréal, Québec, Canada
| | - Malik Elharram
- Division of Cardiology, McGill University Health Centre, McGill University, Montréal, Québec, Canada; DREAM-CV Lab, McGill University Health Centre, McGill University, Montréal, Québec, Canada
| | - Emily Oulousian
- Division of Cardiology, McGill University Health Centre, McGill University, Montréal, Québec, Canada; DREAM-CV Lab, McGill University Health Centre, McGill University, Montréal, Québec, Canada
| | - Amir Razaghizad
- Division of Cardiology, McGill University Health Centre, McGill University, Montréal, Québec, Canada; DREAM-CV Lab, McGill University Health Centre, McGill University, Montréal, Québec, Canada
| | - Robert Avram
- Division of Cardiology, Department of Medicine, Ottawa Heart Institute, University of Ottawa, Ottawa, Ontario, Canada; Division of Cardiology, University of California San Francisco, San Francisco, California, USA; Montréal Heart Institute, Université de Montréal, Montréal, Québec, Canada
| | | | - Varinder Kaur Randhawa
- Department of Cardiovascular Medicine, Kaufman Center for Heart Failure, Heart, Vascular and Thoracic Institute, Cleveland, Ohio, USA
| | | | - Wei Ni
- Eli Lilly and Company, Indianapolis, Indiana, USA
| | - Mona Fiuzat
- Division of Cardiology, Duke University, Durham, North Carolina, USA
| | - Christopher O'Connor
- Division of Cardiology, Duke University, Durham, North Carolina, USA; Inova Heart and Vascular Institute, Falls Church, Virginia, USA
| | | | - Jonathan Fox
- Eidos Therapeutics, San Francisco, California, USA
| | - Benoit Tyl
- Center for Therapeutic Innovation Cardiovascular and Metabolic diseases, Institut de Recherches Internationales Servier, Suresnes, France
| | - David Kao
- Department of Medicine, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Abhinav Sharma
- Division of Cardiology, McGill University Health Centre, McGill University, Montréal, Québec, Canada; DREAM-CV Lab, McGill University Health Centre, McGill University, Montréal, Québec, Canada.
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Yao X, Attia ZI, Behnken EM, Walvatne K, Giblon RE, Liu S, Siontis KC, Gersh BJ, Graff-Radford J, Rabinstein AA, Friedman PA, Noseworthy PA. Batch enrollment for an artificial intelligence-guided intervention to lower neurologic events in patients with undiagnosed atrial fibrillation: rationale and design of a digital clinical trial. Am Heart J 2021; 239:73-79. [PMID: 34033803 DOI: 10.1016/j.ahj.2021.05.006] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Accepted: 05/16/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND Clinical trials are a fundamental tool to evaluate medical interventions but are time-consuming and resource-intensive. OBJECTIVES To build infrastructure for digital trials to improve efficiency and generalizability and test it using a study to validate an artificial intelligence algorithm to detect atrial fibrillation (AF). DESIGN We will prospectively enroll 1,000 patients who underwent an electrocardiogram for any clinical reason in routine practice, do not have a previous diagnosis of AF or atrial flutter and would be eligible for anticoagulation if AF is detected. Eligible patients will be identified using digital phenotyping algorithms, including natural language processing that runs on the electronic health records. Study invitations will be sent in batches via patient portal or letter, which will direct patients to a website to verify eligibility, learn about the study (including video-based informed consent), and consent electronically. The method aims to enroll participants representative of the general patient population, rather than a convenience sample of patients presenting to clinic. A device will be mailed to patients to continuously monitor for up to 30 days. The primary outcome is AF diagnosis and burden; secondary outcomes include patients' experience with the trial conduct methods and the monitoring device. The enrollment, intervention, and follow-up will be conducted remotely, ie, a patient-centered site-less trial. SUMMARY This is among the first wave of trials to adopt digital technologies, artificial intelligence, and other pragmatic features to create efficiencies, which will pave the way for future trials in a broad range of disease and treatment areas. Clinicaltrials.gov: NCT04208971.
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Patient Engagement Initiatives in Clinical Trials: Recent Trends and Implications. Ther Innov Regul Sci 2021; 55:1059-1065. [PMID: 34097288 PMCID: PMC8182995 DOI: 10.1007/s43441-021-00306-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Accepted: 05/19/2021] [Indexed: 11/10/2022]
Abstract
BACKGROUND As clinical trial protocol designs become more complex and eligible patient populations narrow, it is becoming increasingly difficult to recruit participants and retain them for the duration of the trial. This study surveyed clinical trial participants to learn about the prevalence and impact of new technologies and other supportive solutions designed to improve patient engagement and retention. Patient perceptions of these convenience-enhancing solutions and how they have changed since our last study in 2017 were examined. METHODS Based on 12,451 responses to a global online survey collected in 2019, we conducted an analysis of respondents who used convenience-enhancing solutions during their participation in a clinical trial. RESULTS We found that the prevalence of convenience-enhancing solutions is increasing and that their use correlates with high ratings for clinical trial satisfaction, as well as with high ratings for care and attention received during the trial. CONCLUSIONS A wide range of strategies and tactics are needed to reduce barriers to participation and improve retention. The use of convenience-enhancing solutions can help reduce these barriers. The solutions are also particularly popular among under-represented populations, revealing further potential opportunities to increase patient engagement specifically among these groups.
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de Aquino CH. Methodological Issues in Randomized Clinical Trials for Prodromal Alzheimer's and Parkinson's Disease. Front Neurol 2021; 12:694329. [PMID: 34421799 PMCID: PMC8377160 DOI: 10.3389/fneur.2021.694329] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 06/22/2021] [Indexed: 01/21/2023] Open
Abstract
Alzheimer's disease (AD) and Parkinson's disease (PD) are the first and second most common neurodegenerative disorders, respectively. Both are proteinopathies with inexorable courses and no approved disease-modifying therapies. A substantial effort has been made to identify interventions that could slow down the progression of AD and PD; to date, with no success. The advances in biomarker research improved the identification of individuals at risk for these disorders before symptom onset, recognizing the pre-clinical stage, in which there is abnormal protein accumulation but no clinical symptoms of the disease, and the prodromal stage, in which mild symptoms are present but the clinical diagnostic criteria for disease cannot be fulfilled. The ability to detect pre-clinical and prodromal stages of these diseases has encouraged clinical trials for disease-modification at earlier phases, seeking to slow or prevent phenoconversion into clinical disease. Clinical trials at these stages have several challenges, such as the identification of the eligible population, the appropriate choice of biomarkers, the definition of clinical endpoints, the duration of follow-up, and the statistical analysis. This article aims to discuss some of the methodological challenges in the design of trials for pre-clinical and prodromal phases of AD and PD, to critically review the recent studies, and to discuss methodological approaches to mitigate these challenges in trial design.
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Affiliation(s)
- Camila Henriques de Aquino
- Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada.,Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada.,Department of Health, Evidence and Impact, McMaster University, Hamilton, ON, Canada
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Owens RL, Birkeland K, Heywood JT, Steinhubl SR, Dorn J, Grant D, Fombu E, Khandwalla R. Sleep Outcomes From AWAKE-HF: A Randomized Clinical Trial of Sacubitril/Valsartan vs Enalapril in Patients With Heart Failure and Reduced Ejection Fraction. J Card Fail 2021; 27:1466-1471. [PMID: 34428592 DOI: 10.1016/j.cardfail.2021.07.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 07/28/2021] [Accepted: 07/28/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND Heart failure and sleep-disordered breathing have been increasingly recognized as co-occurring conditions. Their bidirectional relationship warrants investigation into whether heart failure therapy improves sleep and sleep-disordered breathing. We sought to explore the effect of treatment with sacubitril/valsartan on sleep-related endpoints from the AWAKE-HF study. METHODS AND RESULTS AWAKE-HF was a randomized, double-blind study conducted in 23 centers in the United States. Study participants with heart failure with reduced rejection fraction and New York Heart Association class II or III symptoms were randomly assigned to receive treatment with either sacubitril/valsartan or enalapril. All endpoints were assessed at baseline and after 8 weeks of treatment. Portable sleep-monitoring equipment was used to measure the apnea-hypopnea index, including obstructive and central events. Total sleep time, wake after sleep onset and sleep efficiency were exploratory measures assessed using wrist actigraphy. THE RESULTS WERE AS FOLLOWS 140 patients received treatment in the double-blind phase (sacubitril/valsartan, n = 70; enalapril, n = 70). At baseline, 39% and 40% of patients randomly assigned to receive sacubitril/valsartan or enalapril, respectively, presented with undiagnosed, untreated, moderate-to-severe sleep-disordered breathing (≥ 15 events/h), and nearly all had obstructive sleep apnea. After 8 weeks of treatment, the mean 4% apnea-hypopnea index changed minimally from 16.3/h to 15.2/h in the sacubitril/valsartan group and from 16.8/h to 17.6/h in the enalapril group. Mean total sleep time was long at baseline and decreased only slightly in both treatment groups at week 8 (-14 and -11 minutes for sacubitril/valsartan and enalapril, respectively), with small changes in wake after sleep onset and sleep efficiency in both groups. CONCLUSIONS In a cohort of patients with heart failure with reduced rejection fraction who met prescribing guidelines for sacubitril/valsartan, one-third had undiagnosed moderate-to-severe obstructive sleep apnea. The addition of sacubitril/valsartan therapy did not significantly improve sleep-disordered breathing or sleep duration or efficiency. Patients who meet indications for treatment with sacubitril/valsartan should be evaluated for sleep-disordered breathing.
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Affiliation(s)
- Robert L Owens
- From the Division of Pulmonary, Critical Care, and Sleep Medicine, San Diego School of Medicine, University of California, La Jolla, CA.
| | - Kade Birkeland
- Clinical Transformation, Cedars-Sinai Health System, Beverly Hills, CA
| | - J Thomas Heywood
- Division of Cardiovascular Medicine, Scripps Clinic, San Diego, CA
| | - Steven R Steinhubl
- Digital Medicine, Scripps Research Translational Science Institute, San Diego, CA
| | | | | | - Emmanuel Fombu
- Locust Walk Partners Biopharma, Boston, MA (former employee of US Clinical Development and Medical Affairs, Novartis Pharmaceuticals, East Hanover, NJ)
| | - Raj Khandwalla
- Department of Cardiology, Cedars-Sinai Care Foundation, Smidt Heart Institute, Beverly Hills, CA
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Qiu Y, Asselin CY, Kallas D, Adreak N, Armstrong K, Colella TJ, Sharma A, Avram R, Gravel GM, Randhawa VK. The Emerging Role of Digital Health Technology in Cardiovascular Care. Can J Cardiol 2021. [DOI: 10.1016/j.cjca.2021.04.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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Sharma A, Oulousian E, Ni J, Lopes R, Cheng MP, Label J, Henriques F, Lighter C, Giannetti N, Avram R. Voice-based screening for SARS-CoV-2 exposure in cardiovascular clinics. EUROPEAN HEART JOURNAL. DIGITAL HEALTH 2021; 2:521-527. [PMID: 36713601 PMCID: PMC8344943 DOI: 10.1093/ehjdh/ztab055] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/14/2021] [Revised: 06/03/2021] [Accepted: 06/15/2021] [Indexed: 02/01/2023]
Abstract
Aims Artificial intelligence (A.I) driven voice-based assistants may facilitate data capture in clinical care and trials; however, the feasibility and accuracy of using such devices in a healthcare environment are unknown. We explored the feasibility of using the Amazon Alexa ('Alexa') A.I. voice-assistant to screen for risk factors or symptoms relating to SARS-CoV-2 exposure in quaternary care cardiovascular clinics. Methods and results We enrolled participants to be screened for signs and symptoms of SARS-CoV-2 exposure by a healthcare provider and then subsequently by the Alexa. Our primary outcome was interrater reliability of Alexa to healthcare provider screening using Cohen's Kappa statistic. Participants rated the Alexa in a post-study survey (scale of 1 to 5 with 5 reflecting strongly agree). This study was approved by the McGill University Health Centre ethics board. We prospectively enrolled 215 participants. The mean age was 46 years [17.7 years standard deviation (SD)], 55% were female, and 31% were French speakers (others were English). In total, 645 screening questions were delivered by Alexa. The Alexa mis-identified one response. The simple and weighted Cohen's kappa statistic between Alexa and healthcare provider screening was 0.989 [95% confidence interval (CI) 0.982-0.997] and 0.992 (955 CI 0.985-0.999), respectively. The participants gave an overall mean rating of 4.4 (out of 5, 0.9 SD). Conclusion Our study demonstrates the feasibility of an A.I. driven multilingual voice-based assistant to collect data in the context of SARS-CoV-2 exposure screening. Future studies integrating such devices in cardiovascular healthcare delivery and clinical trials are warranted. Registration https://clinicaltrials.gov/ct2/show/NCT04508972.
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Affiliation(s)
- Abhinav Sharma
- DREAM-CV Lab, McGill University Health Centre, 1001 Decarie Blvd, Montreal, Quebec H4A 3J1, Canada,Division of Cardiology, McGill University, Montreal, Quebec, Canada,Corresponding author. Tel: +1 514 934 1934 x35414, Fax: +1 514 938 7396,
| | - Emily Oulousian
- DREAM-CV Lab, McGill University Health Centre, 1001 Decarie Blvd, Montreal, Quebec H4A 3J1, Canada,Division of Cardiology, McGill University, Montreal, Quebec, Canada
| | - Jiayi Ni
- Division of Cardiology, McGill University, Montreal, Quebec, Canada
| | - Renato Lopes
- Duke Clinical Research Institute, Duke University, 300 W Morgan St, Durham, North Carolina 27701, USA
| | - Matthew Pellan Cheng
- Divisions of Infectious Diseases and Medical Microbiology, McGill University Health Centre, 1001 Decarie Blvd, Montreal, Quebec H4A 3J1, Canada
| | - Julie Label
- Division of Cardiology, McGill University, Montreal, Quebec, Canada
| | - Filipe Henriques
- Division of Cardiology, McGill University, Montreal, Quebec, Canada
| | - Claudia Lighter
- DREAM-CV Lab, McGill University Health Centre, 1001 Decarie Blvd, Montreal, Quebec H4A 3J1, Canada,Division of Cardiology, McGill University, Montreal, Quebec, Canada
| | - Nadia Giannetti
- Division of Cardiology, McGill University, Montreal, Quebec, Canada
| | - Robert Avram
- Division of Cardiology, University of Ottawa, 40 Ruskin Street Ottawa, Ontario K1Y 4W7 Canada, Canada,Montreal Heart Institute, University of Montreal, Montreal, 5000 Rue Bélanger, Montréal, Quebec H1T 1C8, Canada
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Liu HH, Ezekowitz MD, Columbo M, Khan O, Martin J, Spahr J, Yaron D, Cushinotto L, Kapelusznik L. Testing the feasibility of operationalizing a prospective, randomized trial with remote cardiac safety EKG monitoring during a pandemic. J Interv Card Electrophysiol 2021; 63:345-356. [PMID: 34037911 PMCID: PMC8149293 DOI: 10.1007/s10840-021-00989-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Accepted: 03/28/2021] [Indexed: 02/06/2023]
Abstract
Background The coronavirus SARS-CoV-2 is highly contagious. Hydroxychloroquine (HCQ) has in vitro activity against SARS-CoV-2. The FDA authorized emergency use of HCQ against COVID-19. HCQ may have dose-related cardiotoxicity. This clinical trial received ethical approval on May 15, 2020, operationalized in June to evaluate a low prophylaxis dose of HCQ (200mg BID) in household contacts of COVID-19-positive patients without physical contact between investigators and participants. It represents the first report of the FDA approved 6-lead EKGs with a smartphone KardiaMobile® 6L application. Methods To reach a sample size of 170, household members were contacted by telephone, emailed consent forms with electronic signature capability, and randomized 2:1 to HCQ or observation for 10 days with follow-up of 14 days. Home saliva PCR tests recorded COVID status on days 1 and 14. Symptoms and 6-lead EKGs were obtained daily. Results Fifty-one participants were randomized with 42 evaluable at day 14. Remote monitoring of 407 EKGs revealed no QTc prolongation or other ECG changes in either group. At time of consent, no participants were symptomatic or COVID+. On days 1 and 14, COVID tests were positive in 4 and 2 in the HCQ group and 4 and 0 in the observation group. No tests converted to positive. There were no deaths or hospitalizations. Conclusions A clinical trial without personal contact, rapidly initiated and operationalized to exclude cardiac toxicity using daily remote 6-lead EKG monitoring, is feasible. Of 407 EKGs from 42 participants, there was no evidence of cardiac toxicity. Clinical trial registration Clinicaltrials.gov: NCT04652648 registration date: December 3, 2020
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Affiliation(s)
- Hans H Liu
- Department of Medicine, Bryn Mawr Hospital, Bryn Mawr, PA, USA
| | - Michael D Ezekowitz
- Department of Medicine, Bryn Mawr Hospital, Bryn Mawr, PA, USA. .,The Sidney Kimmel Medical College, Philadelphia, PA, USA.
| | - Michele Columbo
- Department of Medicine, Bryn Mawr Hospital, Bryn Mawr, PA, USA
| | - Oneib Khan
- Lankenau Internal Medicine Residency Program, Lankenau Hospital, Main Line Health System, Wynnewood, PA, USA
| | - Jack Martin
- Department of Medicine, Bryn Mawr Hospital, Bryn Mawr, PA, USA
| | | | - David Yaron
- Bryn Mawr Family Practice Residency, Bryn Mawr Hospital, Bryn Mawr, PA, USA
| | - Lisa Cushinotto
- Department of Pharmacy, Bryn Mawr Hospital, Bryn Mawr, PA, USA
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The Future of Meat: Health Impact Assessment with Randomized Evidence. Am J Med 2021; 134:569-575. [PMID: 33316249 DOI: 10.1016/j.amjmed.2020.11.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2020] [Revised: 11/12/2020] [Accepted: 11/18/2020] [Indexed: 01/07/2023]
Abstract
Massive animal farming for meat production poses major problems in terms of resource use, environmental impact, and biodiversity. Furthermore, excessive meat consumption has been associated with multiple deleterious health consequences. However, more and better-designed randomized trials are needed to increase the level of evidence on the health impacts of meat. Novel meat alternatives, such as plant- and cell-based meat, are much less impactful to the environment and might replace traditional animal meat in the future, but, despite promising early data, the health consequences of these novel products need further study. This manuscript focuses on the health impacts of meat over 3 main sections: 1) overview of the evidence highlighting the association of meat consumption with health; 2) novel alternatives to meat, including plant-based and cell-based alternatives; and 3) examine the rationale for randomized studies to evaluate the effects of the novel meat alternatives compared with the standard animal meat.
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Data from Digital Health Devices Informs Ideal Cardiovascular Health. J Pers Med 2021; 11:jpm11030189. [PMID: 33801949 PMCID: PMC7998383 DOI: 10.3390/jpm11030189] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 03/05/2021] [Accepted: 03/05/2021] [Indexed: 12/15/2022] Open
Abstract
Ideal cardiovascular health is associated with a decrease in adverse cardiovascular events. The My Research Legacy study examined ideal cardiovascular health using the Life's Simple 7 survey and data from digital health devices. We hypothesized that digital devices provide a more objective view of overall cardiovascular health status than self-reported measures. Therefore, we analyzed weight and activity data recorded by digital devices to recalculate the Life's Simple 7 Health Score. All study participants (n = 1561) answered the survey, while a subgroup (n = 390) provided data from digital devices. Individuals with digital devices had a lower body mass index (BMI) and higher weekly minutes of vigorous exercise than participants without digital devices (p < 0.01). Baseline Health Scores were higher in individuals with digital devices compared to those without (7.0 ± 1.6 vs. 6.6 ± 1.6, p < 0.01). Data from digital devices reveal both increases and decreases in measured vs. self-reported BMI (p < 0.04) and weekly minutes of moderate and vigorous exercise activity (p < 0.01). Using these data, a significant difference was found between the recalculated and the self-reported Life's Simple 7 Health Score (p < 0.05). These findings suggest that incorporation of digital health devices should be considered as part of a precision medicinal approach to assessing ideal cardiovascular health.
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Kitsiou S, Vatani H, Paré G, Gerber BS, Buchholz SW, Kansal MM, Leigh J, Masterson Creber RM. Effectiveness of Mobile Health Technology Interventions for Patients With Heart Failure: Systematic Review and Meta-analysis. Can J Cardiol 2021; 37:1248-1259. [PMID: 33667616 DOI: 10.1016/j.cjca.2021.02.015] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 02/19/2021] [Accepted: 02/19/2021] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Heart failure (HF) is a complex and serious condition associated with substantial morbidity, mortality, and health care costs. We conducted a systematic review and meta-analysis to evaluate the effects of mobile health (mHealth) interventions compared with usual care in patients with HF. METHODS We searched MEDLINE, CENTRAL, CINAHL, and EMBASE databases to identify eligible randomized controlled trials (RCTs) of mHealth interventions. Primary outcomes included: all-cause mortality, cardiovascular mortality, HF-related hospitalizations, and all-cause hospitalizations. Meta-analyses using a random effects model were performed for all outcomes. Risk of bias and quality of evidence were evaluated using the Cochrane Tool and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework. RESULTS Sixteen RCTs involving 4389 patients were included. Compared with usual care, mHealth interventions reduced the risk of all-cause mortality (risk ratio [RR], 0.80; 95% confidence interval [CI], 0.65-0.97; absolute risk reduction [ARR], 2.1%; high-quality evidence), cardiovascular mortality (RR, 0.70; 95% CI, 0.53-0.91; ARR, 2.9%; high-quality evidence), and HF hospitalizations (RR, 0.77; 95% CI, 0.67-0.88; ARR, 5%; high-quality evidence), but had no effect on all-cause hospitalizations. Results were driven by mHealth interventions with remote monitoring and clinical feedback, which were associated with larger reductions than stand-alone mHealth interventions. However, subgroup differences were not statistically significant. CONCLUSIONS mHealth interventions with remote monitoring and clinical feedback reduce mortality and HF-related hospitalizations, but might not reduce all-cause hospitalizations in patients with HF. Additional studies are needed to determine the efficacy of stand-alone mHealth interventions as well as active features of mHealth that contribute to efficacy.
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Affiliation(s)
- Spyros Kitsiou
- Department of Biomedical and Health Information Sciences, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Haleh Vatani
- Department of Biomedical and Health Information Sciences, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Guy Paré
- Research Chair in Diginal Health, HEC Montréal, Montréal, Quebec, Canada
| | - Ben S Gerber
- Division of Academic Internal Medicine and Geriatrics, Department of Medicine, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Susan W Buchholz
- Department of Adult Health and Gerontological Nursing, Rush University College of Nursing, Chicago, Illinois, USA
| | - Mayank M Kansal
- Division of Cardiology, Department of Medicine, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Jonathan Leigh
- Department of Biomedical and Health Information Sciences, University of Illinois at Chicago, Chicago, Illinois, USA; Division of Cardiology, Department of Medicine, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Ruth M Masterson Creber
- Department of Population Health Sciences, Division of Health Informatics, Weill Cornell Medicine, New York, New York, USA
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Pereira NL, Avram R, So DY, Iturriaga E, Byrne J, Lennon RJ, Murthy V, Geller N, Goodman SG, Rihal C, Rosenberg Y, Bailey K, Pletcher MJ, Marcus GM, Farkouh ME, Olgin JE. Rationale and design of the TAILOR-PCI digital study: Transitioning a randomized controlled trial to a digital registry. Am Heart J 2021; 232:84-93. [PMID: 33129990 PMCID: PMC7833248 DOI: 10.1016/j.ahj.2020.10.069] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Accepted: 10/24/2020] [Indexed: 01/23/2023]
Abstract
BACKGROUND Tailored Antiplatelet Initiation to Lessen Outcomes Due to Decreased Clopidogrel Response after Percutaneous Coronary Intervention (TAILOR-PCI) is the largest cardiovascular genotype-based randomized pragmatic trial (NCT#01742117) to evaluate the role of genotype-guided selection of oral P2Y12 inhibitor therapy in improving ischemic outcomes after PCI. The trial has been extended from the original 12- to 24-month follow-up, using study coordinator-initiated telephone visits. TAILOR-PCI Digital Study tests the feasibility of extending the trial follow-up in a subset of patients for up to 24 months using state-of-the-art digital solutions. The rationale, design, and approach of extended digital study of patients recruited into a large, international, multi-center clinical trial has not been previously described. METHODS A total of 930 patients from U.S. and Canadian sites previously enrolled in the 5,302 patient TAILOR-PCI trial within 23 months of randomization are invited by mail to the Digital Study website (http://tailorpci.eurekaplatform.org) and by up to 2 recruiting telephone calls. Eureka, a direct-to-participant digital research platform, is used to consent and collect prospective data on patients for the digital study. Patients are asked to answer health-related surveys at fixed intervals using the Eureka mobile app and or desktop platform. The likelihood of patients enrolled in a randomized clinical trial transitioning to a registry using digital technology, the reasons for nonparticipation and engagement rates are evaluated. To capture hospitalizations, patients may optionally enable geofencing, a process that allows background location tracking and triggering of surveys if a hospital visit greater than 4 hours is detected. In addition, patients answer digital hospitalization surveys every month. Hospitalization data received from the Digital Study will be compared to data collected from study coordinator telephone visits during the same time frame. CONCLUSIONS The TAILOR-PCI Digital Study evaluates the feasibility of transitioning a large multicenter randomized clinical trial to a digital registry. The study could provide evidence for the ability of digital technology to follow clinical trial patients and to ascertain trial-related events thus also building the foundation for conducting digital clinical trials. Such a digital approach may be especially pertinent in the era of COVID-19.
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Affiliation(s)
- Naveen L Pereira
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN.
| | - Robert Avram
- University of California San Francisco, San Francisco, CA
| | - Derek Y So
- University of Ottawa Heart Institute, Ottawa, Canada
| | - Erin Iturriaga
- National Heart, Lung, and Blood Institute (NHLBI), National Institutes of Health (NIH), Bethesda, MD
| | - Julia Byrne
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN
| | - Ryan J Lennon
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN
| | | | - Nancy Geller
- National Heart, Lung, and Blood Institute (NHLBI), National Institutes of Health (NIH), Bethesda, MD
| | - Shaun G Goodman
- St. Michael's Hospital, University of Toronto, Toronto, and Canadian VIGOUR Centre, University of Alberta, Edmonton, Canada
| | - Charanjit Rihal
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN
| | - Yves Rosenberg
- National Heart, Lung, and Blood Institute (NHLBI), National Institutes of Health (NIH), Bethesda, MD
| | - Kent Bailey
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN
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Marquis-Gravel G, Robertson H, Jones WS, Riley D, Ford DE, Crenshaw D, Joosten YA, Rudov L, Hernandez AF, Hess R. Streamlining the institutional review board process in pragmatic randomized clinical trials: challenges and lessons learned from the Aspirin Dosing: A Patient-centric Trial Assessing Benefits and Long-Term Effectiveness (ADAPTABLE) trial. Trials 2021; 22:90. [PMID: 33494785 PMCID: PMC7831187 DOI: 10.1186/s13063-021-05026-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Accepted: 01/06/2021] [Indexed: 11/10/2022] Open
Abstract
Background New considerations during the ethical review processes may emerge from innovative, yet unfamiliar operational methods enabled in pragmatic randomized controlled trials (RCT), potentially making institutional review board (IRB) evaluation more complex. In this manuscript, key components of the pragmatic “Aspirin Dosing: A Patient-Centric Trial Assessing Benefits and Long-term Effectiveness (ADAPTABLE)” randomized trial that required a reappraisal of the IRB submission, review, and approval processes are discussed. Main text ADAPTABLE is a pragmatic, multicenter, open-label RCT evaluating the comparative effectiveness of two doses of aspirin widely used for secondary prevention (81 mg and 325 mg) in 15,000 patients with an established history of atherosclerotic cardiovascular disease. The electronic informed consent form is completed online by the participants at the time of enrollment, and endpoint ascertainment is conducted through queries of electronic health records. IRB challenges encountered regarding centralized IRB evaluation, electronic informed consent, patient engagement, and risk determination in ADAPTABLE are described in this manuscript. The experience of ADAPTABLE encapsulates how pragmatic protocol components intended to facilitate the study conduct have been tempered by unexpected, yet justified concerns raised by local IRBs. How the lessons learned can be applied to future similar pragmatic trials is delineated. Conclusion Development of engaging communication channels between IRB and study personnel in pragmatic randomized trials as early as at the time of protocol design allows to reduce issues with IRB approval. Integrations of the lessons learned in ADAPTABLE regarding the IRB process for centralized IRBs, informed consent, patient engagement, and risk determination can be emulated and will be instrumental in future pragmatic studies. Supplementary Information The online version contains supplementary material available at 10.1186/s13063-021-05026-w.
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Affiliation(s)
| | - Holly Robertson
- Duke Clinical Research Institute, 200 Morris St, Durham, NC, 27701, USA
| | - W Schuyler Jones
- Duke Clinical Research Institute, 200 Morris St, Durham, NC, 27701, USA.,Duke University Medical Center, 2301 Erwin Road, Durham, NC, 27710, USA
| | - Danielle Riley
- University of Iowa College of Public Health, 145 N Riverside Dr, Iowa City, IA, 52242, USA
| | - Daniel E Ford
- Institute for Clinical and Translational Research, Johns Hopkins School of Medicine, 750 E. Pratt Street, Baltimore, MD, 21202, USA
| | - David Crenshaw
- Institute for Medicine and Public Health, Vanderbilt University Medical Center, 2525 West End Avenue, Suite 1200, Nashville, TN, 37203, USA
| | - Yvonne A Joosten
- Institute for Medicine and Public Health, Vanderbilt University Medical Center, 2525 West End Avenue, Suite 1200, Nashville, TN, 37203, USA
| | - Lindsey Rudov
- Louisiana Public Health Institute, 1515 Poydras St #1200, New Orleans, LA, 70112, USA
| | - Adrian F Hernandez
- Duke Clinical Research Institute, 200 Morris St, Durham, NC, 27701, USA.,Duke University Medical Center, 2301 Erwin Road, Durham, NC, 27710, USA
| | - Rachel Hess
- Departments of Population Health Sciences and Internal Medicine, University of Utah School of Medicine, 295 Chipeta Way Williams Building Room 1N492, Salt Lake City, UT, 84108, USA.
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Marquis-Gravel G, Roe MT, Robertson HR, Harrington RA, Pencina MJ, Berdan LG, Hammill BG, Faulkner M, Muñoz D, Fonarow GC, Nallamothu BK, Fintel DJ, Ford DE, Zhou L, Daugherty SE, Nauman E, Kraschnewski J, Ahmad FS, Benziger CP, Haynes K, Merritt JG, Metkus T, Kripalani S, Gupta K, Shah RC, McClay JC, Re RN, Geary C, Lampert BC, Bradley SM, Jain SK, Seifein H, Whittle J, Roger VL, Effron MB, Alvarado G, Goldberg YH, VanWormer JL, Girotra S, Farrehi P, McTigue KM, Rothman R, Hernandez AF, Jones WS. Rationale and Design of the Aspirin Dosing-A Patient-Centric Trial Assessing Benefits and Long-term Effectiveness (ADAPTABLE) Trial. JAMA Cardiol 2021; 5:598-607. [PMID: 32186653 DOI: 10.1001/jamacardio.2020.0116] [Citation(s) in RCA: 54] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Importance Determining the right dosage of aspirin for the secondary prevention treatment of atherosclerotic cardiovascular disease (ASCVD) remains an unanswered and critical question. Objective To report the rationale and design for a randomized clinical trial to determine the optimal dosage of aspirin to be used for secondary prevention of ASCVD, using an innovative research method. Design, Setting, and Participants This pragmatic, open-label, patient-centered, randomized clinical trial is being conducted in 15 000 patients within the National Patient-Centered Clinical Research Network (PCORnet), a distributed research network of partners including clinical research networks, health plan research networks, and patient-powered research networks across the United States. Patients with established ASCVD treated in routine clinical practice within the network are eligible. Patient recruitment began in April 2016. Enrollment was completed in June 2019. Final follow-up is expected to be completed by June 2020. Interventions Participants are randomized on a web platform in a 1:1 fashion to either 81 mg or 325 mg of aspirin daily. Main Outcomes and Measures The primary efficacy end point is the composite of all-cause mortality, hospitalization for nonfatal myocardial infarction, or hospitalization for a nonfatal stroke. The primary safety end point is hospitalization for major bleeding associated with a blood-product transfusion. End points are captured through regular queries of the health systems' common data model within the structure of PCORnet's distributed data environment. Conclusions and Relevance As a pragmatic study and the first interventional trial conducted within the PCORnet electronic data infrastructure, this trial is testing several unique and innovative operational approaches that have the potential to disrupt and transform the conduct of future patient-centered randomized clinical trials by evaluating treatments integrated in clinical practice while at the same time determining the optimal dosage of aspirin for secondary prevention of ASCVD. Trial Registration ClinicalTrials.gov Identifier: NCT02697916.
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Affiliation(s)
| | - Matthew T Roe
- Duke Clinical Research Institute, Durham, North Carolina.,Duke University Medical Center, Durham, North Carolina
| | | | | | - Michael J Pencina
- Department of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina
| | - Lisa G Berdan
- Duke Clinical Research Institute, Durham, North Carolina
| | | | - Madelaine Faulkner
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco
| | - Daniel Muñoz
- Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Gregg C Fonarow
- Department of Medicine, University of California, Los Angeles, Los Angeles.,Associate Editor
| | - Brahmajee K Nallamothu
- Michigan Integrated Center of Health Analytics and Medical Prediction, Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan School of Medicine, Ann Arbor
| | - Dan J Fintel
- Feinberg School of Medicine, Division of Cardiology, Department of Medicine, Northwestern University, Chicago, Illinois
| | - Daniel E Ford
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Li Zhou
- Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | | | | | - Jennifer Kraschnewski
- Department of Medicine, Department of Public Health Sciences, Penn State College of Medicine, Hershey, Pennsylvania
| | - Faraz S Ahmad
- Center for Health Information Partnerships, Feinberg School of Medicine, Institute of Public Health and Medicine, Division of Cardiology, Department of Medicine, Northwestern University, Chicago, Illinois
| | | | | | - J Greg Merritt
- Patient-Centered Network of Learning Health Systems (LHSNet), Ann Arbor, Michigan
| | - Thomas Metkus
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland.,Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Sunil Kripalani
- Division of General Internal Medicine and Public Health, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Kamal Gupta
- Division of Cardiovascular Medicine, Department of Medicine, University of Kansas Medical Center, Kansas City
| | - Raj C Shah
- Rush Alzheimer's Disease Center, Department of Family Medicine, Rush University Medical Center, Chicago, Illinois
| | - James C McClay
- Department of Emergency Medicine, University of Nebraska Medical Center College of Medicine, Omaha
| | | | - Carol Geary
- University of Nebraska Medical Center, Omaha
| | - Brent C Lampert
- Wexner Medical Center, Division of Cardiovascular Medicine, The Ohio State University, Columbus
| | - Steven M Bradley
- Minneapolis Heart Institute, Minneapolis Heart Institute Foundation, Minneapolis
| | - Sandeep K Jain
- UPMC Heart and Vascular Institute, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Hani Seifein
- AdventHealth Medical Group Cardiology, Oviedo, Florida
| | - Jeff Whittle
- Department of Medicine, Division of General Internal Medicine, Medical College of Wisconsin, Milwaukee
| | | | - Mark B Effron
- Ochsner Clinical School, John Ochsner Heart and Vascular Institute, University of Queensland School of Medicine, New Orleans, Louisiana
| | - Giselle Alvarado
- Herbert H. Lehman College, Department of Biological Sciences, City University of New York, Bronx
| | | | | | - Saket Girotra
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City
| | | | | | - Russell Rothman
- Center for Health Services Research, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Adrian F Hernandez
- Duke Clinical Research Institute, Durham, North Carolina.,Duke University Medical Center, Durham, North Carolina
| | - W Schuyler Jones
- Duke Clinical Research Institute, Durham, North Carolina.,Duke University Medical Center, Durham, North Carolina
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46
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Gouda P, Ganni E, Chung P, Randhawa VK, Marquis-Gravel G, Avram R, Ezekowitz JA, Sharma A. Feasibility of Incorporating Voice Technology and Virtual Assistants in Cardiovascular Care and Clinical Trials. CURRENT CARDIOVASCULAR RISK REPORTS 2021; 15:13. [PMID: 34178205 PMCID: PMC8214838 DOI: 10.1007/s12170-021-00673-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/28/2021] [Indexed: 02/06/2023]
Abstract
PURPOSE OF REVIEW With the rising cost of cardiovascular clinical trials, there is interest in determining whether new technologies can increase cost effectiveness. This review focuses on current and potential uses of voice-based technologies, including virtual assistants, in cardiovascular clinical trials. RECENT FINDINGS Numerous potential uses for voice-based technologies have begun to emerge within cardiovascular medicine. Voice biomarkers, subtle changes in speech parameters, have emerged as a potential tool to diagnose and monitor many cardiovascular conditions, including heart failure, coronary artery disease, and pulmonary hypertension. With the increasing use of virtual assistants, numerous pilot studies have examined whether these devices can supplement initiatives to promote transitional care, physical activity, smoking cessation, and medication adherence with promising initial results. Additionally, these devices have demonstrated the ability to streamline data collection by administering questionnaires accurately and reliably. With the use of these technologies, there are several challenges that must be addressed before wider implementation including respecting patient privacy, maintaining regulatory standards, acceptance by patients and healthcare providers, determining the validity of voice-based biomarkers and endpoints, and increased accessibility. SUMMARY Voice technology represents a novel and promising tool for cardiovascular clinical trials; however, research is still required to understand how it can be best harnessed.
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Affiliation(s)
- Pishoy Gouda
- Division of Cardiology, University of Alberta, Edmonton, Alberta Canada
| | - Elie Ganni
- DREAM-CV Lab, McGill University Health Centre, McGill University, Montreal, Quebec, Canada
| | - Peter Chung
- DREAM-CV Lab, McGill University Health Centre, McGill University, Montreal, Quebec, Canada
| | - Varinder Kaur Randhawa
- Department of Cardiovascular Medicine, Kaufman Center for Heart Failure and Recovery, Heart, Thoracic, and Vascular Institute, Cleveland Clinic, Cleveland, OH USA
| | | | - Robert Avram
- Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada ,Division of Cardiology, Department of Medicine, Ottawa Heart Institute, University of Ottawa, Ottawa, Ontario Canada
| | - Justin A. Ezekowitz
- Division of Cardiology, University of Alberta, Edmonton, Alberta Canada ,Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta Canada
| | - Abhinav Sharma
- DREAM-CV Lab, McGill University Health Centre, McGill University, Montreal, Quebec, Canada ,Division of Cardiology, McGill University Health Centre, McGill University, 1001 Decarie Blvd, Montreal, Quebec, H4A 3J1 Canada
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Abstract
The year 2020 has undoubtedly made Digital Health a necessity and no longer an exception. Many technological advances that seemed futuristic became a reality in a few months due to the pandemic's needs. Stroke was one of the diseases that most benefited from the digital health revolution. Due to the need for immediate care and a shortage of neurologists worldwide, telestroke has revolutionized the acute care of cerebrovascular diseases in many areas based on strong scientific evidence. In this brief article, we have tried to summarize all we have experienced in 2020, the year which irreversibly transformed the practice of medicine.
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Affiliation(s)
- Gisele Sampaio Silva
- Universidade Federal de São Paulo-UNIFESP and Academic Research Organization, Hospital Israelita Albert Einstein, Brazil (G.S.S.)
| | - Lee H Schwamm
- C. Miller Fisher Chair of Vascular Neurology, Massachusetts General Hospital, Harvard Medical School, Boston (L.H.S.)
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48
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Digital Health Applications for Pharmacogenetic Clinical Trials. Genes (Basel) 2020; 11:genes11111261. [PMID: 33114567 PMCID: PMC7692850 DOI: 10.3390/genes11111261] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Revised: 10/20/2020] [Accepted: 10/24/2020] [Indexed: 12/15/2022] Open
Abstract
Digital health (DH) is the use of digital technologies and data analytics to understand health-related behaviors and enhance personalized clinical care. DH is increasingly being used in clinical trials, and an important field that could potentially benefit from incorporating DH into trial design is pharmacogenetics. Prospective pharmacogenetic trials typically compare a standard care arm to a pharmacogenetic-guided therapeutic arm. These trials often require large sample sizes, are challenging to recruit into, lack patient diversity, and can have complicated workflows to deliver therapeutic interventions to both investigators and patients. Importantly, the use of DH technologies could mitigate these challenges and improve pharmacogenetic trial design and operation. Some DH use cases include (1) automatic electronic health record-based patient screening and recruitment; (2) interactive websites for participant engagement; (3) home- and tele-health visits for patient convenience (e.g., samples for lab tests, physical exams, medication administration); (4) healthcare apps to collect patient-reported outcomes, adverse events and concomitant medications, and to deliver therapeutic information to patients; and (5) wearable devices to collect vital signs, electrocardiograms, sleep quality, and other discrete clinical variables. Given that pharmacogenetic trials are inherently challenging to conduct, future pharmacogenetic utility studies should consider implementing DH technologies and trial methodologies into their design and operation.
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49
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Physiological Monitoring and Hearing Loss: Toward a More Integrated and Ecologically Validated Health Mapping. Ear Hear 2020; 41 Suppl 1:120S-130S. [DOI: 10.1097/aud.0000000000000960] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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50
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Geoghegan C, Nido V, Bemden ABV, Hallinan Z, Jordan L, Kehoe LS, Morin SL, Niskar A, Okubagzi PG, Wood WA. Learning from patient and site perspectives to develop better digital health trials: Recommendations from the Clinical Trials Transformation Initiative. Contemp Clin Trials Commun 2020; 19:100636. [PMID: 32913915 PMCID: PMC7473867 DOI: 10.1016/j.conctc.2020.100636] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Revised: 07/27/2020] [Accepted: 08/09/2020] [Indexed: 01/22/2023] Open
Abstract
In order to harness the potential of digital health technologies to enhance the quality of clinical research, it is critical to first understand how to engage patients and research sites when planning and conducting digital health trials. To pave the way for the more effective use of digital health technologies in trials, the Clinical Trials Transformation Initiative has developed the first comprehensive, evidence-based set of recommendations for incorporating patient and site perspectives in digital health trials. While directed primarily at sponsors, these recommendations are expected to be valuable for all stakeholders including investigators.
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Affiliation(s)
| | | | | | | | | | | | - Steve L. Morin
- Office of Health and Constituent Affairs, US Food and Drug Administration, Silver Spring, MD, USA
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