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Fantini MC, Fiorino G, Colli A, Laharie D, Armuzzi A, Caprioli FA, Gisbert JP, Kirchgesner J, Macaluso FS, Magro F, Ghosh S. Pragmatic Trial Design to Compare Real-world Effectiveness of Different Treatments for Inflammatory Bowel Diseases: The PRACTICE-IBD European Consensus. J Crohns Colitis 2024; 18:1222-1231. [PMID: 38367197 PMCID: PMC11324339 DOI: 10.1093/ecco-jcc/jjae026] [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: 10/11/2023] [Revised: 01/10/2024] [Accepted: 02/15/2024] [Indexed: 02/19/2024]
Abstract
BACKGROUND AND AIMS Pragmatic studies designed to test interventions in everyday clinical settings can successfully complement the evidence from registration and explanatory clinical trials. The European consensus project PRACTICE-IBD was developed to identify essential criteria and address key methodological issues needed to design valid, comparative, pragmatic studies in inflammatory bowel diseases [BDs]. METHODS Statements were issued by a panel of 11 European experts in IBD management and trial methodology, on four main topics: [I] study design; [II] eligibility, recruitment and organisation, flexibility; [III] outcomes; [IV] analysis. The consensus process followed a modified Delphi approach, involving two rounds of assessment and rating of the level of agreement [1 to 9; cut-off ≥7 for approval] with the statements by 18 additional European experts in IBD. RESULTS At the first voting round, 25 out of the 26 statements reached a mean score ≥7. Following the discussion that preceded the second round of voting, it was decided to eliminate two statements and to split one into two. At the second voting round, 25 final statements were approved: seven for study design; six for eligibility, recruitment and organisation, flexibility; eight for outcomes; and four for analysis. CONCLUSIONS Pragmatic, randomised, clinical trials can address important questions in IBD clinical practice, and may provide complementary, high-level evidence, as long as they follow a methodologically rigorous approach. These 25 statements intend to offer practical guidance in the design of high-quality, pragmatic, clinical trials that can aid decision making in choosing a management strategy for IBDs.
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Affiliation(s)
- Massimo Claudio Fantini
- Department of Medical Science and Public Health, University of Cagliari, Cagliari, Italy; Gastroenterology Unit, Azienda Ospedaliero-Universitaria di Cagliari,Italy
| | - Gionata Fiorino
- IBD Unit, Department of Gastroenterology and Digestive Endoscopy, San Camillo-Forlanini, Rome, Italy; Department of Gastroenterology and Digestive Endoscopy, San Raffaele Hospital and Vita-Salute San Raffaele Hospital, Milan, Italy
| | - Agostino Colli
- Department of Transfusion Medicine and Haematology, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico di Milano, Milan, Italy
| | - David Laharie
- CHU de Bordeaux, Hôpital Haut-Lévêque, Service d’Hépato-gastroentérologie et Oncologie Digestive, Université de Bordeaux, Bordeaux, France
| | - Alessandro Armuzzi
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
- IBD Center, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Flavio Andrea Caprioli
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Cà Granda, Ospedale Maggiore Policlinico di Milano, Milan, Italy
| | - Javier P Gisbert
- Gastroenterology Unit, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa [IIS-Princesa], Universidad Autónoma de Madrid [UAM], Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas [CIBEREHD], Madrid, Spain
| | - Julien Kirchgesner
- INSERM, Institut Pierre Louis d’Epidémiologie et de Santé Publique, Sorbonne Université, Department of Gastroenterology, Hôpital Saint-Antoine, Assistance Publique-Hôpitaux de Paris, Paris, France
| | | | - Fernando Magro
- CINTESIS@RISE, Faculty of Medicine, University of Porto, Porto, Portugal; Department of Biomedicine, Unit of Pharmacology and Therapeutics, Faculty of Medicine, University of Porto, Porto, Portugal; Department of Clinical Pharmacology, São João University Hospital Center [CHUSJ], Porto, Portugal; Center for Health Technology and Services Research [CINTESIS], Porto, Portugal
| | - Subrata Ghosh
- College of Medicine and Health, University College Cork, Cork, Ireland
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Amstutz A, Schönenberger CM, Speich B, Griessbach A, Schwenke JM, Glasstetter J, James S, Verkooijen HM, Nickolls B, Relton C, Hemkens LG, Chammartin F, Gerber F, Labhardt ND, Schandelmaier S, Briel M. Characteristics, consent patterns, and challenges of randomized trials using the Trials within Cohorts (TwiCs) design - A scoping review. J Clin Epidemiol 2024; 174:111469. [PMID: 39032590 DOI: 10.1016/j.jclinepi.2024.111469] [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: 12/27/2023] [Revised: 06/07/2024] [Accepted: 07/15/2024] [Indexed: 07/23/2024]
Abstract
OBJECTIVES Trials within Cohorts (TwiCs) is a pragmatic design approach that may overcome frequent challenges of traditional randomized trials such as slow recruitment, burdensome consent procedures, or limited external validity. This scoping review aims to identify all randomized controlled trials using the TwiCs design and to summarize their design characteristics, ways to obtain informed consent, output, reported challenges and mitigation strategies. STUDY DESIGN AND SETTING Systematic search of Medline, Embase, Cochrane, trial registries and citation tracking up to December 2022. TwiCs were defined as randomized trials embedded in a cohort with postrandomization consent for the intervention group and no specific postrandomization consent for the usual care control group. Information from identified TwiCs was extracted in duplicate from protocols, publications, and registry entries. We analyzed the information descriptively and qualitatively to highlight methodological challenges and solutions related to nonuptake of interventions and informed consent procedure. RESULTS We identified a total of 46 TwiCs conducted between 2005 and 2022 in 14 different countries by a handful of research groups. The most common medical fields were oncology (11/46; 24%), infectious diseases (8/46; 17%), and mental health (7/46; 15%). A typical TwiCs was investigator-initiated (46/46; 100%), publicly funded (36/46; 78%), and recruited outpatients (27/46; 59%). Excluding eight pilot trials, only 16/38 (42%) TwiCs adjusted their calculated sample size for nonuptake of the intervention, anticipating a median nonuptake of 25% (interquartile range 10%-32%) in the experimental arm. Seventeen TwiCs (45%) planned analyses to adjust effect estimates for nonuptake. Regarding informed consent, we observed three patterns: 1) three separate consents for cohort participation, randomization, and intervention (17/46; 37%); 2) combined consent for cohort participation and randomization and a separate intervention consent (10/46; 22%); and 3) consent only for cohort participation and intervention (randomization consent not mentioned; 19/46; 41%). CONCLUSION Existing TwiCs are globally scattered across a few research groups covering a wide range of medical fields and interventions. Despite the potential advantages, the number of TwiCs remains small. The variability in consent procedures and the possibility of substantial nonuptake of the intervention warrants further research to guide the planning, implementation, and analysis of TwiCs.
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Affiliation(s)
- Alain Amstutz
- CLEAR Methods Center, Division of Clinical Epidemiology, Department of Clinical Research, University Hospital Basel, University of Basel, Basel, Switzerland; Oslo Center for Biostatistics and Epidemiology, Oslo University Hospital, University of Oslo, Oslo, Norway; Bristol Medical School, University of Bristol, Bristol, UK
| | - Christof M Schönenberger
- CLEAR Methods Center, Division of Clinical Epidemiology, Department of Clinical Research, University Hospital Basel, University of Basel, Basel, Switzerland.
| | - Benjamin Speich
- CLEAR Methods Center, Division of Clinical Epidemiology, Department of Clinical Research, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Alexandra Griessbach
- CLEAR Methods Center, Division of Clinical Epidemiology, Department of Clinical Research, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Johannes M Schwenke
- CLEAR Methods Center, Division of Clinical Epidemiology, Department of Clinical Research, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Jan Glasstetter
- CLEAR Methods Center, Division of Clinical Epidemiology, Department of Clinical Research, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Sophie James
- York Trials Unit, Department of Health Sciences, University of York, York, UK
| | - Helena M Verkooijen
- Imaging Division, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Beverley Nickolls
- Wolfson Institute of Population Health, Queen Mary University, London, UK
| | - Clare Relton
- Wolfson Institute of Population Health, Queen Mary University, London, UK
| | - Lars G Hemkens
- Research Center for Clinical Neuroimmunology and Neuroscience Basel (RC2NB), University Hospital Basel, University of Basel, Basel, Switzerland; Department of Clinical Research, University Hospital Basel, University of Basel, Basel, Switzerland; Meta-Research Innovation Center at Stanford (METRICS), Stanford University, Stanford, CA, USA
| | - Frédérique Chammartin
- International Clinical Health Services Research Unit, Division of Clinical Epidemiology, Department of Clinical Research, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Felix Gerber
- International Clinical Health Services Research Unit, Division of Clinical Epidemiology, Department of Clinical Research, University Hospital Basel, University of Basel, Basel, Switzerland; Department of Medicine, Swiss Tropical and Public Health Institute, Allschwil, Switzerland
| | - Niklaus D Labhardt
- International Clinical Health Services Research Unit, Division of Clinical Epidemiology, Department of Clinical Research, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Stefan Schandelmaier
- CLEAR Methods Center, Division of Clinical Epidemiology, Department of Clinical Research, University Hospital Basel, University of Basel, Basel, Switzerland; School of Public Health, University College Cork, Cork, Ireland; MTA-PET Lendület "Momentum" Evidence Group, Medical School, University of Pécs, Pécs, Hungary
| | - Matthias Briel
- CLEAR Methods Center, Division of Clinical Epidemiology, Department of Clinical Research, University Hospital Basel, University of Basel, Basel, Switzerland; Department of Health Research Methods, Evidence, and Impact (HEI), McMaster University, Hamilton, Canada
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Nickolls BJ, Relton C, Hemkens L, Zwarenstein M, Eldridge S, McCall SJ, Griffin XL, Sohanpal R, Verkooijen HM, Maguire JL, McCord KA. Randomised trials conducted using cohorts: a scoping review. BMJ Open 2024; 14:e075601. [PMID: 38458814 PMCID: PMC10928784 DOI: 10.1136/bmjopen-2023-075601] [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: 05/12/2023] [Accepted: 11/24/2023] [Indexed: 03/10/2024] Open
Abstract
INTRODUCTION Cohort studies generate and collect longitudinal data for a variety of research purposes. Randomised controlled trials (RCTs) increasingly use cohort studies as data infrastructures to help identify and recruit trial participants and assess outcomes. OBJECTIVE To examine the extent, range and nature of research using cohorts for RCTs and describe the varied definitions and conceptual boundaries for RCTs using cohorts. DESIGN Scoping review. DATA SOURCES Searches were undertaken in January 2021 in MEDLINE (Ovid) and EBM Reviews-Cochrane Methodology Registry (Final issue, third Quarter 2012). ELIGIBILITY CRITERIA Reports published between January 2007 and December 2021 of (a) cohorts used or planned to be used, to conduct RCTs, or (b) RCTs which use cohorts to recruit participants and/or collect trial outcomes, or (c) methodological studies discussing the use of cohorts for RCTs. DATA EXTRACTION AND SYNTHESIS Data were extracted on the condition being studied, age group, setting, country/continent, intervention(s) and comparators planned or received, unit of randomisation, timing of randomisation, approach to informed consent, study design and terminology. RESULTS A total of 175 full-text articles were assessed for eligibility. We identified 61 protocols, 9 descriptions of stand-alone cohorts intended to be used for future RCTs, 39 RCTs using cohorts and 34 methodological papers.The use and scope of this approach is growing. The thematics of study are far-ranging, including population health, oncology, mental and behavioural disorders, and musculoskeletal conditions.Authors reported that this approach can lead to more efficient recruitment, more representative samples, and lessen disappointment bias and crossovers. CONCLUSION This review outlines the development of cohorts to conduct RCTs including the range of use and innovative changes and adaptations. Inconsistencies in the use of terminology and concepts are highlighted. Guidance now needs to be developed to support the design and reporting of RCTs conducted using cohorts.
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Affiliation(s)
- Beverley Jane Nickolls
- Centre for Evaluation and Methods, Wolfson Institute of Population Health, Queen Mary University of London, London, UK
| | - Clare Relton
- Centre for Evaluation and Methods, Wolfson Institute of Population Health, Queen Mary University of London, London, UK
| | - Lars Hemkens
- Research Center for Clinical Neuroimmunology and Neuroscience Basel (RC2NB), University Hospital Basel, Basel, Switzerland
- Department of Clinical Research, University of Basel, Basel, Switzerland
- Meta-Research Innovation Center at Stanford (METRICS), Stanford University, Stanford, California, USA
- Meta-Research Innovation Center Berlin (METRICS-B), Berlin Institute of Health, Berlin, Germany
| | - Merrick Zwarenstein
- Department of Family Medicine, Western University, London, Ontario, Canada
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Sandra Eldridge
- Centre for Evaluation and Methods, Wolfson Institute of Population Health, Queen Mary University of London, London, UK
| | - Stephen J McCall
- National Perinatal Epidemiology Unit, Clinical Trials Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
- Center for Research on Population and Health, Faculty of Health Sciences, American University of Beirut, Ras Beirut, Lebanon
| | - Xavier Luke Griffin
- Bone and Joint Health, Blizard Institute, Queen Mary University of London, London, UK
- Barts Health NHS Trust, Royal London Hospital, London, UK
| | - Ratna Sohanpal
- Centre for Primary Care, Wolfson Institute of Population Health, Queen Mary University of London, London, UK
| | - Helena M Verkooijen
- University Medical Centre Utrecht, Utrecht, The Netherlands
- University of Utrecht, Utrecht, The Netherlands
| | - Jonathon L Maguire
- University of Toronto Institute of Health Policy Management and Evaluation, Toronto, Ontario, Canada
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Mooney KE, Welch C, Crossley K, Bywater T, Wright J, Dickerson J, Blower S. Is it feasible to nest a Trial within a Cohort Study (TwiCS) to evaluate an early years parenting programme? A Born in Bradford's Better Start study protocol. Pilot Feasibility Stud 2024; 10:19. [PMID: 38291514 PMCID: PMC10826243 DOI: 10.1186/s40814-023-01441-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Accepted: 12/21/2023] [Indexed: 02/01/2024] Open
Abstract
BACKGROUND Evaluating the effectiveness of early years parenting interventions provides evidence to improve the development and wellbeing of children. This protocol paper describes a study to explore the feasibility of evaluating the Incredible Years Toddler early life intervention programme, which is offered to parents of 1-3-year-olds via the Better Start Bradford programme. The study aims to use a Trial within a Cohort Study (TwiCS) design that randomly selects individuals participating in a cohort to be offered an intervention. The TwiCS information and consent process is person-centred and aims to replicate real-world practice whereby only those who are offered the intervention are given information about the intervention. The cohort is the Born in Bradford's Better Start (BiBBS) cohort, an interventional birth cohort recruiting expectant parents in three areas of Bradford, UK. The study will assess the feasibility of TwiCS procedures, staged consent, and intervention take-up. METHODS We will conduct a feasibility TwiCS to test study procedures. We aim to establish the following: (1) whether TwiCS methodology can be implemented to create control and intervention arms, whilst documenting any incidences of contamination within the cohort; (2) whether satisfactory rates of intervention uptake are achieved among participants allocated to the intervention; and (3) whether satisfactory rates of retention of participants in the intervention can be achieved. A Red Amber Green (RAG) rating system has been applied to support the feasibility assessment of each objective: to be rated red (not achieved), amber (partly achieved), and green (achieved). Eligible participants in the BiBBS cohort will be individually randomised 1:1 to the intervention or control arms, with stratification by child age (1 or 2 years old at the time of randomisation) and ethnicity (White British, South Asian, or other). BiBBS researchers will seek consent from participants randomised to the intervention to pass their contact details onto Incredible Years' delivery agents. DISCUSSION This feasibility study will inform the utility of the TwiCs approach within an experimental birth cohort to evaluate interventions for infants, toddlers, and their families. TRIAL REGISTRATION The study was prospectively registered on ISRCTN (ISRCTN16150114).
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Affiliation(s)
- Kate E Mooney
- Department of Health Sciences, University of York, York, UK.
- Bradford Institute for Health Research, Bradford, UK.
| | - Charlie Welch
- Department of Health Sciences, University of York, York, UK
| | | | - Tracey Bywater
- Department of Health Sciences, University of York, York, UK
| | - John Wright
- Bradford Institute for Health Research, Bradford, UK
| | | | - Sarah Blower
- Department of Health Sciences, University of York, York, UK
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Leviton A, Loddenkemper T. Design, implementation, and inferential issues associated with clinical trials that rely on data in electronic medical records: a narrative review. BMC Med Res Methodol 2023; 23:271. [PMID: 37974111 PMCID: PMC10652539 DOI: 10.1186/s12874-023-02102-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Accepted: 11/08/2023] [Indexed: 11/19/2023] Open
Abstract
Real world evidence is now accepted by authorities charged with assessing the benefits and harms of new therapies. Clinical trials based on real world evidence are much less expensive than randomized clinical trials that do not rely on "real world evidence" such as contained in electronic health records (EHR). Consequently, we can expect an increase in the number of reports of these types of trials, which we identify here as 'EHR-sourced trials.' 'In this selected literature review, we discuss the various designs and the ethical issues they raise. EHR-sourced trials have the potential to improve/increase common data elements and other aspects of the EHR and related systems. Caution is advised, however, in drawing causal inferences about the relationships among EHR variables. Nevertheless, we anticipate that EHR-CTs will play a central role in answering research and regulatory questions.
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Affiliation(s)
- Alan Leviton
- Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA.
| | - Tobias Loddenkemper
- Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
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Walker S, Spillane E, Stringer K, Trepte L, Davies SM, Bresson J, Sandall J, Shennan A. OptiBreech collaborative care versus standard care for women with a breech-presenting fetus at term: A pilot parallel group randomised trial to evaluate the feasibility of a randomised trial nested within a cohort. PLoS One 2023; 18:e0294139. [PMID: 37967120 PMCID: PMC10650999 DOI: 10.1371/journal.pone.0294139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 10/18/2023] [Indexed: 11/17/2023] Open
Abstract
OptiBreech collaborative care is a multi-disciplinary care pathway for breech presentation at term, with continuity from a breech specialist midwife, including where chosen, for vaginal breech birth (VBB). Pilot randomised trial using unblinded 1:1 parallel group allocation to OptiBreech versus standard care, within a cohort. Participants were women with a breech-presenting fetus > 33 weeks, at four sites in England, January-June 2022. A two-stage consent process was used. Participants consented to undergo random selection to be offered a 'new care process', with a choice to accept it, or not. Primary objectives were to identify recruitment, acceptance, and attrition rates. Randomisation procedures and potential primary outcomes for a substantive study were also feasibility-tested. 68 women were randomised between January-June 2022. The consent process was acceptable to participants, but randomisation was unacceptable to women who specifically sought OptiBreech care. Two women withdrew due to concerns about sharing personal information. More women planned a VBB when randomised to OptiBreech Care (23.5% vs 0, p = .002, 95% CI = 9.3%,37.8%). Women randomised to OptiBreech care had: lower rates of cephalic presentation at birth (38.2% vs 54.5%), higher rates of vaginal birth (32.4% vs 24.2%), lower rates of in-labour caesarean birth (20.6% vs 36.4%), lower rates of neonatal intensive care (5.9% vs 9.1%), and lower rates of severe neonatal morbidity (2.9% vs 9.1%). Randomisation was stopped on the advice of the steering committee before the planned sample of 104, as lack of access to VBB within standard care prohibited comparison of outcomes. Demand for VBB is sufficient for a cohort study, but comparison of outcomes by 1:1 randomisation is not feasible. OptiBreech care would be best evaluated using stepped wedge cluster randomisation. Funded by the United Kingdom National Institute for Health and Care Research (NIHR300582). Clinical trial registration: ISRCTN 14521381.
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Affiliation(s)
- Shawn Walker
- Faculty of Life Sciences & Medicine, Department of Women & Children’s Health, School of Life Course & Population Sciences, King’s College London, London, United Kingdom
- Women’s and Children’s Services, Chelsea and Westminster Hospital NHS Foundation Trust, London, United Kingdom
| | - Emma Spillane
- Kingston Maternity, Kingston Hospital NHS Foundation Trust, Kingston upon Thames, Surrey, United Kingdom
| | - Kate Stringer
- Women’s Services, Surrey and Sussex Healthcare NHS Trust, East Surrey Hospital, Redhill, United Kingdom
| | - Lauren Trepte
- Women’s and Children’s Services, Chelsea and Westminster Hospital NHS Foundation Trust, London, United Kingdom
| | - Siân M. Davies
- Faculty of Life Sciences & Medicine, Department of Women & Children’s Health, School of Life Course & Population Sciences, King’s College London, London, United Kingdom
| | - Jacana Bresson
- Faculty of Life Sciences & Medicine, Department of Women & Children’s Health, School of Life Course & Population Sciences, King’s College London, London, United Kingdom
| | - Jane Sandall
- Faculty of Life Sciences & Medicine, Department of Women & Children’s Health, School of Life Course & Population Sciences, King’s College London, London, United Kingdom
| | - Andrew Shennan
- Faculty of Life Sciences & Medicine, Department of Women & Children’s Health, School of Life Course & Population Sciences, King’s College London, London, United Kingdom
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Conway RJ, Smith N, Cooper W, Lynch G, Patole S, Symonds J, Edey A, Maskell NA, Bibby AC. Reflecting real-world patients with mesothelioma in research: an interim report of baseline characteristics from the ASSESS-meso cohort. ERJ Open Res 2023; 9:00467-2023. [PMID: 38174143 PMCID: PMC10763666 DOI: 10.1183/23120541.00467-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Accepted: 10/24/2023] [Indexed: 01/05/2024] Open
Abstract
Objective Mesothelioma varies in clinical phenotype and survival. Clinical trials are unavoidably affected by selection bias, reducing generalisability. ASSESS-meso is a UK, multicentre, prospective, mesothelioma cohort study (ISRCTN61861764). This pre-specified interim analysis, conducted when recruitment reached 25% of target, summarised participant characteristics and evaluated external validity through comparison with real-world and clinical trial cohorts. Methods The study took place at 14 hospitals across the UK. People diagnosed with mesothelioma, at any anatomical site, were eligible. Clinical, radiological and biochemical data were collected at enrolment. In this interim report, the external validity of the cohort was investigated through comparison of baseline demographic data with populations included in the 2020 UK National Mesothelioma Audit (real-world cohort), and CHECKMATE-743 and MAPS trials (clinical trial cohorts). Results 244 patients were enrolled between 7 April 2017 and 1 March 2022. The cohort was predominantly male (195 out of 244; 80%) with a median age of 74 years. Pleural disease and epithelioid subtypes were most prevalent. ASSESS-meso participants were more similar to the real-world population with regard to age, performance status, disease site and stage than the clinical trial population. ASSESS-meso participants were more likely to be formally staged and less likely to have undifferentiated histology compared with the real-world cohort, possibly reflecting high rates of discussion of ASSESS-meso participants at regional mesothelioma multidisciplinary team meetings. As expected, poorer performance status, non-epithelioid histology and neutrophil-lymphocyte ratio were associated with shorter survival in the adjusted analysis. Conclusion ASSESS-meso is representative of the UK mesothelioma population. Future outputs from the cohort will help characterise different mesothelioma phenotypes with high external validity.
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Affiliation(s)
- Ruairi J.H. Conway
- Department of Respiratory Medicine, North Bristol NHS Trust, Bristol, UK
- Academic Respiratory Unit, School of Translational Sciences, University of Bristol, Bristol, UK
| | - Natalie Smith
- Department of Respiratory Medicine, North Bristol NHS Trust, Bristol, UK
| | - William Cooper
- Department of Radiology, North Bristol NHS Trust, Bristol, UK
| | - Geraldine Lynch
- Academic Respiratory Unit, School of Translational Sciences, University of Bristol, Bristol, UK
| | - Sonia Patole
- Academic Respiratory Unit, School of Translational Sciences, University of Bristol, Bristol, UK
| | - Jenny Symonds
- Department of Respiratory Medicine, North Bristol NHS Trust, Bristol, UK
- Academic Respiratory Unit, School of Translational Sciences, University of Bristol, Bristol, UK
| | - Anthony Edey
- Department of Radiology, North Bristol NHS Trust, Bristol, UK
| | - Nick A. Maskell
- Department of Respiratory Medicine, North Bristol NHS Trust, Bristol, UK
- Academic Respiratory Unit, School of Translational Sciences, University of Bristol, Bristol, UK
| | - Anna C. Bibby
- Department of Respiratory Medicine, North Bristol NHS Trust, Bristol, UK
- Academic Respiratory Unit, School of Translational Sciences, University of Bristol, Bristol, UK
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8
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Kessels R, May AM, Koopman M, Roes KCB. The Trial within Cohorts (TwiCs) study design in oncology: experience and methodological reflections. BMC Med Res Methodol 2023; 23:117. [PMID: 37179306 PMCID: PMC10183126 DOI: 10.1186/s12874-023-01941-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Accepted: 05/06/2023] [Indexed: 05/15/2023] Open
Abstract
A Trial within Cohorts (TwiCs) study design is a trial design that uses the infrastructure of an observational cohort study to initiate a randomized trial. Upon cohort enrollment, the participants provide consent for being randomized in future studies without being informed. Once a new treatment is available, eligible cohort participants are randomly assigned to the treatment or standard of care. Patients randomized to the treatment arm are offered the new treatment, which they can choose to refuse. Patients who refuse will receive standard of care instead. Patients randomized to the standard of care arm receive no information about the trial and continue receiving standard of care as part of the cohort study. Standard cohort measures are used for outcome comparisons. The TwiCs study design aims to overcome some issues encountered in standard Randomized Controlled Trials (RCTs). An example of an issue in standard RCTs is the slow patient accrual. A TwiCs study aims to improve this by selecting patients using a cohort and only offering the intervention to patients in the intervention arm. In oncology, the TwiCs study design has gained increasing interest during the last decade. Despite its potential advantages over RCTs, the TwiCs study design has several methodological challenges that need careful consideration when planning a TwiCs study. In this article, we focus on these challenges and reflect on them using experiences from TwiCs studies initiated in oncology. Important methodological challenges that are discussed are the timing of randomization, the issue of non-compliance (refusal) after randomization in the intervention arm, and the definition of the intention-to-treat effect in a TwiCs study and how this effect is related to its counterpart in standard RCTs.
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Affiliation(s)
- Rob Kessels
- Dutch Oncology Research Platform, Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Anne M May
- Julius Center for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht University, STR 6.131 , P.O. Box 85500, 3508 GA, Utrecht, the Netherlands.
| | - Miriam Koopman
- Department of Medical Oncology, University Medical Centre Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Kit C B Roes
- Department of Health Evidence, Radboud University Medical Center, Section Biostatistics, Nijmegen, the Netherlands
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Chaput KH, Freeman M, McMorris C, Metcalfe A, Cameron EE, Jung J, Tough S, Hicks LM, Dimidjian S, Tomfohr-Madsen LM. Effect of Remote Peer-Counsellor- delivered Behavioral Activation and Peer-support for Antenatal Depression on Gestational Age at Delivery: a single-blind, randomized control trial. Trials 2023; 24:240. [PMID: 36997966 PMCID: PMC10061403 DOI: 10.1186/s13063-023-07077-7] [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: 11/15/2022] [Accepted: 01/05/2023] [Indexed: 04/01/2023] Open
Abstract
BACKGROUND Antenatal depression (AD) is the most common complication of pregnancy in developed countries and increases the risk of preterm birth (PTB). Many pregnant individuals with AD do not obtain treatment due in part to risks associated with antidepressant medications, the expense and wait times for psychological services, and perceived stigma. Accessible and timely treatment of antenatal depression is crucial to minimize foetal impacts and associated long-term child health outcomes. Previous studies show that behavioural activation and peer support are promising avenues of treatment for perinatal depression. Additionally, remote and paraprofessional counselling interventions show promise as more accessible, sustainable, and cost-effective treatment avenues than traditional psychological services. The primary aim of this trial is to test the effectiveness of a remote, behavioural activation and peer support intervention, administered by trained peer para-professionals, for increasing gestational age at delivery among those with antenatal depression. The secondary aims are to evaluate the effectiveness for treating AD prior to delivery, with persistence into the postpartum; improving anxiety symptoms; and improving parenting self-efficacy compared to controls. METHODS A two-arm, single-blinded, parallel groups randomized controlled trial (RCT) with repeated measures will be conducted. Participants scoring >10 on the Edinburgh Postnatal Depression Scale will be recruited from the larger P3 cohort and invited to enroll. Assessments will be conducted prior to 27 weeks' gestation at trial intake (T1), post-intervention, prior to delivery (T2), 5-6 months postpartum (T3), and 11-12 months postpartum (T4) and will include self-report questionnaires and linked medical records. DISCUSSION Our remote, peer paraprofessional-delivered behavioural activation plus peer support intervention has the potential to successfully reduce symptoms of AD, which may in turn decrease the risk of PTB and subsequent health impacts. The current trial builds on previous findings and uses a patient-oriented approach to address priorities for patient care and to provide a cost-effective, accessible, and evidence-based treatment to pregnant individuals with AD. TRIAL REGISTRATION International Standard Randomised Controlled Trial Number (ISRCTN) registry (ISRCTN51098220) ISRCTN51098220. Registered on April 7, 2022.
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Affiliation(s)
- Kathleen H Chaput
- Department of Obstetrics and Gynecology, Cumming School of Medicine, University of Calgary, 2500 University Drive, NW, Calgary, AB, T2N 1N4, Canada.
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10
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Wood GE, Chamberlain F, Tran B, Conduit C, Liow E, Nicol DL, Shamash J, Alifrangis C, Rajan P. Treatment de-escalation for stage II seminoma. Nat Rev Urol 2023:10.1038/s41585-023-00727-0. [PMID: 36882564 DOI: 10.1038/s41585-023-00727-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/31/2023] [Indexed: 03/09/2023]
Abstract
International Germ Cell Cancer Collaborative Group good-risk metastatic seminoma has cure rates of >95%. Within this risk group, patients with stage II disease exhibit the best oncological outcomes with the standard-of-care treatment strategies of radiotherapy or combination chemotherapy. However, these treatments can be associated with substantial early and late toxic effects. Therapy de-escalation aims to reduce treatment morbidity whilst preserving oncological outcomes. The evidence supporting such approaches is largely from non-randomized institutional data, and therefore this strategy is not recognized as standard of care. Current de-escalation approaches for stage II seminoma include single-agent chemotherapy, radiotherapy and surgery based on early data from clinical studies. Increased recognition of emerging data on treatment modification to reduce morbidity whilst maintaining cure rates and consideration of therapy de-escalation could improve patient survivorship outcomes.
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Affiliation(s)
- Georgina E Wood
- Department of Medical Oncology, University College London Hospitals NHS Foundation Trust, London, UK.,Department of Medical Oncology, Barts Health NHS Trust, London, UK
| | | | - Ben Tran
- Department of Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,Division of Personalized Medicine, Walter and Eliza Hall Institute of Medical Research, Melbourne, Victoria, Australia
| | - Ciara Conduit
- Department of Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,Division of Personalized Medicine, Walter and Eliza Hall Institute of Medical Research, Melbourne, Victoria, Australia
| | - Elizabeth Liow
- Division of Personalized Medicine, Walter and Eliza Hall Institute of Medical Research, Melbourne, Victoria, Australia
| | - David L Nicol
- Department of Urology, The Royal Marsden Hospital NHS Foundation Trust, London, UK
| | - Jonathan Shamash
- Department of Medical Oncology, Barts Health NHS Trust, London, UK
| | - Constantine Alifrangis
- Department of Medical Oncology, University College London Hospitals NHS Foundation Trust, London, UK. .,National Institute for Health Research University College London Hospitals Biomedical Research Centre, University College London Hospitals NHS Foundation Trust, London, UK.
| | - Prabhakar Rajan
- Centre for Cancer Cell and Molecular Biology, Barts Cancer Institute, Queen Mary University of London, London, UK. .,Division of Surgery and Interventional Science, University College London, London, UK. .,Department of Urology, Barts Health NHS Trust, London, UK. .,Department of Urology, University College London Hospitals NHS Foundation Trust, London, UK.
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11
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Emile SH, Horesh N. Underestimating the benefits of screening colonoscopy for colorectal cancer. Int J Colorectal Dis 2023; 38:1. [PMID: 36598581 DOI: 10.1007/s00384-022-04298-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/14/2022] [Indexed: 01/05/2023]
Affiliation(s)
- Sameh Hany Emile
- Colorectal Surgery Department, Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, Weston, USA.
- General Surgery Department, Colorectal Surgery Unit, Mansoura University Hospitals, Mansoura, Egypt.
| | - Nir Horesh
- Colorectal Surgery Department, Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, Weston, USA
- Department of Surgery and Transplantation, Sheba Medical Center, Ramat-Gan, Israel
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12
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Abstract
PURPOSE OF REVIEW People with persistent depressive disorders and with bipolar disorder are more likely to feel lonely than people in the general population. This evidence update focused on studies in the last 2 years, characterized by the COVID-19 pandemic and consequent social distancing directives. RECENT FINDINGS Longitudinal studies identified that people who feel lonely are more likely to become depressed or to experience relapse of mood disorders. There is emerging evidence that feelings of loneliness or mandatory social isolation can precede manic episodes. Hence the relationship between loneliness and mood disorders is complex and bidirectional. Interventions were developed to reduce loneliness in people with mental health problems, including depressive disorders, through cognitive modification and/or supported socialisation. No loneliness-focused interventions have been specifically tailored to people with bipolar disorder. SUMMARY Studies carried out before and during the COVID-19 pandemic found that feelings of loneliness can be both consequences and precursors of persistent depression and bipolar disorder. Mood symptoms and loneliness have a cumulative negative effect on physical and mental health outcomes. Conceptual overlaps and relations between loneliness and mood symptoms should be clarified in qualitative studies. Theory-driven intervention models should be developed and tested in methodologically robust studies.
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13
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Dal-Ré R, Caplan AL, Voo TC. Participants' informed consent in adaptive, platform drug trials in hospitalized COVID-19 patients: Not all approaches are ethically acceptable. Eur J Intern Med 2022; 103:1-3. [PMID: 35780073 PMCID: PMC9236980 DOI: 10.1016/j.ejim.2022.06.018] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2022] [Revised: 06/23/2022] [Accepted: 06/26/2022] [Indexed: 01/09/2023]
Affiliation(s)
- Rafael Dal-Ré
- Epidemiology Unit, Health Research Institute-Fundación Jiménez Díaz University Hospital, Universidad Autónoma de Madrid, Avda. Reyes Católicos 2, Madrid E-28040, Spain.
| | - Arthur L Caplan
- Division of Medical Ethics, Grossman School of Medicine, NYU Langone Medical Center, 550 1st Ave., New York, NY 10016, USA
| | - Teck Chuan Voo
- Centre for Biomedical Ethics, Yong Loo Lin School of Medicine, Clinical research Centre, National University of Singapore, 21 Lower Kent Ridge Rd 117597, Block MD11, #02-03, 10 Medical Drive, Singapore 119077, Singapore
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14
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Gathier CS, van der Jagt M, van den Bergh WM, Dankbaar JW, Rinkel GJE, Slooter AJC. Slow recruitment in the HIMALAIA study: lessons for future clinical trials in patients with delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage based on feasibility data. Pilot Feasibility Stud 2022; 8:193. [PMID: 36042527 PMCID: PMC9426269 DOI: 10.1186/s40814-022-01155-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Accepted: 08/15/2022] [Indexed: 11/21/2022] Open
Abstract
Background Our randomized clinical trial on induced hypertension in patients with delayed cerebral ischemia (DCI) after aneurysmal subarachnoid hemorrhage (aSAH) was halted prematurely due to unexpected slow recruitment rates. This raised new questions regarding recruitment feasibility. As our trial can therefore be seen as a feasibility trial, we assessed the reasons for the slow recruitment, aiming to facilitate the design of future randomized trials in aSAH patients with DCI or other critically ill patient categories. Methods Efficiency of recruitment and factors influencing recruitment were evaluated, based on the patient flow in the two centers that admitted most patients during the study period. We collected numbers of patients who were screened for eligibility, provided informed consent, and developed DCI and who eventually were randomized. Results Of the 862 aSAH patients admitted in the two centers during the course of the trial, 479 (56%) were eligible for trial participation of whom 404 (84%) were asked for informed consent. Of these, 188 (47%) provided informed consent, of whom 50 (27%) developed DCI. Of these 50 patients, 12 (24%) could not be randomized due to a logistic problem or a contraindication for induced hypertension emerging at the time of randomization, and four (8%) were missed for randomization. Eventually, 34 patients were randomized and received intervention or control treatment. Conclusions Enrolling patients in a randomized trial on a treatment strategy for DCI proved unfeasible: only 1 out of 25 admitted and 1 out of 14 eligible patients could eventually be randomized. These rates, caused by a large proportion of ineligible patients, a small proportion of patients providing informed consent, and a large proportion of patients with contraindications for treatment, can be used to make sample size calculations for future randomized trials in DCI or otherwise critically ill patients. Facilitating informed consent through improved provision of information on risks, possible benefits, and study procedures may result in improved enrolment. Trial registration The original trial was prospectively registered with ClinicalTrials.gov (NCT01613235), date of registration 07-06-2012.
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Affiliation(s)
- Celine S Gathier
- Department of Intensive Care Medicine, UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands. .,Department of Neurology and Neurosurgery, UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, 3508, Utrecht, The Netherlands.
| | - Mathieu van der Jagt
- Department of Intensive Care Adults and Erasmus MC Stroke Center, Erasmus MC - University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Walter M van den Bergh
- Department of Critical Care, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Jan Willem Dankbaar
- Department of Radiology, UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Gabriel J E Rinkel
- Department of Neurology and Neurosurgery, UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, 3508, Utrecht, The Netherlands
| | - Arjen J C Slooter
- Department of Intensive Care Medicine, UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
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15
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Quinn L, Playle R, Drew CJG, Taiyari K, Williams-Thomas R, Muratori LM, Hamana K, Griffin BA, Kelson M, Schubert R, Friel C, Morgan-Jones P, Rosser A, Busse M. Physical activity and exercise outcomes in Huntington's disease (PACE-HD): results of a 12-month trial-within-cohort feasibility study of a physical activity intervention in people with Huntington's disease. Parkinsonism Relat Disord 2022; 101:75-89. [PMID: 35809488 DOI: 10.1016/j.parkreldis.2022.06.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Revised: 06/02/2022] [Accepted: 06/19/2022] [Indexed: 10/17/2022]
Abstract
INTRODUCTION While physical activity (PA) is recognized as important in Huntington's disease (HD) disease management, there has been no long-term evaluation undertaken. We aimed to evaluate the feasibility of a nested (within cohort) randomized controlled trial (RCT) of a physical therapist-led PA intervention. METHODS Participants were recruited from six HD specialist centers participating in the Enroll-HD cohort study in Germany, Spain and U.S. Assessments were completed at baseline and 12 months and linked to Enroll-HD cohort data. Participants at three sites (cohort) received no contact between baseline and 12 month assessments. Participants at three additional sites (RCT) were randomized to PA intervention or control group. The intervention consisted of 18 sessions delivered over 12 months; control group participants received no intervention, however both groups completed monthly exercise/falls diaries and 6-month assessments. RESULTS 274 participants were screened, 204 met inclusion criteria and 116 were enrolled (59 in cohort; 57 in RCT). Retention rates at 12-months were 84.7% (cohort) and 79.0% (RCT). Data completeness at baseline ranged from 42.3 to 100% and at 12-months 19.2-85.2%. In the RCT, there was 80.5% adherence, high intervention fidelity, and similar adverse events between groups. There were differences in fitness, walking endurance and self-reported PA at 12 months favoring the intervention group, with data completeness >60%. Participants in the cohort had motor and functional decline at rates comparable to previous studies. CONCLUSION Predefined progression criteria indicating feasibility were met. PACE-HD lays the groundwork for a future, fully-powered within cohort trial, but approaches to ensure data completeness must be considered. CLINICALTRIALS GOV: NCT03344601.
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Affiliation(s)
- Lori Quinn
- Dept of Biobehavioral Sciences, Teachers College, Columbia University, NY, NY, USA; Centre for Trials Research, Cardiff University, UK
| | | | | | | | | | - Lisa M Muratori
- George-Huntington-Institute and Institute for Clinical Radiology, University of Münster, Münster, Germany; Stony Brook University, Stony Brook, NY, USA
| | - Katy Hamana
- School of Healthcare Sciences, Cardiff University, UK
| | | | - Mark Kelson
- Department of Mathematics, Exeter University, Exeter, UK
| | - Robin Schubert
- George-Huntington-Institute and Institute for Clinical Radiology, University of Münster, Münster, Germany
| | - Ciaran Friel
- Feinstein Institutes for Medical Research, Northwell Health, NY, NY, UK
| | - Philippa Morgan-Jones
- Centre for Trials Research, Cardiff University, UK; School of Engineering, Cardiff University, Cardiff, UK
| | - Anne Rosser
- Schools of Medicine and Biosciences, Cardiff University, Cardiff, UK
| | - Monica Busse
- Centre for Trials Research, Cardiff University, UK.
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16
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Porcher R, Ravaud P, Resche-Rigon M, Tharaux PL, Mariette X, Hermine O. COVID-19 drug research and the cohort multiple randomised controlled trial design. Eur Respir J 2022; 60:13993003.01187-2022. [PMID: 35896213 PMCID: PMC9353064 DOI: 10.1183/13993003.01187-2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Accepted: 06/18/2022] [Indexed: 11/15/2022]
Abstract
We read with interest the comment of R. Dal-Ré on the CORIMUNO-19 trials
design [1–5]. The key argument is that the cohort multiple randomised
controlled trial (cmRCT) design implies an alteration of the informed process
that can only be justified if three requirements are fulfilled: the research has
important social value, it poses no more than minimal risks to participants, and
it would be impracticable to carry out without consent process modification [6].
R. Dal-Ré acknowledges that the first two requirements were fulfilled for
CORIMUNO-19 trials, but argues that, given the huge number of patients
hospitalised with severe or critical coronavirus disease 2019 (COVID-19) in
March 2020, trials would have been feasible without consent modification. The use of cohort multiple randomised controlled trials and epidemic
crises https://bit.ly/39Obd4N
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Affiliation(s)
| | - Philippe Ravaud
- Statistic, Assistance Publique - Hôpitaux de Paris, Paris, France
| | | | - Pierre Louis Tharaux
- Paris Cardiovascular Centre - PARCC, INSERM, Paris, France.,Paris Cardiovascular Centre - PARCC, Université de Paris, Paris, France
| | - Xavier Mariette
- Rheumatology, Université Paris-Saclay Faculté de Médecine, Le Kremlin-Bicetre, France
| | - Olivier Hermine
- INSERM U 1163 laboratory of physiopathology of hematological disorders and their treatment, Imagine Institute, Paris, France .,Hematology, Hôpital universitaire Necker-Enfants malades, Paris, France.,AB Science, Paris, France
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17
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Teunissen FR, Willigenburg T, Meijer RP, van Melick HHE, Verkooijen HM, van der Voort van Zyp JRN. The first patient-reported outcomes from the Utrecht Prostate Cohort (UPC): the first platform facilitating 'trials within cohorts' (TwiCs) for the evaluation of interventions for prostate cancer. World J Urol 2022; 40:2205-2212. [PMID: 35861861 PMCID: PMC9427931 DOI: 10.1007/s00345-022-04092-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Accepted: 06/29/2022] [Indexed: 01/31/2023] Open
Abstract
Purpose To describe the development and first outcomes of the Utrecht Prostate Cohort (UPC): the first ‘trials within cohorts’ (TwiCs) platform for prostate cancer (PCa). Methods All non-metastasized, histologically proven PCa patients who are planned to receive standard of care are eligible for inclusion in UPC. Patients provide informed consent for the collection of clinical and technical patient data, physician-reported outcomes, and patient-reported outcomes (PROs) up to 10 years post-treatment. Additionally, patients may provide broad consent for future randomization for experimental-intervention trials (TwiCs). Changes in PROs (EPIC-26 questionnaire domains) of the participants who received standard of care were analyzed using Wilcoxon signed-rank tests. Results In two years, 626 patients were enrolled, 503 (80.4%) of whom provided broad consent for future randomization. Among these, 293 (46.8%) patients underwent magnetic resonance-guided adaptive radiotherapy (MRgRT), 116 (18.5%) CT-guided external beam radiation therapy (EBRT), 109 (17.4%) robot-assisted radical prostatectomy (RARP), and 65 (10.4%) patients opted for active surveillance. Patients treated with MRgRT and CT-guided EBRT showed a transient but significant decline in urinary irritative/obstructive and bowel domain scores at 1-month follow-up. RARP patients showed a significant deterioration of urinary incontinence domain scores between baseline and all follow-up moments and significant improvement of urinary irritative/obstructive domain scores between baseline and 9- and 12-month follow-up. All radical treatment groups showed a significant decline in sexual domain scores during follow-up. Active surveillance patients showed no significant deterioration over time in all domains. Conclusion The first results from the UPC study show distinct differences in PROs between treatment options for PCa. Registration No.: NCT04228211. Supplementary Information The online version contains supplementary material available at 10.1007/s00345-022-04092-2.
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Affiliation(s)
- Frederik R Teunissen
- Department of Radiation Oncology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CZ, Utrecht, The Netherlands.
| | - Thomas Willigenburg
- Department of Radiation Oncology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CZ, Utrecht, The Netherlands
| | - Richard P Meijer
- Department of Oncologic Urology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Harm H E van Melick
- Department of Urology, St. Antonius Hospital, Nieuwegein, Utrecht, The Netherlands
| | - Helena M Verkooijen
- Imaging Division, University Medical Center Utrecht, Utrecht, The Netherlands
- Utrecht University, Utrecht, The Netherlands
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Bywater T, Berry V, Blower S, Bursnall M, Cox E, Mason-Jones A, McGilloway S, McKendrick K, Mitchell S, Pickett K, Richardson G, Solaiman K, Teare MD, Walker S, Whittaker K. A proportionate, universal parenting programme to enhance social-emotional well-being in infants and toddlers in England: the E-SEE Steps RCT. PUBLIC HEALTH RESEARCH 2022. [DOI: 10.3310/bcfv2964] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background
Mental disorders have become a public health crisis. Early prevention is key. Parenting programmes are effective for children aged ≥ 3 years; however, there is a lack of evidence of their effectiveness for children aged ≤ 2 years.
Objectives
To establish if the model named Enhancing Social–Emotional Health and Well-being in the Early Years (E-SEE) Steps can (1) enhance child social emotional well-being and establish whether or not it is cost-effective at 20 months of age when compared with services as usual; and (2) be delivered as a proportionate universal model with fidelity.
Design
A pragmatic two-arm randomised controlled trial and economic appraisal, with an embedded process evaluation to examine the outcomes, implementation and cost-effectiveness of the intervention, and intervention uptake, compared with services as usual. The study had an external pilot phase (which was originally planned as an internal pilot).
Setting
The intervention was delivered in community settings by early years children’s services and/or public health staff in four sites.
Participants
A total of 341 parents of infants aged ≤ 8 weeks were randomised in a ratio of 5 : 1 (intervention, n = 285; control, n = 56). The target sample was 606 parents.
Intervention
Two Incredible Years® parenting programmes (i.e. infant and toddler) delivered in a proportionate universal model with three levels [one universal (book) and two targeted group-based parenting programmes].
Main outcome measures
Child social and emotional well-being (primary outcome) was assessed using the Ages and Stages Questionnaire: Social and Emotional, 2nd edition, at 2, 9 and 18 months after randomisation. Parent depression (secondary key outcome) was assessed using the Patient Health Questionnaire-9 items. Both questionnaires were eligibility screeners for targeted groups.
Results
The primary outcome analysis provided no evidence that the E-SEE Steps model was effective in enhancing child social and emotional well-being. The adjusted mean difference was 3.02 on the original Ages and Stages Questionnaire: Social and Emotional, 2nd edition, in favour of the control [95% confidence interval –0.03 to 6.08; p = 0.052; N = 321 (intervention, n = 268; control, n = 53)]. Analysis of the key secondary outcome (i.e. parent depression levels as assessed by the Patient Health Questionnaire-9 items) provided weak evidence on the Patient Health Questionnaire-9 items in favour of the intervention (adjusted mean difference –0.61, 95% confidence interval –1.34 to 0.12; p = 0.1). Other secondary outcomes did not differ between arms. The economic analysis showed that the E-SEE Steps model was associated with higher costs and was marginally more effective (0.031 quality-adjusted life-years gained from E-SEE Steps compared with SAU, 95% confidence interval –0.008 to 0.071) than services as usual, resulting in an incremental cost-effectiveness ratio of approximately £20,062 per quality-adjusted life-year compared with services as usual. Overall take-up of the targeted parenting programmes was low. Sites, although enthusiastic, identified barriers to delivering the intervention.
Limitations
The target sample size was not met and the study was not powered to explore the effectiveness of each level of intervention. Most parents in the sample were well educated and, therefore, the results are unlikely to be generalisable, particularly to those at greatest risk of poor social and emotional well-being.
Conclusions
The E-SEE Steps proportionate universal model did not enhance child social and emotional well-being, but generated non-significant improvements in parent health outcomes, resulting in considerable uncertainty around the cost-effectiveness of the intervention. The primary and key secondary outcome gave inconsistent signals. Although, with system changes, increased resources and adaptations to the intervention, the model could be implemented, evidence for positive outcomes from the E-SEE Steps model is poor.
Future work
The universal-level E-SEE Step data (i.e. the Incredible Years book) from the external pilot will be pooled with the main trial data for further exploration up to follow-up 1, which is the time point at which most change was seen.
Trial registration
This trial is registered as ISRCTN11079129.
Funding
This project was funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme and will be published in full in Public Health Research; Vol. 10, No. 8. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Tracey Bywater
- Department of Health Sciences, University of York, York, UK
| | - Vashti Berry
- College of Medicine and Health, University of Exeter, Exeter, UK
| | - Sarah Blower
- Department of Health Sciences, University of York, York, UK
| | | | - Edward Cox
- Centre for Health Economics, University of York, York, UK
| | | | - Sinéad McGilloway
- Centre for Mental Health and Community Research, Maynooth University, Maynooth, Ireland
| | | | - Siobhan Mitchell
- College of Medicine and Health, University of Exeter, Exeter, UK
| | - Kate Pickett
- Department of Health Sciences, University of York, York, UK
| | | | | | - M Dawn Teare
- Sheffield Clinical Trials Research Unit, Sheffield, UK
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | - Simon Walker
- Centre for Health Economics, University of York, York, UK
| | - Karen Whittaker
- School of Nursing, University of Central Lancashire, Preston, UK
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Verweij ME, Gal R, Burbach JPM, Young-Afat DA, van der Velden JM, van der Graaf R, May AM, Relton C, Intven MP, Verkooijen HM. Most patients reported positively or neutrally of having served as controls in the Trials within Cohorts (TwiCs) design. J Clin Epidemiol 2022; 148:39-47. [DOI: 10.1016/j.jclinepi.2022.04.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Revised: 03/29/2022] [Accepted: 04/12/2022] [Indexed: 11/15/2022]
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20
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Drew CJG, Busse M. Considerations for clinical trial design and conduct in the evaluation of novel advanced therapeutics in neurodegenerative disease. INTERNATIONAL REVIEW OF NEUROBIOLOGY 2022; 166:235-279. [PMID: 36424094 DOI: 10.1016/bs.irn.2022.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
The recent advances in the development of potentially disease modifying cell and gene therapies for neurodegenerative disease has resulted in the production of a number of promising novel therapies which are now moving forward to clinical evaluation. The robust evaluation of these therapies pose a significant number of challenges when compared to more traditional evaluations of pharmacotherapy, which is the current mainstay of neurodegenerative disease symptom management. Indeed, there is an inherent complexity in the design and conduct of these trials at multiple levels. Here we discuss specific aspects requiring consideration in the context of investigating novel cell and gene therapies for neurodegenerative disease. This extends to overarching trial designs that could be employed and the factors that underpin design choices such outcome assessments, participant selection and methods for delivery of cell and gene therapies. We explore methods of data collection that may improve efficiency in trials of cell and gene therapy to maximize data sharing and collaboration. Lastly, we explore some of the additional context beyond efficacy evaluations that should be considered to ensure implementation across relevant healthcare settings.
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Affiliation(s)
- Cheney J G Drew
- Centre For Trials Research, Cardiff University, Cardiff, United Kingdom; Brain Repair and Intracranial Neurotherapeutics Unit (BRAIN), College of Biomedical and Life Sciences, Cardiff University, Cardiff, United Kingdom.
| | - Monica Busse
- Centre For Trials Research, Cardiff University, Cardiff, United Kingdom; Brain Repair and Intracranial Neurotherapeutics Unit (BRAIN), College of Biomedical and Life Sciences, Cardiff University, Cardiff, United Kingdom
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BROWN ANDREWW, ASLIBEKYAN STELLA, BIER DENNIS, DA SILVA RAFAELFERREIRA, HOOVER ADAM, KLURFELD DAVIDM, LOKEN ERIC, MAYO-WILSON EVAN, MENACHEMI NIR, PAVELA GREG, QUINN PATRICKD, SCHOELLER DALE, TEKWE CARMEN, VALDEZ DANNY, VORLAND COLBYJ, WHIGHAM LEAHD, ALLISON DAVIDB. Toward more rigorous and informative nutritional epidemiology: The rational space between dismissal and defense of the status quo. Crit Rev Food Sci Nutr 2021; 63:3150-3167. [PMID: 34678079 PMCID: PMC9023609 DOI: 10.1080/10408398.2021.1985427] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
To date, nutritional epidemiology has relied heavily on relatively weak methods including simple observational designs and substandard measurements. Despite low internal validity and other sources of bias, claims of causality are made commonly in this literature. Nutritional epidemiology investigations can be improved through greater scientific rigor and adherence to scientific reporting commensurate with research methods used. Some commentators advocate jettisoning nutritional epidemiology entirely, perhaps believing improvements are impossible. Still others support only normative refinements. But neither abolition nor minor tweaks are appropriate. Nutritional epidemiology, in its present state, offers utility, yet also needs marked, reformational renovation. Changing the status quo will require ongoing, unflinching scrutiny of research questions, practices, and reporting-and a willingness to admit that "good enough" is no longer good enough. As such, a workshop entitled "Toward more rigorous and informative nutritional epidemiology: the rational space between dismissal and defense of the status quo" was held from July 15 to August 14, 2020. This virtual symposium focused on: (1) Stronger Designs, (2) Stronger Measurement, (3) Stronger Analyses, and (4) Stronger Execution and Reporting. Participants from several leading academic institutions explored existing, evolving, and new better practices, tools, and techniques to collaboratively advance specific recommendations for strengthening nutritional epidemiology.
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Affiliation(s)
- ANDREW W. BROWN
- Indiana University School of Public Health-Bloomington, Bloomington, Indiana, USA
| | | | - DENNIS BIER
- Baylor College of Medicine, Houston, Texas, USA
| | | | - ADAM HOOVER
- Clemson University, Clemson, South Carolina, USA
| | - DAVID M. KLURFELD
- United States Department of Agriculture, Agricultural Research Service, Beltsville, Maryland, USA
| | - ERIC LOKEN
- University of Connecticut, Storrs, Connecticut, USA
| | - EVAN MAYO-WILSON
- Indiana University School of Public Health-Bloomington, Bloomington, Indiana, USA
| | - NIR MENACHEMI
- Indiana University Fairbanks School of Public Health at IUPUI, Indianapolis, Indiana, USA
| | - GREG PAVELA
- University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - PATRICK D. QUINN
- Indiana University School of Public Health-Bloomington, Bloomington, Indiana, USA
| | - DALE SCHOELLER
- University of Wisconsin-Madison Biotechnology Center, Madison, Wisconsin, USA
| | - CARMEN TEKWE
- Indiana University School of Public Health-Bloomington, Bloomington, Indiana, USA
| | - DANNY VALDEZ
- Indiana University School of Public Health-Bloomington, Bloomington, Indiana, USA
| | - COLBY J. VORLAND
- Indiana University School of Public Health-Bloomington, Bloomington, Indiana, USA
| | - LEAH D. WHIGHAM
- University of Texas Health Science Center School of Public Health, El Paso, Texas, USA
| | - DAVID B. ALLISON
- Indiana University School of Public Health-Bloomington, Bloomington, Indiana, USA
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22
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Aguiar M, Laba TL, Munro S, Burch T, Beckett J, Kaal KJ, Bansback N, Hudson M, Harrison M. Co-production of randomized clinical trials with patients: a case study in autologous hematopoietic stem cell transplant for patients with scleroderma. Trials 2021; 22:611. [PMID: 34503552 PMCID: PMC8428135 DOI: 10.1186/s13063-021-05575-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Accepted: 08/27/2021] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Increasingly, it is argued that clinical trials struggle to recruit participants because they do not respond to key questions or study treatments that patients will be willing or able to use. This study explores how elicitation of patient-preferences can help designers of randomized controlled trials (RCTs) understand the impact of changing modifiable aspects of treatments or trial design on recruitment. METHODS Focus groups and a discrete choice experiment (DCE) survey were used to elicit preferences of people with scleroderma for autologous hematopoietic stem cell transplant (AHSCT) treatment interventions. Preferences for seven attributes of treatment (effectiveness, immediate and long-term risk, care team composition and experience, cost, travel distance) were estimated using a mixed-logit model and used to predict participation in RCTs. RESULTS Two hundred seventy-eight people with scleroderma answered the survey. All AHSCT treatment attributes significantly influenced preferences. Treatment effectiveness and risk of late complications contributed the most to participants' choices, but modifiable factors of distance to treatment center and cost also affected preferences. Predicted recruitment rates calibrated with participation in a recent trial (33%) and suggest offering a treatment closer to home, at lower patient cost, and with holistic, multidisciplinary care could increase participation to 51%. CONCLUSIONS Through a patient engaged approach to preference elicitation for different features of AHSCT treatment options, we were able to predict what drives the decisions of people with scleroderma to participate in RCTs. Knowledge regarding concerns and the trade-offs people are willing to make can inform clinical study design, improving recruitment rates and potential uptake of the treatment of interest.
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Affiliation(s)
- Magda Aguiar
- Faculty of Pharmaceutical Sciences, University of British Columbia, 4625-2405 Wesbrook Mall, Vancouver, BC, V6T 1Z3, Canada
| | - Tracey-Lea Laba
- Centre for Health Economics Research and Evaluation, University Technology Sydney, Sydney, NSW, Australia
| | - Sarah Munro
- Centre for Healthcare Evaluation and Outcome Sciences, Vancouver, BC, Canada
- Department of Family Practice, University of British Columbia, Vancouver, BC, Canada
| | - Tiasha Burch
- Scleroderma Association of BC, Vancouver, BC, Canada
- Patient Partner, Vancouver, Canada
| | | | - K Julia Kaal
- Faculty of Pharmaceutical Sciences, University of British Columbia, 4625-2405 Wesbrook Mall, Vancouver, BC, V6T 1Z3, Canada
- School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
| | - Nick Bansback
- Centre for Healthcare Evaluation and Outcome Sciences, Vancouver, BC, Canada
- School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
- Arthritis Research Canada, Richmond, BC, Canada
| | - Marie Hudson
- Arthritis Research Canada, Richmond, BC, Canada
- Division of Rheumatology, Jewish General Hospital and Lady Davis Institute, and Department of Medicine, McGill University, Montreal, QC, Canada
| | - Mark Harrison
- Faculty of Pharmaceutical Sciences, University of British Columbia, 4625-2405 Wesbrook Mall, Vancouver, BC, V6T 1Z3, Canada.
- Centre for Healthcare Evaluation and Outcome Sciences, Vancouver, BC, Canada.
- Arthritis Research Canada, Richmond, BC, Canada.
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23
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Janiaud P, Hemkens LG, Ioannidis JPA. Challenges and Lessons Learned From COVID-19 Trials: Should We Be Doing Clinical Trials Differently? Can J Cardiol 2021; 37:1353-1364. [PMID: 34077789 PMCID: PMC8164884 DOI: 10.1016/j.cjca.2021.05.009] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Revised: 05/18/2021] [Accepted: 05/22/2021] [Indexed: 12/15/2022] Open
Abstract
The COVID-19 crisis led to a flurry of clinical trials activity. The COVID-evidence database shows 2814 COVID-19 randomized trials registered as of February 16, 2021. Most were small (only 18% have a planned sample size > 500) and the rare completed ones have not provided published results promptly (only 283 trial publications as of February 2021). Small randomized trials and observational, nonrandomized analyses have not had a successful track record and have generated misleading expectations. Different large trials on the same intervention have generally been far more efficient in producing timely and consistent evidence. The rapid generation of evidence and accelerated dissemination of results have led to new challenges for systematic reviews and meta-analyses (eg, rapid, living, and scoping reviews). Pressure to regulatory agencies has also mounted with massive emergency authorizations, but some of them have had to be revoked. Pandemic circumstances have disrupted the way trials are conducted; therefore, new methods have been developed and adopted more widely to facilitate recruitment, consent, and overall trial conduct. On the basis of the COVID-19 experience and its challenges, planning of several large, efficient trials, and wider use of adaptive designs might change the future of clinical research. Pragmatism, integration in clinical care, efficient administration, promotion of collaborative structures, and enhanced integration of existing data and facilities might be several of the legacies of COVID-19 on future randomized trials.
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Affiliation(s)
- Perrine Janiaud
- Department of Clinical Research, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Lars G Hemkens
- Department of Clinical Research, University Hospital Basel, University of Basel, Basel, Switzerland; Meta-Research Innovation Center at Stanford (METRICS), Stanford University, Stanford, California, USA; Meta-Research Innovation Center Berlin (METRIC-B), Berlin Institute of Health, Berlin, Germany
| | - John P A Ioannidis
- Meta-Research Innovation Center at Stanford (METRICS), Stanford University, Stanford, California, USA; Meta-Research Innovation Center Berlin (METRIC-B), Berlin Institute of Health, Berlin, Germany; Department of Medicine, Stanford University School of Medicine, Stanford, California, USA; Department of Epidemiology and Population Health, Stanford University School of Medicine, Stanford, California, USA; Department of Biomedical Data Science, Stanford University School of Medicine, Stanford, California, USA; Department of Statistics, Stanford University School of Humanities and Sciences, Stanford, California, USA.
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24
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Henderson GE, Rennie S, Corneli A, Peay HL. Cohorts as collections of bodies and communities of persons: insights from the SEARCH010/RV254 research cohort. Int Health 2021; 12:584-590. [PMID: 33165552 PMCID: PMC7650957 DOI: 10.1093/inthealth/ihaa060] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Revised: 07/28/2020] [Accepted: 08/20/2020] [Indexed: 12/11/2022] Open
Abstract
Longitudinal research cohorts are uniquely suited to answer research questions about morbidity and mortality. Cohorts may be comprised of individuals identified by specific conditions or other shared traits. We argue that research cohorts are more than simply aggregations of individuals and their associated data to meet research objectives. They are social communities comprised of members, investigators and organizations whose own interests, identities and cultures interact and evolve over time. The literature describes a range of scientific and ethical challenges and opportunities associated with cohorts. To advance these deliberations, we report examples from the literature and our own research on the Thai SEARCH010/RV254 cohort, comprising individuals diagnosed with human immunodeficiency virus (HIV) during acute infection. We reflect on the impact of cohort experiences and identity, and specifically how people incorporate cohort participation into meaning making associated with their diagnosis, the influence of cohort participation on decision making for early-phase clinical trials recruited from within the cohort, and the impact of the relationships that exist between researchers and participants. These data support the concept of cohorts as communities of persons, where identity is shaped, in part, through cohort experiences. The social meanings associated with cohorts have implications for the ethics of cohort-based research, as social contexts inevitably affect the ways that ethical concerns manifest.
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Affiliation(s)
- Gail E Henderson
- Department of Social Medicine, University of North Carolina School of Medicine, 347A MacNider, 333 South Columbia Street, Chapel Hill, NC 27599-7240, USA
| | - Stuart Rennie
- Department of Social Medicine, University of North Carolina School of Medicine, 347A MacNider, 333 South Columbia Street, Chapel Hill, NC 27599-7240, USA
| | - Amy Corneli
- Departments of Population Health Sciences and Medicine, School of Medicine, Duke Clinical Research Institute, Duke University, 215 Morris Street, Durham, NC 27701
| | - Holly L Peay
- RTI International, 3040 E Cornwallis Rd, Research Triangle Park, NC 27709
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25
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Nicholls SG, Carroll K, Hey SP, Zwarenstein M, Zhang JZ, Nix HP, Brehaut JC, McKenzie JE, McDonald S, Weijer C, Fergusson DA, Taljaard M. A review of pragmatic trials found a high degree of diversity in design and scope, deficiencies in reporting and trial registry data, and poor indexing. J Clin Epidemiol 2021; 137:45-57. [PMID: 33789151 DOI: 10.1016/j.jclinepi.2021.03.021] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Revised: 02/24/2021] [Accepted: 03/18/2021] [Indexed: 01/01/2023]
Abstract
OBJECTIVE We established a large database of trials to serve as a resource for future methodological and ethical analyses. Here, we use meta-data to describe the broad landscape of pragmatic trials including research areas, identification as pragmatic, quality of trial registry data and enrolment. STUDY DESIGN AND SETTING Trials were identified by a validated search filter and included if a primary report of a health-related randomized trial published January 2014-April 2019. Data were collated from MEDLINE, Web of Science, ClinicalTrials.gov, and full text. RESULTS 4337 eligible trials were identified from 13,065 records, of which 1988 were registered in ClinicalTrials.gov. Research areas were diverse, with the most common being general and internal medicine; public, environmental and occupational health; and health care sciences and services. The term "pragmatic" was seldom used in titles or abstracts. Several domains in ClinicalTrials.gov had questionable data quality. We estimated that one-fifth of trials under-accrued by at least 15%. CONCLUSION There is a need to improve reporting of pragmatic trials and quality of trial registry data. Under accrual remains a challenge in pragmatic RCTs despite calls for more streamlined recruitment approaches. The diversity of pragmatic trials should be reflected in future ethical analyses.
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Affiliation(s)
- Stuart G Nicholls
- Clinical Epidemiology Program, Ottawa Hospital Research Institute (OHRI).
| | - Kelly Carroll
- Clinical Epidemiology Program, Ottawa Hospital Research Institute (OHRI)
| | | | - Merrick Zwarenstein
- Centre for Studies in Family Medicine, Department of Family Medicine, Schulich School of Medicine & Dentistry, Western University, 1151 Richmond Street, London, Ontario, Canada, N6A 3K7; Department of Family Medicine, Western University, London, Canada; Schulich School of Medicine & Dentistry, Western University, London, Canada
| | - Jennifer Zhe Zhang
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
| | - Hayden P Nix
- Schulich School of Medicine & Dentistry, Western University, London, Canada
| | - Jamie C Brehaut
- Clinical Epidemiology Program, Ottawa Hospital Research Institute (OHRI); School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
| | - Joanne E McKenzie
- School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, Victoria 3004, Australia
| | - Steve McDonald
- School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, Victoria 3004, Australia
| | - Charles Weijer
- Department of Medicine, Western University, London, Canada; Department of Epidemiology and Biostatistics, Western University, London, Canada; Department of Philosophy, Western University, London, Canada
| | - Dean A Fergusson
- Clinical Epidemiology Program, Ottawa Hospital Research Institute (OHRI); School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada; Department of Medicine, University of Ottawa, Ottawa, Canada
| | - Monica Taljaard
- Clinical Epidemiology Program, Ottawa Hospital Research Institute (OHRI); School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
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Rombach I, Tillett W, Jadon D, Tucker L, Watson M, Francis A, Sinomati Y, Eldridge L, Dritsaki M, Dutton SJ, Al-Mossawi H, Gullick N, Thompson B, Coates LC. Treating to target in psoriatic arthritis: assessing real-world outcomes and optimising therapeutic strategy for adults with psoriatic arthritis-study protocol for the MONITOR-PsA study, a trials within cohorts study design. Trials 2021; 22:185. [PMID: 33663566 PMCID: PMC7931500 DOI: 10.1186/s13063-021-05142-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Accepted: 02/20/2021] [Indexed: 11/15/2022] Open
Abstract
Background The Tight Control of psoriatic arthritis (TICOPA) trial confirmed improved clinical outcomes with a treat to target (T2T) strategy in psoriatic arthritis (PsA). This consisted of 4-weekly review and escalation of ‘step up’ therapy (single disease modifying therapy (DMARD), combination DMARDs and then biologics) based on remission criteria. Based on this, a T2T approach is supported by European PsA treatment recommendations. However, it is not commonly implemented in routine care primarily due to feasibility and cost concerns. In the TICOPA trial, the same treatment regime was used for all participants regardless of their disease profile. Despite the recognition of PsA as a highly heterogeneous condition, no studies have tailored which drugs are used depending on disease severity. The cohort will establish real world outcomes for the T2T approach in PsA and also form the basis of a trials within cohorts (TWiCs) design to test alternative therapeutic approaches within embedded clinical trials providing an evidence base for treatment strategy in PsA. Methods The Multicentre Observational Initiative in Treat to target Outcomes in Psoriatic Arthritis (MONITOR-PsA) cohort will apply a T2T approach within routine care. It will recruit newly diagnosed adult patients with PsA starting systemic therapies. The cohort is observational allowing routine therapeutic care within NHS clinics but a T2T approach will be supported when monitoring treatment within the cohort. Eligible participants will be adults (≥18 years) with active PsA with ≥ 1 tender or swollen joints or enthesis who have not previously had treatment with DMARDs for articular disease. Discussion This study is the first TWiC designed to support a fully powered randomised drug trial. The results from the observational cohort will be compared with those observed in the TICOPA trial investigating the clinical effectiveness and health care costs of the pragmatic T2T approach. Nested trials will provide definitive RCT evidence establishing the optimal management of PsA within the T2T approach. The TWiCs design allows robust generalizability to routine healthcare, avoids disappointment bias, aids recruitment and in future will allow assessment of longer-term outcomes. Trial registration ClinicalTrials.gov NCT03531073. Retrospectively registered on 21 May 2018.
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Affiliation(s)
- Ines Rombach
- Oxford Clinical Trials Research Unit, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - William Tillett
- Royal National Hospital for Rheumatic Diseases, Bath, UK.,Department of Pharmacy and Pharmacology, University of Bath, Bath, UK
| | - Deepak Jadon
- Department of Medicine, University of Cambridge, Cambridge, UK
| | - Laura Tucker
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Marion Watson
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Anne Francis
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Yvonne Sinomati
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Lucy Eldridge
- Oxford Clinical Trials Research Unit, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Melina Dritsaki
- Oxford Clinical Trials Research Unit, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Susan J Dutton
- Oxford Clinical Trials Research Unit, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Hussein Al-Mossawi
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Nicola Gullick
- Rheumatology Department, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Ben Thompson
- Department of Rheumatology, Musculoskeletal Unit, Newcastle-upon-Tyne Hospitals NHS Trust, Newcastle upon Tyne, UK
| | - Laura C Coates
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK.
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27
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Vickers AJ, Vertosick EA, Carlsson SV, Ehdaie B, Kim SYH. Patient accrual and understanding of informed consent in a two-stage consent design. Clin Trials 2021; 18:377-382. [PMID: 33530713 DOI: 10.1177/1740774520988500] [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: 11/15/2022]
Abstract
BACKGROUND We previously introduced the concept of "two-stage" (or "just-in-time") informed consent for randomized trials with usual care control. We argued that conducting consent in two stages-splitting information about research procedures from information about the experimental intervention-would reduce the decisional anxiety, confusion, and information overload commonly associated with informed consent. We implemented two-stage consent in a low-stakes randomized trial of a mindfulness meditation intervention for procedural distress in patients undergoing prostate biopsy. Here, we report accrual rates and patient understanding of the consent process. METHODS Patients approached for consent for the biopsy trial were asked to complete the standard "Quality of Informed Consent" questionnaire to assess their knowledge and understanding of the trial. RESULTS Accrual was excellent with 108 of 110 (98%) patients approached for consent signing first-stage consent. All 51 patients randomized to the experimental arm and who later presented for biopsy signed second-stage consent and received the mindfulness intervention. Quality of Informed Consent data were available for 48 patients assigned to the mindfulness treatment arm and 44 controls. The mean Quality of Informed Consent score was similar in the meditation and control arms with and overall mean of 75 (95% confidence interval = 74-76) for the knowledge section and 86 (95% confidence interval = 81-90) for understanding, comparable to the normative scores of 80 and 88. On further analysis and patient interview, two of the Quality of Informed Consent questions were found to be misleading in the context of a two-stage consent study for a mindfulness intervention. Excluding these questions increased knowledge scores to 88 (95% confidence interval = 87-90). CONCLUSION We found promising data that two-stage consent facilitated accrual without compromising patient understanding of randomized trials or compliance with allocated treatment. Further research is needed incorporating randomized comparison of two-stage consent to standard consent approaches, measuring patient anxiety and distress as an outcome, using suitable modifications to the Quality of Informed Consent questionnaire and trials with higher stakes.
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Affiliation(s)
- Andrew J Vickers
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Emily A Vertosick
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Sigrid V Carlsson
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA.,Department of Surgery (Urology Service), Memorial Sloan Kettering Cancer Center, New York, NY, USA.,Department of Urology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Behfar Ehdaie
- Department of Surgery (Urology Service), Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Scott Y H Kim
- Department of Bioethics, Clinical Center, National Institutes of Health, Bethesda, MD, USA
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28
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Land J, McCourt O, Heinrich M, Beeken RJ, Koutoukidis DA, Paton B, Yong K, Hackshaw A, Fisher A. The adapted Zelen was a feasible design to trial exercise in myeloma survivors. J Clin Epidemiol 2020; 125:76-83. [PMID: 32289352 PMCID: PMC7482584 DOI: 10.1016/j.jclinepi.2020.04.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Revised: 03/04/2020] [Accepted: 04/07/2020] [Indexed: 11/20/2022]
Abstract
OBJECTIVES We used a method rarely seen in cancer behavioral trials to explore methods of overcoming difficulties often seen in randomized controlled trials. We report our experiences of the adapted Zelen design, so that other researchers can consider this approach for behavioral trials. STUDY DESIGN AND SETTING The adapted Zelen design was used to explore the effects of exercise on multiple myeloma patients fatigue, quality of life, and physical outcomes. All participants consented to an observational cohort study of lifestyle factors but were unaware of subsequent randomization to remain in cohort only group or be offered an exercise intervention requiring second consent. RESULTS There was lower than expected uptake to the exercise offered group (57%), so the length of recruitment increased from 24 to 29 months to ensure power was reached. At enrollment, patients were unaware of the potential increased commitment, and as a result, 62% of participants allocated to the intervention declined because of the extra time/travel commitment required. This emulates clinical settings and suggests improvements in intervention delivery are required. Our findings suggest that the adapted Zelen design may be useful in limiting dropout of controls due to dissatisfaction from group allocation, or contamination of control arm. CONCLUSION Future use of this design warrants careful consideration of the study resources and recruitment time frames required but holds potential value in reducing contamination, control group dissatisfaction, and resulting dropout. Adapted Zelen design reduces selection bias and therefore gives clinicians a better understanding of acceptability in clinical settings. Future studies should evaluate control group experiences of the design and formally record contamination throughout the study to confirm its acceptability.
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Affiliation(s)
- Joanne Land
- Department of Behavioural Science and Health, University College London, WC1E 7HB, London, UK
| | - Orla McCourt
- Department of Behavioural Science and Health, University College London, WC1E 7HB, London, UK; Research Department of Haematology, Cancer Institute, University College London, London, UK; University College London Hospitals NHS Foundation Trust, London, UK
| | - Malgorzata Heinrich
- Department of Behavioural Science and Health, University College London, WC1E 7HB, London, UK
| | - Rebecca J Beeken
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Dimitrios A Koutoukidis
- Department of Behavioural Science and Health, University College London, WC1E 7HB, London, UK; Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK; NIHR Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Bruce Paton
- Institute of Sport Exercise & Health, London, UK
| | - Kwee Yong
- Research Department of Haematology, Cancer Institute, University College London, London, UK
| | - Allan Hackshaw
- Cancer Research UK & UCL Cancer Trials Centre, University College London, London, UK
| | - Abigail Fisher
- Department of Behavioural Science and Health, University College London, WC1E 7HB, London, UK.
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29
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Wouters RH, van der Graaf R, Voest EE, Bredenoord AL. Learning health care systems: Highly needed but challenging. Learn Health Syst 2020; 4:e10211. [PMID: 32685681 PMCID: PMC7362679 DOI: 10.1002/lrh2.10211] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Revised: 09/16/2019] [Accepted: 11/03/2019] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Learning health care systems (LHSs) have the potential to transform health care. However, this transformation process faces significant challenges. MATERIALS AND METHODS Based on proposals and early examples of LHSs in the literature and conceptual analysis of the LHS mission, we provide four models with distinct organizational and ethical implications that may facilitate the transformation. RESULTS An LHS could be developed in the following ways: by taking away practical impediments that prevent patients and professionals from engaging in scientific research (model 1: optimization LHS); by routinely analyzing observational data from electronic health records and other sources (model 2: comprehensive data LHS); by making clinical decisions based on the outcomes of the aforementioned data analyses and directly evaluating the outcomes in order to continuously improve decision-making (model 3: real-time LHS); or by embedding clinical trials into routine care delivery (model 4: full LHS). CONCLUSIONS Each model has different ethical implications for consent and oversight. Also, the four-model approach shows that reorganizing a health care center into an LHS is not an all-or-nothing decision. Rather, it is a choice from a menu of possibilities. Instead of discussing the advantages and disadvantages of the LHS menu in its entirety, the medical community should focus on the designs and ethical aspects of each of the separate options.
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Affiliation(s)
- Roel H.P. Wouters
- Department of Medical Humanities, Julius Center for Health Sciences and Primary CareUniversity Medical Center Utrecht/Utrecht UniversityUtrechtThe Netherlands
| | - Rieke van der Graaf
- Department of Medical Humanities, Julius Center for Health Sciences and Primary CareUniversity Medical Center Utrecht/Utrecht UniversityUtrechtThe Netherlands
| | - Emile E. Voest
- Department of Medical OncologyNetherlands Cancer InstituteAmsterdamThe Netherlands
| | - Annelien L. Bredenoord
- Department of Medical Humanities, Julius Center for Health Sciences and Primary CareUniversity Medical Center Utrecht/Utrecht UniversityUtrechtThe Netherlands
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30
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Abstract
PURPOSE OF REVIEW In this review, we present the application of pragmatic clinical trials for evaluating interventions in osteoporosis, and we discuss methodological considerations for designing and conducting a pragmatic clinical trial compared with a classical randomized clinical trial. RECENT FINDINGS Pragmatic clinical trials are a popular study design testing effectiveness of health interventions and are intended to address the limitations associated with traditional explanatory randomized clinical trials testing efficacy of interventions. To date, only few pragmatic clinical trials have been conducted in osteoporosis. Pragmatic clinical trials are conducted under routine clinical practice setting and are intended to inform policy makers and clinical decisions. Osteoporosis is a chronic disease well-suited to this particular study design given the existence of a clear and specific natural endpoint, namely fracture occurrence, and the availability of several treatments to prevent fractures.
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Affiliation(s)
- Giovanni Adami
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, 510 20th Street South, Faculty Office Tower 820D, Birmingham, AL, 35294, USA
- Rheumatology Unit, University of Verona, Pz Scuro 10, 37135, Verona, Italy
| | - Kenneth G Saag
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, 510 20th Street South, Faculty Office Tower 820D, Birmingham, AL, 35294, USA.
| | - Maria I Danila
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, 510 20th Street South, Faculty Office Tower 820D, Birmingham, AL, 35294, USA
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Kypri K, Bowe SJ, Karlsson N, McCambridge J. Enrolment-latency in randomized behavior change trials: individual participant data meta-analysis showed association with attrition but not effect-size. J Clin Epidemiol 2019; 118:55-59. [PMID: 31706962 DOI: 10.1016/j.jclinepi.2019.09.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Revised: 09/03/2019] [Accepted: 09/24/2019] [Indexed: 01/18/2023]
Abstract
OBJECTIVES Nonresponse can bias prevalence estimates in population surveys. Effects of selective participation in behavior change intervention trials have been little studied. We tested hypotheses that trial participants who are hard to recruit are (1) more likely to be lost-to-follow-up and (2) less responsive to intervention. STUDY DESIGN AND SETTING We undertook a two-stage individual participant data meta-analysis of four alcohol intervention trials involving 9,251 university students in Australia, New Zealand, and Sweden, comparing participants who enrolled "late" (after the final invitation to participate) vs. "early" (before that). Outcomes were whether participants completed assessments at each trial's primary endpoint (late/early) and number of drinks consumed per week (intervention/control) among late enrolees vs. early enrolees. RESULTS Late enrolees were more likely to be lost-to-follow-up than early enrolees (OR 2.3, 95% CI: 1.7, 2.9). Intervention effect estimates were smaller for late vs. early enrolees, but not significantly so (RR = 0.93; 95% CI: 0.79, 1.08). CONCLUSION Greater effort to recruit trial participants was associated with higher attrition, but there was no clear evidence of bias in effect estimation. The possibility that intervention effect estimates do not generalize beyond a relatively compliant minority of trial participants may warrant further study.
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Affiliation(s)
- Kypros Kypri
- Centre for Clinical Epidemiology & Biostatistics, School of Medicine & Public Health, University of Newcastle, Newcastle, Australia.
| | - Steven J Bowe
- Deakin Biostatistics Unit, Faculty of Health, Deakin University, Melbourne, Australia
| | - Nadine Karlsson
- Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
| | - Jim McCambridge
- Department of Health Sciences, University of York, York, England
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Neves JB, Cullen D, Grant L, Walkden M, Bandula S, Patki P, Barod R, Mumtaz F, Aitchison M, Pizzo E, Ranieri V, Williams N, Wildgoose W, Gurusamy K, Emberton M, Bex A, Tran MGB. Protocol for a feasibility study of a cohort embedded randomised controlled trial comparing NEphron Sparing Treatment (NEST) for small renal masses. BMJ Open 2019; 9:e030965. [PMID: 31189686 PMCID: PMC6577353 DOI: 10.1136/bmjopen-2019-030965] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
INTRODUCTION Small renal masses (SRMs; ≤4 cm) account for two-thirds of new diagnoses of kidney cancer, the majority of which are incidental findings. The natural history of the SRM seems largely indolent. There is an increasing concern regarding surgical overtreatment and the associated health burden in terms of morbidity and economy. Observational data support the safety and efficacy of percutaneous cryoablation but there is an unmet need for high-quality evidence on non-surgical management options and a head-to-head comparison with standard of care is lacking. Historical interventional trial recruitment difficulties demand novel study conduct approaches. We aim to assess if a novel trial design, the cohort embedded randomised controlled trial (RCT), will enable carrying out such a comparison. METHODS AND ANALYSIS Single-centre prospective cohort study of adults diagnosed with SRM (n=200) with an open label embedded interventional RCT comparing nephron sparing interventions. Cohort participants will be managed at patient and clinicians' discretion and agree with longitudinal clinical data and biological sample collection, with invitation for trial interventions and participation in comparator control groups. Cohort participants with biopsy-proven renal cell carcinoma eligible for both percutaneous cryoablation and partial nephrectomy will be randomly selected (1:1) and invited to consider percutaneous cryoablation (n=25). The comparator group will be robotic partial nephrectomy (n=25). The primary outcome of this feasibility study is participant recruitment. Qualitative research techniques will assess barriers and recruitment improvement opportunities. Secondary outcomes are participant trial retention, health-related quality of life, treatment complications, blood transfusion rate, intensive care unit admission and renal replacement requirement rates, length of hospital stay, time to return to pre-treatment activities, number of work days lost, and health technologies costs. ETHICS AND DISSEMINATION Ethical approval has been granted (UK HRA REC 19/EM/0004). Study outputs will be presented and published. TRIAL REGISTRATION ISRCTN18156881; Pre-results.
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Affiliation(s)
- Joana B Neves
- Department of Surgical Biotechnology, Division of Surgery and Interventional Science, University College London, London, UK
- Specialist Centre for Kidney Cancer, Royal Free London NHS Foundation Trust, London, UK
| | - David Cullen
- Specialist Centre for Kidney Cancer, Royal Free London NHS Foundation Trust, London, UK
| | - Lee Grant
- Specialist Centre for Kidney Cancer, Royal Free London NHS Foundation Trust, London, UK
- Department of Radiology, Royal Free London NHS Foundation Trust, London, UK
| | - Miles Walkden
- Specialist Centre for Kidney Cancer, Royal Free London NHS Foundation Trust, London, UK
- Department of Interventional Radiology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Steve Bandula
- Department of Interventional Radiology, University College London Hospitals NHS Foundation Trust, London, UK
- Department of Medicine, Centre for Medical Imaging, University College London, London, UK
| | - Prasad Patki
- Specialist Centre for Kidney Cancer, Royal Free London NHS Foundation Trust, London, UK
- Department of Urology, Barts Health NHS Trust, London, UK
| | - Ravi Barod
- Specialist Centre for Kidney Cancer, Royal Free London NHS Foundation Trust, London, UK
| | - Faiz Mumtaz
- Specialist Centre for Kidney Cancer, Royal Free London NHS Foundation Trust, London, UK
| | - Michael Aitchison
- Specialist Centre for Kidney Cancer, Royal Free London NHS Foundation Trust, London, UK
| | - Elena Pizzo
- Department of Applied Health Research, Institute of Epidemiology and Health, University College London, London, UK
| | | | - Norman Williams
- Department of Surgical Biotechnology, Division of Surgery and Interventional Science, University College London, London, UK
| | | | - Kurinchi Gurusamy
- Department of Surgical Biotechnology, Division of Surgery and Interventional Science, University College London, London, UK
| | - Mark Emberton
- Department of Surgery, Faculty of Medical Sciences, University College London, London, UK
- Department of Urology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Axel Bex
- Department of Surgical Biotechnology, Division of Surgery and Interventional Science, University College London, London, UK
- Specialist Centre for Kidney Cancer, Royal Free London NHS Foundation Trust, London, UK
| | - Maxine G B Tran
- Department of Surgical Biotechnology, Division of Surgery and Interventional Science, University College London, London, UK
- Specialist Centre for Kidney Cancer, Royal Free London NHS Foundation Trust, London, UK
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Miller DG, Kim SYH, Li X, Dickert NW, Flory J, Runge CP, Relton C. Ethical Acceptability of Postrandomization Consent in Pragmatic Clinical Trials. JAMA Netw Open 2018; 1:e186149. [PMID: 30646316 PMCID: PMC6324565 DOI: 10.1001/jamanetworkopen.2018.6149] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Pragmatic clinical trials that seek informed consent after randomization (ie, postrandomization consent) are increasingly used, but debate on ethics persists because control arm patients are not specifically informed about the trials and randomization occurs before consent for the trials. The public's attitude toward postrandomization consent trials is unknown, but the way the trials are described could bias people's views. OBJECTIVES To assess the attitudes of the US general public toward postrandomization informed consent for pragmatic trials and to measure potential framing and other factors associated with those attitudes. DESIGN, SETTING, AND PARTICIPANTS An online, 2 × 2 experimental survey (fielded between February 23 and April 3, 2018) portraying 4 scenarios of postrandomization informed consent (with prior broad consent for medical record use) was conducted. These scenarios included traditional randomized clinical trial language framing vs alternative framing in a high-stakes trial (ie, survival in leukemia) or low-stakes trial (ie, blood glucose level in diabetes). A total of 3793 individuals invited to participate were part of an existing panel representative of the US general public (GfK KnowledgePanel). MAIN OUTCOMES AND MEASURES The proportion of participants who would recommend that an ethics review board approve a postrandomization consent pragmatic trial. RESULTS A total of 2042 of 3739 invitees (54.6%) responded; after exclusion of 38 incomplete surveys, 2004 participants were included in the analysis. Of these, 997 (49.8%) were women, 1440 (71.9%) were white non-Hispanic, 199 (9.9%) were black non-Hispanic, and 233 (11.6%) were Hispanic. Mean (SD) age was 47.5 (17.4) years. Across scenarios, weighted data showed that 75.4% of the participants would recommend approval of the postrandomization consent pragmatic trial, 20.4% would probably not recommend approval, and 4.2% would definitely not recommend approval. Approval was not sensitive to framing language (traditional vs new framing in high-stakes scenario, 74.3% vs 76.8%, P = .40; in low-stakes scenario, 77.7% vs 72.9%, P = .10) or to the stakes (low vs high stakes in traditional framing, 77.7% vs 74.3%, P = .25; in new framing, 72.9% vs 76.8%, P = .18). Better understanding of the postrandomization consent design was associated with higher rate of approval (78.1% vs 65.0%, P = .002 for high-stakes scenario; 77.2% vs 64.9%, P = .004 for low-stakes scenario), especially among those with less education. However, opinions about personal involvement in the control arm were more cautious (range depending on scenario, 45.6%-59.7%) and sensitive to stakes but not to framing. CONCLUSIONS AND RELEVANCE The public's generally high rate of approval of the ethics of postrandomization informed consent for pragmatic trial designs does not appear to be affected by whether postrandomization consent design is framed using traditional randomized clinical trial terminology, regardless of the stakes of the trial. Promoting better understanding of the design may increase its acceptance by the public.
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Affiliation(s)
- David Gibbes Miller
- Department of Bioethics, Clinical Center, National Institutes of Health, Bethesda, Maryland
| | - Scott Y. H. Kim
- Department of Bioethics, Clinical Center, National Institutes of Health, Bethesda, Maryland
| | - Xiaobai Li
- Biostatistics and Clinical Epidemiology Service, Clinical Center, National Institutes of Health, Bethesda, Maryland
| | - Neal W. Dickert
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - James Flory
- Endocrinology Service, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Carlisle P. Runge
- Department of Bioethics, Clinical Center, National Institutes of Health, Bethesda, Maryland
| | - Clare Relton
- Public Health Section, School of Health and Related Research, University of Sheffield, Sheffield, United Kingdom
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Kim SY, Flory J, Relton C. Rejoinder. Clin Trials 2018; 15:27-28. [PMID: 29400564 DOI: 10.1177/1740774517746629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Scott Yh Kim
- 1 The Department of Bioethics, National Institutes of Health, Bethesda, Maryland and Center for Bioethics and Social Sciences in Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - James Flory
- 2 Memorial Sloan Kettering Cancer Center, New York, NY, USA
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Wendler D. Innovative approaches to informed consent for randomized clinical trials: Identifying the ethical challenges. Clin Trials 2018; 15:17-20. [PMID: 29250988 PMCID: PMC5799024 DOI: 10.1177/1740774517746621] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- David Wendler
- Department of Bioethics, Clinical Center, National Institutes of Health, Bethesda, MD, USA
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Weijer C, Goldstein CE, Taljaard M. TwiC or treat? Are trials within cohorts ethically defensible? Clin Trials 2017; 15:21-24. [PMID: 29250989 PMCID: PMC5802521 DOI: 10.1177/1740774517746622] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Charles Weijer
- 1 Rotman Institute of Philosophy, Western University, London, ON, Canada
| | - Cory E Goldstein
- 1 Rotman Institute of Philosophy, Western University, London, ON, Canada
| | - Monica Taljaard
- 2 Ottawa Hospital Research Institute, Ottawa, ON, Canada.,3 School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
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Vickers AJ, Young-Afat DA, Ehdaie B, Kim SY. Just-in-time consent: The ethical case for an alternative to traditional informed consent in randomized trials comparing an experimental intervention with usual care. Clin Trials 2017; 15:3-8. [PMID: 29224379 PMCID: PMC5799028 DOI: 10.1177/1740774517746610] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Informed consent for randomized trials often causes significant and persistent anxiety, distress and confusion to patients. Where an experimental treatment is compared to a standard care control, much of this burden is potentially avoidable in the control group. We propose a "just-in-time" consent in which consent discussions take place in two stages: an initial consent to research from all participants and a later specific consent to randomized treatment only from those assigned to the experimental intervention. All patients are first approached and informed about research procedures, such as questionnaires or tests. They are also informed that they might be randomly selected to receive an experimental treatment and that, if selected, they can learn more about the treatment and decide whether or not to accept it at that time. After randomization, control patients undergo standard clinical consent whereas patients randomized to the experimental procedure undergo a second consent discussion. Analysis would be by intent-to-treat, which protects the trial from selection bias, although not from poor acceptance of experimental treatment. The advantages of just-in-time consent stem from the fact that only patients randomized to the experimental treatment are subject to a discussion of that intervention. We hypothesize that this will reduce much of the patient's burden associated with the consent process, such as decisional anxiety, confusion and information overload. We recommend well-controlled studies to compare just-in-time and traditional consent, with endpoints to include characteristics of participants, distress and anxiety and participants' understanding of research procedures.
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Affiliation(s)
- Andrew J Vickers
- 1 Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Danny A Young-Afat
- 2 Department of Clinical Epidemiology, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Behfar Ehdaie
- 3 Department of Surgery, Sidney Kimmel Center for Prostate and Urologic Cancers, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Scott Yh Kim
- 4 Department of Bioethics, Clinical Center, National Institutes of Health, Bethesda, MD, USA
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