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Hau C, Woods PA, Guski AS, Raju SI, Zhu L, Alba PR, Cushman WC, Glassman PA, Ishani A, Taylor AA, Ferguson RE, Leatherman SM. Strategies for secondary use of real-world clinical and administrative data for outcome ascertainment in pragmatic clinical trials. J Biomed Inform 2024; 150:104587. [PMID: 38244956 DOI: 10.1016/j.jbi.2024.104587] [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: 08/23/2023] [Revised: 12/04/2023] [Accepted: 01/09/2024] [Indexed: 01/22/2024]
Abstract
BACKGROUND Pragmatic trials are gaining popularity as a cost-effective way to examine treatment effectiveness and generate timely comparative evidence. Incorporating supplementary real-world data is recommended for robust outcome monitoring. However, detailed operational guidelines are needed to inform effective use and integration of heterogeneous databases. OBJECTIVE Lessons learned from the Veterans Affairs (VA) Diuretic Comparison Project (DCP) are reviewed, providing adaptable recommendations to capture clinical outcomes from real-world data. METHODS Non-cancer deaths and major cardiovascular (CV) outcomes were determined using VA, Medicare, and National Death Index (NDI) data. Multiple ascertainment strategies were applied, including claims-based algorithms, natural language processing, and systematic chart review. RESULTS During a mean follow-up of 2.4 (SD = 1.4) years, 907 CV events were identified within the VA healthcare system. Slight delays (∼1 year) were expected in obtaining Medicare data. An additional 298 patients were found having a CV event outside of the VA in 2016 - 2021, increasing the CV event rate from 3.5 % to 5.7 % (770 of 13,523 randomized). NDI data required ∼2 years waiting period. Such inclusion did not increase the number of deaths identified (all 894 deaths were captured by VA data) but enhanced the accuracy in determining cause of death. CONCLUSION Our experience supports the recommendation of integrating multiple data sources to improve clinical outcome ascertainment. While this approach is promising, hierarchical data aggregation is required when facing different acquisition timelines, information availability/completeness, coding practice, and system configurations. It may not be feasible to implement comparable applications and solutions to studies conducted under different constraints and practice. The recommendations provide guidance and possible action plans for researchers who are interested in applying cross-source data to ascertain all study outcomes.
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Affiliation(s)
- Cynthia Hau
- Cooperative Studies Program Coordinating Center, VA Boston Healthcare System, Boston, MA, United States.
| | - Patricia A Woods
- Cooperative Studies Program Coordinating Center, VA Boston Healthcare System, Boston, MA, United States
| | - Amanda S Guski
- Cooperative Studies Program Coordinating Center, VA Boston Healthcare System, Boston, MA, United States
| | - Srihari I Raju
- Minneapolis VA Healthcare System, Minneapolis, MN, United States
| | - Liang Zhu
- Cooperative Studies Program Coordinating Center, VA Boston Healthcare System, Boston, MA, United States
| | - Patrick R Alba
- VA Informatics and Computing Infrastructure, Salt Lake City VA Healthcare System, Salt Lake City, CT, United States; Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, United States
| | - William C Cushman
- Medical Service, Memphis VA Medical Center, Memphis, TN, United States; Department of Preventive Medicine, University of Tennessee Health Science Center, Memphis, TN, United States
| | - Peter A Glassman
- Pharmacy Benefits Management Services, Department of Veterans Affairs, Washington DC, United States; VA Greater Los Angeles Healthcare System, Los Angeles, CA, United States; David Geffen School of Medicine at UCLA, Los Angeles, CA, United States
| | - Areef Ishani
- Minneapolis VA Healthcare System, Minneapolis, MN, United States; Department of Medicine, University of Minnesota, Minneapolis, MN, United States
| | - Addison A Taylor
- Michael E. DeBakey VA Medical Center, Houston, TX, United States; Baylor College of Medicine, Department of Medicine, Houston, TX, United States
| | - Ryan E Ferguson
- Cooperative Studies Program Coordinating Center, VA Boston Healthcare System, Boston, MA, United States; Department of Medicine, Boston University Chobanian and Avedisian School of Medicine, Boston, MA, United States
| | - Sarah M Leatherman
- Cooperative Studies Program Coordinating Center, VA Boston Healthcare System, Boston, MA, United States; Department of Biostatistics, Boston University School of Public Health, Boston, MA, United States
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Waitman LR, Bailey LC, Becich MJ, Chung-Bridges K, Dusetzina SB, Espino JU, Hogan WR, Kaushal R, McClay JC, Merritt JG, Rothman RL, Shenkman EA, Song X, Nauman E. Avenues for Strengthening PCORnet's Capacity to Advance Patient-Centered Economic Outcomes in Patient-Centered Outcomes Research (PCOR). Med Care 2023; 61:S153-S160. [PMID: 37963035 PMCID: PMC10635342 DOI: 10.1097/mlr.0000000000001929] [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] [Indexed: 11/16/2023]
Abstract
PCORnet, the National Patient-Centered Clinical Research Network, provides the ability to conduct prospective and observational pragmatic research by leveraging standardized, curated electronic health records data together with patient and stakeholder engagement. PCORnet is funded by the Patient-Centered Outcomes Research Institute (PCORI) and is composed of 8 Clinical Research Networks that incorporate at total of 79 health system "sites." As the network developed, linkage to commercial health plans, federal insurance claims, disease registries, and other data resources demonstrated the value in extending the networks infrastructure to provide a more complete representation of patient's health and lived experiences. Initially, PCORnet studies avoided direct economic comparative effectiveness as a topic. However, PCORI's authorizing law was amended in 2019 to allow studies to incorporate patient-centered economic outcomes in primary research aims. With PCORI's expanded scope and PCORnet's phase 3 beginning in January 2022, there are opportunities to strengthen the network's ability to support economic patient-centered outcomes research. This commentary will discuss approaches that have been incorporated to date by the network and point to opportunities for the network to incorporate economic variables for analysis, informed by patient and stakeholder perspectives. Topics addressed include: (1) data linkage infrastructure; (2) commercial health plan partnerships; (3) Medicare and Medicaid linkage; (4) health system billing-based benchmarking; (5) area-level measures; (6) individual-level measures; (7) pharmacy benefits and retail pharmacy data; and (8) the importance of transparency and engagement while addressing the biases inherent in linking real-world data sources.
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Affiliation(s)
- Lemuel R. Waitman
- Department of Biomedical Informatics, Biostatistics, and Medical Epidemiology, University of Missouri School of Medicine, Greater Plains Collaborative, PCORnet Clinical Research Network, Columbia, MO
| | | | | | | | | | | | | | - Rainu Kaushal
- Weill Cornell University School of Medicine, New York, NY
| | | | | | | | | | - Xing Song
- University of Missouri School of Medicine, Columbia, MO
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3
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Faridi KF, Strom JB, Kundi H, Butala NM, Curtis JP, Gao Q, Song Y, Zheng L, Tamez H, Shen C, Secemsky EA, Yeh RW. Association Between Claims-Defined Frailty and Outcomes Following 30 Versus 12 Months of Dual Antiplatelet Therapy After Percutaneous Coronary Intervention: Findings From the EXTEND-DAPT Study. J Am Heart Assoc 2023; 12:e029588. [PMID: 37449567 PMCID: PMC10382113 DOI: 10.1161/jaha.123.029588] [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: 01/24/2023] [Accepted: 05/31/2023] [Indexed: 07/18/2023]
Abstract
Background Frailty is rarely assessed in clinical trials of patients who receive dual antiplatelet therapy (DAPT) after percutaneous coronary intervention. This study investigated whether frailty defined using claims data is associated with outcomes following percutaneous coronary intervention, and if there is a differential association in patients receiving standard versus extended duration DAPT. Methods and Results Patients ≥65 years of age in the DAPT (Dual Antiplatelet Therapy) Study, a randomized trial comparing 30 versus 12 months of DAPT following percutaneous coronary intervention, had data linked to Medicare claims (n=1326), and a previously validated claims-based index was used to define frailty. Net adverse clinical events, a composite of all-cause mortality, myocardial infarction, stroke, and major bleeding, were compared between frail and nonfrail patients. Patients defined as frail using claims data (12.0% of the cohort) had higher incidence of net adverse clinical events (23.1%) compared with nonfrail patients (10.7%; P<0.001) at 18-month follow-up and increased risk after multivariable adjustment (adjusted hazard ratio [HR], 2.24 [95% CI, 1.38-3.63]). There were no differences in effects of extended duration DAPT on net adverse clinical events for frail (HR, 1.42 [95% CI, 0.73-2.75]) and nonfrail patients (HR, 1.18 [95% CI, 0.83-1.68]; interaction P=0.61), although analyses were underpowered. Bleeding was highest among frail patients who received extended duration DAPT. Conclusions Among older patients in the DAPT Study, claims-defined frailty was associated with higher net adverse clinical events. Effects of extended duration DAPT were not different for frail patients, although comparisons were underpowered. Further investigation of how frailty influences ischemic and bleeding risks with DAPT are warranted. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT00977938.
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Affiliation(s)
- Kamil F Faridi
- Section of Cardiovascular Medicine, Department of Medicine Yale School of Medicine New Haven CT USA
| | - Jordan B Strom
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Division of Cardiovascular Medicine Beth Israel Deaconess Medical Center Boston MA USA
| | - Harun Kundi
- Department of Cardiology Ankara City Hospital Ankara Turkey
| | - Neel M Butala
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Division of Cardiovascular Medicine Beth Israel Deaconess Medical Center Boston MA USA
- Cardiology Division, Department of Medicine Massachusetts General Hospital, Harvard Medical School Boston MA USA
| | - Jeptha P Curtis
- Section of Cardiovascular Medicine, Department of Medicine Yale School of Medicine New Haven CT USA
| | - Qi Gao
- Baim Institute for Clinical Research Boston MA USA
| | - Yang Song
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Division of Cardiovascular Medicine Beth Israel Deaconess Medical Center Boston MA USA
| | - Luke Zheng
- Baim Institute for Clinical Research Boston MA USA
| | - Hector Tamez
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Division of Cardiovascular Medicine Beth Israel Deaconess Medical Center Boston MA USA
| | - Changyu Shen
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Division of Cardiovascular Medicine Beth Israel Deaconess Medical Center Boston MA USA
- Biogen Cambridge MA USA
| | - Eric A Secemsky
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Division of Cardiovascular Medicine Beth Israel Deaconess Medical Center Boston MA USA
| | - Robert W Yeh
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Division of Cardiovascular Medicine Beth Israel Deaconess Medical Center Boston MA USA
- Baim Institute for Clinical Research Boston MA USA
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Hope Weissler E, Stebbins A, Wruck L, Muñoz D, Gupta K, Girotra S, Whittle J, Benziger CP, Polonsky TS, Bradley SM, Hammill BG, Merritt JG, Zemon DN, Hernandez AF, Schuyler Jones W. Outcomes among patients with peripheral artery disease in the Aspirin Dosing: A Patient-Centric Trial Assessing Benefits and Long-Term Effectiveness (ADAPTABLE) study. Vasc Med 2023; 28:122-130. [PMID: 37025023 PMCID: PMC10795754 DOI: 10.1177/1358863x231154951] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/08/2023]
Abstract
BACKGROUND We aimed to understand the effects of aspirin dose on outcomes in patients with peripheral artery disease (PAD) as well as their participation in a pragmatic randomized controlled trial. METHODS In a subanalysis of the Aspirin Dosing: A Patient-Centric Trial Assessing Benefits and Long-Term Effectiveness (ADAPTABLE) study, we compared aspirin doses (81 vs 325 mg) among participants with PAD and study participation metrics in patients with and without PAD. The primary outcome composite was all-cause mortality, nonfatal myocardial infarction, and nonfatal stroke. RESULTS Among 14,662 participants enrolled in ADAPTABLE with PAD status available, 3493 (23.8%) had PAD. Participants with PAD were more likely to experience the primary composite (13.76% vs 5.31%, p < 0.001), all-cause mortality (7.55% vs 3.01%, p < 0.001), myocardial infarction (5.71% vs 2.09%, p < 0.001), stroke (2.45% vs 0.86%, p < 0.001), and major bleeding (1.19% vs 0.44%, p < 0.001). A higher aspirin dose did not reduce the primary outcome in patients with PAD (13.68% vs 13.84% in 81 mg and 325 mg groups; OR 1.05, 95% CI 0.88-1.25). Participants with PAD were less likely to enroll via email (33.0% vs 41.9%, p < 0.0001), less likely to choose internet follow-up (79.2% vs 89.5%, p < 0.0001), and were more likely to change their aspirin doses (39.7% vs 30.7%, p < 0.0001). CONCLUSIONS ADAPTABLE participants with PAD did not benefit from a higher dose of aspirin and participated in the study differently from those without PAD. These results reinforce the need for additional PAD-specific research and suggest that different trial strategies may be needed for optimal engagement of patients with PAD. (ClinicalTrials.gov Identifier: NCT02697916).
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Affiliation(s)
| | | | - Lisa Wruck
- Duke Clinical Research Institute, Durham, NC
| | - Daniel Muñoz
- Vanderbilt University Medical Center, Nashville, TN
| | - Kamal Gupta
- University of Kansas Medical Center, Kansas City, KS
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Raman SR, O’Brien EC, Hammill BG, Nelson AJ, Fish LJ, Curtis LH, Marsolo K. Evaluating fitness-for-use of electronic health records in pragmatic clinical trials: reported practices and recommendations. J Am Med Inform Assoc 2022; 29:798-804. [PMID: 35171985 PMCID: PMC9006695 DOI: 10.1093/jamia/ocac004] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2021] [Revised: 12/10/2021] [Accepted: 02/12/2022] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE To empirically explore how pragmatic clinical trials (PCTs) that used real-world data (RWD) assessed study-specific fitness-for-use. METHODS We conducted interviews and surveys with PCT teams who used electronic health record (EHR) data to ascertain endpoints. The survey cataloged key concerns about RWD, activities used to assess data fitness-for-use, and related barriers encountered by study teams. Patterns and commonalities across trials were used to develop recommendations for study-specific fitness-for-use assessments. RESULTS Of 15 invited trial teams, 7 interviews were conducted. Of 31 invited trials, 15 responded to the survey. Most respondents had prior experience using RWD (93%). Major concerns about EHR data were data reliability, missingness or incompleteness of EHR elements, variation in data quality across study sites, and presence of implausible or incorrect values. Although many PCTs conducted fitness-for-use activities (eg, data quality assessments, 11/14, 79%), less than a quarter did so before choosing a data source. Fitness-for-use activities, findings, and resulting study design changes were not often publically documented. Overall costs and personnel costs were barriers to fitness-for-use assessments. DISCUSSION These results support three recommendations for PCTs that use EHR data for endpoint ascertainment. Trials should detail the rationale and plan for study-specific fitness-for-use activities, conduct study-specific fitness-for-use assessments early in the prestudy phase to inform study design changes before the trial begins, and share results of fitness-for-use assessments and description of relevant challenges and facilitators. CONCLUSION These recommendations can help researchers and end-users of real-world evidence improve characterization of RWD reliability and relevance in the PCT-specific context.
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Affiliation(s)
- Sudha R Raman
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
- Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Emily C O’Brien
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
- Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Bradley G Hammill
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
- Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Adam J Nelson
- Duke Clinical Research Institute, Durham, North Carolina, USA
- Monash Heart, Monash University, Melbourne, Victoria, Australia
| | - Laura J Fish
- Department of Family Medicine and Community Health, Duke University School of Medicine, Durham, North Carolina, USA
| | - Lesley H Curtis
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
- Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Keith Marsolo
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
- Duke Clinical Research Institute, Durham, North Carolina, USA
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6
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Grabner M, Molife C, Wang L, Winfree KB, Cui ZL, Cuyun Carter G, Hess LM. Data Integration to Improve Real-world Health Outcomes Research for Non-Small Cell Lung Cancer in the United States: Descriptive and Qualitative Exploration. JMIR Cancer 2021; 7:e23161. [PMID: 33843600 PMCID: PMC8076987 DOI: 10.2196/23161] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Revised: 01/29/2021] [Accepted: 02/01/2021] [Indexed: 12/20/2022] Open
Abstract
Background The integration of data from disparate sources could help alleviate data insufficiency in real-world studies and compensate for the inadequacies of single data sources and short-duration, small sample size studies while improving the utility of data for research. Objective This study aims to describe and evaluate a process of integrating data from several complementary sources to conduct health outcomes research in patients with non–small cell lung cancer (NSCLC). The integrated data set is also used to describe patient demographics, clinical characteristics, treatment patterns, and mortality rates. Methods This retrospective cohort study integrated data from 4 sources: administrative claims from the HealthCore Integrated Research Database, clinical data from a Cancer Care Quality Program (CCQP), clinical data from abstracted medical records (MRs), and mortality data from the US Social Security Administration. Patients with lung cancer who initiated second-line (2L) therapy between November 01, 2015, and April 13, 2018, were identified in the claims and CCQP data. Eligible patients were 18 years or older and received atezolizumab, docetaxel, erlotinib, nivolumab, pembrolizumab, pemetrexed, or ramucirumab in the 2L setting. The main analysis cohort included patients with claims data and data from at least one additional data source (CCQP or MR). Patients without integrated data (claims only) were reported separately. Descriptive and univariate statistics were reported. Results Data integration resulted in a main analysis cohort of 2195 patients with NSCLC; 2106 patients had CCQP and 407 patients had MR data. The claims-only cohort included 931 eligible patients. For the main analysis cohort, the mean age was 62.1 (SD 9.27) years, 48.56% (1066/2195) were female, the median length of follow-up was 6.8 months, and for 37.77% (829/2195), death was observed. For the claims-only cohort, the mean age was 66.6 (SD 12.69) years, 52.1% (485/931) were female, the median length of follow-up was 8.6 months, and for 29.3% (273/931), death was observed. The most frequent 2L treatment was immunotherapy (1094/2195, 49.84%), followed by platinum-based regimens (472/2195, 21.50%) and single-agent chemotherapy (441/2195, 20.09%); mean duration of 2L therapy was 5.6 (SD 4.9, median 4) months. We describe challenges and learnings from the data integration process, and the benefits of the integrated data set, which includes a richer set of clinical and outcome data to supplement the utilization metrics available in administrative claims. Conclusions The management of patients with NSCLC requires care from a multidisciplinary team, leading to a lack of a single aggregated data source in real-world settings. The availability of integrated clinical data from MRs, health plan claims, and other sources of clinical care may improve the ability to assess emerging treatments.
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Affiliation(s)
| | - Cliff Molife
- Eli Lilly and Company, Indianapolis, IN, United States
| | - Liya Wang
- HealthCore Inc, Wilmington, DE, United States
| | | | | | | | - Lisa M Hess
- Eli Lilly and Company, Indianapolis, IN, United States
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7
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Ma Q, Mack M, Shambhu S, McTigue K, Haynes K. Characterization of bariatric surgery and outcomes using administrative claims data in the research network of a nationwide commercial health plan. BMC Health Serv Res 2021; 21:116. [PMID: 33541346 PMCID: PMC7860025 DOI: 10.1186/s12913-021-06074-3] [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: 08/13/2020] [Accepted: 01/12/2021] [Indexed: 11/10/2022] Open
Abstract
Background The supplementation of electronic health records data with administrative claims data may be used to capture outcome events more comprehensively in longitudinal observational studies. This study investigated the utility of administrative claims data to identify outcomes across health systems using a comparative effectiveness study of different types of bariatric surgery as a model. Methods This observational cohort study identified patients who had bariatric surgery between 2007 and 2015 within the HealthCore Anthem Research Network (HCARN) database in the National Patient-Centered Clinical Research Network (PCORnet) common data model. Patients whose procedures were performed in a member facility affiliated with PCORnet Clinical Research Networks (CRNs) were selected. The outcomes included a 30-day composite adverse event (including venous thromboembolism, percutaneous/operative intervention, failure to discharge and death), and all-cause hospitalization, abdominal operation or intervention, and in-hospital death up to 5 years after the procedure. Outcomes were classified as occurring within or outside PCORnet CRN health systems using facility identifiers. Results We identified 4899 patients who had bariatric surgery in one of the PCORnet CRN health systems. For 30-day composite adverse event, the inclusion of HCARN multi-site claims data marginally increased the incidence rate based only on HCARN single-site claims data for PCORnet CRNs from 3.9 to 4.2%. During the 5-year follow-up period, 56.8% of all-cause hospitalizations, 31.2% abdominal operations or interventions, and 32.3% of in-hospital deaths occurred outside PCORnet CRNs. Incidence rates (events per 100 patient-years) were significantly lower when based on claims from a single PCORnet CRN only compared to using claims from all health systems in the HCARN: all-cause hospitalization, 11.0 (95% Confidence Internal [CI]: 10.4, 11.6) to 25.3 (95% CI: 24.4, 26.3); abdominal operations or interventions, 4.2 (95% CI: 3.9, 4.6) to 6.1 (95% CI: 5.7, 6.6); in-hospital death, 0.2 (95% CI: 0.11, 0.27) to 0.3 (95% CI: 0.19, 0.38). Conclusions Short-term inclusion of multi-site claims data only marginally increased the incidence rate computed from single-site claims data alone. Longer-term follow up captured a notable number of events outside of PCORnet CRNs. The findings suggest that supplementing claims data improves the outcome ascertainment in longitudinal observational comparative effectiveness studies. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-021-06074-3.
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Affiliation(s)
- Qinli Ma
- Translational Research for Affordability and Quality, HealthCore, Inc, Wilmington, DE, USA.
| | - Michael Mack
- Translational Research for Affordability and Quality, HealthCore, Inc, Wilmington, DE, USA
| | - Sonali Shambhu
- Translational Research for Affordability and Quality, HealthCore, Inc, Wilmington, DE, USA
| | - Kathleen McTigue
- Department of Epidemiology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Kevin Haynes
- Translational Research for Affordability and Quality, HealthCore, Inc, Wilmington, DE, USA
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8
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Marquis-Gravel G, Roe MT, Robertson HR, Harrington RA, Pencina MJ, Berdan LG, Hammill BG, Faulkner M, Muñoz D, Fonarow GC, Nallamothu BK, Fintel DJ, Ford DE, Zhou L, Daugherty SE, Nauman E, Kraschnewski J, Ahmad FS, Benziger CP, Haynes K, Merritt JG, Metkus T, Kripalani S, Gupta K, Shah RC, McClay JC, Re RN, Geary C, Lampert BC, Bradley SM, Jain SK, Seifein H, Whittle J, Roger VL, Effron MB, Alvarado G, Goldberg YH, VanWormer JL, Girotra S, Farrehi P, McTigue KM, Rothman R, Hernandez AF, Jones WS. Rationale and Design of the Aspirin Dosing-A Patient-Centric Trial Assessing Benefits and Long-term Effectiveness (ADAPTABLE) Trial. JAMA Cardiol 2021; 5:598-607. [PMID: 32186653 DOI: 10.1001/jamacardio.2020.0116] [Citation(s) in RCA: 54] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Importance Determining the right dosage of aspirin for the secondary prevention treatment of atherosclerotic cardiovascular disease (ASCVD) remains an unanswered and critical question. Objective To report the rationale and design for a randomized clinical trial to determine the optimal dosage of aspirin to be used for secondary prevention of ASCVD, using an innovative research method. Design, Setting, and Participants This pragmatic, open-label, patient-centered, randomized clinical trial is being conducted in 15 000 patients within the National Patient-Centered Clinical Research Network (PCORnet), a distributed research network of partners including clinical research networks, health plan research networks, and patient-powered research networks across the United States. Patients with established ASCVD treated in routine clinical practice within the network are eligible. Patient recruitment began in April 2016. Enrollment was completed in June 2019. Final follow-up is expected to be completed by June 2020. Interventions Participants are randomized on a web platform in a 1:1 fashion to either 81 mg or 325 mg of aspirin daily. Main Outcomes and Measures The primary efficacy end point is the composite of all-cause mortality, hospitalization for nonfatal myocardial infarction, or hospitalization for a nonfatal stroke. The primary safety end point is hospitalization for major bleeding associated with a blood-product transfusion. End points are captured through regular queries of the health systems' common data model within the structure of PCORnet's distributed data environment. Conclusions and Relevance As a pragmatic study and the first interventional trial conducted within the PCORnet electronic data infrastructure, this trial is testing several unique and innovative operational approaches that have the potential to disrupt and transform the conduct of future patient-centered randomized clinical trials by evaluating treatments integrated in clinical practice while at the same time determining the optimal dosage of aspirin for secondary prevention of ASCVD. Trial Registration ClinicalTrials.gov Identifier: NCT02697916.
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Affiliation(s)
| | - Matthew T Roe
- Duke Clinical Research Institute, Durham, North Carolina.,Duke University Medical Center, Durham, North Carolina
| | | | | | - Michael J Pencina
- Department of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina
| | - Lisa G Berdan
- Duke Clinical Research Institute, Durham, North Carolina
| | | | - Madelaine Faulkner
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco
| | - Daniel Muñoz
- Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Gregg C Fonarow
- Department of Medicine, University of California, Los Angeles, Los Angeles.,Associate Editor
| | - Brahmajee K Nallamothu
- Michigan Integrated Center of Health Analytics and Medical Prediction, Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan School of Medicine, Ann Arbor
| | - Dan J Fintel
- Feinberg School of Medicine, Division of Cardiology, Department of Medicine, Northwestern University, Chicago, Illinois
| | - Daniel E Ford
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Li Zhou
- Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | | | | | - Jennifer Kraschnewski
- Department of Medicine, Department of Public Health Sciences, Penn State College of Medicine, Hershey, Pennsylvania
| | - Faraz S Ahmad
- Center for Health Information Partnerships, Feinberg School of Medicine, Institute of Public Health and Medicine, Division of Cardiology, Department of Medicine, Northwestern University, Chicago, Illinois
| | | | | | - J Greg Merritt
- Patient-Centered Network of Learning Health Systems (LHSNet), Ann Arbor, Michigan
| | - Thomas Metkus
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland.,Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Sunil Kripalani
- Division of General Internal Medicine and Public Health, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Kamal Gupta
- Division of Cardiovascular Medicine, Department of Medicine, University of Kansas Medical Center, Kansas City
| | - Raj C Shah
- Rush Alzheimer's Disease Center, Department of Family Medicine, Rush University Medical Center, Chicago, Illinois
| | - James C McClay
- Department of Emergency Medicine, University of Nebraska Medical Center College of Medicine, Omaha
| | | | - Carol Geary
- University of Nebraska Medical Center, Omaha
| | - Brent C Lampert
- Wexner Medical Center, Division of Cardiovascular Medicine, The Ohio State University, Columbus
| | - Steven M Bradley
- Minneapolis Heart Institute, Minneapolis Heart Institute Foundation, Minneapolis
| | - Sandeep K Jain
- UPMC Heart and Vascular Institute, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Hani Seifein
- AdventHealth Medical Group Cardiology, Oviedo, Florida
| | - Jeff Whittle
- Department of Medicine, Division of General Internal Medicine, Medical College of Wisconsin, Milwaukee
| | | | - Mark B Effron
- Ochsner Clinical School, John Ochsner Heart and Vascular Institute, University of Queensland School of Medicine, New Orleans, Louisiana
| | - Giselle Alvarado
- Herbert H. Lehman College, Department of Biological Sciences, City University of New York, Bronx
| | | | | | - Saket Girotra
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City
| | | | | | - Russell Rothman
- Center for Health Services Research, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Adrian F Hernandez
- Duke Clinical Research Institute, Durham, North Carolina.,Duke University Medical Center, Durham, North Carolina
| | - W Schuyler Jones
- Duke Clinical Research Institute, Durham, North Carolina.,Duke University Medical Center, Durham, North Carolina
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9
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Rosa C, Marsch LA, Winstanley EL, Brunner M, Campbell ANC. Using digital technologies in clinical trials: Current and future applications. Contemp Clin Trials 2020; 100:106219. [PMID: 33212293 DOI: 10.1016/j.cct.2020.106219] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 10/05/2020] [Accepted: 11/10/2020] [Indexed: 12/20/2022]
Abstract
In 2015, we provided an overview of the use of digital technologies in clinical trials, both as a methodological tool and as a mechanism to deliver interventions. At that time, there was limited guidance and limited use of digital technologies in clinical research. However, since then smartphones have become ubiquitous and digital health technologies have exploded. This paper provides an update to our earlier publication and an overview of how technology has been used in the past five years in clinical trials, providing examples with varying levels of technological integration and across different health conditions. Digital technology integration ranges from the incorporation of artificial intelligence in diagnostic devices to the use of real-world data (e.g., electronic health records) for study recruitment. Clinical trials can now be conducted entirely virtually, eliminating the need for in-person interaction. Much of the published research demonstrates how digital approaches can improve the design and implementation of clinical trials. While challenges remain, progress over the last five years is encouraging, and barriers can be overcome with careful planning.
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Affiliation(s)
- Carmen Rosa
- National Institutes of Health, National Institute on Drug Abuse, Bethesda, MD, USA.
| | - Lisa A Marsch
- Center for Technology and Behavioral Health, Geisel School of Medicine, Dartmouth College, USA.
| | - Erin L Winstanley
- West Virginia University, School of Medicine and Rockefeller Neuroscience Institute, Department of Behavioral Medicine and Psychiatry, Morgantown, West Virginia, USA; West Virginia University, School of Medicine, Department of Neuroscience Morgantown, West Virginia, USA.
| | - Meg Brunner
- Alcohol and Drug Abuse Institute, University of Washington, Seattle, WA, USA.
| | - Aimee N C Campbell
- New York State Psychiatric Institute, Department of Psychiatry, Columbia University Irving Medical Center, New York State Psychiatric Institute, New York, NY, USA.
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10
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Forrest CB, McTigue KM, Hernandez AF, Cohen LW, Cruz H, Haynes K, Kaushal R, Kho AN, Marsolo KA, Nair VP, Platt R, Puro JE, Rothman RL, Shenkman EA, Waitman LR, Williams NA, Carton TW. PCORnet® 2020: current state, accomplishments, and future directions. J Clin Epidemiol 2020; 129:60-67. [PMID: 33002635 PMCID: PMC7521354 DOI: 10.1016/j.jclinepi.2020.09.036] [Citation(s) in RCA: 95] [Impact Index Per Article: 23.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 09/01/2020] [Accepted: 09/22/2020] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To describe PCORnet, a clinical research network developed for patient-centered outcomes research on a national scale. STUDY DESIGN AND SETTING Descriptive study of the current state and future directions for PCORnet. We conducted cross-sectional analyses of the health systems and patient populations of the 9 Clinical Research Networks and 2 Health Plan Research Networks that are part of PCORnet. RESULTS Within the Clinical Research Networks, electronic health data are currently collected from 337 hospitals, 169,695 physicians, 3,564 primary care practices, 338 emergency departments, and 1,024 community clinics. Patients can be recruited for prospective studies from any of these clinical sites. The Clinical Research Networks have accumulated data from 80 million patients with at least one visit from 2009 to 2018. The PCORnet Health Plan Research Network population of individuals with a valid enrollment segment from 2009 to 2019 exceeds 60 million individuals, who on average have 2.63 years of follow-up. CONCLUSION PCORnet's infrastructure comprises clinical data from a diverse cohort of patients and has the capacity to rapidly access these patient populations for pragmatic clinical trials, epidemiological research, and patient-centered research on rare diseases.
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Affiliation(s)
- Christopher B Forrest
- Applied Clinical Research Center, Children's Hospital of Philadelphia, 2716 South St., Suite 11-473, Philadelphia, PA 19146, USA.
| | - Kathleen M McTigue
- Department of Medicine, University of Pittsburgh, 230 McKee Place, Suite 600, Pittsburgh, PA 15213 USA
| | - Adrian F Hernandez
- Duke Clinical Research Institute, Duke University School of Medicine, 200 Trent Drive, Durham, NC 27710, USA
| | - Lauren W Cohen
- Duke Clinical Research Institute, Duke University School of Medicine, 200 Trent Drive, Durham, NC 27710, USA
| | - Henry Cruz
- Weill Cornell Medicine and New York-Presbyterian Hospital, 515 E 71st St, New York, NY 10021, USA
| | - Kevin Haynes
- Scientific Affairs, HealthCore Inc., 123 Justison St, Wilmington, DE 19801, USA
| | - Rainu Kaushal
- Weill Cornell Medicine and New York-Presbyterian Hospital, 515 E 71st St, New York, NY 10021, USA
| | - Abel N Kho
- Center for Health Information Partnerships, Feinberg School of Medicine, 625 N. Michigan Ave, Chicago, IL 60611, USA
| | - Keith A Marsolo
- Duke Clinical Research Institute, Duke University School of Medicine, 200 Trent Drive, Durham, NC 27710, USA
| | - Vinit P Nair
- PRACnet, 15 South Main Street, Sharon, MA 02067, USA
| | - Richard Platt
- Harvard Medical School Department of Population Medicine, Harvard Pilgrim Health Care Institute, 401 Park Drive, Boston, MA 02215, USA
| | - Jon E Puro
- OCHIN, Inc., 1881 SW Naito Pkwy, Portland, OR 97201, USA
| | - Russell L Rothman
- Institute for Medicine and Public Health, Vanderbilt University Medical Center, 1161 21st Ave S, Nashville, TN 37232, USA
| | - Elizabeth A Shenkman
- Department of Health Outcomes and Biomedical Informatics, College of Medicine, University of Florida, 1600 SW Archer Rd, Gainesville, FL 32610, USA
| | - Lemuel Russell Waitman
- Department of Internal Medicine, Division of Medical Informatics, University of Kansas Medical Center, 3901 Rainbow Blvd, Kansas City, KS 66160, USA
| | - Neely A Williams
- Institute for Medicine and Public Health, Vanderbilt University Medical Center, 1161 21st Ave S, Nashville, TN 37232, USA
| | - Thomas W Carton
- Louisiana Public Health Institute, 1515 Poydras St, New Orleans, LA 70112, USA
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11
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Shi Q, Shambhu S, Marshall A, Rose-Kennedy E, Robertson H, Paullin M, Jones WS, Cziraky M, Haynes K. Role of health plan administrative claims data in participant recruitment for pragmatic clinical trials: An Aspirin Dosing: A Patient-centric Trial Assessing Benefits and Long-term Effectiveness (ADAPTABLE) example. Clin Trials 2020; 17:212-222. [DOI: 10.1177/1740774520902989] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Aim: The purpose of this study is to evaluate HealthCore/Anthem Research Network recruitment strategies, compare response and enrollment rates for different recruitment strategies, and describe demographic and clinical characteristics of responders and enrollees. Methods: HealthCore/Anthem Research Network, a part of the Health Plan Research Network of the Patient-Centered Clinical Data Research Network, used administrative claims data to identify eligible health plan members for potential participation in the Aspirin Dosing: A Patient-centric Trial Assessing Benefits and Long-term Effectiveness study. We approached health plan members, identified with a validated Patient-Centered Clinical Data Research Network common data model computable phenotype, and their clinical providers during November 2017 to August 2018. Providers were offered the option to exclude their patients’ participation in Aspirin Dosing: A Patient-centric Trial Assessing Benefits and Long-term Effectiveness prior to our direct patient (member) outreach. Member identification was in two phases: Phase 1: 1 January 2006 to 1 April 2017, and Phase 2: 1 January 2006 to 2 February 2018. Phase 1 consisted of two batches of mail and one phone call per patient. In Phase 2, which included two similar batches of patients, outreach was via either mail or brochure and one phone call. Results: Phase 1 and Phase 2 included 133,373 and 51,777 members, respectively. We engaged 28,593 providers in Phase 1, and 5077 in Phase 2. In Phase 1, 264,158 mixed email/mail messages were delivered to 133,373 members, followed by 90,481 phone calls from November 2017 to February 2018. In Phase 2, after simple randomization to letter or brochure, 51,777 members were sent email/mail or mailed brochure in three waves from May 2018 to July 2018. In this 9-week period, 51,623 communications were sent to 25,914 members in the email/mail group, and 50,160 brochures to 25,863 in the brochure group. Following email/mail or mailed brochure outreach, 16,624 and 16,580 calls were made to the groups, respectively. Overall, 1549 health plan members visited the study portal by 1 September 2018; 355 electronically signed the Informed Consent Form and enrolled. Mailed brochures drove more portal visits in Phase 2, but a lower percentage of responders enrolled. Recruitment was better in Phase 2—2.3 enrollees per 1000 outreach members versus 1.8 in Phase 1. Conclusion: This study showed the ability of a health plan within Patient-Centered Clinical Data Research Network to identify potential study participants with administrative claims, and use different outreach methods to facilitate recruitment and enrollment for pragmatic clinical trials.
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Affiliation(s)
| | | | | | | | - Holly Robertson
- Duke University Medical Center, Duke University, Durham, NC, USA
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