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Sydes MR, Murray ML, Ahmed S, Apostolidou S, Bliss JM, Bloomfield C, Cannings-John R, Carpenter J, Clayton T, Clout M, Cosgriff R, Farrin AJ, Gentry-Maharaj A, Gilbert DC, Harper C, James ND, Langley RE, Lessels S, Lugg-Widger F, Mackenzie IS, Mafham M, Menon U, Mintz H, Pinches H, Robling M, Wright-Hughes A, Yorke-Edwards V, Love SB. Getting our ducks in a row: The need for data utility comparisons of healthcare systems data for clinical trials. Contemp Clin Trials 2024; 141:107514. [PMID: 38537901 DOI: 10.1016/j.cct.2024.107514] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Revised: 02/23/2024] [Accepted: 03/24/2024] [Indexed: 05/03/2024]
Abstract
BACKGROUND Better use of healthcare systems data, collected as part of interactions between patients and the healthcare system, could transform planning and conduct of randomised controlled trials. Multiple challenges to widespread use include whether healthcare systems data captures sufficiently well the data traditionally captured on case report forms. "Data Utility Comparison Studies" (DUCkS) assess the utility of healthcare systems data for RCTs by comparison to data collected by the trial. Despite their importance, there are few published UK examples of DUCkS. METHODS-AND-RESULTS Building from ongoing and selected recent examples of UK-led DUCkS in the literature, we set out experience-based considerations for the conduct of future DUCkS. Developed through informal iterative discussions in many forums, considerations are offered for planning, protocol development, data, analysis and reporting, with comparisons at "patient-level" or "trial-level", depending on the item of interest and trial status. DISCUSSION DUCkS could be a valuable tool in assessing where healthcare systems data can be used for trials and in which trial teams can play a leading role. There is a pressing need for trials to be more efficient in their delivery and research waste must be reduced. Trials have been making inconsistent use of healthcare systems data, not least because of an absence of evidence of utility. DUCkS can also help to identify challenges in using healthcare systems data, such as linkage (access and timing) and data quality. We encourage trial teams to incorporate and report DUCkS in trials and funders and data providers to support them.
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Affiliation(s)
- Matthew R Sydes
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, University College London, London, UK; Health Data Research UK (HDR UK), London, UK; BHF Data Science Centre, Health Data Research UK (HDR UK), London, UK.
| | - Macey L Murray
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, University College London, London, UK; Health Data Research UK (HDR UK), London, UK.
| | - Saiam Ahmed
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, University College London, London, UK; UCL Comprehensive Clinical Trials Unit, Institute of Clinical Trials and Methodology, University College London, London, UK.
| | - Sophia Apostolidou
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, University College London, London, UK.
| | - Judith M Bliss
- Clinical Trials and Statistics Unit, Division of Clinical Studies, The Institute of Cancer Research, London, UK.
| | - Claire Bloomfield
- Insitro Inc, San Francisco, CA, USA; NHS Transformation Directorate, NHS England & NHS Improvement, London, UK.
| | | | - James Carpenter
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, University College London, London, UK; London School of Hygiene and Tropical Medicine, London, UK.
| | - Tim Clayton
- Department of Medical Statistics and Clinical Trials Unit, London School of Hygiene and Tropical Medicine (LSHTM), London, UK.
| | | | - Rebecca Cosgriff
- NHS Transformation Directorate, NHS England & NHS Improvement, London, UK.
| | - Amanda J Farrin
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK.
| | - Aleksandra Gentry-Maharaj
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, University College London, London, UK; Department of Women's Cancer, UCL Elizabeth Garrett Anderson Institute for Women's Health, University College London, London, UK.
| | - Duncan C Gilbert
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, University College London, London, UK.
| | - Charlie Harper
- Nuffield Department of Population Health, University of Oxford, Oxford, UK.
| | | | - Ruth E Langley
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, University College London, London, UK.
| | - Sarah Lessels
- BHF Data Science Centre, Health Data Research UK (HDR UK), London, UK.
| | | | - Isla S Mackenzie
- MEMO Research, Division of Molecular and Clinical Medicine, University of Dundee, Dundee, UK.
| | - Marion Mafham
- Health Data Research UK (HDR UK), London, UK; Nuffield Department of Population Health, University of Oxford, Oxford, UK; Clinical Trial Service Unit and Epidemiological Studies Unit (CTSU), NDPH, University of Oxford, Oxford, UK.
| | - Usha Menon
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, University College London, London, UK.
| | - Harriet Mintz
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, University College London, London, UK.
| | | | - Michael Robling
- Centre for Trials Research, Cardiff University, Cardiff, UK.
| | - Alexandra Wright-Hughes
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK.
| | - Victoria Yorke-Edwards
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, University College London, London, UK; Centre for Advanced Research Computing, University College London, London, UK.
| | - Sharon B Love
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, University College London, London, UK.
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Bojke C, Cottrell D, Wright-Hughes A, Farrin A, Tubeuf S. Long-term cost-utility analysis of family therapy vs. treatment as usual for young people seen after self-harm. COST EFFECTIVENESS AND RESOURCE ALLOCATION 2024; 22:49. [PMID: 38811931 PMCID: PMC11138073 DOI: 10.1186/s12962-024-00546-z] [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: 05/23/2023] [Accepted: 04/16/2024] [Indexed: 05/31/2024] Open
Abstract
BACKGROUND The joint evidence of the cost and the effectiveness of family-based therapies is modest. OBJECTIVE To study the cost-effectiveness of family therapy (FT) versus treatment-as-usual (TAU) for young people seen after self-harm combining data from an 18-month trial and hospital records up to 60-month from randomisation. METHODS We estimate the cost-effectiveness of FT compared to TAU over 5 years using a quasi-Markov state model based on self-harm hospitalisations where probabilities of belonging in a state are directly estimated from hospital data. The primary outcome is quality-adjusted life years (QALY). Cost perspective is NHS and PSS and includes treatment costs, health care use, and hospital attendances whether it is for self-harm or not. Incremental cost-effectiveness ratios are calculated and deterministic and probabilistic sensitivity analyses are conducted. RESULTS Both trial arms show a significant decrease in hospitalisations over the 60-month follow-up. In the base case scenario, FT participants incur higher costs (mean +£1,693) and negative incremental QALYs (-0.01) than TAU patients. The associated ICER at 5 years is dominated and the incremental health benefit at the £30,000 per QALY threshold is -0.067. Probabilistic Sensitivity Analysis finds the probability that FT is cost-effective is around 3 - 2% up to a maximum willingness to pay of £50,000 per QALY. This suggest that the extension of the data to 60 months show no difference in effectiveness between treatments. CONCLUSION Whilst extended trial follow-up from routinely collected statistics is useful to improve the modelling of longer-term cost-effectiveness, FT is not cost-effective relative to TAU and dominated in a cost-utility analysis.
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Affiliation(s)
- Chris Bojke
- Leeds Institute of Health Sciences, Academic Unit of Health Economics, University of Leeds, Leeds, UK
| | - David Cottrell
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK.
| | | | - Amanda Farrin
- Leeds Institute of Clinical Trials, University of Leeds, Leeds, UK
| | - Sandy Tubeuf
- Institute of Health and Society, Institute of Social and Economic Research, Université catholique de Louvain, Louvain-la-Neuve, Belgium
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3
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Woodland H, Buchanan RM, Pring A, Dancox M, McCune A, Forbes K, Verne J. Inequity in end-of-life care for patients with chronic liver disease in England. Liver Int 2023; 43:2393-2403. [PMID: 37519025 DOI: 10.1111/liv.15684] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Revised: 06/05/2023] [Accepted: 07/17/2023] [Indexed: 08/01/2023]
Abstract
BACKGROUND AND AIMS The World Health Assembly recommends integration of palliative care into treatment of patients with any life-limiting condition, yet patients with non-malignant disease are less likely to receive specialist palliative care (SPC). This study compares SPC offered to patients with hepatocellular carcinoma (HCC) versus patients with chronic liver disease without HCC (CLD without HCC). METHODS Patients who died from CLD or HCC over 5 years (2013-2017) in England were identified using a dataset linking national data on all hospital admissions (Hospital Episode Statistics - HES) with national mortality data from the Office for National Statistics (HES - ONS). The primary outcome was the proportion of patients who received inpatient SPC in their last year of life (LYOL). Secondary outcomes were (1) early inpatient SPC input and (2) the proportion dying in a hospice. The outcomes were compared between patients with HCC and CLD without HCC. RESULTS 29 669 patients were identified, 8143 of whom had HCC. Patients with HCC were significantly more likely to receive inpatient SPC input-adjusted OR 3.74 (95% CI 3.52-3.97) and early inpatient SPC input-adjusted OR 7.26 (95% CI 6.38-8.25) and die in a hospice OR 8.23 (95% CI 7.33-9.24) than patients with CLD without HCC. CONCLUSIONS These data highlight the stark inequity in access to SPC services between patients with HCC and patients with CLD without HCC in England. Addressing these inequities will improve end-of-life care for patients with CLD.
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Affiliation(s)
- Hazel Woodland
- Department of Population Health Sciences, University of Bristol, Bristol, UK
- Gastrointestinal Unit, Salisbury NHS Foundation Trust, Salisbury, UK
| | - Ryan M Buchanan
- Faculty of Medicine, University of Southampton, Southampton, UK
| | - Andy Pring
- Office for Health Improvement and Disparities, Department of Health and Social Care, London, UK
| | - Mark Dancox
- Office for Health Improvement and Disparities, Department of Health and Social Care, London, UK
| | - Anne McCune
- Department of Hepatology, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Karen Forbes
- Department of Population Health Sciences, University of Bristol, Bristol, UK
| | - Julia Verne
- Office for Health Improvement and Disparities, Department of Health and Social Care, London, UK
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Wilson BE, Hay AE, Chan KKW, Cheung MC, Hanna TP. Augmenting clinical trial economic analysis by linking cancer trial data to administrative data: current landscape and future opportunities. BMJ Open 2023; 13:e073353. [PMID: 37567744 PMCID: PMC10423795 DOI: 10.1136/bmjopen-2023-073353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Accepted: 07/24/2023] [Indexed: 08/13/2023] Open
Abstract
BACKGROUND Economic analyses based on clinical trial data are costly and time consuming, and alternative methods for performing economic analyses should be explored. OBJECTIVE AND METHODS In this perspective, we examine the emerging role of administrative data for economic analyses in cancer. RESULTS Compared with routinely collected clinical trial data, routinely collected administrative data have several strengths including high capture rates for healthcare encounters, less resource utilisation, low rates of misclassification, long follow-up periods and the opportunity to collect data points not traditionally captured in clinical trials. However, there are also limitations including the need for accurate data linkage across multiple databases and systems, the costs and time associated with data linkage, the potential time lag between trial data collection and the availability of administrative data, and limited data on quality of life, toxicity and indirect costs. In this perspective, we identify important barriers and potential solutions to performing economic analyses for oncology using administrative data, and outline strategies to increase research in this field. CONCLUSION The use of routinely collected administrative data sets for economic analyses of clinical trials presents a unique opportunity that could complement and validate economic analyses based on trial-level data.
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Affiliation(s)
- Brooke E Wilson
- Department of Oncology, Queen's University, Kingston, Ontario, Canada
- Cancer Care and Epidemiology, Queen's Cancer Research Institute, Kingston, Ontario, Canada
| | - Annette E Hay
- Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Kelvin Kar-Wing Chan
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Division of Hematology and Oncology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Matthew C Cheung
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Division of Hematology and Oncology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Timothy P Hanna
- Department of Oncology, Queen's University, Kingston, Ontario, Canada
- Cancer Care and Epidemiology, Queen's Cancer Research Institute, Kingston, Ontario, Canada
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Valencia-Hernández CA, Lindbohm JV, Shipley MJ, Wilkinson IB, McEniery CM, Ahmadi-Abhari S, Singh-Manoux A, Kivimaki M, Brunner EJ. Aortic Pulse Wave Velocity as Adjunct Risk Marker for Assessing Cardiovascular Disease Risk: Prospective Study. Hypertension 2022; 79:836-843. [PMID: 35139665 PMCID: PMC9148390 DOI: 10.1161/hypertensionaha.121.17589] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Accepted: 01/04/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND Aortic pulse wave velocity is a noninvasive measure of aortic stiffness and arterial aging. Its current value in cardiovascular risk estimation practice is unknown. We aimed to establish whether aortic pulse wave velocity identified individuals with higher risk of incident major adverse cardiovascular events and improved performance of the American Heart Association/American College of Cardiology atherosclerotic cardiovascular disease risk score. METHODS This prospective analysis included 3837 Whitehall II cohort participants screened in 2008 to 2009, and followed for 11.7 years (mean=10.3, SD=1.81), without history of stroke, myocardial infarction, or coronary heart disease. RESULTS Mean age of the sample was 65.0 years (SD=5.6), 2831 participants (73.8%) were male and mean atherosclerotic cardiovascular disease risk score was 13.8%. At the end of follow-up, 411 individuals (10.7%) had suffered a major cardiovascular event. Those in the highest aortic pulse wave velocity quartile were at high risk (hazard ratio, 2.99 [95% CI, 2.25-3.97]) and reached the threshold for statin medication (7.5% risk) after 5 years whereas others reached it after 10 years (difference P<0.001). The addition of aortic pulse wave velocity to the risk score improved the C statistic (0.68 versus 0.67, P=0.03) and net reclassification index (4.6%, P=0.04 and 11.3%, P=0.02). CONCLUSIONS Our results show that aortic stiffness predicted major adverse cardiovascular events in a cohort of elderly individuals, improving the performance of a widely used cardiovascular disease risk estimator. Aortic pulse wave velocity measurement is scalable, radiation-free, and easy to perform. Further studies on its applicability in cardiovascular disease risk assessment in primary care settings are needed.
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Affiliation(s)
| | - Joni V. Lindbohm
- Research Department of Epidemiology and Public Health, University College London, London, UK
- Clinicum, Department of Public Health, University of Helsinki
| | - Martin J. Shipley
- Research Department of Epidemiology and Public Health, University College London, London, UK
| | - Ian B. Wilkinson
- Clinical Pharmacology Unit, University of Cambridge, Cambridge, UK
| | | | | | - Archana Singh-Manoux
- Research Department of Epidemiology and Public Health, University College London, London, UK
- Université de Paris, Inserm U1153, Epidemiology of Ageing and Neurodegenerative diseases, France
| | - Mika Kivimaki
- Research Department of Epidemiology and Public Health, University College London, London, UK
| | - Eric J. Brunner
- Research Department of Epidemiology and Public Health, University College London, London, UK
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Witt KG, Hetrick SE, Rajaram G, Hazell P, Taylor Salisbury TL, Townsend E, Hawton K. Interventions for self-harm in children and adolescents. Cochrane Database Syst Rev 2021; 3:CD013667. [PMID: 33677832 PMCID: PMC8094399 DOI: 10.1002/14651858.cd013667.pub2] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Self-harm (SH; intentional self-poisoning or self-injury regardless of degree of suicidal intent or other types of motivation) is a growing problem in most countries, often repeated, and associated with suicide. Evidence assessing the effectiveness of interventions in the treatment of SH in children and adolescents is lacking, especially when compared with the evidence for psychosocial interventions in adults. This review therefore updates a previous Cochrane Review (last published in 2015) on the role of interventions for SH in children and adolescents. OBJECTIVES To assess the effects of psychosocial interventions or pharmacological agents or natural products for SH compared to comparison types of care (e.g. treatment-as-usual, routine psychiatric care, enhanced usual care, active comparator, placebo, alternative pharmacological treatment, or a combination of these) for children and adolescents (up to 18 years of age) who engage in SH. SEARCH METHODS We searched the Cochrane Common Mental Disorders Specialized Register, the Cochrane Library (Central Register of Controlled Trials [CENTRAL] and Cochrane Database of Systematic Reviews [CDSR]), together with MEDLINE, Ovid Embase, and PsycINFO (to 4 July 2020). SELECTION CRITERIA We included all randomised controlled trials (RCTs) comparing specific psychosocial interventions or pharmacological agents or natural products with treatment-as-usual (TAU), routine psychiatric care, enhanced usual care (EUC), active comparator, placebo, alternative pharmacological treatment, or a combination of these, in children and adolescents with a recent (within six months of trial entry) episode of SH resulting in presentation to hospital or clinical services. The primary outcome was the occurrence of a repeated episode of SH over a maximum follow-up period of two years. Secondary outcomes included treatment adherence, depression, hopelessness, general functioning, social functioning, suicidal ideation, and suicide. DATA COLLECTION AND ANALYSIS We independently selected trials, extracted data, and appraised trial quality. For binary outcomes, we calculated odds ratios (ORs) and their 95% confidence internals (CIs). For continuous outcomes, we calculated the mean difference (MD) or standardised mean difference (SMD) and 95% CIs. The overall quality of evidence for the primary outcome (i.e. repetition of SH at post-intervention) was appraised for each intervention using the GRADE approach. MAIN RESULTS We included data from 17 trials with a total of 2280 participants. Participants in these trials were predominately female (87.6%) with a mean age of 14.7 years (standard deviation (SD) 1.5 years). The trials included in this review investigated the effectiveness of various forms of psychosocial interventions. None of the included trials evaluated the effectiveness of pharmacological agents in this clinical population. There was a lower rate of SH repetition for DBT-A (30%) as compared to TAU, EUC, or alternative psychotherapy (43%) on repetition of SH at post-intervention in four trials (OR 0.46, 95% CI 0.26 to 0.82; N = 270; k = 4; high-certainty evidence). There may be no evidence of a difference for individual cognitive behavioural therapy (CBT)-based psychotherapy and TAU for repetition of SH at post-intervention (OR 0.93, 95% CI 0.12 to 7.24; N = 51; k = 2; low-certainty evidence). We are uncertain whether mentalisation based therapy for adolescents (MBT-A) reduces repetition of SH at post-intervention as compared to TAU (OR 0.70, 95% CI 0.06 to 8.46; N = 85; k = 2; very low-certainty evidence). Heterogeneity for this outcome was substantial ( I² = 68%). There is probably no evidence of a difference between family therapy and either TAU or EUC on repetition of SH at post-intervention (OR 1.00, 95% CI 0.49 to 2.07; N = 191; k = 2; moderate-certainty evidence). However, there was no evidence of a difference for compliance enhancement approaches on repetition of SH by the six-month follow-up assessment, for group-based psychotherapy at the six- or 12-month follow-up assessments, for a remote contact intervention (emergency cards) at the 12-month assessment, or for therapeutic assessment at the 12- or 24-month follow-up assessments. AUTHORS' CONCLUSIONS Given the moderate or very low quality of the available evidence, and the small number of trials identified, there is only uncertain evidence regarding a number of psychosocial interventions in children and adolescents who engage in SH. Further evaluation of DBT-A is warranted. Given the evidence for its benefit in adults who engage in SH, individual CBT-based psychotherapy should also be further developed and evaluated in children and adolescents.
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Affiliation(s)
- Katrina G Witt
- Orygen, Parkville, Melbourne, Australia
- Centre for Youth Mental Health, The University of Melbourne, Melbourne, Australia
| | - Sarah E Hetrick
- Department of Psychological Medicine, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
- Children and Young People Satellite, Cochrane Common Mental Disorders, The University of Auckland, Auckland, New Zealand
| | - Gowri Rajaram
- Orygen, Parkville, Melbourne, Australia
- Centre for Youth Mental Health, The University of Melbourne, Melbourne, Australia
| | - Philip Hazell
- Speciality of Psychiatry, University of Sydney School of Medicine, Sydney, Australia
| | - Tatiana L Taylor Salisbury
- Health Service and Population Research Department, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Ellen Townsend
- Self-Harm Research Group, School of Psychology, University of Nottingham, Nottingham, UK
| | - Keith Hawton
- Centre for Suicide Research, Department of Psychiatry, University of Oxford, Oxford, UK
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Cragg WJ, Hurley C, Yorke-Edwards V, Stenning SP. Assessing the potential for prevention or earlier detection of on-site monitoring findings from randomised controlled trials: Further analyses of findings from the prospective TEMPER triggered monitoring study. Clin Trials 2021; 18:115-126. [PMID: 33231127 PMCID: PMC7876652 DOI: 10.1177/1740774520972650] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND/AIMS Clinical trials should be designed and managed to minimise important errors with potential to compromise patient safety or data integrity, employ monitoring practices that detect and correct important errors quickly, and take robust action to prevent repetition. Regulators highlight the use of risk-based monitoring, making greater use of centralised monitoring and reducing reliance on centre visits. The TEMPER study was a prospective evaluation of triggered monitoring (a risk-based monitoring method), whereby centres are prioritised for visits based on central monitoring results. Conducted in three UK-based randomised cancer treatment trials of investigational medicine products with time-to-event outcomes, it found high levels of serious findings at triggered centre visits but also at visits to matched control centres that, based on central monitoring, were not of concern. Here, we report a detailed review of the serious findings from TEMPER centre visits. We sought to identify feasible, centralised processes which might detect or prevent these findings without a centre visit. METHODS The primary outcome of this study was the proportion of all 'major' and 'critical' TEMPER centre visit findings theoretically detectable or preventable through a feasible, centralised process. To devise processes, we considered a representative example of each finding type through an internal consensus exercise. This involved (a) agreeing the potential, by some described process, for each finding type to be centrally detected or prevented and (b) agreeing a proposed feasibility score for each proposed process. To further assess feasibility, we ran a consultation exercise, whereby the proposed processes were reviewed and rated for feasibility by invited external trialists. RESULTS In TEMPER, 312 major or critical findings were identified at 94 visits. These findings comprised 120 distinct issues, for which we proposed 56 different centralised processes. Following independent review of the feasibility of the proposed processes by 87 consultation respondents across eight different trial stakeholder groups, we conclude that 306/312 (98%) findings could theoretically be prevented or identified centrally. Of the processes deemed feasible, those relating to informed consent could have the most impact. Of processes not currently deemed feasible, those involving use of electronic health records are among those with the largest potential benefit. CONCLUSIONS This work presents a best-case scenario, where a large majority of monitoring findings were deemed theoretically preventable or detectable by central processes. Caveats include the cost of applying all necessary methods, and the resource implications of enhanced central monitoring for both centre and trials unit staff. Our results will inform future monitoring plans and emphasise the importance of continued critical review of monitoring processes and outcomes to ensure they remain appropriate.
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Affiliation(s)
- William J Cragg
- MRC Clinical Trials Unit at UCL, London,
UK
- Clinical Trials Research Unit, Leeds
Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Caroline Hurley
- Health Research Board-Trials Methodology
Research Network (HRB-TMRN), National University of Ireland, Galway, Ireland
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Brookes MJ, Waller J, Cappelleri JC, Modesto I, DiBonaventura MD, Bohm N, Mokgokong R, Massey O, Wood R, Bargo D. Living with Ulcerative Colitis Study (LUCY) in England: a retrospective study evaluating healthcare resource utilisation and direct healthcare costs of postoperative care in ulcerative colitis. BMJ Open Gastroenterol 2020; 7:bmjgast-2020-000456. [PMID: 32938582 PMCID: PMC7497134 DOI: 10.1136/bmjgast-2020-000456] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Revised: 07/15/2020] [Accepted: 07/17/2020] [Indexed: 12/30/2022] Open
Abstract
Objective Ulcerative colitis (UC) is a lifelong, relapsing-remitting disease. Patients non-responsive to pharmacological treatment may require a colectomy. We estimated pre-colectomy and post-colectomy healthcare resource utilisation (HCRU) and costs in England. Design/Method A retrospective, longitudinal cohort study indexing adult patients with UC undergoing colectomy (2009–2015), using linked Clinical Practice Research Datalink/Hospital Episode Statistics data, was conducted. HCRU, healthcare costs and pharmacological treatments were evaluated during 12 months prior to and including colectomy (baseline) and 24 months post-colectomy (follow-up; F-U), comparing baseline/F-U, emergency/elective colectomy and subtotal/full colectomy using descriptive statistics and paired/unpaired tests. Results 249 patients from 26 165 identified were analysed including 145 (58%) elective and 184 (74%) full colectomies. Number/cost of general practitioner consultations increased post-colectomy (p<0.001), and then decreased at 13–24 months (p<0.05). From baseline to F-U, the number of outpatient visits, number/cost of hospitalisations and total direct healthcare costs decreased (all p<0.01). Postoperative HCRU was similar between elective and emergency colectomies, except for the costs of colectomy-related hospitalisations and medication, which were lower in the elective group (p<0.05). Postoperative costs were higher for subtotal versus full colectomies (p<0.001). At 1–12 month F-U, 30%, 19% and 5% of patients received aminosalicylates, steroids and immunosuppressants, respectively. Conclusion HCRU/costs increased for primary care in the first year post-colectomy but decreased for secondary care, and varied according to the colectomy type. Ongoing and potentially unnecessary pharmacological therapy was seen in up to 30% of patients. These findings can inform patients and decision-makers of potential benefits and burdens of colectomy in UC.
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Affiliation(s)
- Matthew J Brookes
- Gastroenterology Department, Royal Wolverhampton NHS Trust, Wolverhampton, UK.,Research Institute in Healthcare Science, Faculty of Science and Engineering, University of Wolverhampton, Wolverhampton, UK
| | | | | | - Irene Modesto
- Inflammation & Immunology, Pfizer Inc, New York, New York, USA
| | | | | | | | | | | | - Danielle Bargo
- Patient Health Impact, Pfizer Inc, New York, New York, USA
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9
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Owens D, Wright-Hughes A, Graham L, Blenkiron P, Burton K, Collinson M, Farrin A, Hatcher S, Martin K, O'Dwyer J, Pembroke L, Protheroe D, Tubeuf S, House A. Problem-solving therapy rather than treatment as usual for adults after self-harm: a pragmatic, feasibility, randomised controlled trial (the MIDSHIPS trial). Pilot Feasibility Stud 2020; 6:119. [PMID: 32832098 PMCID: PMC7437039 DOI: 10.1186/s40814-020-00668-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Accepted: 08/07/2020] [Indexed: 11/23/2022] Open
Abstract
Background Non-fatal self-harm is one of the commonest reasons for adults’ emergency hospital attendance. Although strongly associated with fatal and non-fatal repetition, there is weak evidence about effective interventions—and no clear NICE guidance or clinical consensus concerning aftercare. We examined the practicability of a definitive trial to evaluate problem-solving therapy (PST) to reduce repetition of self-harm; MIDSHIPS is a single-centre, parallel-group, individually randomised controlled feasibility trial comparing treatment-as-usual (TAU) alone to TAU plus up to six sessions of brief problem-solving therapy (PST) with adults who had recently attended hospital because of self-harm. Objectives were to adapt the intervention for a UK setting, train therapists, recruit and randomise patients, deliver PST under supervision, and establish comparative outcomes, assessed blindly. Methods We adapted the problem-solving intervention from an earlier trial and trained a mental-health nurse to deliver it. Adult patients attending the general hospital for self-harm were recruited while undergoing psychosocial assessment by the mental health team, and 62 were randomly allocated (32 TAU, 30 PST). The primary outcome assessed repeat hospital attendance due to further self-harm 6 months post-randomisation. Secondary outcomes included participant-reported outcomes and service use at 3 and 6 months post-randomisation. Results The recruitment period had to be extended and 710 patients screened in order to establish a trial sample of the planned size (N = 62). A quarter of participants allocated to PST did not undertake the therapy offered; those who received PST attended a median of three sessions. Secondary outcomes were established for 49 (79%) participants at 6 months; all participants’ hospital records were retrieved. Repetition of self-harm leading to hospital presentation occurred in 19 of the 62 participants (30.6%, 95% CI 19.2%, 42.1%) within 6 months of randomisation. Promising differential rates of self-harm were observed with an event rate of 23.3% (95% CI 8.2%, 38.5%) in the PST arm; and 37.5% (95% CI 20.7%, 54.3%) in TAU. Economic findings were also encouraging, with a small QALY gain (0.0203) in the PST arm together with less reported use of the NHS in the PST arm (average £2120) than with TAU-only (£2878). Conclusions The feasibility trial achieved its objectives despite considerable difficulties with recruitment—adapting the PST, training a therapist, recruiting patients who had recently self-harmed, delivering the therapy, and establishing primary and secondary outcomes. These data provide a robust platform for a definitive multicentre randomised controlled trial of brief problem-solving therapy after hospital attendance due to self-harm. Trial registration Identification number and URL: ISRCTN54036115 http://www.isrctn.com/search?q=midships. Registered: 13 January 2012
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Affiliation(s)
- David Owens
- Leeds Institute of Health Sciences, University of Leeds, Worsley Building, Leeds, LS2 9NL UK
| | | | - Liz Graham
- Leeds Institute of Clinical Trials Research, Worsley Building, Leeds, LS2 9NL UK.,Academic Unit of Elderly Care and Rehabilitation, Bradford Institute for Health Research, Temple Bank House, Bradford, BD9 6RJ UK
| | - Paul Blenkiron
- Tees, Esk & Wear Valleys NHS Foundation Trust, West Park Hospital, Edward Pease Way, Darlington, DL2 2TS UK
| | - Kayleigh Burton
- Leeds Institute of Clinical Trials Research, Worsley Building, Leeds, LS2 9NL UK
| | - Michelle Collinson
- Leeds Institute of Clinical Trials Research, Worsley Building, Leeds, LS2 9NL UK
| | - Amanda Farrin
- Leeds Institute of Clinical Trials Research, Worsley Building, Leeds, LS2 9NL UK
| | - Simon Hatcher
- Department of Psychiatry, University of Ottawa, 1145 Carling Avenue, Ottawa, Ontario K1Z 7 K4 Canada
| | - Katie Martin
- Tees, Esk & Wear Valleys NHS Foundation Trust, West Park Hospital, Edward Pease Way, Darlington, DL2 2TS UK
| | - John O'Dwyer
- Leeds Institute of Health Sciences, University of Leeds, Worsley Building, Leeds, LS2 9NL UK
| | - Louise Pembroke
- Leeds Institute of Health Sciences, University of Leeds, Worsley Building, Leeds, LS2 9NL UK
| | - David Protheroe
- Leeds and York Partnership NHS Foundation Trust, 2150 Century Way, Thorpe Park, Leeds, LS15 8ZB UK
| | - Sandy Tubeuf
- Leeds Institute of Health Sciences, University of Leeds, Worsley Building, Leeds, LS2 9NL UK.,Institute of Health and Society, Université Catholique de Louvain, Clos Chapelle-aux-Champs, 30, Box B1.30.01, B-1200 Brussels, Belgium
| | - Allan House
- Leeds Institute of Health Sciences, University of Leeds, Worsley Building, Leeds, LS2 9NL UK
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Cottrell D, Wright-Hughes A, Eisler I, Fortune S, Green J, House A, Kerfoot M, Owens D, Simic M, McLellan V, Tubeuf S, Farrin A. Longer-term effectiveness of systemic family therapy compared with treatment as usual for young people after self-harm: An extended follow up of pragmatic randomised controlled trial. EClinicalMedicine 2020; 18:100246. [PMID: 31956857 PMCID: PMC6956753 DOI: 10.1016/j.eclinm.2019.100246] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Revised: 11/22/2019] [Accepted: 12/12/2019] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND Self-harm in adolescents is common and repetition frequent. Evidence for effective interventions to reduce self-harm is limited. Long term follow-up of existing studies is rare. METHODS Extended follow up, from 18 to at least 36-months, of the SHIFT trial: a pragmatic, multi-centre, individually-randomised, controlled trial involving young people (11-17) who had self-harmed at least twice and presented to Child & Adolescent Mental Health Services (CAMHS). SHIFT evaluated manualised family therapy (FT) versus treatment as usual (TAU) in reducing repetition of self-harm leading to hospital attendance 18 months post-randomisation.We obtained ONS mortality data, adult mental health data, and further details of hospital attendance from routine Hospital Episode Statistics (HES) data plus researcher follow-up. We assessed longer-term differences in outcome using multivariable Cox Proportional Hazards regression analysis, and assessed all-cause mortality and morbidity relating to hospital attendances for reasons other than self-harm. STUDY REGISTRATION ISRCTN 59793150. OUTCOMES The original sample of 832 were randomised between April 2010 and December 2013. Extended follow-up continued until February 2017 for a median 55·4 months (range 0-82·5 months), providing post 18-month data for 804 (96·6%) participants, of whom 785 (94·4%) had a minimum of 36-months follow-up.There was no evidence of a between-group difference in the primary outcome during the extended follow-up period (Hazard Ratio (HR) 1·03; 95% CI: 0·83, 1·28; p-value=0·78), consistent with our findings in the original trial with 18 months follow-up (HR 1·14, 95% CI 0·87, 1·49; p-value 0·33). There was a reduced rate of self-harm in older participants aged 15-17 (HR 0·7, 95% CI 0·56, 0·88), as compared with those aged 11-14; and significantly increased rates of self-harm in participants whose index episode combined self-injury and poisoning (HR 1·8, 95% CI 1·2, 2·7). Two deaths were reported during the extended follow up period. INTERPRETATION For adolescents referred to CAMHS after self-harm, having self-harmed at least once before, trial FT confers no benefits over TAU in reducing subsequent hospitalisation for self-harm over 18 months or 36 months. FUNDING NIHR HTA Reference: 07/33/01.
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Affiliation(s)
- D.J. Cottrell
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
- Corresponding author.
| | | | - I. Eisler
- Institute of Psychiatry, Psychology and Neurological Science Kings College London, London, UK
| | - S. Fortune
- Department of Psychological Medicine, University of Otago, New Zealand
| | - J. Green
- Division of Neuroscience & Experimental Psychology, School of Biological Science, University of Manchester, Manchester, UK
- Royal Manchester Children's Hospital, Manchester, UK
| | - A.O. House
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - M. Kerfoot
- University of Manchester, Manchester, UK
| | - D.W. Owens
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - M. Simic
- South London and Maudsley NHS Foundation Trust, London, UK
| | - V. McLellan
- Clinical Trials Research Unit, University of Leeds, Leeds, UK
| | - S. Tubeuf
- Institute of Health and Society (IRSS), Université Catholique de Louvain, Louvain-La-Neuve, Belgium
| | - A.J. Farrin
- Clinical Trials Research Unit, University of Leeds, Leeds, UK
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Lugg-Widger FV, Robling M. Routinely collected data for trialists: The need for continued conversations and solution sharing. Clin Trials 2019; 16:217-218. [PMID: 30445829 DOI: 10.1177/1740774518814760] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Effectiveness of systemic family therapy versus treatment as usual for young people after self-harm: a pragmatic, phase 3, multicentre, randomised controlled trial. Lancet Psychiatry 2018; 5:203-216. [PMID: 29449180 PMCID: PMC5835764 DOI: 10.1016/s2215-0366(18)30058-0] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2017] [Revised: 01/05/2018] [Accepted: 01/11/2018] [Indexed: 11/30/2022]
Abstract
BACKGROUND Self-harm in adolescents is common and repetition occurs in a high proportion of these cases. Scarce evidence exists for effectiveness of interventions to reduce self-harm. METHODS This pragmatic, multicentre, randomised, controlled trial of family therapy versus treatment as usual was done at 40 UK Child and Adolescent Mental Health Services (CAMHS) centres. We recruited young people aged 11-17 years who had self-harmed at least twice and presented to CAMHS after self-harm. Participants were randomly assigned (1:1) to receive manualised family therapy delivered by trained and supervised family therapists or treatment as usual by local CAMHS. Participants and therapists were aware of treatment allocation; researchers were masked. The primary outcome was hospital attendance for repetition of self-harm in the 18 months after group assignment. Primary and safety analyses were done in the intention-to-treat population. The trial is registered at the ISRCTN registry, number ISRCTN59793150. FINDINGS Between Nov 23, 2009, and Dec 31, 2013, 3554 young people were screened and 832 eligible young people consented to participation and were randomly assigned to receive family therapy (n=415) or treatment as usual (n=417). Primary outcome data were available for 795 (96%) participants. Numbers of hospital attendances for repeat self-harm events were not significantly different between the groups (118 [28%] in the family therapy group vs 103 [25%] in the treatment as usual group; hazard ratio 1·14 [95% CI 0·87-1·49] p=0·33). Similar numbers of adverse events occurred in both groups (787 in the family therapy group vs 847 in the treatment as usual group). INTERPRETATION For adolescents referred to CAMHS after self-harm, having self-harmed at least once before, our family therapy intervention conferred no benefits over treatment as usual in reducing subsequent hospital attendance for self-harm. Clinicians are therefore still unable to recommend a clear, evidence-based intervention to reduce repeated self-harm in adolescents. FUNDING National Institute for Health Research Health Technology Assessment programme.
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