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Ribeiro DC, Wilkinson A, Gava V, Lamb SE, Abbott JH. Patients' perspectives on planned interventions tested in the Otago MASTER feasibility trial: an implementation-based process evaluation study. Braz J Phys Ther 2024; 28:101086. [PMID: 38936312 DOI: 10.1016/j.bjpt.2024.101086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Revised: 04/25/2024] [Accepted: 06/02/2024] [Indexed: 06/29/2024] Open
Abstract
BACKGROUND Patients are key stakeholders of clinical research, and their perspectives are relevant for researchers when planning and conducting clinical trials. Numerous aspects of trial process can influence participants' experiences. Their experiences within a trial can impact retention rates. Poor treatment adherence may bias treatment effect estimates. One way to improve recruitment and adherence is to design trials that are aligned with patients' needs and preferences. This study reports a process evaluation of the Otago MASTER feasibility trial. OBJECTIVES Our aims were to investigate the patients' perceptions of the trial interventions through individual interviews. METHODS Twenty-five participants were recruited for the feasibility trial and were allocated to two groups: tailored or standardised exercise. Sixteen participants agreed to take part in individual semi-structured interviews. Interviews were transcribed verbatim, and all interviews were analysed thematically using an iterative approach. RESULTS Our key findings suggest participants: (1) took part in the study to access healthcare services and contribute to research; (2) valued interventions received; (3) reported certain barriers and facilitators to participate in the trial; and (4) highlighted areas for improvement when designing the full trial. CONCLUSION Participants volunteered to access healthcare and to contribute to research. Participants valued the personalised care, perceived that their engagement within the trial improved their self-management and self-efficacy behaviour, valued the time spent with clinicians, and the empathetic environment and education received. Facilitators and barriers will require careful consideration in the future as the barriers may impact reliability and validity of future trial results.
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Affiliation(s)
- Daniel Cury Ribeiro
- Centre for Health, Activity and Rehabilitation Research, School of Physiotherapy, University of Otago, Dunedin, New Zealand.
| | - Amanda Wilkinson
- Centre for Health, Activity and Rehabilitation Research, School of Physiotherapy, University of Otago, Dunedin, New Zealand; Department of Nursing, University of Otago, Christchurch, New Zealand
| | - Vander Gava
- Department of Physical Therapy, Universidade Federal de São Carlos, São Carlos, Brazil
| | - Sarah E Lamb
- University of Exeter Medical School, St Luke's Campus, Heavitree Road, Exeter, EX1 2LU, UK
| | - J Haxby Abbott
- Department of Surgical Sciences, University of Otago Medical School, Dunedin, New Zealand
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Staras SAS, Wollney EN, Emerson LE, Silver N, Dziegielewski PT, Hansen MD, Sanchez G, D'Ingeo D, Johnson‐Mallard V, Renne R, Fredenburg K, Gutter M, Zamojski K, Vandeweerd C, Bylund CL. Identifying locally actionable strategies to increase participant acceptability and feasibility to participate in Phase I cancer clinical trials. Health Expect 2023; 27:e13920. [PMID: 38041447 PMCID: PMC10726272 DOI: 10.1111/hex.13920] [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: 06/26/2023] [Revised: 10/16/2023] [Accepted: 11/09/2023] [Indexed: 12/03/2023] Open
Abstract
BACKGROUND Recruitment of cancer clinical trial (CCT) participants, especially participants representing the diversity of the US population, is necessary to create successful medications and a continual challenge. These challenges are amplified in Phase I cancer trials that focus on evaluating the safety of new treatments and are the gateway to treatment development. In preparation for recruitment to a Phase I recurrent head and neck cancer (HNC) trial, we assessed perceived barriers to participation or referral and suggestions for recruitment among people with HNC and community physicians (oncologist, otolaryngologist or surgeon). METHODS Between December 2020 and February 2022, we conducted a qualitative needs assessment via semistructured interviews with a race and ethnicity-stratified sample of people with HNC (n = 30: 12 non-Hispanic White, 9 non-Hispanic African American, 8 Hispanic and 1 non-Hispanic Pacific Islander) and community physicians (n = 16) within the University of Florida Health Cancer Center catchment area. Interviews were analyzed using a qualitative content analysis approach to describe perspectives and identify relevant themes. RESULTS People with HNC reported thematic barriers included: concerns about side effects, safety and efficacy; lack of knowledge and systemic and environmental obstacles. Physicians identified thematic barriers of limited physician knowledge; clinic and physician barriers and structural barriers. People with HNC and physicians recommended themes included: improved patient education, dissemination of trial information and interpersonal communication between community physicians and CCT staff. CONCLUSIONS The themes identified by people with HNC and community physicians are consistent with research efforts and recommendations on how to increase the participation of people from minoritized populations in CCTs. This community needs assessment provides direction on the selection of strategies to increase CCT participation and referral. PATIENT OR PUBLIC CONTRIBUTION This study focused on people with HNC and community physicians' lived experience and their interpretations of how they would consider a future Phase I clinical trial. In addition to our qualitative data reflecting community voices, a community member reviewed the draft interview guide before data collection and both people with HNC and physicians aided interpretation of the findings.
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Affiliation(s)
- Stephanie A. S. Staras
- Department of Health Outcomes and Biomedical InformaticsUniversity of Florida College of MedicineGainesvilleFloridaUSA
| | - Easton N. Wollney
- Department of Health Outcomes and Biomedical InformaticsUniversity of Florida College of MedicineGainesvilleFloridaUSA
| | - Lisa E. Emerson
- Department of Microbiology and Cell Science, Institute of Food and Agricultural SciencesUniversity of FloridaGainesvilleFloridaUSA
| | | | - Peter T. Dziegielewski
- Department of OtolaryngologyUniversity of Florida College of MedicineGainesvilleFloridaUSA
| | - Marta D. Hansen
- Department of Health Outcomes and Biomedical InformaticsUniversity of Florida College of MedicineGainesvilleFloridaUSA
| | - Gabriela Sanchez
- Department of Health Outcomes and Biomedical InformaticsUniversity of Florida College of MedicineGainesvilleFloridaUSA
| | - Dalila D'Ingeo
- Department of Health Outcomes and Biomedical InformaticsUniversity of Florida College of MedicineGainesvilleFloridaUSA
| | | | - Rolf Renne
- Department of Molecular Genetics and MicrobiologyUniversity of Florida College of MedicineGainesvilleFloridaUSA
| | - Kristianna Fredenburg
- Department of PathologyUniversity of Florida College of MedicineGainesvilleFloridaUSA
| | - Michael Gutter
- Department of Family, Youth and Community Sciences, Institute of Food and Agricultural SciencesUniversity of FloridaGainesvilleFloridaUSA
| | - Kendra Zamojski
- Department of Family, Youth and Community Sciences, Institute of Food and Agricultural SciencesUniversity of FloridaGainesvilleFloridaUSA
| | - Carla Vandeweerd
- Department of Health Outcomes and Biomedical InformaticsUniversity of Florida College of MedicineGainesvilleFloridaUSA
| | - Carma L. Bylund
- Department of Health Outcomes and Biomedical InformaticsUniversity of Florida College of MedicineGainesvilleFloridaUSA
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Thomson S, Ainsworth G, Selvanathan S, Kelly R, Collier H, Mujica-Mota R, Talbot R, Brown ST, Croft J, Rousseau N, Higham R, Al-Tamimi Y, Buxton N, Carleton-Bland N, Gledhill M, Halstead V, Hutchinson P, Meacock J, Mukerji N, Pal D, Vargas-Palacios A, Prasad A, Wilby M, Stocken D. Posterior cervical foraminotomy versus anterior cervical discectomy for Cervical Brachialgia: the FORVAD RCT. Health Technol Assess 2023; 27:1-228. [PMID: 37929307 PMCID: PMC10641711 DOI: 10.3310/otoh7720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2023] Open
Abstract
Background Posterior cervical foraminotomy and anterior cervical discectomy are routinely used operations to treat cervical brachialgia, although definitive evidence supporting superiority of either is lacking. Objective The primary objective was to investigate whether or not posterior cervical foraminotomy is superior to anterior cervical discectomy in improving clinical outcome. Design This was a Phase III, unblinded, prospective, United Kingdom multicentre, parallel-group, individually randomised controlled superiority trial comparing posterior cervical foraminotomy with anterior cervical discectomy. A rapid qualitative study was conducted during the close-down phase, involving remote semistructured interviews with trial participants and health-care professionals. Setting National Health Service trusts. Participants Patients with symptomatic unilateral cervical brachialgia for at least 6 weeks. Interventions Participants were randomised to receive posterior cervical foraminotomy or anterior cervical discectomy. Allocation was not blinded to participants, medical staff or trial staff. Health-care use from providing the initial surgical intervention to hospital discharge was measured and valued using national cost data. Main outcome measures The primary outcome measure was clinical outcome, as measured by patient-reported Neck Disability Index score 52 weeks post operation. Secondary outcome measures included complications, reoperations and restricted American Spinal Injury Association score over 6 weeks post operation, and patient-reported Eating Assessment Tool-10 items, Glasgow-Edinburgh Throat Scale, Voice Handicap Index-10 items, PainDETECT and Numerical Rating Scales for neck and upper-limb pain over 52 weeks post operation. Results The target recruitment was 252 participants. Owing to slow accrual, the trial closed after randomising 23 participants from 11 hospitals. The qualitative substudy found that there was support and enthusiasm for the posterior cervical FORaminotomy Versus Anterior cervical Discectomy in the treatment of cervical brachialgia trial and randomised clinical trials in this area. However, clinical equipoise appears to have been an issue for sites and individual surgeons. Randomisation on the day of surgery and processes for screening and approaching participants were also crucial factors in some centres. The median Neck Disability Index scores at baseline (pre surgery) and at 52 weeks was 44.0 (interquartile range 36.0-62.0 weeks) and 25.3 weeks (interquartile range 20.0-42.0 weeks), respectively, in the posterior cervical foraminotomy group (n = 14), and 35.6 weeks (interquartile range 34.0-44.0 weeks) and 45.0 weeks (interquartile range 20.0-57.0 weeks), respectively, in the anterior cervical discectomy group (n = 9). Scores appeared to reduce (i.e. improve) in the posterior cervical foraminotomy group, but not in the anterior cervical discectomy group. The median Eating Assessment Tool-10 items score for swallowing was higher (worse) after anterior cervical discectomy (13.5) than after posterior cervical foraminotomy (0) on day 1, but not at other time points, whereas the median Glasgow-Edinburgh Throat Scale score for globus was higher (worse) after anterior cervical discectomy (15, 7, 6, 6, 2, 2.5) than after posterior cervical foraminotomy (3, 0, 0, 0.5, 0, 0) at all postoperative time points. Five postoperative complications occurred within 6 weeks of surgery, all after anterior cervical discectomy. Neck pain was more severe on day 1 following posterior cervical foraminotomy (Numerical Rating Scale - Neck Pain score 8.5) than at the same time point after anterior cervical discectomy (Numerical Rating Scale - Neck Pain score 7.0). The median health-care costs of providing initial surgical intervention were £2610 for posterior cervical foraminotomy and £4411 for anterior cervical discectomy. Conclusions The data suggest that posterior cervical foraminotomy is associated with better outcomes, fewer complications and lower costs, but the trial recruited slowly and closed early. Consequently, the trial is underpowered and definitive conclusions cannot be drawn. Recruitment was impaired by lack of individual equipoise and by concern about randomising on the day of surgery. A large prospective multicentre trial comparing anterior cervical discectomy and posterior cervical foraminotomy in the treatment of cervical brachialgia is still required. Trial registration This trial is registered as ISRCTN10133661. Funding This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 27, No. 21. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Simon Thomson
- Department of Neurosurgery, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Gemma Ainsworth
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | | | - Rachel Kelly
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Howard Collier
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | | | - Rebecca Talbot
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Sarah Tess Brown
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Julie Croft
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Nikki Rousseau
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Ruchi Higham
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Yahia Al-Tamimi
- Department of Neurosurgery, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Neil Buxton
- Department of Neurosurgery, The Walton Centre NHS Foundation Trust, Liverpool, UK
| | | | - Martin Gledhill
- Department of Speech and Language Therapy, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | | | - Peter Hutchinson
- Department of Clinical Neurosciences, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - James Meacock
- Department of Neurosurgery, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Nitin Mukerji
- Department of Neurosurgery, The James Cook University Hospital, South Tees Hospitals NHS Foundation Trust, Middlesbrough, UK
| | - Debasish Pal
- Department of Neurosurgery, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | | | - Anantharaju Prasad
- Department of Neurosurgery, Royal Preston Hospital, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, UK
| | - Martin Wilby
- Department of Neurosurgery, The Walton Centre NHS Foundation Trust, Liverpool, UK
| | - Deborah Stocken
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
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Ribeiro DC, Wilkinson A, Voney M, Sole G, Lamb SE, Abbott JH. Clinicians' perspectives on planned interventions tested in the Otago MASTER feasibility trial: an implementation-based process evaluation study. BMJ Open 2023; 13:e067745. [PMID: 37094901 PMCID: PMC10151965 DOI: 10.1136/bmjopen-2022-067745] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/26/2023] Open
Abstract
OBJECTIVES This study reports a process evaluation of the Otago MASTER (MAnagement of Subacromial disorders of The shouldER) feasibility trial. This mixed-methods, process evaluation study was conducted parallel to the Otago MASTER feasibility trial. Our aims were to investigate: (1) supervised treatment fidelity of the interventions and (2) clinicians' perceptions of the trial interventions through a focus group. DESIGN Nested process evaluation study using a mixed-methods approach. SETTING Outpatient clinic. PARTICIPANTS Five clinicians (two men, three women) aged 47-67 years, with clinical experience of 18-43 years and a minimum of postgraduate certificate training, were involved with the delivery of interventions within the feasibility trial. We assessed treatment fidelity for supervised exercises through audit of clinicians' records and compared those with the planned protocol. Clinicians took part in a focus group that lasted for approximately 1 hour. The focus group was transcribed verbatim and focus group discussion was analysed thematically using an iterative approach. RESULTS The fidelity score for the tailored exercise and manual therapy intervention was 80.3% (SD: 7.7%) and for the standardised exercise intervention, 82.9% (SD: 5.9%). Clinicians' perspectives about the trial and planned intervention were summarised by one main theme 'conflict experienced between individual clinical practice and the intervention protocol', which was supported by three subthemes: (1) programme strengths and weaknesses; (2) design-related and administrative barriers; and (3) training-related barriers. CONCLUSION This mixed-methods study assessed supervised treatment fidelity of interventions and clinicians' perceptions on planned interventions tested in the Otago MASTER feasibility trial. Overall, treatment fidelity was acceptable for both intervention arms; however, we observed low fidelity for certain domains within the tailored exercise and manual therapy intervention. Our focus group identified several barriers clinicians faced while delivering the planned interventions. Those findings are of relevance for planning the definite trial and for researchers conducting feasibility trials. TRIAL REGISTRATION NUMBER ANZCTR: 12617001405303.
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Affiliation(s)
- Daniel C Ribeiro
- Centre for Health, Activity and Rehabilitation Research, School of Physiotherapy, University of Otago, Dunedin, New Zealand
| | - Amanda Wilkinson
- Centre for Health, Activity and Rehabilitation Research, School of Physiotherapy, University of Otago, Dunedin, New Zealand
- Centre for Postgraduate Nursing Studies, University of Otago, Christchurch, New Zealand
| | - Melanie Voney
- Centre for Health, Activity and Rehabilitation Research, School of Physiotherapy, University of Otago, Dunedin, New Zealand
| | - Gisela Sole
- Centre for Health, Activity and Rehabilitation Research, School of Physiotherapy, University of Otago, Dunedin, New Zealand
| | - Sarah E Lamb
- The University of Exeter Medical School, University of Exeter, Exeter, UK
| | - J Haxby Abbott
- Centre for Musculoskeletal Outcomes Research, Department of Surgical Sciences, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
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Farrar N, Elliott D, Houghton C, Jepson M, Mills N, Paramasivan S, Plumb L, Wade J, Young B, Donovan JL, Rooshenas L. Understanding the perspectives of recruiters is key to improving randomised controlled trial enrolment: a qualitative evidence synthesis. Trials 2022; 23:883. [PMID: 36266700 PMCID: PMC9585862 DOI: 10.1186/s13063-022-06818-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Accepted: 10/05/2022] [Indexed: 11/10/2022] Open
Abstract
Background Recruiting patients to randomised controlled trials (RCTs) is often reported to be challenging, and the evidence base for effective interventions that could be used by staff (recruiters) undertaking recruitment is lacking. Although the experiences and perspectives of recruiters have been widely reported, an evidence synthesis is required in order to inform the development of future interventions. This paper aims to address this by systematically searching and synthesising the evidence on recruiters’ perspectives and experiences of recruiting patients into RCTs. Methods A qualitative evidence synthesis (QES) following Thomas and Harden’s approach to thematic synthesis was conducted. The Ovid MEDLINE, CINAHL, EMBASE, PsycInfo, Cochrane Central Register of Controlled Trials, ORRCA and Web of Science electronic databases were searched. Studies were sampled to ensure that the focus of the research was aligned with the phenomena of interest of the QES, their methodological relevance to the QES question, and to include variation across the clinical areas of the studies. The GRADE CERQual framework was used to assess confidence in the review findings. Results In total, 9316 studies were identified for screening, which resulted in 128 eligible papers. The application of the QES sampling strategy resulted in 30 papers being included in the final analysis. Five overlapping themes were identified which highlighted the complex manner in which recruiters experience RCT recruitment: (1) recruiting to RCTs in a clinical environment, (2) enthusiasm for the RCT, (3) making judgements about whether to approach a patient, (4) communication challenges, (5) interplay between recruiter and professional roles. Conclusions This QES identified factors which contribute to the complexities that recruiters can face in day-to-day clinical settings, and the influence recruiters and non-recruiting healthcare professionals have on opportunities afforded to patients for RCT participation. It has reinforced the importance of considering the clinical setting in its entirety when planning future RCTs and indicated the need to better normalise and support research if it is to become part of day-to-day practice. Trial registration PROSPERO CRD42020141297 (registered 11/02/2020). Supplementary Information The online version contains supplementary material available at 10.1186/s13063-022-06818-4.
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Affiliation(s)
- Nicola Farrar
- Population Health Sciences, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK.
| | - Daisy Elliott
- Population Health Sciences, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK
| | - Catherine Houghton
- School of Nursing and Midwifery, Áras Moyola, National University of Ireland Galway, Galway, Ireland
| | - Marcus Jepson
- Population Health Sciences, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK
| | - Nicola Mills
- Population Health Sciences, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK
| | - Sangeetha Paramasivan
- Population Health Sciences, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK
| | - Lucy Plumb
- Population Health Sciences, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK.,UK Kidney Association, UK Renal Registry, Bristol, UK
| | - Julia Wade
- Population Health Sciences, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK
| | - Bridget Young
- Department of Public Health, Policy and Systems, Institute of Population Health, University of Liverpool, Liverpool, L69 3GB, UK
| | - Jenny L Donovan
- Population Health Sciences, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK
| | - Leila Rooshenas
- Population Health Sciences, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK
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Davies L, Beard D, Cook JA, Price A, Osbeck I, Toye F. The challenge of equipoise in trials with a surgical and non-surgical comparison: a qualitative synthesis using meta-ethnography. Trials 2021; 22:678. [PMID: 34620194 PMCID: PMC8495989 DOI: 10.1186/s13063-021-05403-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Accepted: 06/26/2021] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Randomised controlled trials in surgery can be a challenge to design and conduct, especially when including a non-surgical comparison. As few as half of initiated surgical trials reach their recruitment target, and failure to recruit is cited as the most frequent reason for premature closure of surgical RCTs. The aim of this qualitative evidence synthesis was to identify and synthesise findings from qualitative studies exploring the challenges in the design and conduct of trials directly comparing surgical and non-surgical interventions. METHODS A qualitative evidence synthesis using meta-ethnography was conducted. Six electronic bibliographic databases (Medline, Central, Cinahl, Embase and PsycInfo) were searched up to the end of February 2018. Studies that explored patients' and health care professionals' experiences regarding participating in RCTs with a surgical and non-surgical comparison were included. The GRADE-CERQual framework was used to assess confidence in review findings. RESULTS In total, 3697 abstracts and 49 full texts were screened and 26 published studies reporting experiences of patients and healthcare professionals were included. The focus of the studies (24/26) was primarily related to the challenge of recruitment. Two studies explored reasons for non-compliance to treatment allocation following randomisation. Five themes related to the challenges to these types of trials were identified: (1) radical choice between treatments; (2) patients' discomfort with randomisation: I want the best treatment for me as an individual; (3) challenge of equipoise: patients' a priori preferences for treatment; (4) challenge of equipoise: clinicians' a priori preferences for treatment and (5) imbalanced presentation of interventions. CONCLUSION The marked dichotomy between the surgical and non-surgical interventions was highlighted in this review as making recruitment to these types of trials particularly challenging. This review identified factors that increase our understanding of why patients and clinicians may find equipoise more challenging in these types of trials compared to other trial comparisons. Trialists may wish to consider exploring the balance of potential factors influencing patient and clinician preferences towards treatments before they start recruitment, to enable issues specific to a particular trial to be identified and addressed. This may enable trial teams to make more efficient considered design choices and benefit the delivery of such trials.
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Affiliation(s)
- Loretta Davies
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Botnar Research Centre, University of Oxford, Headington, Oxford, OX3 7LD, UK.
| | - David Beard
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Botnar Research Centre, University of Oxford, Headington, Oxford, OX3 7LD, UK
| | - Jonathan A Cook
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Botnar Research Centre, University of Oxford, Headington, Oxford, OX3 7LD, UK
| | - Andrew Price
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Botnar Research Centre, University of Oxford, Headington, Oxford, OX3 7LD, UK
| | | | - Francine Toye
- Nuffield Orthopaedic Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
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Daniels N, Gillen P, Casson K. Practitioner Engagement by Academic Researchers: A Scoping Review of Nursing, Midwifery, and Therapy Professions Literature. Res Theory Nurs Pract 2021; 34:85-128. [PMID: 32457119 DOI: 10.1891/rtnp-d-18-00125] [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] [Indexed: 11/25/2022]
Abstract
BACKGROUND Engagement of frontline practitioners by academic researchers in the research process is believed to afford benefits toward closing the research practice gap. However, little is known about if and how academic researchers engage nurses, midwives, or therapists in research activities or if evidence supports these claims of positive impact. METHOD A scoping review was undertaken using the Arksey and O'Malley (2005) framework to identify the extent to which this phenomenon has been considered in the literature. RESULTS An iterative search carried out in CINAHL, Pubmed, Medline, and Embase retrieved 32 relevant papers published 2000 to 2017, with the majority from the last 2-years. Retained papers described or evaluated active engagement of a practitioner from nursing, midwifery, and therapy disciplines in at least one stage of a research project other than as a study participant. Engagement most often took place in one research activity with few examples of engagement throughout the research process. Limited use of theory and variations in terms used to describe practitioner engagement by researchers was observed. Subjective perspectives of practitioners' experiences and a focus on challenges and benefits were the most prominently reported outcomes. Few attempts were found to establish effects which could support claims that practitioner engagement can enhance the use of findings or impact health outcomes. CONCLUSION It is recommended that a culture of practitioner engagement is cultivated by developing guiding theory, establishing consistent terminology, and building an evidence base through empirical evaluations which provide objective data to support claims that this activity can positively influence the research practice gap.
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Affiliation(s)
- Nicola Daniels
- School of Nursing, Ulster University, Belfast, Northern Ireland, UK
| | - Patricia Gillen
- School of Nursing, Ulster University, Belfast, Northern Ireland, UK
| | - Karen Casson
- School of Nursing, Ulster University, Belfast, Northern Ireland, UK
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Phelps EE, Tutton E, Costa M, Hing C. Unattainable equipoise in randomized controlled trials : staff views of a feasibility study of surgical treatments for segmental tibial fractures. Bone Jt Open 2021; 2:486-492. [PMID: 34236209 PMCID: PMC8325976 DOI: 10.1302/2633-1462.27.bjo-2021-0055.r1] [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] [Indexed: 11/07/2022] Open
Abstract
Aims To explore staff experiences of a multicentre pilot randomized controlled trial (RCT) comparing intramedullary nails and circular frame external fixation for segmental tibial fractures. Methods A purposeful sample of 19 staff (nine surgeons) involved in the study participated in an interview. Interviews explored participants’ experience and views of the study and the treatments. The interviews drew on phenomenology, were face-to-face or by telephone, and were analyzed using thematic analysis. Results The findings identify that for the treatment of segmental tibial fractures equipoise was a theoretical ideal that was most likely unattainable in clinical practice. This was conveyed through three themes: the ambiguity of equipoise, where multiple definitions of equipoise and a belief in community equipoise were evident; an illusion of equipoise, created by strong treatment preferences and variation in collective surgical skills; and treating the whole patient, where the complexity and severity of the injury required a patient-centred approach and doing the best for the individual patient took priority over trial recruitment. Conclusion Equipoise can be unattainable for rare injuries such as segmental tibial fractures, where there are substantially different surgical treatments requiring specific expertise, high levels of complexity, and a concern for poor outcomes. Surgeons are familiar with community equipoise. However, a shared understanding of factors that limit the feasibility of RCTs may identify instances where community equipoise is unlikely to translate into practice. Cite this article: Bone Jt Open 2021;2(7):486–492.
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Affiliation(s)
- Emma Elizabeth Phelps
- Kadoorie, Oxford Trauma and Emergency Care, Nuffield Department Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Elizabeth Tutton
- Kadoorie, Oxford Trauma and Emergency Care, Nuffield Department Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK.,Trauma and MTC, Oxford University NHS Foundation Hospital Trust, John Radcliffe, Oxford, UK
| | - Matthew Costa
- Kadoorie, Oxford Trauma and Emergency Care, Nuffield Department Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Caroline Hing
- Department of Trauma and Orthopaedics, St George's University Hospitals NHS Foundation Trust, London, UK
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Rai T, Dixon S, Ziebland S. Shifting research culture to address the mismatch between where trials recruit and where populations with the most disease live: a qualitative study. BMC Med Res Methodol 2021; 21:80. [PMID: 33882874 PMCID: PMC8058580 DOI: 10.1186/s12874-021-01268-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Accepted: 04/05/2021] [Indexed: 02/01/2023] Open
Abstract
Background Research participation is beneficial to patients, clinicians and healthcare services. There is currently poor alignment between UK clinical research activity and local prevalence of disease. The National Institute of Health Research is keen to encourage chief investigators (CIs) to base their research activity in areas of high patient need, to support equity, efficiency and capacity building. We explored how CIs choose sites for their trials and suggest ways to encourage them to recruit from areas with the heaviest burden of disease. Methods Qualitative, semi-structured telephone interviews with a purposive sample of 30 CIs of ongoing or recently completed multi-centre trials, all of which were funded by the UK National Institute of Health Research. Results CIs want to deliver world-class trials to time and budget. Approaching newer, less research-active sites appears risky, potentially compromising trial success. CIs fear that funders may close the trial if recruitment (or retention) is low, with potential damage to their research reputation. We consider what might support a shift in CI behaviour. The availability of ‘heat maps’ showing the disparity between disease prevalence and current research activity will help to inform site selection. Embedded qualitative research during trial set up and early, appropriate patient and public involvement and engagement can provide useful insights for a more nuanced and inclusive approach to recruitment. Public sector funders could request more granularity in recruitment reports and incentivise research activity in areas of greater patient need. Accounts from the few CIs who had ‘broken the mould’ suggest that nurturing new sites can be very successful in terms of efficient recruitment and retention. Conclusion While improvements in equity and capacity building certainly matter to CIs, most are primarily motivated by their commitment to delivering successful trials. Highlighting the benefits to trial delivery is therefore likely to be the best way to encourage CIs to focus their research activity in areas of greatest need. Supplementary Information The online version contains supplementary material available at 10.1186/s12874-021-01268-z.
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Affiliation(s)
- Tanvi Rai
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, UK.
| | - Sharon Dixon
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, UK
| | - Sue Ziebland
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, UK
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10
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Daniels N, Gillen P, Casson K. Researcher practitioner engagement in health research: The development of a new concept. Res Nurs Health 2021; 44:534-547. [PMID: 33774826 DOI: 10.1002/nur.22128] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Revised: 01/24/2021] [Accepted: 03/08/2021] [Indexed: 11/11/2022]
Abstract
The engagement of frontline practitioners in the production of research-derived knowledge is often advocated. Doing so can address perceived gaps between what is known from research and what happens in clinical practice. Engagement practices span a continuum, from co-production approaches underpinned by principles of equality and power sharing to those which can minimalize practitioners' contributions to the knowledge production process. We observed a conceptual gap in published healthcare literature that labels or defines practitioners' meaningful contribution to the research process. We, therefore, aimed to develop the concept of "Researcher Practitioner Engagement" in the context of academically initiated healthcare research in the professions of nursing, midwifery, occupational therapy, physiotherapy, and speech and language therapy. Guided by Schwartz-Barcott et al.'s hybrid model of concept development, published examples were analyzed to establish the attributes, antecedents, and consequences of this type of engagement. Academic researchers (n = 17) and frontline practitioners (n = 8) with relevant experience took part in online focus groups to confirm, eliminate, or elaborate on these proposed concept components. Combined analysis of theoretical and focus group data showed that the essence of this form of engagement is that practitioners' clinical knowledge is valued from a study's formative stages. The practitioner's clinical perspectives inform problem-solving and decision-making in study activities and enhance the professional and practice relevance of a study. The conceptual model produced from the study findings forms a basis to guide engagement practices, future concept testing, and empirical evaluation of engagement practices.
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Affiliation(s)
- Nicola Daniels
- Institute of Nursing and Health Research, School of Nursing, Faculty of Life and Health Sciences, Ulster University, Newtownabbey, UK
| | - Patricia Gillen
- Institute of Nursing and Health Research, School of Nursing, Faculty of Life and Health Sciences, Ulster University, Newtownabbey, UK.,Southern Health and Social Care Trust, Rosedale, Gilford, UK
| | - Karen Casson
- Institute of Nursing and Health Research, School of Nursing, Faculty of Life and Health Sciences, Ulster University, Newtownabbey, UK
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11
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Lehmann BA, Lindert L, Ohlmeier S, Schlomann L, Pfaff H, Choi KE. "And Then He Got into the Wrong Group": A Qualitative Study Exploring the Effects of Randomization in Recruitment to a Randomized Controlled Trial. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17061886. [PMID: 32183250 PMCID: PMC7143713 DOI: 10.3390/ijerph17061886] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Revised: 02/21/2020] [Accepted: 03/09/2020] [Indexed: 11/16/2022]
Abstract
Background: Randomized controlled trials (RCTs) are regarded as the most internally valid means of estimating the effectiveness of complex public health interventions, but the recruitment of participants can be difficult. The aim of this study was to explore factors that may have affected the recruitment of employees with musculoskeletal disorders (MSDs) to a multicenter worksite health promotion program from the perspective of recruiting case managers. Methods: Factors in recruitment to the RCT were explored using three focus group discussions with case managers. Data were processed using MAXQDA and analyzed with a combination of content and sequence analysis. Results: Findings showed that randomization is a major challenge for recruitment. Case managers adapted their communication with, and approaches to possible participants because of the randomization design and employed coping strategies to compensate for allocation into the control arm of the study. Perceptions of the superiority of the intervention group over the control group, perceptions of the (mis)match of participants to one of the groups, as well as the understanding of the necessity of randomization for effectiveness evaluations, further affected recruitment. Perceived expectations of possible participants and their (emotional) reactions to the randomization allocation also complicated recruitment. Conclusion: We were able to gain insight into the challenges of randomization for the recruitment of participants to a multicenter RCT. This study assisted the development of strategies to overcome barriers in the ongoing implementation process of the trial (i.e., the adaption of best practice information sheets and newsletters). There remains a need to develop effective interventions to help those recruiting to trials.
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Affiliation(s)
- Birthe Andrea Lehmann
- Communication Science, University of Amsterdam, 1001 NH Amsterdam, The Netherlands
- Correspondence:
| | - Lara Lindert
- Institute of Medical Sociology, Health Services Research and Rehabilitation Science, University of Cologne, 50933 Köln, Germany; (L.L.); (S.O.); (L.S.); (H.P.); (K.-E.C.)
| | - Silke Ohlmeier
- Institute of Medical Sociology, Health Services Research and Rehabilitation Science, University of Cologne, 50933 Köln, Germany; (L.L.); (S.O.); (L.S.); (H.P.); (K.-E.C.)
| | - Lara Schlomann
- Institute of Medical Sociology, Health Services Research and Rehabilitation Science, University of Cologne, 50933 Köln, Germany; (L.L.); (S.O.); (L.S.); (H.P.); (K.-E.C.)
| | - Holger Pfaff
- Institute of Medical Sociology, Health Services Research and Rehabilitation Science, University of Cologne, 50933 Köln, Germany; (L.L.); (S.O.); (L.S.); (H.P.); (K.-E.C.)
| | - Kyung-Eun Choi
- Institute of Medical Sociology, Health Services Research and Rehabilitation Science, University of Cologne, 50933 Köln, Germany; (L.L.); (S.O.); (L.S.); (H.P.); (K.-E.C.)
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12
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Frost J, Britten N. Learning from a Feasibility Trial of a Simple Intervention: Is Research a Barrier to Service Delivery, or is Service Delivery a Barrier to Research? Healthcare (Basel) 2020; 8:healthcare8010053. [PMID: 32138337 PMCID: PMC7151079 DOI: 10.3390/healthcare8010053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Accepted: 02/27/2020] [Indexed: 11/16/2022] Open
Abstract
(1) Background: Applied health services research (AHSR) relies upon coordination across multiple organizational boundaries. Our aim was to understand how competing organizational and professional goals enhance or impede the conduct of high quality AHSR. (2) Methods: A qualitative study was conducted in two local health care systems in the UK, linked to a feasibility trial of a clinic-based intervention in secondary care. Data collection involved 24 semi-structured interviews with research managers, clinical research staff, health professionals, and patients. (3) Results: This study required a dynamic network of interactions between heterogeneous health and social care stakeholders, each characterized by differing ways of organizing activities which constitute their core functions; cultures of collaboration and interaction and understanding of what research involves and how it contributes to patient care. These interrelated factors compounded the occupational and organizational boundaries that hindered communication and coordination. (4) Conclusions: Despite the strategic development of multiple organizations to foster inter-professional collaboration, the competing goals of research and clinical practice can impede the conduct of high quality AHSR. To remedy this requires the alignment and streamlining of organizational goals, so that all agencies involved in AHSR develop a shared understanding and mutual respect for the progress of evidence-based medicine and the complex and often nuanced environments in which it is created and practiced.
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13
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Rühle A, Oehme F, Link BC, Metzger J, Fischer H, Stickel M, Delagrammaticas DE, Babst R, Beeres FJP. Swiss chocolate and free beverages to increase the motivation for scientific work amongst residents: a prospective interventional study in a non-academic teaching hospital in Switzerland. Trials 2020; 21:74. [PMID: 31931852 PMCID: PMC6958759 DOI: 10.1186/s13063-019-3956-5] [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: 11/13/2018] [Accepted: 12/04/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The success of a clinical trial depends on its recruitment of eligible patients; therefore, the recruitment period requires special attention. We hypothesized that with a new approach focused on continuous information and gratification, resident motivation to participate in scientific work will increase and recruitment rates will improve. METHODS Our new recruitment approach was applied to the recruitment phase of two prospective randomized trials (registered at the German Clinical Trials Register). Randomization of these trials was performed first using blinded envelopes; later a soft drink machine was used as the delivery tool of randomization as a lighthearted motivation to join scientific work and to reward the resident with free soft drinks for each recruitment. Residents were informed about the trial via a lecture and by mail. To increase interest everyone received Swiss chocolate. With a multiple choice survey we investigated the success of our actions at 6 and 12 months. Recruitment rates of the trials were evaluated and associated with the motivational approaches. RESULTS Our residents rated their awareness of the trials with median 9 (IQR 7;9) during the first and 8 (IQR 5;9) during the second survey and their interest in scientific work with median 7 (IQR 4;8) and 6 (IQR 5;8). The percentage of residents feeling highly motivated improved from 58% to 70%. The recruitment rates stayed stably high over time with 73% and 72% in trial 1 and 90% and 85% in trial 2; 24% of residents stated their motivation could be increased by gratifications. CONCLUSIONS After implementation of our new recruitment approach we found positively motivated residents and high recruitment rates in the corresponding trials. We propose this procedure may help to ensure the successful initiation of clinical trials. Larger studies testing this approach are warranted.
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Affiliation(s)
- Annika Rühle
- Department of General and Visceral Surgery, Cantonal Hospital of Lucerne, Spitalstrasse, 6000, Lucerne, Switzerland.
| | - Florian Oehme
- Department of General and Visceral Surgery, Cantonal Hospital of Lucerne, Spitalstrasse, 6000, Lucerne, Switzerland
| | - Björn-Christian Link
- Department of Traumatology and Orthopaedic Surgery, Cantonal Hospital Lucerne, Spitalstrasse, 6000, Lucerne, Switzerland
| | - Jürg Metzger
- Department of General and Visceral Surgery, Cantonal Hospital of Lucerne, Spitalstrasse, 6000, Lucerne, Switzerland
| | - Henning Fischer
- Department of General and Visceral Surgery, Cantonal Hospital of Lucerne, Spitalstrasse, 6000, Lucerne, Switzerland.,Emergency Department, Cantonal Hospital of Lucerne, Spitalstrasse, 6000, Lucerne, Switzerland
| | - Michael Stickel
- Emergency Department, Cantonal Hospital of Lucerne, Spitalstrasse, 6000, Lucerne, Switzerland
| | - Dimitri E Delagrammaticas
- Department of Orthopaedic Surgery, Northwestern University Feinberg School of Medicine, 676 N. Saint Clair, Chicago, IL, 60611, USA
| | - Reto Babst
- Department of Traumatology and Orthopaedic Surgery, Cantonal Hospital Lucerne, Spitalstrasse, 6000, Lucerne, Switzerland
| | - Frank J P Beeres
- Department of Traumatology and Orthopaedic Surgery, Cantonal Hospital Lucerne, Spitalstrasse, 6000, Lucerne, Switzerland
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14
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Lotzke H, Gutke A, den Hollander M, Smeets R, Lundberg M. Developing an evidence-based prehabilitation programme designed to improve functional outcomes after lumbar fusion surgery - A feasibility study using the Medical Research Council framework. EUROPEAN JOURNAL OF PHYSIOTHERAPY 2020. [DOI: 10.1080/21679169.2018.1553999] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- Hanna Lotzke
- Department of Orthopaedics at Sahlgrenska Academy, Institute of the Clinical Sciences, University of Gothenburg, Gothenburg, Sweden
| | - Annelie Gutke
- Department of Health and Rehabilitation, Division of Physiotherapy, Institute of Neuroscience and Physiology, University of Gothenburg, Gothenburg, Sweden
| | - Marlies den Hollander
- Adelante Centre of Expertise in Rehabilitation, Hoensbroek, The Netherlands
- Department of Rehabilitation Medicine, Maastricht University, Maastricht, The Netherlands
| | - Rob Smeets
- Department of Rehabilitation Medicine, Maastricht University, Maastricht, The Netherlands
| | - Mari Lundberg
- Department of Health and Rehabilitation, Division of Physiotherapy, Institute of Neuroscience and Physiology, University of Gothenburg, Gothenburg, Sweden
- Department of Orthopaedics, Sahlgrenska University Hospital, Gothenburg, Sweden
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15
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Keding A, Handoll H, Brealey S, Jefferson L, Hewitt C, Corbacho B, Torgerson D, Rangan A. The impact of surgeon and patient treatment preferences in an orthopaedic trauma surgery trial. Trials 2019; 20:570. [PMID: 31533863 PMCID: PMC6751812 DOI: 10.1186/s13063-019-3631-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Accepted: 08/07/2019] [Indexed: 12/12/2022] Open
Abstract
Background Surgeon and patient treatment preferences are important threats to the internal and external validity of surgical trials such as PROFHER, which compared surgical versus non-surgical treatment for displaced fractures of the proximal humerus in adults. We explored the treatment preferences expressed by surgeons and patients in the trial and how these impacted on patient selection, trial conduct and patient outcome. Methods A series of exploratory secondary analyses of the PROFHER trial data were undertaken. We reviewed the extent of surgeon and patient treatment preferences (surgery or not surgery) at screening (n = 1250) as well as prior preference (including no preference) of randomised patients (n = 250), and assessed their impact on recruitment and adherence to follow-up and rehabilitation. Changes in treatment after 2 years’ follow-up were explored. Patient preference and characteristics associated with trial inclusion or treatment preference (t test, chi-squared test, Wilcoxon rank-sum test) were included as treatment interaction terms in the primary trial analysis of shoulder functioning (Oxford Shoulder Score, OSS). Results Surgeons excluded 17% of otherwise eligible patients based on lack of equipoise; these patients had less complex fractures (p < 0.001) and tended to be older (p = 0.062). Surgeons were more likely to recommend surgery for patients under 65 years of age (p = 0.059) and who had injured their right shoulder (p = 0.052). Over half of eligible patients (56%) did not consent to take part in the trial; these patients tended to be older (p = 0.022), with a preference for not surgery (74%; which was associated with older age, p = 0.039). There were no differential treatment effects (p value of interaction) for shoulder functioning (OSS) based on subgroups of patient preference (p = 0.751), age group (p = 0.264), fracture type (p = 0.954) and shoulder dominance (p = 0.850). Patients who were randomised to their preferred treatment had better follow-up rates (94 vs 84% at 2 years) and treatment adherence (90 vs 83% reported completing home exercises). Patients who were not randomised to their preferred treatment were more likely to change their treatment preference at 24 months (60 vs 26%). Conclusions The robustness of the PROFHER trial findings was confirmed against possible bias introduced by surgeon and patient preferences. The importance of collecting preference data is highlighted. Trial registration ISRCTN50850043. Registered on 25 March 2008.
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Affiliation(s)
- Ada Keding
- York Trials Unit, Department of Health Sciences, University of York, Heslington, YO10 5DD, UK.
| | - Helen Handoll
- School of Health and Social Care, Teesside University, Middlesbrough, Tees Valley, TS1 3BA, UK
| | - Stephen Brealey
- York Trials Unit, Department of Health Sciences, University of York, Heslington, YO10 5DD, UK
| | - Laura Jefferson
- Department of Health Sciences, University of York, Heslington, YO10 5DD, UK
| | - Catherine Hewitt
- York Trials Unit, Department of Health Sciences, University of York, Heslington, YO10 5DD, UK
| | - Belen Corbacho
- York Trials Unit, Department of Health Sciences, University of York, Heslington, YO10 5DD, UK
| | - David Torgerson
- York Trials Unit, Department of Health Sciences, University of York, Heslington, YO10 5DD, UK
| | - Amar Rangan
- York Trials Unit, Department of Health Sciences, University of York, Heslington, YO10 5DD, UK.,Department of Trauma and Orthopaedics, James Cook University Hospital, South Tees Hospitals NHS Trust, Marton Road, Middlesbrough, TS4 3BW, UK
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16
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Phelps EE, Tutton E, Griffin X, Baird J. Facilitating trial recruitment: A qualitative study of patient and staff experiences of an orthopaedic trauma trial. Trials 2019; 20:492. [PMID: 31399134 PMCID: PMC6688236 DOI: 10.1186/s13063-019-3597-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Accepted: 07/18/2019] [Indexed: 11/10/2022] Open
Abstract
Background Qualitative research has been used to explore patients’ and healthcare professionals’ experiences of surgical randomised controlled trials (RCTs). From this research, reasons why patients accept or decline participation and barriers to engaging clinicians in trials have been identified. In a trauma setting, recruitment to surgical trials can be particularly difficult as patients may require urgent treatment and their ability to consider their options, ask questions and reach a decision may be hindered by the impact of their injury. Little research, however, has explored patients’ and healthcare professionals’ experiences of surgical RCTs in a trauma setting. This study aimed to understand patients’ and staff’s experiences of an orthopaedic trauma trial. Methods We carried out semi-structured interviews with 11 patients and 24 staff (10 surgeons and 14 research associates) participating in a UK multi-centre feasibility trial comparing intramedullary nails versus distal locking plates for fractures of the distal femur (TrAFFix). Interviews explored patients’ experience of TrAFFix and their reason for participating and staffs' experience of recruiting to TrAFFix and trauma trials more generally. Interviews were audio recorded and transcribed verbatim. Transcripts were analysed using thematic analysis. Results Three themes were identified. These were i) navigating research with patients after orthopaedic trauma, ii) knowing that it is the right decision and iii) making it work. These themes reflect: i) how research associates supported and guided patients through the consent process enabling them to participate, ii) the difficulty in engaging surgeons in a trial when individual equipoise and experience of the interventions are low despite the presence of community equipoise and iii) the way in which research teams worked together and encouraged the development of a research culture within the clinical teams in order to facilitate recruitment. Conclusions Our findings highlight the pivotal role of research associates (RAs) in facilitating trial recruitment. RAs supported patients to enable them to make a decision about participation and assisted in developing a research culture within the team by promoting studies and communicating research to clinical staff. Our findings also reinforce surgeons’ difficulty with equipoise and suggest that accepting community equipoise could facilitate recruitment.
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Affiliation(s)
- Emma Elizabeth Phelps
- NDORMS, Kadoorie Centre, level 3, John Radcliffe Hospital, University of Oxford, Oxford, OX3 9DU, UK
| | - Elizabeth Tutton
- NDORMS, Kadoorie Centre, level 3, John Radcliffe Hospital, University of Oxford, Oxford, OX3 9DU, UK. .,Oxford University Hospitals NHS Foundation Trust, Oxford, UK. .,Warwick Research in Nursing, University of Warwick, Coventry, UK.
| | - Xavier Griffin
- NDORMS, Kadoorie Centre, level 3, John Radcliffe Hospital, University of Oxford, Oxford, OX3 9DU, UK
| | - Janis Baird
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, SO16 6YD, UK
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17
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Deutsch GB, Deneve JL, Al-Kasspooles MF, Nfonsam VN, Gunderson CC, Secord AA, Rodgers P, Hendren S, Silberfein EJ, Grant M, Sloan J, Sun V, Arnold KB, Anderson GL, Krouse RS. Intellectual Equipoise and Challenges: Accruing Patients With Advanced Cancer to a Trial Randomizing to Surgical or Nonsurgical Management (SWOG S1316). Am J Hosp Palliat Care 2019; 37:12-18. [PMID: 31122027 DOI: 10.1177/1049909119851471] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Prospective, randomized trials are needed to determine optimal treatment approaches for palliative care problems such as malignant bowel obstruction (MBO). Randomization poses unique issues for such studies, especially with divergent treatment approaches and varying levels of equipoise. We report our experience accruing randomized patients to the Prospective Comparative Effectiveness Trial for Malignant Bowel Obstruction (SWOG S1316) study, comparing surgical and nonsurgical management of MBO. METHODS Patients with MBO who were surgical candidates and had treatment equipoise were accrued and offered randomization to surgical or nonsurgical management. Patients choosing nonrandomization were offered prospective observation. Trial details are listed on www.clinicaltrials.gov (NCT #02270450). An accrual algorithm was developed to enhance enrollment. RESULTS Accrual is ongoing with 176 patients enrolled. Most (89%) patients chose nonrandomization, opting for nonsurgical management. Of 25 sites that have accrued to this study, 6 enrolled patients on the randomization arm. Approximately 59% (20/34) of the randomization accrual goal has been achieved. Patient-related factors and clinician bias have been the most prevalent reasons for lack of randomization. An algorithm was developed from clinician experience to aid randomization. Using principles in this tool, repeated physician conversations discussing treatment options and goals of care, and a supportive team-approach has helped increase accrual. CONCLUSIONS Experience gained from the S1316 study can aid future palliative care trials. Although difficult, it is possible to randomize patients to palliative studies by giving clinicians clear recommendations utilizing an algorithm of conversation, allotment of necessary time to discuss the trial, and encouragement to overcome internal bias.
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Affiliation(s)
- Gary B Deutsch
- Department of Surgery, Northwell Health, Lake Success, NY, USA
| | - Jeremiah L Deneve
- Department of Surgery, University of Tennessee Health Science Center, Memphis, TN, USA
| | | | | | - Camille C Gunderson
- Department of Obstetrics and Gynecology, University of Oklahoma, Oklahoma City, OK, USA
| | - Angeles Alvarez Secord
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Duke Cancer Institute, Durham, NC, USA
| | - Phillip Rodgers
- Department of Family Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Samantha Hendren
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | | | - Marcia Grant
- Division of Nursing Research and Education, City of Hope National Medical Center, Duarte, CA, USA
| | - Jeff Sloan
- Mayo Clinic Rochester, Rochester, MN, USA
| | - Virginia Sun
- Division of Nursing Research and Education, City of Hope National Medical Center, Duarte, CA, USA
| | - Kathryn B Arnold
- SWOG Statistics and Data Management Center, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Garnet L Anderson
- SWOG Statistics and Data Management Center, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Robert S Krouse
- Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA, USA.,Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA.,Leonard Davis Institute of Health Policy, Philadelphia, PA, USA
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18
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Husbands S, Caskey F, Winton H, Gibson A, Donovan JL, Rooshenas L. Pre-trial qualitative work with health care professionals to refine the design and delivery of a randomised controlled trial on kidney care. Trials 2019; 20:224. [PMID: 30992024 PMCID: PMC6469088 DOI: 10.1186/s13063-019-3281-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Accepted: 03/07/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Recruitment to randomised controlled trials (RCTs) is challenging. Pre-trial qualitative research provides insights into the feasibility and acceptability of proposed trial designs and delivery; however, this is rarely conducted. This paper reports on work undertaken in advance of the Prepare for Kidney Care trial (formerly PrepareME), which compares preparing for dialysis with preparing for conservative care for patients with chronic kidney disease. The paper describes how the findings refined plans for the forthcoming trial. METHODS Semi-structured interviews were undertaken with health-care professionals involved in delivering or recruiting to the trial. Interview findings were considered in relation to observations of a patient advisory group workshop and introductory site visits, which were set up to present the trial to professionals involved in the internal pilot phase of the RCT. The use of findings and input from multiple sources was intended to support suggested refinements to the forthcoming trial. The findings were fed back to the trial management group and other expert stakeholders. RESULTS Sixteen health-care professionals were interviewed, and one patient advisory group workshop and six introductory visits to sites involved in the internal pilot were observed. The professionals interviewed included renal consultants, nurses and renal social workers. Key themes identified from the interviews, supported by the observations, were concerns around the eligibility criteria, the feasibility of the trial intervention, imbalances in the presentation of the trial arms, and anticipated recruitment issues arising from patients' and clinicians' preferences for one arm or the other. Changes to the design were made in response, including to the content of the intervention, the presentation of the trial arms and the name of the RCT. CONCLUSIONS This study highlights the value of carrying out pre-trial work with health-care professionals to identify issues with delivering the proposed trial. This work can be particularly valuable in trials of new interventions, for which the barriers to their integration into routine care are unknown. This work has important implications for facilitating the identification of further obstacles in the main RCT. We suggest that pre-trial qualitative work is undertaken to address design issues early on, in addition to ongoing qualitative research to monitor the emergence of obstacles affecting recruitment.
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Affiliation(s)
- Samantha Husbands
- Population Health Sciences, Bristol Medical School, University of Bristol, 1-5 Whiteladies Road, Bristol, BS8 1NU UK
| | - Fergus Caskey
- Population Health Sciences, Bristol Medical School, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS UK
| | - Helen Winton
- Population Health Sciences, Bristol Medical School, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS UK
| | - Andy Gibson
- Department of Health and Applied Social Sciences, University of West of England, Bristol, UK
| | - Jenny L. Donovan
- Population Health Sciences, Bristol Medical School, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS UK
| | - Leila Rooshenas
- Population Health Sciences, Bristol Medical School, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS UK
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19
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Inwald D, Canter RR, Woolfall K, O'Hara CB, Mouncey PR, Zenasni Z, Hudson N, Saunders S, Carter A, Jones N, Lyttle MD, Nadel S, Peters MJ, Harrison DA, Rowan KM. Restricted fluid bolus versus current practice in children with septic shock: the FiSh feasibility study and pilot RCT. Health Technol Assess 2019; 22:1-106. [PMID: 30238870 DOI: 10.3310/hta22510] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND There has been no randomised controlled trial (RCT) of fluid bolus therapy in paediatric sepsis in the developed world despite evidence that excess fluid may be associated with harm. OBJECTIVES To determine the feasibility of the Fluids in Shock (FiSh) trial - a RCT comparing restricted fluid bolus (10 ml/kg) with current practice (20 ml/kg) in children with septic shock in the UK. DESIGN (1) Qualitative feasibility study exploring parents' views about the pilot RCT. (2) Pilot RCT over a 9-month period, including integrated parental and staff perspectives study. SETTING (1) Recruitment took place across four NHS hospitals in England and on social media. (2) Recruitment took place across 13 NHS hospitals in England. PARTICIPANTS (1) Parents of children admitted to a UK hospital with presumed septic shock in the previous 3 years. (2) Children presenting to an emergency department with clinical suspicion of infection and shock after 20 ml/kg of fluid. Exclusion criteria were receipt of > 20 ml/kg of fluid, conditions requiring fluid restriction and the patient not for full active treatment (i.e. palliative care plan in place). Site staff and parents of children in the pilot were recruited to the perspectives study. INTERVENTIONS (1) None. (2) Children were randomly allocated (1 : 1) to 10- or 20-ml/kg fluid boluses every 15 minutes for 4 hours if in shock. MAIN OUTCOME MEASURES (1) Acceptability of FiSh trial, proposed consent model and potential outcome measures. (2) Outcomes were based on progression criteria, including recruitment and retention rates, protocol adherence and separation between the groups, and collection and distribution of potential outcome measures. RESULTS (1) Twenty-one parents were interviewed. All would have consented for the pilot study. (2) Seventy-five children were randomised, 40 to the 10-ml/kg fluid bolus group and 35 to the 20-ml/kg fluid bolus group. Two children were withdrawn. Although the anticipated recruitment rate was achieved, there was variability across the sites. Fifty-nine per cent of children in the 10-ml/kg fluid bolus group and 74% in the 20-ml/kg fluid bolus group required only a single trial bolus before shock resolved. The volume of fluid (in ml/kg) was 35% lower in the first hour and 44% lower over the 4-hour period in the 10-ml/kg fluid bolus group. Fluid boluses were delivered per protocol (volume and timing) for 79% of participants in the 10-ml/kg fluid bolus group and for 55% in the 20-ml/kg fluid bolus group, mainly as a result of delivery not being completed within 15 minutes. There were no deaths. Length of hospital stay, paediatric intensive care unit (PICU) transfers, and days alive and PICU free did not differ significantly between the groups. Two adverse events were reported in each group. A questionnaire was completed by 45 parents, 20 families and seven staff were interviewed and 20 staff participated in focus groups. Although a minority of site staff lacked equipoise in favour of more restricted boluses, all supported the trial. CONCLUSIONS Even though a successful feasibility and pilot RCT were conducted, participants were not as unwell as expected. A larger trial is not feasible in its current design in the UK. FUTURE WORK Further observational work is required to determine the epidemiology of severe childhood infection in the UK in the postvaccine era. TRIAL REGISTRATION Current Controlled Trials ISRCTN15244462. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 22, No. 51. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- David Inwald
- Paediatric Intensive Care Unit, St Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Ruth R Canter
- Clinical Trials Unit, Intensive Care National Audit and Research Centre, London, UK
| | - Kerry Woolfall
- Department of Psychological Sciences, North West Hub for Trials Methodology Research, University of Liverpool, Liverpool, UK
| | - Caitlin B O'Hara
- Department of Psychological Sciences, North West Hub for Trials Methodology Research, University of Liverpool, Liverpool, UK
| | - Paul R Mouncey
- Clinical Trials Unit, Intensive Care National Audit and Research Centre, London, UK
| | - Zohra Zenasni
- Clinical Trials Unit, Intensive Care National Audit and Research Centre, London, UK
| | - Nicholas Hudson
- Clinical Trials Unit, Intensive Care National Audit and Research Centre, London, UK
| | - Steven Saunders
- Clinical Trials Unit, Intensive Care National Audit and Research Centre, London, UK
| | | | | | - Mark D Lyttle
- Faculty of Health and Applied Sciences, University of the West of England, Bristol, UK
| | - Simon Nadel
- Paediatric Intensive Care Unit, St Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Mark J Peters
- Respiratory, Critical Care and Anaesthesia Section, University College London Great Ormond Street Institute of Child Health, London, UK
| | - David A Harrison
- Clinical Trials Unit, Intensive Care National Audit and Research Centre, London, UK
| | - Kathryn M Rowan
- Clinical Trials Unit, Intensive Care National Audit and Research Centre, London, UK
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Robinson AHN, Johnson-Lynn SE, Humphrey JA, Haddad FS. The challenges of translating the results of randomized controlled trials in orthopaedic surgery into clinical practice. Bone Joint J 2019; 101-B:121-123. [DOI: 10.1302/0301-620x.101b2.bjj-2018-1352.r1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
| | | | - J. A. Humphrey
- Milton Keynes University Hospital NHS Foundation Trust, Milton Keynes, UK
| | - F. S. Haddad
- The Bone & Joint Journal, Professor of Orthopaedic Surgery, University College London Hospitals, The Princess Grace Hospital, and The NIHR Biomedical Research Unit at UCLH, London, UK
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Byrne BE, Rooshenas L, Lambert H, Blazeby JM. Evidence into practice: protocol for a new mixed-methods approach to explore the relationship between trials evidence and clinical practice through systematic identification and analysis of articles citing randomised controlled trials. BMJ Open 2018; 8:e023215. [PMID: 30413510 PMCID: PMC6231588 DOI: 10.1136/bmjopen-2018-023215] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Randomised controlled trials (RCTs) provide high-quality evidence to inform practice. However, much routine care is not based on available RCT evidence. Understanding this disconnect may improve trial design, reporting and implementation. Published literature commenting on RCTs may yield relevant insights. This protocol presents a new approach examining how researchers understand, contextualise and use evidence from RCTs, through analysis of letters, editorials and discussion pieces citing individual RCTs. Surgical case studies will illustrate its ability to identify wide-ranging factors influencing application of trials evidence. METHODS AND ANALYSIS In-depth study of published literature will explore written responses to RCTs. After purposefully selecting individual RCTs, we will systematically identify all citing articles covered in Web of Science and Scopus. Editorials, discussions and letters will be included. These are considered most likely to provide critiques and opinions about index RCTs. Original articles and reviews will be excluded. Clinical specialty, RCT design, outcomes and bibliographical data will be collected for RCTs and citing articles. Citing articles will be thematically analysed using the constant comparison technique to explore author understanding, contextualisation and relationship to clinical practice for the index trial. Coding will include generic issues relevant to all RCTs, such as sample size or blinding, and features specific to surgery, such as learning curve. Index trial quality will be examined using validated tools. Results will be combined to create a broad overview of the understanding and use of RCT evidence. ETHICS AND DISSEMINATION This study involves secondary use of existing articles and does not require ethical approval. Pilot work will establish its feasibility and inform progression to larger scale utilisation across a broad range of RCTs. Findings will be published in a peer-reviewed journal and presented at surgical and methodological conferences. Results will guide future work on trial design to optimise implementation of results.
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Affiliation(s)
- Benjamin E Byrne
- Centre for Surgical Research, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Leila Rooshenas
- Centre for Surgical Research, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Helen Lambert
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Jane M Blazeby
- Centre for Surgical Research, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
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Cook JA, Campbell MK, Gillies K, Skea Z. Surgeons' and methodologists' perceptions of utilising an expertise-based randomised controlled trial design: a qualitative study. Trials 2018; 19:478. [PMID: 30189868 PMCID: PMC6127897 DOI: 10.1186/s13063-018-2832-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Accepted: 08/01/2018] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Randomised controlled trials (RCTs) are widely recognised to be the most rigorous way to test new and emerging clinical interventions. When the interventions under study are two different surgical procedures, however, surgeons are required to be trained and sufficiently proficient in the different surgical approaches to take part in such a trial. It is often the case that even where surgeons can perform both trial surgical procedures, they have a preference and/or have more expertise in one of the procedures. The expertise-based trial design, where participating surgeons only provide the procedure in which they have appropriate expertise, has been proposed to overcome this problem. When expertise-based designs should be best used remains unclear; such approaches may be more suited to addressing specific questions. The aim of this qualitative study was to improve understanding about the range of views that surgeons and methodologists have regarding the use of the expertise-based RCT design. METHODS Twelve individual interviews with surgeons and methodologists with experience of surgical trials were conducted. Interviews were semi-structured and conducted face-to-face or by telephone. Interviews were audio-recorded, transcribed and analysed systematically using an interpretive approach. RESULTS Both surgeons and methodologists saw potential advantages in the expertise-based design particularly in terms of surgeons' participation and in trials where the procedures being evaluated were significantly different. The main disadvantages identified were methodological (e.g. the potential for surgeons carrying out one of the trial procedure being systematically different) and operational (e.g. the need to 'transfer' patients between surgeons with potential consequences for the surgeon/patient relationship). CONCLUSION This study suggests that the expertise-based trial design has significant potential to increase surgeon participation in trials in some settings. In other settings the standard design was generally seen as the preferable design. Particularly suitable conditions for an expertise-based design include those where the surgical procedures under evaluation are substantially different, where they are routinely delivered by different health professionals/surgeons with clear proficiencies in each; and contexts in which a multiple-surgeon model is in use and trust between the patient and surgeons can be suitably protected. The standard design was seen by most participants as the default design. Several logistical and methodological concerns remain to be addressed before the expertise-based design is likely to be more widely adopted.
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Affiliation(s)
- Jonathan A Cook
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Windmill Rd, Oxford, OX3 7LD, UK. .,Surgical Intervention Trials Unit, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Botnar Research Centre, Windmill Rd, Oxford, OX3 7LD, UK.
| | - Marion K Campbell
- Health Services Research Unit, University of Aberdeen, Health Sciences Building, Foresterhill, Aberdeen, AB25 2ZD, UK
| | - Katie Gillies
- Health Services Research Unit, University of Aberdeen, Health Sciences Building, Foresterhill, Aberdeen, AB25 2ZD, UK
| | - Zoë Skea
- Health Services Research Unit, University of Aberdeen, Health Sciences Building, Foresterhill, Aberdeen, AB25 2ZD, UK
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Frost J, Gibson A, Harris-Golesworthy F, Harris J, Britten N. Patient involvement in qualitative data analysis in a trial of a patient-centred intervention: Reconciling lay knowledge and scientific method. Health Expect 2018; 21:1111-1121. [PMID: 30073734 PMCID: PMC6250869 DOI: 10.1111/hex.12814] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/19/2018] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND We conducted a pilot study of an intervention to facilitate patients' agenda setting in clinical consultations. The primary aim of the study was to test the feasibility of running the randomized controlled trial. A secondary objective was to assess the extent to which patient and public involvement (PPI) could contribute to the process of qualitative data analysis (QDA). AIMS To describe a novel approach to including patient partners in QDA; to illustrate the kinds of contribution that patient partners made to QDA in this context; and to propose a characterization of a process by which patient involvement can contribute to knowledge production. METHODS Six patient and public representatives were supported to contribute to data analysis via a range of modalities. During a series of QDA workshops, experienced research staff role-played consultations and interviews, and provided vignettes. Workshop data and PPI diaries were analysed using thematic discourse analysis. RESULTS We characterized a process of thesis, antithesis and synthesis. This PPI group contributed to the rigour and validity of the study findings by challenging their own and the researchers' assumptions, and by testing the emerging hypotheses. By training PPI representatives to undertake qualitative data analysis, we transformed our understanding of doctor-patient consultations. CONCLUSIONS This research required changes to our usual research practices but was in keeping with the objective of establishing meaningful patient involvement for a future definitive trial. This work was informed by concepts of critical humility, and a process of knowledge production enabled via the construction of a knowledge space.
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Affiliation(s)
- Julia Frost
- University of Exeter Medical School, Exeter, UK
| | - Andy Gibson
- Department of Health and Social Sciences, University of West England, Bristol, UK
| | | | - Jim Harris
- PenCLAHRC Patient and Public Involvement Team, University of Exeter Medical School, Exeter, UK
| | - Nicky Britten
- University of Exeter Medical School, University of Exeter, Exeter, UK
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Minns Lowe CJ, Moser J, Barker KL. Why participants in The United Kingdom Rotator Cuff Tear (UKUFF) trial did not remain in their allocated treatment arm: a qualitative study. Physiotherapy 2018; 104:224-231. [DOI: 10.1016/j.physio.2017.09.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2017] [Accepted: 09/06/2017] [Indexed: 11/28/2022]
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Leighton PA, Brealey SD, Dias JJ. Interventions to improve retention in a surgical, clinical trial: A pragmatic, stakeholder-driven approach. J Evid Based Med 2018; 11:12-19. [PMID: 29356437 DOI: 10.1111/jebm.12271] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Accepted: 07/23/2017] [Indexed: 01/11/2023]
Abstract
OBJECTIVE To explore stakeholder perspectives upon participant retention in clinical trials, and to generate strategies to support retention in a surgical, clinical trial. STUDY DESIGN AND SETTING The SWIFFT trial is a multicenter study comparing treatments for the fracture of the waist of the scaphoid bone in adults. Here we report upon a multistage, iterative consultative process with SWIFFT stakeholders, these include workshops with members of the public, with nurses involved in data collection, and with consultant clinicians. Structured discussions were digitally recorded and transcribed, data were handled and analyzed following a framework approach to qualitative data analysis. RESULTS Removing practical barriers were identified as important factors in supporting retention. Stakeholders also identified that (i) how well a study is understood and (ii) how much it is valued are important factors in an individual's willingness to maintain their involvement. A number of strategies resulted from this consultation, these include: in-clinic data collection, co-ordinated clinical and research appointments, a SWIFFT website, and newsletter. CONCLUSION A participatory approach to trial retention might engage all relevant stakeholders in the delivery of a clinical trial, it might also support the generation of specific and contextually relevant solutions to the challenge of participant retention.
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Affiliation(s)
- Paul A Leighton
- School of Medicine, University of Nottingham, Nottingham, UK
| | - Stephen D Brealey
- York Trials Unit, Department of Health Sciences, University of York, York, UK
| | - Joseph J Dias
- Clinical Division of Orthopaedic Surgery, University Hospitals of Leicester NHS Trust, Leicester, UK
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26
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Understanding and Improving Recruitment to Randomised Controlled Trials: Qualitative Research Approaches. Eur Urol 2017; 72:789-798. [DOI: 10.1016/j.eururo.2017.04.036] [Citation(s) in RCA: 83] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Accepted: 04/28/2017] [Indexed: 11/22/2022]
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Presseau J, Mutsaers B, Al-Jaishi AA, Squires J, McIntyre CW, Garg AX, Sood MM, Grimshaw JM. Barriers and facilitators to healthcare professional behaviour change in clinical trials using the Theoretical Domains Framework: a case study of a trial of individualized temperature-reduced haemodialysis. Trials 2017; 18:227. [PMID: 28532509 PMCID: PMC5440991 DOI: 10.1186/s13063-017-1965-9] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2016] [Accepted: 04/30/2017] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Implementing the treatment arm of a clinical trial often requires changes to healthcare practices. Barriers to such changes may undermine the delivery of the treatment making it more likely that the trial will demonstrate no treatment effect. The 'Major outcomes with personalized dialysate temperature' (MyTEMP) is a cluster-randomised trial to be conducted in 84 haemodialysis centres across Ontario, Canada to investigate whether there is a difference in major outcomes with an individualized dialysis temperature (IDT) of 0.5 °C below a patient's body temperature measured at the beginning of each haemodialysis session, compared to a standard dialysis temperature of 36.5 °C. To inform how to deploy the IDT across many haemodialysis centres, we assessed haemodialysis physicians' and nurses' perceived barriers and enablers to IDT use. METHODS We developed two topic guides using the Theoretical Domains Framework (TDF) to assess perceived barriers and enablers to IDT ordering and IDT setting (physician and nurse behaviours, respectively). We recruited a purposive sample of haemodialysis physicians and nurses from across Ontario and conducted in-person or telephone interviews. We used directed content analysis to double-code transcribed utterances into TDF domains, and inductive thematic analysis to develop themes. RESULTS We interviewed nine physicians and nine nurses from 11 Ontario haemodialysis centres. We identified seven themes of potential barriers and facilitators to implementing IDTs: (1) awareness of clinical guidelines and how IDT fits with local policies (knowledge; goals), (2) benefits and motivation to use IDT (beliefs about consequences; optimism; reinforcement; intention; goals), (3) alignment of IDTs with usual practice and roles (social/professional role and identity; nature of the behaviour; beliefs about capabilities), (4) thermometer availability/accuracy and dialysis machine characteristics (environmental context and resources), (5) impact on workload (beliefs about consequences; beliefs about capabilities), (6) patient comfort (behavioural regulation; beliefs about consequences; emotion), and (7) forgetting to prescribe or set IDT (memory, attention, decision making processes; emotion). CONCLUSIONS There are anticipatable barriers to changing healthcare professionals' behaviours to effectively deliver an intervention within a randomised clinical trial. A behaviour change framework can help to systematically identify such barriers to inform better delivery and evaluation of the treatment, therefore potentially increasing the fidelity of the intervention to increase the internal validity of the trial. These findings will be used to optimise the delivery of IDT in the MyTEMP trial and demonstrate how this approach can be used to plan intervention delivery in other clinical trials. TRIAL REGISTRATION ClinicalTrials.gov NCT02628366 . Registered November 16 2015.
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Affiliation(s)
- Justin Presseau
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, General Campus, 501 Smyth Road, Ottawa, Canada
- School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa, Ottawa, Canada
| | - Brittany Mutsaers
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, General Campus, 501 Smyth Road, Ottawa, Canada
- School of Psychology, University of Ottawa, Ottawa, Canada
| | - Ahmed A. Al-Jaishi
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON Canada
| | - Janet Squires
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, General Campus, 501 Smyth Road, Ottawa, Canada
- School of Nursing, University of Ottawa, Ottawa, Canada
| | - Christopher W. McIntyre
- Division of Nephrology, Departments of Medicine, Epidemiology and Biostatistics, Western University, London, ON Canada
| | - Amit X. Garg
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON Canada
- Division of Nephrology, Departments of Medicine, Epidemiology and Biostatistics, Western University, London, ON Canada
| | - Manish M. Sood
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, General Campus, 501 Smyth Road, Ottawa, Canada
- School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa, Ottawa, Canada
| | - Jeremy M. Grimshaw
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, General Campus, 501 Smyth Road, Ottawa, Canada
- School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa, Ottawa, Canada
- Department of Medicine, University of Ottawa, Ottawa, Canada
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Staff experiences of closing out a clinical trial involving withdrawal of treatment: qualitative study. Trials 2017; 18:61. [PMID: 28173843 PMCID: PMC5297163 DOI: 10.1186/s13063-017-1813-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2016] [Accepted: 01/24/2017] [Indexed: 11/10/2022] Open
Abstract
Background The ending of a clinical trial may be challenging, particularly if staff are required to withdraw the investigated treatment(s); however, this aspect of trial work is surprisingly under-researched. To address this gap, we explored the experiences of staff involved in closing out a trial that entailed withdrawal of treatment (insulin pumps) from some patients. Methods Interviews were conducted with n = 22 staff, recruited from seven trial sites. Data were analysed thematically. Results Staff described a myriad of ethical and emotional challenges at closeout, many of which had been unforeseen when the trial began. A key challenge for staff was that, while patients gave their agreement to participate on the understanding that pump treatment could be withdrawn, they often found themselves benefitting from this regimen in ways they could not have foreseen. Hence, as the trial progressed, patients became increasingly anxious about withdrawal of treatment. This situation forced staff to consider whether the consent patients had given at the outset remained valid; it also presented them with a dilemma at closeout because many of those who had wanted to remain on a pump did not meet the clinical criteria required for post-trial funding. When deciding whether to withdraw treatment, staff not only had to take funding pressures and patient distress into account, but they also found themselves caught between an ethic of Hippocratic individualism and one of utilitarianism. These conflicting pressures and ethical considerations resulted in staff decision-making varying across the sites, an issue that some described as a further source of ethical unease. Staff concluded that, had there been more advanced planning and discussion, and greater accountability to an ethics committee, some of the challenges they had confronted at closeout could have been lessened or even prevented. Conclusions The same kinds of ethical issues that may vex staff at the beginning of a trial (e.g. patients having unrealistic expectations of trial participation; staff experiencing conflicts between research and clinical roles) may re-present themselves at the end. To safeguard the wellbeing of staff and patients, greater planning, coordination and ethical oversight should go into the closeout of trials involving withdrawal of treatment(s). Trial registration International Standard Randomised Controlled Trials Number (ISRCTN) Registry, ISRCTN61215213. Registered on 11 May 2011 Electronic supplementary material The online version of this article (doi:10.1186/s13063-017-1813-y) contains supplementary material, which is available to authorized users.
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Donovan JL, Rooshenas L, Jepson M, Elliott D, Wade J, Avery K, Mills N, Wilson C, Paramasivan S, Blazeby JM. Optimising recruitment and informed consent in randomised controlled trials: the development and implementation of the Quintet Recruitment Intervention (QRI). Trials 2016; 17:283. [PMID: 27278130 PMCID: PMC4898358 DOI: 10.1186/s13063-016-1391-4] [Citation(s) in RCA: 151] [Impact Index Per Article: 18.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2015] [Accepted: 05/06/2016] [Indexed: 11/27/2022] Open
Abstract
Background Pragmatic randomised controlled trials (RCTs) are considered essential to determine effective interventions for routine clinical practice, but many fail to recruit participants efficiently, and some really important RCTs are not undertaken because recruitment is thought to be too difficult. The ‘QuinteT Recruitment Intervention’ (QRI) aims to facilitate informed decision making by patients about RCT participation and to increase recruitment. This paper presents the development and implementation of the QRI. Methods The QRI developed iteratively as a complex intervention. It emerged from the National Institute for Health Research (NIHR) ProtecT trial and has been developed further in 13 RCTs. The final version of the QRI uses a combination of standard and innovative qualitative research methods with some simple quantification to understand recruitment and identify sources of difficulties. Results The QRI has two major phases: understanding recruitment as it happens and then developing a plan of action to address identified difficulties and optimise informed consent in collaboration with the RCT chief investigator (CI) and the Clinical Trials Unit (CTU). The plan of action usually includes RCT-specific, as well as generic, aspects. The QRI can be used in two ways: it can be integrated into the feasibility/pilot or main phase of an RCT to prevent difficulties developing and optimise recruitment from the start, or it can be applied to an ongoing RCT experiencing recruitment shortfalls, with a view to rapidly improving recruitment and informed consent or gathering evidence to justify RCT closure. Conclusions The QRI provides a flexible way of understanding recruitment difficulties and producing a plan to address them while ensuring engaged and well-informed decision making by patients. It can facilitate recruitment to the most controversial and important RCTs. QRIs are likely to be of interest to the CIs and CTUs developing proposals for ‘difficult’ RCTs or for RCTs with lower than expected recruitment and to the funding bodies wishing to promote efficient recruitment in pragmatic RCTs. Electronic supplementary material The online version of this article (doi:10.1186/s13063-016-1391-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Jenny L Donovan
- School of Social and Community Medicine, University of Bristol, Bristol, BS8 2PR, UK. .,Collaboration for Leadership in Applied Health Research and Care West at University Hospitals Bristol, Bristol, BS1 2NT, UK.
| | - Leila Rooshenas
- School of Social and Community Medicine, University of Bristol, Bristol, BS8 2PR, UK
| | - Marcus Jepson
- School of Social and Community Medicine, University of Bristol, Bristol, BS8 2PR, UK
| | - Daisy Elliott
- School of Social and Community Medicine, University of Bristol, Bristol, BS8 2PR, UK
| | - Julia Wade
- School of Social and Community Medicine, University of Bristol, Bristol, BS8 2PR, UK
| | - Kerry Avery
- School of Social and Community Medicine, University of Bristol, Bristol, BS8 2PR, UK
| | - Nicola Mills
- School of Social and Community Medicine, University of Bristol, Bristol, BS8 2PR, UK
| | - Caroline Wilson
- School of Social and Community Medicine, University of Bristol, Bristol, BS8 2PR, UK
| | - Sangeetha Paramasivan
- School of Social and Community Medicine, University of Bristol, Bristol, BS8 2PR, UK
| | - Jane M Blazeby
- School of Social and Community Medicine, University of Bristol, Bristol, BS8 2PR, UK
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Hallowell N, Snowdon C, Morrow S, Norman JE, Denison FC, Lawton J. The role of therapeutic optimism in recruitment to a clinical trial in a peripartum setting: balancing hope and uncertainty. Trials 2016; 17:267. [PMID: 27245155 PMCID: PMC4888535 DOI: 10.1186/s13063-016-1394-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2016] [Accepted: 04/30/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Hope has therapeutic value because it enables people to cope with uncertainty about their future health. Indeed, hope, or therapeutic optimism (TO), is seen as an essential aspect of the provision and experience of medical care. The role of TO in clinical research has been briefly discussed, but the concept, and whether it can be transferred from care to research and from patients to clinicians, has not been fully investigated. The role played by TO in research emerged during interviews with staff involved in a peripartum trial. This paper unpacks the concept of TO in this setting and considers the role it may play in the wider delivery of clinical trials. METHODS The Got-it trial is a UK-based, randomised placebo-controlled trial that investigates the use of sublingual glyceryl trinitrate (GTN) spray to treat retained placenta. Qualitative data were collected in open-ended interviews with obstetricians, research and clinical midwives (n =27) involved in trial recruitment. Data were analysed using the method of constant comparison. RESULTS TO influenced staff engagement with Got-it at different points in the trial and in different ways. Prior knowledge of, and familiarity with, GTN meant that from the outset staff perceived the trial as low risk. TO facilitated staff involvement in the trial; staff who already understood GTN's effects were optimistic that it would work, and staff collaborated because they hoped that the trial would address what they identified as an important clinical need. TO could fluctuate over the course of the trial, and was sustained or undermined by unofficial observation of clinical outcomes and speculations about treatment allocation. Thus, TO appeared to be influenced by key situational factors: prior knowledge and experience, clinical need and observed participant outcomes. CONCLUSIONS Situational TO plays a role in facilitating staff engagement with clinical research. TO may affect trial recruitment by enabling staff to sustain the levels of uncertainty, or individual equipoise, necessary to collaborate with research while also responding to patients' clinical needs. Staff may benefit from training to deal with fluctuations in TO. TRIAL REGISTRATION ISCRTN88609453 . Registered on 26 March 2014.
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Affiliation(s)
- Nina Hallowell
- Ethox Centre, Nuffield Department of Population Health, University of Oxford, Oxford, OX3 7LF, UK.
| | - Claire Snowdon
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, UK
| | - Susan Morrow
- Centre for Population Health Sciences, University of Edinburgh, Edinburgh, UK
| | - Jane E Norman
- MRC Centre for Reproductive Health, University of Edinburgh, Edinburgh, UK
| | - Fiona C Denison
- MRC Centre for Reproductive Health, University of Edinburgh, Edinburgh, UK
| | - Julia Lawton
- Centre for Population Health Sciences, University of Edinburgh, Edinburgh, UK
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Handoll HHG. Not quite what was planned: accommodating the reality of clinical practice in Cochrane Reviews. Cochrane Database Syst Rev 2016; 4:ED000112. [PMID: 27103345 PMCID: PMC10845856 DOI: 10.1002/14651858.ed000112] [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] [Indexed: 11/09/2022]
Affiliation(s)
- Helen HG Handoll
- Teesside UniversityHealth and Social Care InstituteMiddlesbroughUK
- Cochrane Bone, Joint, and Muscle Trauma Group
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Rushforth A. Meeting pragmatism halfway: making a pragmatic clinical trial protocol. SOCIOLOGY OF HEALTH & ILLNESS 2015; 37:1285-1298. [PMID: 26235211 DOI: 10.1111/1467-9566.12311] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Pragmatic clinical trials (PCTs) are today an increasingly prominent means of measuring the 'effectiveness' of healthcare interventions in 'real world' clinical settings, in order to produce evidence on which to base regulatory and clinical decision-making. Although several sociological studies have shown persuasively how PCTs are co-constructed within particular healthcare systems in which they are based, they have tended to focus on relatively later stages in careers of trials. The paper contributes to literature by considering how the 'real world' of the UK National Health Service (NHS) is incorporated into the design of a research protocol. Drawing on a meeting held just prior to patient recruitment for a PCT in maternal health, the paper analyses a trial collective's efforts to purify the messy domain of NHS clinical care into the orderly confines of the protocol (Law 2004), which meant satisfying demands for both scientific and social robustness (c.f. Nowotny et al. 2001). The findings show how efforts to inscribe robustness into the PCT protocol were themselves mediated through epistemic and regulatory conventions surrounding protocols as devices in healthcare research. Finally it is argued that meetings constitute an important epistemic instrument through which to settle various emerging tensions in PCT protocol design.
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Perlman A, Dreusicke M, Keever T, Ali A. Perceptions of Massage Therapists Participating in a Randomized Controlled Trial. Int J Ther Massage Bodywork 2015; 8:10-5. [PMID: 26388961 PMCID: PMC4560530 DOI: 10.3822/ijtmb.v8i3.278] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Background Clinical practice and randomized trials often have disparate aims, despite involving similar interventions. Attitudes and expectancies of practitioners influence patient outcomes, and there is growing emphasis on optimizing provider–patient relationships. In this study, we evaluated the experiences of licensed massage therapists involved in a randomized controlled clinical trial using qualitative methodology. Methods Seven massage therapists who were interventionists in a randomized controlled trial participated in structured interviews approximately 30 minutes in length. Interviews focused on their experiences and perceptions regarding aspects of the clinical trial, as well as recommendations for future trials. Transcribed interviews were analyzed for emergent topics and themes using standard qualitative methods. Results Six themes emerged. Therapists discussed 1) promoting the profession of massage therapy through research, 2) mixed views on using standardized protocols, 3) challenges of sham interventions, 4) participant response to the sham intervention, 5) views on scheduling and compensation, and 6) unanticipated benefits of participating in research. Conclusions Therapists largely appreciated the opportunity to promote massage through research. They demonstrated insight and understanding of the rationale for a clinical trial adhering to a standardized protocol. Evaluating the experiences and ideas of complementary and alternative medicine practitioners provides valuable insight that is relevant for the implementation and design of randomized trials.
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Affiliation(s)
- Adam Perlman
- Duke Integrative Medicine, Duke University, Durham, NC, USA
| | - Mark Dreusicke
- Duke Integrative Medicine, Duke University, Durham, NC, USA
| | - Teresa Keever
- Duke Integrative Medicine, Duke University, Durham, NC, USA
| | - Ather Ali
- Department of Pediatrics, Yale University, New Haven, CT, USA
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Stuart J, Barnes J, Spiby H, Elbourne D. Understanding barriers to involving community midwives in identifying research participants; experience of the first steps randomised controlled trial. Midwifery 2015; 31:779-86. [PMID: 25981807 DOI: 10.1016/j.midw.2015.04.011] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2014] [Revised: 03/24/2015] [Accepted: 04/22/2015] [Indexed: 11/29/2022]
Abstract
OBJECTIVE to explore barriers to the involvement of community midwives in identifying women in early pregnancy as potential participants in the first steps study, a randomised controlled trial of a new intervention to provide health and parenting support to potentially vulnerable women. DESIGN descriptive qualitative investigation using semi-structured audio-recorded interviews. SETTING community midwifery offices. PARTICIPANTS volunteer sample of 13 community midwives. MEASUREMENT themes derived from content analysis. FINDINGS understanding of their role in the research process was unclear to many midwives. Confusion arose about the difference between potential participant identification and trial recruitment. There were concerns about the eligibility criteria and it was suggested that there was insufficient time during booking appointments, and sometimes insufficient information, to determine potential eligibility. Midwives had concerns about some aspects of the intervention, which incorporated routine midwifery care, and had expectations that women may not like a group programme. This may have led some not to mention the trial. They were, however positive about the programme׳s potential for beneficial impacts on mothers and infants. KEY CONCLUSIONS dedicated research midwives may be the best option if research studies need to identify potential participants early in pregnancy, so that they can communicate with all their colleagues. IMPLICATIONS FOR PRACTICE if community midwives are asked to be involved in time-critical research they are likely to need additional local resources and support.
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Affiliation(s)
- Jane Stuart
- Institute for the Study of Children, Families and Social Issues, Department of Psychological Sciences, Birkbeck, University of London, Malet Street, London WC1E 7HX, UK.
| | - Jacqueline Barnes
- Institute for the Study of Children, Families and Social Issues, Department of Psychological Sciences, Birkbeck, University of London, Malet Street, London WC1E 7HX, UK.
| | - Helen Spiby
- School of Health Sciences, 12th Floor, Tower Building, University of Nottingham, Nottingham NG7 2RD, UK.
| | - Diana Elbourne
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, University of London, Keppel Street, London WC1E 7HT, UK.
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Hawe P, Riley T, Gartrell A, Turner K, Canales C, Omstead D. Comparison communities in a cluster randomised trial innovate in response to 'being controlled'. Soc Sci Med 2015; 133:102-10. [PMID: 25863725 DOI: 10.1016/j.socscimed.2015.03.033] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
We conducted qualitative interviews among primary health care teams and community agencies in eight communities in Victoria, Australia which had (1) agreed to be part of a universal primary care and community development intervention to reduce post natal depression and promote maternal health; and (2) were randomised to the comparison arm. The purpose was to document their experience with and interpretation of the trial. Although 'control' in a controlled trial refers to the control of confounding of the trial result by factors other than allocation to the intervention, participants interpreted 'control' to mean restrictions on what they were allowed to do during the trial period. They had agreed not to use the Edinburgh Post Natal Depression Scale or the SF 36 in clinical practice and not to implement any of the elements of the intervention. We found that no elements of the intervention were implemented. However, the extension of the trial from three to five years made the trial agreement a strain. The imposition of trial conditions also encouraged a degree of lateral thinking and innovation in service delivery (quality improvement). This may have potentially contributed to the null trial results. The observations invite interrogation of intervention theory and consequent rethinking of the way contamination in a cluster trial is defined.
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Affiliation(s)
- Penelope Hawe
- Menzies Centre for Health Policy, University of Sydney, Australia; The Australian Prevention Partnership Centre, Australia.
| | - Therese Riley
- Judith Lumley Centre, LaTrobe University (Now based at Centre of Excellence in Intervention and Prevention Science, Melbourne), Australia
| | - Alexandra Gartrell
- Judith Lumley Centre, Now based at School of Geography and Environmental Sciences, Monash University, Australia
| | - Karen Turner
- Centre for Health and Society, Melbourne School of Population and Global Health, University of Melbourne (Now based at Department of Anthropology, School of Social and Political Sciences, University of Melbourne, Australia
| | - Claudia Canales
- O'Brien Institute of Public Health, University of Calgary, Canada
| | - Darlene Omstead
- O'Brien Institute of Public Health, University of Calgary, Canada
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Being a surgeon--the myth and the reality: a meta-synthesis of surgeons' perspectives about factors affecting their practice and well-being. Ann Surg 2015; 260:721-8; discussion 728-9. [PMID: 25379843 DOI: 10.1097/sla.0000000000000962] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES Synthesize the findings from individual qualitative studies about surgeons' account of their practice. BACKGROUND Social and contextual factors of practice influence doctors' well-being and therapeutic relationships. Little is known about surgery, but it is generally assumed that surgeons are not affected by them. METHODS We searched international publications (2000-2012) to identify relevant qualitative research exploring how surgeons talk about their practice. Meta-ethnography (a systematic analysis of qualitative literature that compensates for the potential lack of generalizability of the primary studies and provides new insight by their conjoint interpretation) was used to identify key themes and synthesize them. RESULTS We identified 51 articles (>1000 surgeons) from different specialties and countries. Two main themes emerged. (i) The patient-surgeon relationship, described surgeons' characterizations of their relationships with patients. We identified factors influencing surgical decision making, communication, and personal involvement in the process of care; these were surgeon-related, patient-related, and contextual. (ii) Group relations and culture described perceived issues related to surgical culture (image and education, teamwork, rules, and guidelines); it highlighted the influence of a social dimension on surgical practice. In both themes, we uncovered an emotional dimension of surgeons' practice. CONCLUSIONS Surgeons' emphasis on technical aspects, individuality, and performance seems to impede a modern patient-centered approach to care and to act as a barrier to well-being. Our findings suggest that taking into account the relational and emotional dimensions of surgical practice (both with patients and within the institution) might improve surgical innovation, surgeons' well-being, and the attractiveness of this specialty.
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Smyth RMD, Jacoby A, Altman DG, Gamble C, Williamson PR. The natural history of conducting and reporting clinical trials: interviews with trialists. Trials 2015; 16:16. [PMID: 25619208 PMCID: PMC4322554 DOI: 10.1186/s13063-014-0536-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2014] [Accepted: 12/19/2014] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND To investigate the nature of the research process as a whole, factors that might influence the way in which research is carried out, and how researchers ultimately report their findings. METHODS Semi-structured qualitative telephone interviews with authors of trials, identified from two sources: trials published since 2002 included in Cochrane systematic reviews selected for the ORBIT project; and trial reports randomly sampled from 14,758 indexed on PubMed over the 12-month period from August 2007 to July 2008. RESULTS A total of 268 trials were identified for inclusion, 183 published since 2002 and included in the Cochrane systematic reviews selected for the ORBIT project and 85 randomly selected published trials indexed on PubMed. The response rate from researchers in the former group was 21% (38/183) and in the latter group was 25% (21/85). Overall, 59 trialists were interviewed from the two different sources. A number of major but related themes emerged regarding the conduct and reporting of trials: establishment of the research question; identification of outcome variables; use of and adherence to the study protocol; conduct of the research; reporting and publishing of findings. Our results reveal that, although a substantial proportion of trialists identify outcome variables based on their clinical experience and knowing experts in the field, there can be insufficient reference to previous research in the planning of a new trial. We have revealed problems with trial recruitment: not reaching the target sample size, over-estimation of recruitment potential and recruiting clinicians not being in equipoise. We found a wide variation in the completeness of protocols, in terms of detailing study rationale, outlining the proposed methods, trial organisation and ethical considerations. CONCLUSION Our results confirm that the conduct and reporting of some trials can be inadequate. Interviews with researchers identified aspects of clinical research that can be especially challenging: establishing appropriate and relevant outcome variables to measure, use of and adherence to the study protocol, recruiting of study participants and reporting and publishing the study findings. Our trialists considered the prestige and impact factors of academic journals to be the most important criteria for selecting those to which they would submit manuscripts.
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Affiliation(s)
- Rebecca M D Smyth
- School of Nursing, Midwifery and Social Work, University of Manchester, Manchester, M13 9PL, UK.
| | - Ann Jacoby
- Division of Public Health, University of Liverpool, Liverpool, L69 3GB, UK.
| | - Douglas G Altman
- Centre for Statistics in Medicine, University of Oxford, Oxford, OX2 6UD, UK.
| | - Carrol Gamble
- Centre for Medical Statistics and Health Evaluation, University of Liverpool, Liverpool, L69 3GS, UK.
| | - Paula R Williamson
- Centre for Medical Statistics and Health Evaluation, University of Liverpool, Liverpool, L69 3GS, UK.
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Lawton J, Kirkham J, White D, Rankin D, Cooper C, Heller S. Uncovering the emotional aspects of working on a clinical trial: a qualitative study of the experiences and views of staff involved in a type 1 diabetes trial. Trials 2015; 16:3. [PMID: 25566971 PMCID: PMC4326295 DOI: 10.1186/1745-6215-16-3] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2014] [Accepted: 12/03/2014] [Indexed: 11/17/2022] Open
Abstract
Background The perspectives and experiences of trial staff are increasingly being investigated as these can be used to improve recruitment, adherence to trial protocols and support given to future staff. We interviewed staff working on a type 1 diabetes trial in order to aid interpretation of trial findings, inform recommendations for the rollout of the treatments investigated and provide recommendations for the conduct of future trials. However, our interviews uncovered aspects of trial work erstwhile unrecognised or underreported in the trials literature, and it is these which form the focus of this paper. Methods In-depth interviews were conducted with (n = 18) staff, recruited from seven centres, who were involved in recruitment and trial delivery. Data were analysed thematically. Results Alongside logistical and practical issues which made trial work challenging, staff often talked spontaneously and at length about how trial work had affected them emotionally. Staff not only described the emotional stresses arising from having to meet recruitment targets and from balancing research roles with clinical responsibilities, they also discussed having to emotionally manage patients and their colleagues. The emotional aspects of trial work particularly came to the fore when staff notified patients about their treatment allocation. On such occasions, staff described having to employ emotional strategies to pre-empt and manage potential patient disappointment and anger. Staff also described having to manage their own emotions when patients withdrew from the trial or were not randomised to the treatment arm which, in their clinical judgment, would have been in their best interests. To help address the emotional challenges they encountered, staff highlighted a need for more practical, emotional and specialist psychological support. Conclusions More attention should be paid to the emotional aspects of trial work to help ensure trial staff are adequately supported. Such support could comprise: increased training for staff to improve their own and patients’ understandings of randomization, role-play to develop techniques to manage patient anger and disappointment, sharing of good practice, formalised team support with psychological input and access to specialist psychological support to troubleshoot complex emotional and ethical issues.
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Affiliation(s)
- Julia Lawton
- Centre for Population Health Sciences, University of Edinburgh, Teviot Place, Edinburgh EH8 9AG, UK.
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Bower P, Brueton V, Gamble C, Treweek S, Smith CT, Young B, Williamson P. Interventions to improve recruitment and retention in clinical trials: a survey and workshop to assess current practice and future priorities. Trials 2014; 15:399. [PMID: 25322807 PMCID: PMC4210542 DOI: 10.1186/1745-6215-15-399] [Citation(s) in RCA: 235] [Impact Index Per Article: 23.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2014] [Accepted: 09/30/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Despite significant investment in infrastructure many trials continue to face challenges in recruitment and retention. We argue that insufficient focus has been placed on the development and testing of recruitment and retention interventions. METHODS In this current paper, we summarize existing reviews about interventions to improve recruitment and retention. We report survey data from Clinical Trials Units in the United Kingdom to indicate the range of interventions used by these units to encourage recruitment and retention. We present the views of participants in a recent workshop and a priority list of recruitment interventions for evaluation (determined by voting among workshop participants). We also discuss wider issues concerning the testing of recruitment interventions. RESULTS Methods used to encourage recruitment and retention were categorized as: patient contact, patient convenience, support for recruiters, monitoring and systems, incentives, design, resources, and human factors. Interventions felt to merit investigation by respondents fell into three categories: training site staff, communication with patients, and incentives. CONCLUSIONS Significant resources continue to be invested into clinical trials and other high quality studies, but recruitment remains a significant challenge. Adoption of innovative methods to develop, test, and implement recruitment interventions are required.
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Affiliation(s)
- Peter Bower
- />National Institute for Health Research School for Primary Care Research, North West Hub for Trials Methodology Research, University of Manchester, Oxford Road, Manchester, M13 9PL UK
| | - Valerie Brueton
- />MRC Clinical Trials Unit at University College London, 125 Kingsway, London, WC2B 6NH UK
| | - Carrol Gamble
- />North West Hub for Trials Methodology Research, University of Liverpool, 1st floor Duncan Building, Daulby Street, Liverpool, L69 3GA UK
| | - Shaun Treweek
- />Health Services Research Unit, University of Aberdeen, Foresterhill, Aberdeen, AB25 2ZD UK
| | - Catrin Tudur Smith
- />North West Hub for Trials Methodology Research and Department of Biostatistics, University of Liverpool, 1st floor Duncan Building, Daulby Street, Liverpool, L69 3GA UK
| | - Bridget Young
- />North West Hub for Trials Methodology Research and Department of Psychological Sciences, University of Liverpool, 1st floor Duncan Building, Daulby Street, Liverpool, L69 3GA UK
| | - Paula Williamson
- />North West Hub for Trials Methodology Research and Department of Biostatistics, University of Liverpool, 1st floor Duncan Building, Daulby Street, Liverpool, L69 3GA UK
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Abstract
The aim of this study was to review the role
of clinical trial networks in orthopaedic surgery. A total of two
electronic databases (MEDLINE and EMBASE) were searched from inception
to September 2013 with no language restrictions. Articles related
to randomised controlled trials (RCTs), research networks and orthopaedic
research, were identified and reviewed. The usefulness of trainee-led
research collaborations is reported and our knowledge of current
clinical trial infrastructure further supplements the review. Searching
yielded 818 titles and abstracts, of which 12 were suitable for
this review. Results are summarised and presented narratively under
the following headings: 1) identifying clinically relevant research
questions; 2) education and training; 3) conduct of multicentre
RCTs and 4) dissemination and adoption of trial results. This review
confirms growing international awareness of the important role research
networks play in supporting trials in orthopaedic surgery. Multidisciplinary
collaboration and adequate investment in trial infrastructure are crucial
for successful delivery of RCTs. Cite this article: Bone Joint Res 2014;3:169–74.
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Affiliation(s)
- A Rangan
- The James Cook University Hospital, Marton Road, Middlesborough, TS4 3BW, UK
| | - L Jefferson
- University of York, York Trials Unit, Department of Health Sciences, York, YO10 5DD, UK
| | - P Baker
- The James Cook University Hospital, Marton Road, Middlesborough, TS4 3BW, UK
| | - L Cook
- University of York, York Trials Unit, Department of Health Sciences, York, YO10 5DD, UK
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Galli L, Knight R, Robertson S, Hoile E, Oladapo O, Francis D, Free C. Using marketing theory to inform strategies for recruitment: a recruitment optimisation model and the txt2stop experience. Trials 2014; 15:182. [PMID: 24886627 PMCID: PMC4057570 DOI: 10.1186/1745-6215-15-182] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2013] [Accepted: 05/08/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Recruitment is a major challenge for many trials; just over half reach their targets and almost a third resort to grant extensions. The economic and societal implications of this shortcoming are significant. Yet, we have a limited understanding of the processes that increase the probability that recruitment targets will be achieved. Accordingly, there is an urgent need to bring analytical rigour to the task of improving recruitment, thereby increasing the likelihood that trials reach their recruitment targets. This paper presents a conceptual framework that can be used to improve recruitment to clinical trials. METHODS Using a case-study approach, we reviewed the range of initiatives that had been undertaken to improve recruitment in the txt2stop trial using qualitative (semi-structured interviews with the principal investigator) and quantitative (recruitment) data analysis. Later, the txt2stop recruitment practices were compared to a previous model of marketing a trial and to key constructs in social marketing theory. RESULTS Post hoc, we developed a recruitment optimisation model to serve as a conceptual framework to improve recruitment to clinical trials. A core premise of the model is that improving recruitment needs to be an iterative, learning process. The model describes three essential activities: i) recruitment phase monitoring, ii) marketing research, and iii) the evaluation of current performance. We describe the initiatives undertaken by the txt2stop trial and the results achieved, as an example of the use of the model. CONCLUSIONS Further research should explore the impact of adopting the recruitment optimisation model when applied to other trials.
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Affiliation(s)
- Leandro Galli
- London School of Hygiene and Tropical Medicine, Coventry CV4 7AL, UK.
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Newington L, Metcalfe A. Researchers' and clinicians' perceptions of recruiting participants to clinical research: a thematic meta-synthesis. J Clin Med Res 2014; 6:162-72. [PMID: 24734142 PMCID: PMC3985558 DOI: 10.14740/jocmr1619w] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/08/2013] [Indexed: 11/16/2022] Open
Abstract
Background Recruiting the desired number of research participants is frequently problematic with resulting financial and clinical implications. The views of individuals responsible for participant recruitment have not been previously reviewed. This systematic review and thematic meta-synthesis explores researchers’ and clinicians’ experiences and perceptions of recruiting participants to clinical research, with the aim of informing improved recruitment systems and strategies. Methods Studies published between January 1995 and May 2013 were identified from: Ovid MEDLINE, Ovid EMBASE, Ovid PSYCHINFO, ASSIA, British Nursing Index, Scopus, Web of Science, CINAHL and PubMed. Included studies were original peer reviewed research, with qualitative methodologies and an aim of exploring the views of clinicians and/or researchers on recruitment to clinical research. Studies discussing the recruitment of patients unable to give informed consent were excluded. The findings sections of the relevant studies were free coded to identify key concepts which were grouped into hierarchical themes. The quality of the identified studies was assessed and the relative contribution of each paper was checked to ensure individual studies did not dominate in any theme. Results Eighteen relevant papers were identified which examined the views of researchers and clinicians in 10 clinical specialties. Five main themes emerged: building a research community, securing resources, the nature of research, professional identities and recruitment strategies. The views of researchers and clinicians were similar, although the role of ‘researcher’ was inconsistently defined. Conclusions The general experience of recruiting participants to clinical research was one of competition and compromise. Competition arose over funding, staffing and participants, and between clinical and research responsibilities. Compromise was needed to create study designs that were acceptable to patients, clinicians and researchers. Forging relationships between clinical and research teams featured extensively, however the involvement of patients and the public within the research community was rarely discussed.
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Affiliation(s)
- Lisa Newington
- NIHR Biomedical Research Centre, Guy's and St Thomas' NHS Foundation Trust and King's College London, Guy's Hospital, SE1 9RT, UK
| | - Alison Metcalfe
- Florence Nightingale School of Nursing and Midwifery, King's College London, James Clerk Maxwell Building, Waterloo Road, SE1 8WA, UK
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Potter S, Mills N, Cawthorn SJ, Donovan J, Blazeby JM. Time to be BRAVE: is educating surgeons the key to unlocking the potential of randomised clinical trials in surgery? A qualitative study. Trials 2014; 15:80. [PMID: 24628821 PMCID: PMC4003809 DOI: 10.1186/1745-6215-15-80] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2013] [Accepted: 02/26/2014] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Well-designed randomised clinical trials (RCTs) provide the best evidence to inform decision-making and should be the default option for evaluating surgical procedures. Such trials can be challenging, and surgeons' preferences may influence whether trials are initiated and successfully conducted and their results accepted. Preferences are particularly problematic when surgeons' views play a key role in procedure selection and patient eligibility. The bases of such preferences have rarely been explored. Our aim in this qualitative study was to investigate surgeons' preferences regarding the feasibility of surgical RCTs and their understanding of study design issues using breast reconstruction surgery as a case study. METHODS Semistructured qualitative interviews were undertaken with a purposive sample of 35 professionals practicing at 15 centres across the United Kingdom. Interviews were transcribed verbatim and analysed thematically using constant comparative techniques. Sampling, data collection and analysis were conducted concurrently and iteratively until data saturation was achieved. RESULTS Surgeons often struggle with the concept of equipoise. We found that if surgeons did not feel 'in equipoise', they did not accept randomisation as a method of treatment allocation. The underlying reasons for limited equipoise were limited appreciation of the methodological weaknesses of data derived from nonrandomised studies and little understanding of pragmatic trial design. Their belief in the value of RCTs for generating high-quality data to change or inform practice was not widely held. CONCLUSION There is a need to help surgeons understand evidence, equipoise and bias. Current National Institute of Health Research/Medical Research Council investment into education and infrastructure for RCTs, combined with strong leadership, may begin to address these issues or more specific interventions may be required.
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Affiliation(s)
- Shelley Potter
- Bristol Centre for Surgical Research, School of Social and Community Medicine, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol BS8 2PS, UK
- Division of Surgery, Head and Neck, University Hospitals Bristol NHS Foundation Trust, Upper Maudlin Street, Bristol BS2 8HW, UK
| | - Nicola Mills
- Bristol Centre for Surgical Research, School of Social and Community Medicine, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol BS8 2PS, UK
| | - Simon J Cawthorn
- Bristol Breast Care Centre, North Bristol NHS Trust, Southmead Hospital, Bristol BS10 5NB, UK
| | - Jenny Donovan
- Bristol Centre for Surgical Research, School of Social and Community Medicine, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol BS8 2PS, UK
| | - Jane M Blazeby
- Bristol Centre for Surgical Research, School of Social and Community Medicine, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol BS8 2PS, UK
- Division of Surgery, Head and Neck, University Hospitals Bristol NHS Foundation Trust, Upper Maudlin Street, Bristol BS2 8HW, UK
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Newington L, Metcalfe A. Factors influencing recruitment to research: qualitative study of the experiences and perceptions of research teams. BMC Med Res Methodol 2014; 14:10. [PMID: 24456229 PMCID: PMC3903025 DOI: 10.1186/1471-2288-14-10] [Citation(s) in RCA: 119] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2013] [Accepted: 01/16/2014] [Indexed: 12/01/2022] Open
Abstract
Background Recruiting the required number of participants is vital to the success of clinical research and yet many studies fail to achieve their expected recruitment rate. Increasing research participation is a key agenda within the NHS and elsewhere, but the optimal methods of improving recruitment to clinical research remain elusive. The aim of this study was to identify the factors that researchers perceive as influential in the recruitment of participants to clinically focused research. Methods Semi-structured interviews were conducted with 11 individuals from three clinical research teams based in London. Sampling was a combination of convenience and purposive. The interviews were audio recorded, transcribed verbatim and analysed using the framework method to identify key themes. Results Four themes were identified as influential to recruitment: infrastructure, nature of the research, recruiter characteristics and participant characteristics. The main reason individuals participate in clinical research was believed to be altruism, while logistical issues were considered important for those who declined. Suggestions to improve recruitment included reducing participant burden, providing support for individuals who do not speak English, and forming collaborations with primary care to improve the identification of, and access to, potentially eligible participants. Conclusions Recruiting the target number of research participants was perceived as difficult, especially for clinical trials. New and diverse strategies to ensure that all potentially eligible patients are invited to participate may be beneficial and require further exploration in different settings. Establishing integrated clinical and academic teams with shared responsibilities for recruitment may also facilitate this process. Language barriers and long journey times were considered negative influences to recruitment; although more prominent, these issues are not unique to London and are likely to be important influences in other locations.
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Affiliation(s)
- Lisa Newington
- NIHR Biomedical Research Centre, Guy's and St Thomas' NHS Foundation Trust and King's College London, Guy's Hospital, SE1 9RT, London, UK.
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Eborall HC, Dallosso HM, Daly H, Martin-Stacey L, Heller SR. The face of equipoise--delivering a structured education programme within a randomized controlled trial: qualitative study. Trials 2014; 15:15. [PMID: 24405854 PMCID: PMC3892103 DOI: 10.1186/1745-6215-15-15] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2013] [Accepted: 12/13/2013] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND In trials of behavioural interventions, the individuals who deliver the intervention are in a position of key influence on the success of the trial. Their fidelity to the intervention is crucial. Yet little is understood about the experiences of this group of trial personnel. This study aimed to investigate the views and experiences of educators who delivered a structured education intervention to people with type 2 diabetes, which incorporated training in self-monitoring of either blood glucose (SMBG) or urine glucose (SMUG) as part of a randomized controlled trial (RCT). METHODS Educators' views were explored through focus groups before and after training (N=18) and approximately 1 year into the trial (N=14), and semi-structured telephone interviews at approximately 2 years (N=7). Analysis was based on the constant comparative method. RESULTS Educators held preferences regarding the intervention variants; thus, they were not in individual equipoise. Training raised awareness of preferences and their potential to impact on delivery. Educators were confident in their unbiased delivery, but acknowledged the challenges involved. Concealing their preferences was helped by a sense of professionalism, the patient-centred nature of the intervention, and concessions in the trial protocol (enabling participants to swap monitoring methods if needed). Commitment to unbiased delivery was explained through a desire for evidence-based knowledge in the contentious area of SMBG. CONCLUSIONS The findings provide insight into a previously unexplored group of trial personnel--intervention deliverers in trials of behavioural interventions--which will be useful to those designing and running similar trials. Rather than individual equipoise, it is intervention deliverers' awareness of personal preferences and their potential impact on the trial outcome that facilitates unbiased delivery. Further, awareness of community equipoise, the need for evidence, and relevance to the individual enhance commitment to the RCT. TRIAL REGISTRATION ISRCTN95696668.
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Affiliation(s)
- Helen C Eborall
- Social Science Applied to Healthcare Improvement Research (SAPPHIRE) Group, Department of Health Sciences, University of Leicester, Leicester, UK
| | - Helen M Dallosso
- Leicester Diabetes Centre, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Heather Daly
- Leicester Diabetes Centre, University Hospitals of Leicester NHS Trust, Leicester, UK
| | | | - Simon R Heller
- Academic Unit of Diabetes, Endocrinology and Metabolism, University of Sheffield, Sheffield, UK
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Woolfall K, Shilling V, Hickey H, Smyth RL, Sowden E, Williamson PR, Young B. Parents' agendas in paediatric clinical trial recruitment are different from researchers' and often remain unvoiced: a qualitative study. PLoS One 2013; 8:e67352. [PMID: 23844006 PMCID: PMC3701006 DOI: 10.1371/journal.pone.0067352] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2013] [Accepted: 05/17/2013] [Indexed: 11/19/2022] Open
Abstract
Ensuring parents make an informed decision about their child's participation in a clinical trial is a challenge for practitioners as a parent's comprehension of a trial may differ from that intended by the practitioners responsible for recruitment. We explored what issues parents consider important when making a decision about participation in a paediatric clinical trial and their comprehension of these issues to inform future recruitment practice. This qualitative interview and observational study examined recruitment in four placebo-controlled, double-blind randomised clinical trials of medicines for children. Audio-recorded trial recruitment discussions between practitioners and parents (N = 41) were matched with semi-structured interviews with parents (N = 41). When making a decision about trial entry parents considered clinical benefit, child safety, practicalities of participation, research for the common good, access to medication and randomisation. Within these prioritised issues parents had specific misunderstandings, which had the potential to influence their decisions. While parents had many questions and concerns about trial participation which influenced their decision-making, they rarely voiced these during discussions about the trials with practitioners. Those involved in the recruitment of children to clinical trials need to be aware of parents' priorities and the sorts of misunderstandings that can arise with parents. Providing trial information that is tailored to what parents consider important in making a decision about a clinical trial may improve recruitment practice and ultimately benefit evidence-based paediatric medicine.
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Affiliation(s)
- Kerry Woolfall
- Department of Psychological Sciences, University of Liverpool, Liverpool, United Kingdom.
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Cook JA, McCulloch P, Blazeby JM, Beard DJ, Marinac-Dabic D, Sedrakyan A. IDEAL framework for surgical innovation 3: randomised controlled trials in the assessment stage and evaluations in the long term study stage. BMJ 2013; 346:f2820. [PMID: 23778425 PMCID: PMC3685513 DOI: 10.1136/bmj.f2820] [Citation(s) in RCA: 133] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/15/2013] [Indexed: 12/29/2022]
Affiliation(s)
- Jonathan A Cook
- Health Services Research Unit, University of Aberdeen, Aberdeen AB25 2ZD, UK.
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Abstract
Randomized controlled trials (RCTs) are considered the most robust design for evaluating health care interventions. However, it is difficult to acquire funding for RCTs, and they are complex to set up. Threats to their successful conduct and impact on clinical practice, particularly in surgical trials, include problems with recruitment, notably in terms of clinical equipoise and patient acceptability. Historically, RCTs are less common in surgical specialties, and their contribution to the orthopaedic literature remains small. Orthopaedic networks, such as orthopaedic associations, specialist societies, travel fellowships, and clinical research networks, provide an opportunity to meet the challenges of promoting RCTs in orthopaedic clinical practice. This can include identifying important research questions to help prioritize funding; educating and training surgeons in the design and practice of RCTs; helping to promote and coordinate RCTs; and disseminating the findings of RCTs. Orthopaedic trial networks should be encouraged to promote a research culture in which RCTs are feasible and to ensure that scarce resources utilized to support their funding are used most efficiently and to best effect. In particular, the use of networks is encouraged to support the conduct of RCTs in achieving patient recruitment, which is crucial in providing the evidence base to inform orthopaedic practice. Furthermore, to improve generalizability, acceptance of study findings and communication between orthopaedic surgeons, as well as international collaboration in trials, should be part of the strategy for the future.
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Affiliation(s)
- Amar Rangan
- Department of Orthopaedic Surgery, The James Cook University Hospital, Marton Road, Middlesbrough TS4 3BW, United Kingdom
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Wells M, Williams B, Treweek S, Coyle J, Taylor J. Intervention description is not enough: evidence from an in-depth multiple case study on the untold role and impact of context in randomised controlled trials of seven complex interventions. Trials 2012; 13:95. [PMID: 22742939 PMCID: PMC3475073 DOI: 10.1186/1745-6215-13-95] [Citation(s) in RCA: 162] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2011] [Accepted: 05/21/2012] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND A number of single case reports have suggested that the context within which intervention studies take place may challenge the assumptions that underpin randomised controlled trials (RCTs). However, the diverse ways in which context may challenge the central tenets of the RCT, and the degree to which this information is known to researchers or subsequently reported, has received much less attention. In this paper, we explore these issues by focusing on seven RCTs of interventions varying in type and degree of complexity, and across diverse contexts. METHODS This in-depth multiple case study using interviews, focus groups and documentary analysis was conducted in two phases. In phase one, a RCT of a nurse-led intervention provided a single exploratory case and informed the design, sampling and data collection within the main study. Phase two consisted of a multiple explanatory case study covering a spectrum of trials of different types of complex intervention. A total of eighty-four data sources across the seven trials were accessed. RESULTS We present consistent empirical evidence across all trials to indicate that four key elements of context (personal, organisational, trial and problem context) are crucial to understanding how a complex intervention works and to enable both assessments of internal validity and likely generalisability to other settings. The ways in which context challenged trial operation was often complex, idiosyncratic, and subtle; often falling outside of current trial reporting formats. However, information on such issues appeared to be available via first hand 'insider accounts' of each trial suggesting that improved reporting on the role of context is possible. CONCLUSIONS Sufficient detail about context needs to be understood and reported in RCTs of complex interventions, in order for the transferability of complex interventions to be assessed. Improved reporting formats that require and encourage the clarification of both general and project-specific threats to the likely internal and external validity need to be developed. In addition, a cultural change is required in which the open and honest reporting of such issues is seen as an indicator of study strength and researcher integrity, rather than a symbol of a poor quality study or investigator ability.
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Affiliation(s)
- Mary Wells
- School of Nursing and Midwifery, University of Dundee, 11 Airlie Place, Dundee, DD1 4HJ, UK
| | - Brian Williams
- Nursing, Midwifery and Allied Health Professions Research Unit, Iris Murdoch Building, University of Stirling, Stirling, FK9 4LA, UK
| | - Shaun Treweek
- Population Health Sciences, School of Medicine, University of Dundee, The Mackenzie building, Kirsty Semple Way, Dundee, DD2 4BF, UK
| | - Joanne Coyle
- Social Dimensions of Health Institute, University of St Andrews and University of Dundee, 11 Airlie Place, Dundee, DD1 4HJ, UK
| | - Julie Taylor
- School of Nursing and Midwifery, University of Dundee, 11 Airlie Place, Dundee, DD1 4HJ, UK
- National Society for the Prevention of Child Abuse and Neglect (NSPCC), Weston House, 42 Curtain Rd, London, EC2A 3NH, UK
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Ashley L, Jones H, Velikova G, Wright P. Cancer patients' and clinicians' opinions on the best time in secondary care to approach patients for recruitment to longitudinal questionnaire-based research. Support Care Cancer 2012; 20:3365-72. [PMID: 22722886 DOI: 10.1007/s00520-012-1518-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2011] [Accepted: 05/28/2012] [Indexed: 11/29/2022]
Abstract
PURPOSE A priority of the UK National Cancer Survivorship Initiative is to increase collection of patient-reported outcome measures (PROMs) longitudinally post-diagnosis. This study aimed to gather cancer patients' and clinicians' opinions and preferences about the best time, in the secondary care pathway, to approach patients about joining longitudinal observational PROMs-based (LO-PROMs) research. METHODS The sample comprised 15 patients with non-metastatic breast, colorectal or prostate cancer, and 15 clinicians including surgeons, oncologists and nurse specialists. Patients and clinicians participated in one face-to-face topic-guided audio-recorded interview. Data were analysed using thematic content analysis. RESULTS Patients did not want to be approached about LO-PROMs research early in the care pathway, near diagnosis and treatment planning or before any surgery and its results. Patients felt that LO-PROMs research is best introduced from the time people are 'settled' on (post-surgical) treatment regimens, provided they are coping well emotionally and not experiencing significant physical side effects; patients emphasised variability in people's experience of and response to cancer and treatment. Clinicians also advised against approach near diagnosis, although generally recommended initiating recruitment somewhat sooner than patients. CONCLUSIONS Patients expressed strong homogeneous preferences and ideally wanted to be approached about LO-PROMs research when their initial fears and anxiety about cancer treatment and survival had diminished, and they felt some sense of certainty and optimism about the future. As the timeline of clinical events varies, maximising recruitment may mean approaching patients at varied time points post-diagnosis. Further recruitment implications are discussed.
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Affiliation(s)
- Laura Ashley
- Psychosocial Oncology and Clinical Practice Research Group, University of Leeds, St James's Institute of Oncology, Beckett Street, Leeds LS9 7TF, UK.
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