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Powell PA, Rowen D, Keetharuth A, Mukuria C, Shah K. Who should value children's health and how? An international Delphi study. Soc Sci Med 2024; 355:117127. [PMID: 39019000 DOI: 10.1016/j.socscimed.2024.117127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2024] [Revised: 06/13/2024] [Accepted: 07/09/2024] [Indexed: 07/19/2024]
Abstract
Valuing child health necessitates normative methodological decisions on whose preferences should be elicited and who should be imagined as experiencing impaired health. Formal guidance is limited and expert consensus unclear. This study sought to establish the degree of consensus among expert stakeholders on normative issues of who to ask and who should be imagined when valuing child health (7-17 years) to inform UK health technology assessment. Sixty-two experts (n = 47 in Round 2) from 18 countries participated in a modified, two-round online Delphi survey (Round 1: May-June 2023; Round 2: September-October 2023). Participants were expert stakeholders in child health valuation, including academics (n = 38); industry/consultancy representatives (including the charity/not-for-profit sector; n = 13); and UK policy/government representatives (n = 11). The Delphi survey was modified between rounds and consisted of 9-point Likert, categorical, multiple-choice, and free-text questions on normative issues in valuing child health. Responses were analysed descriptively and thematically. An a priori criterion of ≥75% agreement was established for formal consensus, while areas approaching consensus (≥70% agreement) and without consensus were identified as a future research primer. Consensus was observed that older adolescents (aged 16-17 years) and adults (18+ years) should be asked to value child health states. There was consensus that the former should think about themselves when valuing the health states and the latter should imagine a child of some form (e.g., imagining themselves as a child or another hypothetical child). However, no consensus was evident on what form this should take. Several other methodological issues also reached consensus. These findings are largely consistent with recent views elicited qualitatively from members of the public and other stakeholders on normative issues in valuing child health. The results mean that, contrary to what has been done in previous child health valuation studies, efforts should be made to involve both older adolescents (16+ years) and adults in child health valuation.
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Affiliation(s)
- Philip A Powell
- Sheffield Centre for Health and Related Research, University of Sheffield, UK.
| | - Donna Rowen
- Sheffield Centre for Health and Related Research, University of Sheffield, UK
| | - Anju Keetharuth
- Sheffield Centre for Health and Related Research, University of Sheffield, UK
| | - Clara Mukuria
- Sheffield Centre for Health and Related Research, University of Sheffield, UK
| | - Koonal Shah
- National Institute for Health and Care Excellence, London, UK
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Manyara AM, Purvis A, Ciani O, Collins GS, Taylor RS. Sample size in multistakeholder Delphi surveys: at what minimum sample size do replicability of results stabilize? J Clin Epidemiol 2024; 174:111485. [PMID: 39069013 DOI: 10.1016/j.jclinepi.2024.111485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2024] [Revised: 07/19/2024] [Accepted: 07/22/2024] [Indexed: 07/30/2024]
Abstract
BACKGROUND AND OBJECTIVE The minimum sample size for multistakeholder Delphi surveys remains understudied. Drawing from three large international multistakeholder Delphi surveys, this study aimed to: 1) investigate the effect of increasing sample size on replicability of results; 2) assess whether the level of replicability of results differed with participant characteristics: for example, gender, age, and profession. METHODS We used data from Delphi surveys to develop guidance for improved reporting of health-care intervention trials: SPIRIT (Standard Protocol Items: Recommendations for Interventional Trials) and CONSORT (Consolidated Standards of Reporting Trials) extension for surrogate end points (n = 175, 22 items rated); CONSORT-SPI [CONSORT extension for Social and Psychological Interventions] (n = 333, 77 items rated); and core outcome set for burn care (n = 553, 88 items rated). Resampling with replacement was used to draw random subsamples from the participant data set in each of the three surveys. For each subsample, the median value of all rated survey items was calculated and compared to the medians from the full participant data set. The median number (and interquartile range) of medians replicated was used to calculate the percentage replicability (and variability). High replicability was defined as ≥80% and moderate as 60% and <80% RESULTS: The average median replicability (variability) as a percentage of total number of items rated from the three datasets was 81% (10%) at a sample size of 60. In one of the datasets (CONSORT-SPI), a ≥80% replicability was reached at a sample size of 80. On average, increasing the sample size from 80 to 160 increased the replicability of results by a further 3% and reduced variability by 1%. For subgroup analysis based on participant characteristics (eg, gender, age, professional role), using resampled samples of 20 to 100 showed that a sample size of 20 to 30 resulted to moderate replicability levels of 64% to 77%. CONCLUSION We found that a minimum sample size of 60-80 participants in multistakeholder Delphi surveys provides a high level of replicability (≥80%) in the results. For Delphi studies limited to individual stakeholder groups (such as researchers, clinicians, patients), a sample size of 20 to 30 per group may be sufficient.
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Affiliation(s)
- Anthony Muchai Manyara
- School of Health and Wellbeing, University of Glasgow, Glasgow, UK; Global Health and Ageing Research Unit, Bristol Medical School, University of Bristol, Bristol, UK.
| | - Anthony Purvis
- School of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Oriana Ciani
- Centre for Research on Health and Social Care Management, SDA Bocconi School of Management, Milan, Italy
| | - Gary S Collins
- UK EQUATOR Centre, Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology & Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Rod S Taylor
- MRC/CSO Social and Public Health Sciences Unit & Robertson Centre for Biostatistics, School of Health and Wellbeing, University of Glasgow, Glasgow, UK
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Tunn R, Boutron I, Chan AW, Collins GS, Hróbjartsson A, Moher D, Schulz KF, de Beyer JA, Hansen Nejstgaard C, Østengaard L, Hopewell S. Methods used to develop the SPIRIT 2024 and CONSORT 2024 Statements. J Clin Epidemiol 2024; 169:111309. [PMID: 38428538 DOI: 10.1016/j.jclinepi.2024.111309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Revised: 02/19/2024] [Accepted: 02/22/2024] [Indexed: 03/03/2024]
Abstract
OBJECTIVES To describe, and explain the rationale for, the methods used and decisions made during development of the updated SPIRIT 2024 and CONSORT 2024 reporting guidelines. METHODS We developed SPIRIT 2024 and CONSORT 2024 together to facilitate harmonization of the two guidelines, and incorporated content from key extensions. We conducted a scoping review of comments suggesting changes to SPIRIT 2013 and CONSORT 2010, and compiled a list of other possible revisions based on existing SPIRIT and CONSORT extensions, other reporting guidelines, and personal communications. From this, we generated a list of potential modifications or additions to SPIRIT and CONSORT, which we presented to stakeholders for feedback in an international online Delphi survey. The Delphi survey results were discussed at an online expert consensus meeting attended by 30 invited international participants. We then drafted the updated SPIRIT and CONSORT checklists and revised them based on further feedback from meeting attendees. RESULTS We compiled 83 suggestions for revisions or additions to SPIRIT and/or CONSORT from the scoping review and 85 from other sources, from which we generated 33 potential changes to SPIRIT (n = 5) or CONSORT (n = 28). Of 463 participants invited to take part in the Delphi survey, 317 (68%) responded to Round 1, 303 (65%) to Round 2 and 290 (63%) to Round 3. Two additional potential checklist changes were added to the Delphi survey based on Round 1 comments. Overall, 14/35 (SPIRIT n = 0; CONSORT n = 14) proposed changes reached the predefined consensus threshold (≥80% agreement), and participants provided 3580 free-text comments. The consensus meeting participants agreed with implementing 11/14 of the proposed changes that reached consensus in the Delphi and supported implementing a further 4/21 changes (SPIRIT n = 2; CONSORT n = 2) that had not reached the Delphi threshold. They also recommended further changes to refine key concepts and for clarity. CONCLUSION The forthcoming SPIRIT 2024 and CONSORT 2024 Statements will provide updated, harmonized guidance for reporting randomized controlled trial protocols and results, respectively. The simultaneous development of the SPIRIT and CONSORT checklists has been informed by current empirical evidence and extensive input from stakeholders. We hope that this report of the methods used will be helpful for developers of future reporting guidelines.
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Affiliation(s)
- Ruth Tunn
- Oxford Clinical Trials Research Unit, University of Oxford, Oxford, UK; Centre for Statistics in Medicine, University of Oxford, Oxford, UK
| | - Isabelle Boutron
- Université Paris Cité and Université Sorbonne Paris Nord, Inserm, INRAE, Centre for Research in Epidemiology and Statistics (CRESS), F-75004 Paris, France; Centre d'Epidémiologie Clinique, AP-HP, Hôpital Hôtel Dieu, Paris, France
| | - An-Wen Chan
- Department of Medicine, Women's College Research Institute, University of Toronto, Toronto, Ontario, Canada
| | - Gary S Collins
- Centre for Statistics in Medicine, University of Oxford, Oxford, UK; UK EQUATOR Centre, University of Oxford, Oxford, UK
| | - Asbjørn Hróbjartsson
- Centre for Evidence-Based Medicine Odense and Cochrane Denmark, Department of Clinical Research, University of Southern Denmark, Odense, Denmark; Open Patient data Explorative Network, Odense University Hospital, Odense, Denmark
| | - David Moher
- Centre for Journalology, Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Kenneth F Schulz
- Department of Obstetrics and Gynecology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Jennifer A de Beyer
- Centre for Statistics in Medicine, University of Oxford, Oxford, UK; UK EQUATOR Centre, University of Oxford, Oxford, UK
| | - Camilla Hansen Nejstgaard
- Centre for Evidence-Based Medicine Odense and Cochrane Denmark, Department of Clinical Research, University of Southern Denmark, Odense, Denmark; Open Patient data Explorative Network, Odense University Hospital, Odense, Denmark
| | - Lasse Østengaard
- Centre for Evidence-Based Medicine Odense and Cochrane Denmark, Department of Clinical Research, University of Southern Denmark, Odense, Denmark; Open Patient data Explorative Network, Odense University Hospital, Odense, Denmark
| | - Sally Hopewell
- Oxford Clinical Trials Research Unit, University of Oxford, Oxford, UK; Centre for Statistics in Medicine, University of Oxford, Oxford, UK.
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Kearney R, Ellard D, Parsons H, Haque A, Mason J, Nwankwo H, Bradley H, Drew S, Modi C, Bush H, Torgerson D, Underwood M. Advice only versus advice and a physiotherapy programme for acute traumatic anterior shoulder dislocation: the ARTISAN RCT. Health Technol Assess 2024; 28:1-94. [PMID: 38695098 PMCID: PMC11089447 DOI: 10.3310/cmyw9226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/15/2024] Open
Abstract
Background The extra benefit of a programme of physiotherapy in addition to advice alone, following first-time traumatic shoulder dislocation, is uncertain. We compared the clinical and cost-effectiveness of a single session of advice with a single session of advice and a programme of physiotherapy. Objective The primary objective was to quantify and draw inferences about observed differences in the Oxford Shoulder Instability Score between the trial treatment groups 6 months post randomisation, in adults with a first-time traumatic shoulder dislocation. Design A pragmatic, multicentre, superiority, randomised controlled trial with embedded qualitative study. Setting Forty-one hospitals in the UK NHS. Participants Adults with a radiologically confirmed first-time traumatic anterior shoulder dislocation, being managed non-operatively. People with neurovascular complications or bilateral dislocations, and those unable to adhere to trial procedures or unable to attend physiotherapy within 6 weeks of injury, or who had previously been randomised, were excluded. Interventions All participants received the same initial shoulder examination followed by advice to aid self-management, lasting up to 1 hour and administered by a physiotherapist (control). Participants randomised to receive an additional programme of physiotherapy were offered sessions lasting for up to 30 minutes, over a maximum duration of 4 months from the date of randomisation (intervention). Main outcome measures The primary outcome measure was the Oxford Shoulder Instability Score. This is a self-completed outcome measure containing 12 questions (0-4 points each), with possible scores from 0 (worst function) to 48 (best function). Measurements were collected at 6 weeks, 3 months, 6 months and 12 months by postal questionnaire; 6 months was the primary outcome time point. The primary health outcome for economic evaluation was the quality-adjusted life-year, in accordance with National Institute of Health and Care Excellence guidelines. Results Between 14 November 2018 and 14 March 2022, 482 participants were randomised to advice (n = 240) or advice and a programme of physiotherapy (n = 242). Participants were 34% female, with a mean age of 45 years, and treatment arms were balanced at baseline. There was not a statistically significant difference in the primary outcome between advice only and advice plus a programme of physiotherapy at 6 months for the primary intention-to-treat adjusted analysis (favours physiotherapy: 1.5, 95% confidence interval -0.3 to 3.5) or at earlier 3-month and 6-week time points on the Oxford Shoulder Instability Score (0-48; higher scores indicate better function). The probability of physiotherapy being cost-effective at a willingness-to-pay threshold of £30,000 was 0.95. Conclusions We found little difference in the primary outcome or other secondary outcomes. Advice with additional physiotherapy sessions was found likely to be cost-effective. However, small imprecise incremental costs and quality-adjusted life-years raise questions on whether it is the best use of scarce physiotherapy resources given current service demands. Limitations Loss to follow-up was 27%; however, the observed standard deviation was much smaller than anticipated. These changes in parameters reduced the number of participants required to observe the planned target difference of four points. Our post hoc sensitivity analysis, accounting for missing data, gives similar results. Future work Further research should be directed towards optimising self-management strategies. Study registration This study is registered as ISRCTN63184243. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 16/167/56) and is published in full in Health Technology Assessment; Vol. 28, No. 22. See the NIHR Funding and Awards website for further award information.
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Affiliation(s)
| | - David Ellard
- Warwick Medical School, University of Warwick, Coventry, UK
- University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Helen Parsons
- Warwick Medical School, University of Warwick, Coventry, UK
- University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Aminul Haque
- Warwick Medical School, University of Warwick, Coventry, UK
| | - James Mason
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Henry Nwankwo
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Helen Bradley
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Steve Drew
- University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Chetan Modi
- University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Howard Bush
- University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | | | - Martin Underwood
- Warwick Medical School, University of Warwick, Coventry, UK
- University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
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Patil SP, Billings ME, Bourjeily G, Collop NA, Gottlieb DJ, Johnson KG, Kimoff RJ, Pack AI. Long-term health outcomes for patients with obstructive sleep apnea: placing the Agency for Healthcare Research and Quality report in context-a multisociety commentary. J Clin Sleep Med 2024; 20:135-149. [PMID: 37904571 PMCID: PMC10758567 DOI: 10.5664/jcsm.10832] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Accepted: 09/21/2023] [Indexed: 11/01/2023]
Abstract
This multisociety commentary critically examines the Agency for Healthcare Research and Quality (AHRQ) final report and systematic review on long-term health outcomes in obstructive sleep apnea. The AHRQ report was commissioned by the Centers for Medicare & Medicaid Services and particularly focused on the long-term patient-centered outcomes of continuous positive airway pressure, the variability of sleep-disordered breathing metrics, and the validity of these metrics as surrogate outcomes. This commentary raises concerns regarding the AHRQ report conclusions and their potential implications for policy decisions. A major concern expressed in this commentary is that the AHRQ report inadequately acknowledges the benefits of continuous positive airway pressure for several established, long-term clinically important outcomes including excessive sleepiness, motor vehicle accidents, and blood pressure. While acknowledging the limited evidence for the long-term benefits of continuous positive airway pressure treatment, especially cardiovascular outcomes, as summarized by the AHRQ report, this commentary reviews the limitations of recent randomized controlled trials and nonrandomized controlled studies and the challenges of conducting future randomized controlled trials. A research agenda to address these challenges is proposed including study designs that may include both high quality randomized controlled trials and nonrandomized controlled studies. This commentary concludes by highlighting implications for the safety and quality of life for the millions of people living with obstructive sleep apnea if the AHRQ report alone was used by payers to limit coverage for the treatment of obstructive sleep apnea while not considering the totality of available evidence. CITATION Patil SP, Billings ME, Bourjeily G, et al. Long-term health outcomes for patients with obstructive sleep apnea: placing the Agency for Healthcare Research and Quality report in context-a multisociety commentary. J Clin Sleep Med. 2024;20(1):135-149.
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Affiliation(s)
- Susheel P. Patil
- Case Western Reserve University School of Medicine, Cleveland, Ohio
- University Hospitals of Cleveland, Cleveland, Ohio
| | | | - Ghada Bourjeily
- Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | | | - Daniel J. Gottlieb
- VA Boston Healthcare System, Boston, Massachusetts
- Brigham and Women’s Hospital, Boston, Massachusetts
| | - Karin G. Johnson
- University of Massachusetts Chan School of Medicine-Baystate, Springfield, Massachusetts
| | - R. John Kimoff
- McGill University Health Centre, Montreal, Quebec, Canada
| | - Allan I. Pack
- University of Pennsylvania, Philadelphia, Pennsylvania
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Purja S, Park S, Oh S, Kim M, Kim E. Reporting quality was suboptimal in a systematic review of randomized controlled trials with adaptive designs. J Clin Epidemiol 2023; 154:85-96. [PMID: 36528234 DOI: 10.1016/j.jclinepi.2022.12.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Revised: 12/04/2022] [Accepted: 12/12/2022] [Indexed: 12/23/2022]
Abstract
OBJECTIVE The study was conducted to evaluate the reporting quality of randomized controlled trials (RCTs) that use an adaptive design (AD) based on the 2020 AD Consolidated Standards for Reporting Trials 2010 extension (ACE) guidelines and identify factors associated with better reporting quality. STUDY DESIGN AND SETTING PubMed, Embase, Cochrane, Web of Science, and Google Scholar were searched until November 1, 2022. Multivariable linear regression analysis was performed to investigate potential predictors. RESULTS In total, 109 RCTs were included in our study. The mean compliance rate for the ACE checklist items was 69.75% ± 16.02. Key methodological items including allocation concealment and its implementations were poorly reported. There was also suboptimal reporting of checklist items related to the conduct of interim analyzes. Multivariable regression analysis showed better reporting quality with trial registration, nonindustry affiliation (first author), a sample size of >100, general medical journal type, publication date (≥2020), funding, and disclosure of the number of interim analyzes. CONCLUSION Our study showed that RCTs with AD had suboptimal reporting of 2020 ACE checklist items, particularly AD-specific items. Following the development of ACE guidelines, stricter adherence to the ACE guideline is necessary to improve their reporting quality. Pre-ACE and post-ACE adherence comparisons can be conducted in the future.
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Affiliation(s)
- Sujata Purja
- Evidence-Based and Clinical Research Laboratory, Department of Health, Social and Clinical Pharmacy, College of Pharmacy, Chung-Ang University, Seoul 06974, Republic of Korea
| | - Sunuk Park
- Evidence-Based and Clinical Research Laboratory, Department of Health, Social and Clinical Pharmacy, College of Pharmacy, Chung-Ang University, Seoul 06974, Republic of Korea
| | - SuA Oh
- Evidence-Based and Clinical Research Laboratory, Department of Health, Social and Clinical Pharmacy, College of Pharmacy, Chung-Ang University, Seoul 06974, Republic of Korea
| | - Minji Kim
- Evidence-Based and Clinical Research Laboratory, Department of Health, Social and Clinical Pharmacy, College of Pharmacy, Chung-Ang University, Seoul 06974, Republic of Korea
| | - EunYoung Kim
- Evidence-Based and Clinical Research Laboratory, Department of Health, Social and Clinical Pharmacy, College of Pharmacy, Chung-Ang University, Seoul 06974, Republic of Korea; The Graduate School for Food and Drug Administration, and The Graduate School for Pharmaceutical Industry Management, College of Pharmacy, Chung-Ang University, Seoul 06974, Republic of Korea.
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Manyara AM, Davies P, Stewart D, Weir CJ, Young A, Butcher NJ, Bujkiewicz S, Chan AW, Collins GS, Dawoud D, Offringa M, Ouwens M, Ross JS, Taylor RS, Ciani O. Protocol for the development of SPIRIT and CONSORT extensions for randomised controlled trials with surrogate primary endpoints: SPIRIT-SURROGATE and CONSORT-SURROGATE. BMJ Open 2022; 12:e064304. [PMID: 36220321 PMCID: PMC9557267 DOI: 10.1136/bmjopen-2022-064304] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 09/27/2022] [Indexed: 12/21/2022] Open
Abstract
INTRODUCTION Randomised controlled trials (RCTs) may use surrogate endpoints as substitutes and predictors of patient-relevant/participant-relevant final outcomes (eg, survival, health-related quality of life). Translation of effects measured on a surrogate endpoint into health benefits for patients/participants is dependent on the validity of the surrogate; hence, more accurate and transparent reporting on surrogate endpoints is needed to limit misleading interpretation of trial findings. However, there is currently no explicit guidance for the reporting of such trials. Therefore, we aim to develop extensions to the SPIRIT (Standard Protocol Items: Recommendations for Interventional Trials) and CONSORT (Consolidated Standards of Reporting Trials) reporting guidelines to improve the design and completeness of reporting of RCTs and their protocols using a surrogate endpoint as a primary outcome. METHODS AND ANALYSIS The project will have four phases: phase 1 (literature reviews) to identify candidate reporting items to be rated in a Delphi study; phase 2 (Delphi study) to rate the importance of items identified in phase 1 and receive suggestions for additional items; phase 3 (consensus meeting) to agree on final set of items for inclusion in the extensions and phase 4 (knowledge translation) to engage stakeholders and disseminate the project outputs through various strategies including peer-reviewed publications. Patient and public involvement will be embedded into all project phases. ETHICS AND DISSEMINATION The study has received ethical approval from the University of Glasgow College of Medical, Veterinary and Life Sciences Ethics Committee (project no: 200210051). The findings will be published in open-access peer-reviewed publications and presented in conferences, meetings and relevant forums.
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Affiliation(s)
- Anthony Muchai Manyara
- MRC/CSO Social and Public Health Sciences Unit, School of Health and Wellbeing, Glasgow, UK, University of Glasgow, Glasgow, UK
| | - Philippa Davies
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | | | - Christopher J Weir
- Edinburgh Clinical Trials Unit, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Amber Young
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Nancy J Butcher
- Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
- Child Health Evaluation Sciences, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Sylwia Bujkiewicz
- Biostatistics Research Group, Department of Health Sciences, University of Leicester, Leicester, UK
| | - An-Wen Chan
- Women's College Institute Research Institute, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Gary S Collins
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology & Musculoskeletal Sciences, Oxford University, Oxford, UK
| | - Dalia Dawoud
- National Institute for Health and Care Excellence, London, UK
| | - Martin Offringa
- Child Health Evaluation Sciences, The Hospital for Sick Children, Toronto, Ontario, Canada
| | | | - Joseph S Ross
- Department of Health Policy and Management, Yale School of Public Health, New Haven, Connecticut, USA
- Section of General Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Rod S Taylor
- MRC/CSO Social and Public Health Sciences Unit, School of Health and Wellbeing, Glasgow, UK, University of Glasgow, Glasgow, UK
- Robertson Centre for Biostatistics, School of Health and Well Being, University of Glasgow, Glasgow, UK
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McGree JM, Hockham C, Kotwal S, Wilcox A, Bassi A, Pollock C, Burrell LM, Snelling T, Jha V, Jardine M, Jones M. Controlled evaLuation of Angiotensin Receptor Blockers for COVID-19 respIraTorY disease (CLARITY): statistical analysis plan for a randomised controlled Bayesian adaptive sample size trial. Trials 2022; 23:361. [PMID: 35477480 PMCID: PMC9044378 DOI: 10.1186/s13063-022-06167-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Accepted: 03/10/2022] [Indexed: 11/10/2022] Open
Abstract
The CLARITY trial (Controlled evaLuation of Angiotensin Receptor Blockers for COVID-19 respIraTorY disease) is a two-arm, multi-centre, randomised controlled trial being run in India and Australia that investigates the effectiveness of angiotensin receptor blockers in addition to standard care compared to placebo (in Indian sites) with standard care in reducing the duration and severity of lung failure in patients with COVID-19. The trial was designed as a Bayesian adaptive sample size trial with regular planned analyses where pre-specified decision rules will be assessed to determine whether the trial should be stopped due to sufficient evidence of treatment effectiveness or futility. Here, we describe the statistical analysis plan for the trial and define the pre-specified decision rules, including those that could lead to the trial being halted. The primary outcome is clinical status on a 7-point ordinal scale adapted from the WHO Clinical Progression scale assessed at day 14. The primary analysis will follow the intention-to-treat principle. A Bayesian adaptive trial design was selected because there is considerable uncertainty about the extent of potential benefit of this treatment.Trial registrationClinicalTrials.gov NCT04394117 . Registered on 19 May 2020Clinical Trial Registry of India CTRI/2020/07/026831Version and revisionsVersion 1.0. No revisions.
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Affiliation(s)
- J. M. McGree
- School of Mathematical Sciences, Queensland University of Technology, Brisbane, Australia
| | - C. Hockham
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
- The George Institute for Global Health, Imperial College London, London, UK
| | - S. Kotwal
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
- Prince of Wales Hospital, Sydney, Australia
| | - A. Wilcox
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
- NHMRC Clinical Trials Centre, The University of Sydney, Sydney, Australia
| | - A. Bassi
- The George Institute for Global Health, New Delhi, India
| | - C. Pollock
- Royal North Shore Hospital, Sydney, Australia
- Kolling Institute of Medical Research, The University of Sydney, Sydney, Australia
| | - L. M. Burrell
- Department of Medicine, The University of Melbourne, Austin Health, Heidelberg, Victoria Australia
| | - T. Snelling
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
- The Sydney Children’s Hospitals Network, Westmead, Australia
| | - V. Jha
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
- The George Institute for Global Health, New Delhi, India
| | - M. Jardine
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
- NHMRC Clinical Trials Centre, The University of Sydney, Sydney, Australia
- Concord Repatriation General Hospital, Sydney, Australia
| | - M. Jones
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
| | - for the CLARITY Trial Steering Committee
- School of Mathematical Sciences, Queensland University of Technology, Brisbane, Australia
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
- The George Institute for Global Health, Imperial College London, London, UK
- Prince of Wales Hospital, Sydney, Australia
- NHMRC Clinical Trials Centre, The University of Sydney, Sydney, Australia
- The George Institute for Global Health, New Delhi, India
- Royal North Shore Hospital, Sydney, Australia
- Kolling Institute of Medical Research, The University of Sydney, Sydney, Australia
- Department of Medicine, The University of Melbourne, Austin Health, Heidelberg, Victoria Australia
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
- The Sydney Children’s Hospitals Network, Westmead, Australia
- Concord Repatriation General Hospital, Sydney, Australia
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Natanegara F, Zariffa N, Buenconsejo J, Ran Liao, Cooner F, Lakshminarayanan D, Ghosh S, Schindler JS, Gamalo M. Statistical Opportunities to Accelerate Development for COVID-19 Therapeutics. Stat Biopharm Res 2021. [DOI: 10.1080/19466315.2020.1865195] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Fanni Natanegara
- Research and Development – Statistics, Eli Lilly and Co, Indianapolis, IN, USA
| | | | - Joan Buenconsejo
- Biometrics, Cardiovascular, Renal and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gaithersburg, MD, USA
| | - Ran Liao
- Research and Development – Statistics, Eli Lilly and Co, Indianapolis, IN, USA
| | - Freda Cooner
- Center for Design and Analysis, Amgen, Thousand Oaks, CA, USA
| | - Divya Lakshminarayanan
- Clinical Statistics, COVID-19, Biostatistics R&D, GlaxoSmithKline, Collegeville, PA, USA
| | - Samiran Ghosh
- Department of Family Medicine & Public Health Sciences and Center for Molecular Medicine and Genetics, School of Medicine, Wayne State University, Detroit, MI, USA
| | | | - Margaret Gamalo
- Research and Development – Statistics, Eli Lilly and Co, Indianapolis, IN, USA
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10
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Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, Shamseer L, Tetzlaff JM, Moher D. Updating guidance for reporting systematic reviews: development of the PRISMA 2020 statement. J Clin Epidemiol 2021; 134:103-112. [PMID: 33577987 DOI: 10.1016/j.jclinepi.2021.02.003] [Citation(s) in RCA: 864] [Impact Index Per Article: 288.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 01/22/2021] [Accepted: 02/03/2021] [Indexed: 12/22/2022]
Abstract
OBJECTIVES To describe the processes used to update the PRISMA 2009 statement for reporting systematic reviews, present results of a survey conducted to inform the update, summarize decisions made at the PRISMA update meeting, and describe and justify changes made to the guideline. METHODS We reviewed 60 documents with reporting guidance for systematic reviews to generate suggested modifications to the PRISMA 2009 statement. We invited 220 systematic review methodologists and journal editors to complete a survey about the suggested modifications. The results of these projects were discussed at a 21-member in-person meeting. Following the meeting, we drafted the PRISMA 2020 statement and refined it based on feedback from co-authors and a convenience sample of 15 systematic reviewers. RESULTS The review of 60 documents revealed that all topics addressed by the PRISMA 2009 statement could be modified. Of the 110 survey respondents, more than 66% recommended keeping six of the original checklist items as they were and modifying 15 of them using wording suggested by us. Attendees at the in-person meeting supported the revised wording for several items but suggested rewording for most to enhance clarity, and further refinements were made over six drafts of the guideline. CONCLUSIONS The PRISMA 2020 statement consists of updated reporting guidance for systematic reviews. We hope that providing this detailed description of the development process will enhance the acceptance and uptake of the guideline and assist those developing and updating future reporting guidelines.
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Affiliation(s)
- Matthew J Page
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.
| | - Joanne E McKenzie
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Patrick M Bossuyt
- Department of Clinical Epidemiology, Biostatistics and Bioinformatics, Amsterdam University Medical Centres, University of Amsterdam, Amsterdam, Netherlands
| | - Isabelle Boutron
- Université de Paris, Centre of Epidemiology and Statistics (CRESS), Inserm, F 75004, Paris, France
| | - Tammy C Hoffmann
- Institute for Evidence-Based Healthcare, Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Australia
| | - Cynthia D Mulrow
- University of Texas Health Science Center at San Antonio, San Antonio, TX, United States
| | - Larissa Shamseer
- School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, Canada
| | | | - David Moher
- School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, Canada; Centre for Journalology, Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa
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11
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Dangond F, Donnelly A, Hohlfeld R, Lubetzki C, Kohlhaas S, Leocani L, Ciccarelli O, Stankoff B, Sormani MP, Chataway J, Bozzoli F, Cucca F, Melton L, Coetzee T, Salvetti M. Facing the urgency of therapies for progressive MS - a Progressive MS Alliance proposal. Nat Rev Neurol 2021; 17:185-192. [PMID: 33483719 DOI: 10.1038/s41582-020-00446-9] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/07/2020] [Indexed: 12/20/2022]
Abstract
Therapies for infiltrative inflammation in multiple sclerosis (MS) have advanced greatly, but neurodegeneration and compartmentalized inflammation remain virtually untargeted as in other diseases of the nervous system. Consequently, many therapies are available for the relapsing-remitting form of MS, but the progressive forms remain essentially untreated. The objective of the International Progressive MS Alliance is to expedite the development of effective therapies for progressive MS through new initiatives that foster innovative thinking and concrete advancements. Based on these principles, the Alliance is developing a new funding programme that will focus on experimental medicine trials. Here, we discuss the reasons behind the focus on experimental medicine trials, the strengths and weaknesses of these approaches and of the programme, and why we hope to advance therapies while improving the understanding of progression in MS. We are soliciting public and academic feedback, which will help shape the programme and future strategies of the Alliance.
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Affiliation(s)
| | - Alexis Donnelly
- Department of Computer Science, O'Reilly Institute, Trinity College, Dublin, Ireland
| | - Reinhard Hohlfeld
- Institute of Clinical Neuroimmunology, Biomedical Center and Hospital of the Ludwig Maximilians Universität München, Munich, Germany.,Munich Cluster for Systems Neurology (Synergy), Munich, Germany
| | - Catherine Lubetzki
- Neurology Department, Sorbonne University, Pitié-Salpêtrière Hospital, Paris, France
| | | | - Letizia Leocani
- Vita-Salute San Raffaele University, Milan, Italy.,Neurorehabilitation Department and Experimental Neurophysiology Unit, INSPE, Scientific Institute Hospital San Raffaele, Milan, Italy
| | - Olga Ciccarelli
- Queen Square Multiple Sclerosis Centre, Department of Neuroinflammation, UCL Institute of Neurology, Faculty of Brain Sciences, University College London, London, UK.,National Institute for Health Research University College London Hospitals Biomedical Research Centre, London, UK
| | - Bruno Stankoff
- Sorbonne University, Brain and Spine Institute, ICM, Pitié-Salpêtrière Hospital, Paris, France
| | - Maria Pia Sormani
- Department of Health Sciences (DISSAL), University of Genova, Genova, Italy.,IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Jeremy Chataway
- Queen Square Multiple Sclerosis Centre, Department of Neuroinflammation, UCL Institute of Neurology, Faculty of Brain Sciences, University College London, London, UK.,National Institute for Health Research University College London Hospitals Biomedical Research Centre, London, UK
| | | | - Francesco Cucca
- Dipartimento di Scienze Biomediche, Università di Sassari, Sassari, Italy
| | - Lisa Melton
- MS Research Australia, North Sydney, New South Wales, Australia
| | | | - Marco Salvetti
- Department of Neurosciences, Mental Health and Sensory Organs, Centre for Experimental Neurological Therapies (CENTERS), Faculty of Medicine and Psychology, Sapienza University, Rome, Italy. .,IRCCS Istituto Neurologico Mediterraneo (INM) Neuromed, Pozzilli, Italy.
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12
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Totton N, Julious S, Hughes D, Cook J, Biggs K, Coates L, Cook A, Hewitt C, Day S. Utilising benefit-risk assessments within clinical trials-a protocol for the BRAINS project. Trials 2021; 22:68. [PMID: 33468202 PMCID: PMC7814532 DOI: 10.1186/s13063-021-05022-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Accepted: 01/05/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Depending on the treatment to be investigated, a clinical trial could be designed to assess objectives of superiority, equivalence or non-inferiority. The design of the study is affected by many different elements including the control treatment, the primary outcome and associated relationships. In some studies, there could be more than one outcome of interest. In these situations, benefit-risk methodologies could be used to assess the outcomes simultaneously and consider the trade-off between the benefits against the risks of a treatment. Benefit-risk is used within the regulatory industry but seldom included within publicly funded clinical trials within the UK. This project aims to gain an expert consensus on how to select the appropriate trial design (e.g. superiority) and when to consider including benefit-risk methods. METHODS The project will consist of four work packages: 1. A web-based survey to elicit current experiences and opinions, 2. A rapid literature review to assess any current recommendations, 3. A two-day consensus workshop to gain agreement on the recommendations, and 4. Production of a guidance document. DISCUSSION The aim of the project is to provide a guideline for clinical researchers, grant funding bodies and reviewers for grant bodies for how to select the most appropriate trial design and when it is appropriate to consider using benefit-risk methods. The focus of the guideline will be on publicly funded trials however, the vision is that the work will be applicable across research settings and we will connect with other organisations and committees as appropriate.
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Affiliation(s)
- Nikki Totton
- School of Health and Related Research, University of Sheffield, Sheffield, UK.
| | - Steven Julious
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Dyfrig Hughes
- Centre for Health Economics and Medicines Evaluation, Bangor University, Bangor, UK
| | - Jonathan Cook
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Katie Biggs
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Lizzie Coates
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Andrew Cook
- Wessex Institute, University of Southampton, Southampton, UK
| | - Catherine Hewitt
- York Trials Unit, Department of Health Sciences, University of York, York, UK
| | - Simon Day
- Clinical Trials Consulting & Training Limited, Buckingham, UK
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13
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Burnett T, Mozgunov P, Pallmann P, Villar SS, Wheeler GM, Jaki T. Adding flexibility to clinical trial designs: an example-based guide to the practical use of adaptive designs. BMC Med 2020; 18:352. [PMID: 33208155 PMCID: PMC7677786 DOI: 10.1186/s12916-020-01808-2] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 10/07/2020] [Indexed: 12/18/2022] Open
Abstract
Adaptive designs for clinical trials permit alterations to a study in response to accumulating data in order to make trials more flexible, ethical, and efficient. These benefits are achieved while preserving the integrity and validity of the trial, through the pre-specification and proper adjustment for the possible alterations during the course of the trial. Despite much research in the statistical literature highlighting the potential advantages of adaptive designs over traditional fixed designs, the uptake of such methods in clinical research has been slow. One major reason for this is that different adaptations to trial designs, as well as their advantages and limitations, remain unfamiliar to large parts of the clinical community. The aim of this paper is to clarify where adaptive designs can be used to address specific questions of scientific interest; we introduce the main features of adaptive designs and commonly used terminology, highlighting their utility and pitfalls, and illustrate their use through case studies of adaptive trials ranging from early-phase dose escalation to confirmatory phase III studies.
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Affiliation(s)
- Thomas Burnett
- Department of Mathematics and Statistics, Lancaster University, Fylde College, Lancaster, LA1 4YF UK
| | - Pavel Mozgunov
- Department of Mathematics and Statistics, Lancaster University, Fylde College, Lancaster, LA1 4YF UK
| | - Philip Pallmann
- Centre for Trials Research, College of Biomedical & Life Sciences, Cardiff University, Cardiff, UK
| | - Sofia S. Villar
- MRC Biostatistics Unit, University of Cambridge School of Clinical Medicine, Cambridge Institute of Public Health, Forvie Site, Robinson Way, Cambridge Biomedical Campus, Cambridge, CB2 0SR UK
| | - Graham M. Wheeler
- Cancer Research UK & UCL Cancer Trials Centre, University College London, 90 Tottenham Court Road, London, W1T 4TJ UK
| | - Thomas Jaki
- Department of Mathematics and Statistics, Lancaster University, Fylde College, Lancaster, LA1 4YF UK
- MRC Biostatistics Unit, University of Cambridge School of Clinical Medicine, Cambridge Institute of Public Health, Forvie Site, Robinson Way, Cambridge Biomedical Campus, Cambridge, CB2 0SR UK
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14
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Branch-Elliman W, Lehmann LS, Boden WE, Ferguson R, Monach P. Pragmatic, adaptive clinical trials: Is 2020 the dawning of a new age? Contemp Clin Trials Commun 2020; 19:100614. [PMID: 32724866 PMCID: PMC7366075 DOI: 10.1016/j.conctc.2020.100614] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2020] [Revised: 06/23/2020] [Accepted: 07/12/2020] [Indexed: 12/27/2022] Open
Abstract
Given the high case fatality rate of SARS-CoV-2, for which there is no cure and no vaccine, clinicians are forced to make decisions about how best to manage patients with limited high-quality evidence to guide treatment. Traditional randomized controlled trials provide strong experimental evidence, however, tend to be slow, inflexible, and have limited generalizability. Adaptive and pragmatic designs are an attractive alternative, which meet our ethical obligation during the SARS-CoV-2 pandemic to balance speed, agility, and generalizability with both prospective study and scientific rigor.
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Affiliation(s)
- Westyn Branch-Elliman
- VA Boston Healthcare System, Department of Medicine, Boston, MA, USA
- VA Boston Center for Healthcare Organization and Implementation Research (CHOIR), Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Lisa Soleymani Lehmann
- VA Boston Healthcare System, Department of Medicine, Boston, MA, USA
- VA Boston Center for Healthcare Organization and Implementation Research (CHOIR), Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - William E. Boden
- VA Boston Healthcare System, Department of Medicine, Boston, MA, USA
- Boston University School of Medicine, Boston, MA, USA
| | - Ryan Ferguson
- Boston University School of Medicine, Boston, MA, USA
- Massachusetts Veterans Epidemiology Research and Information Center (MAVERIC), Boston, MA, USA
- Boston University School of Public Health, Boston, MA, USA
| | - Paul Monach
- VA Boston Healthcare System, Department of Medicine, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Division of Rheumatology Inflammation and Immunity, Brigham and Women's Hospital, USA
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15
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Jones MA, Graves T, Middleton B, Totterdell J, Snelling TL, Marsh JA. The ORVAC trial: a phase IV, double-blind, randomised, placebo-controlled clinical trial of a third scheduled dose of Rotarix rotavirus vaccine in Australian Indigenous infants to improve protection against gastroenteritis: a statistical analysis plan. Trials 2020; 21:741. [PMID: 32843086 PMCID: PMC7447587 DOI: 10.1186/s13063-020-04602-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2020] [Accepted: 07/12/2020] [Indexed: 11/30/2022] Open
Abstract
Objective The purpose of this double-blind, randomised, placebo-controlled, adaptive design trial with frequent interim analyses is to determine if Australian Indigenous children, who receive an additional (third) dose of human rotavirus vaccine (Rotarix, GlaxoSmithKline) for children aged 6 to < 12 months, would improve protection against clinically significant all-cause gastroenteritis. Participants Up to 1000 Australian Aboriginal and Torres Strait Islander (hereafter Indigenous) infants aged 6 to < 12 months will be recruited from all regions of the Northern Territory. Interventions The intervention is the addition of a third scheduled dose of human monovalent rotavirus vaccine. Co-primary and secondary outcome measures ORVAC has two co-primary outcomes: (1) anti-rotavirus IgA seroconversion, defined as serum anti-rotavirus IgA ≥ 20 U/ml 28 to 55 days post Rotarix/placebo, and (2) time from randomisation to medical attendance for which the primary reason for presentation is acute gastroenteritis or acute diarrhoea illness before age 36 months. Secondary outcomes include (1) change in anti-rotavirus IgA log titre, (2) time from randomisation to hospitalisation with primary admission code presumed or confirmed acute diarrhoea illness before age 36 months, (3) time from randomisation to hospitalisation for which the admission is rotavirus confirmed diarrhoea illness before age 36 months and (4) time from randomisation to rotavirus infection (not necessarily requiring hospitalisation) meeting the jurisdictional definition before age 36 months. Discussion A detailed, prospective statistical analysis plan is presented for this Bayesian adaptive design. The plan was written by the trial statistician and details the study design, pre-specified adaptative elements, decision thresholds, statistical methods and the simulations used to evaluate the operating characteristics of the trial. As at August 2020, four interim analyses have been run, but no stopping rules have been triggered. Application of this SAP will minimise bias and supports transparent and reproducible research. Trial registration Clinicaltrials.gov NCT02941107. Registered on 21 October 2016 Original protocol for the study 10.1136/bmjopen-2019-032549
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Affiliation(s)
- Mark A Jones
- Wesfarmers Centre of Vaccines and Infectious Diseases, Telethon Kids InstituteUniversity of Western Australia, Perth, 6009, WA, Australia.
| | - Todd Graves
- Berry Consultants, 3345 Bee Caves Rd Suite 201, Austin, 78746, TX, USA
| | - Bianca Middleton
- Menzies School of Health Research, Royal Darwin Hospital Campus, Rocklands Drive, Casuarina, 0811, NT, Australia
| | - James Totterdell
- Wesfarmers Centre of Vaccines and Infectious Diseases, Telethon Kids InstituteUniversity of Western Australia, Perth, 6009, WA, Australia
| | - Thomas L Snelling
- Wesfarmers Centre of Vaccines and Infectious Diseases, Telethon Kids InstituteUniversity of Western Australia, Perth, 6009, WA, Australia.,Perth Children's Hospital, 15 Hospital Ave, Perth, 6009, WA, Australia.,Curtin University, School of Public Health, Perth, WA, Australia.,Menzies School of Health Research, Royal Darwin Hospital Campus, Rocklands Drive, Casuarina, 0811, NT, Australia
| | - Julie A Marsh
- Wesfarmers Centre of Vaccines and Infectious Diseases, Telethon Kids InstituteUniversity of Western Australia, Perth, 6009, WA, Australia
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16
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Dimairo M, Pallmann P, Wason J, Todd S, Jaki T, Julious SA, Mander AP, Weir CJ, Koenig F, Walton MK, Nicholl JP, Coates E, Biggs K, Hamasaki T, Proschan MA, Scott JA, Ando Y, Hind D, Altman DG. The adaptive designs CONSORT extension (ACE) statement: a checklist with explanation and elaboration guideline for reporting randomised trials that use an adaptive design. Trials 2020; 21:528. [PMID: 32546273 PMCID: PMC7298968 DOI: 10.1186/s13063-020-04334-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Adaptive designs (ADs) allow pre-planned changes to an ongoing trial without compromising the validity of conclusions and it is essential to distinguish pre-planned from unplanned changes that may also occur. The reporting of ADs in randomised trials is inconsistent and needs improving. Incompletely reported AD randomised trials are difficult to reproduce and are hard to interpret and synthesise. This consequently hampers their ability to inform practice as well as future research and contributes to research waste. Better transparency and adequate reporting will enable the potential benefits of ADs to be realised.This extension to the Consolidated Standards Of Reporting Trials (CONSORT) 2010 statement was developed to enhance the reporting of randomised AD clinical trials. We developed an Adaptive designs CONSORT Extension (ACE) guideline through a two-stage Delphi process with input from multidisciplinary key stakeholders in clinical trials research in the public and private sectors from 21 countries, followed by a consensus meeting. Members of the CONSORT Group were involved during the development process.The paper presents the ACE checklists for AD randomised trial reports and abstracts, as well as an explanation with examples to aid the application of the guideline. The ACE checklist comprises seven new items, nine modified items, six unchanged items for which additional explanatory text clarifies further considerations for ADs, and 20 unchanged items not requiring further explanatory text. The ACE abstract checklist has one new item, one modified item, one unchanged item with additional explanatory text for ADs, and 15 unchanged items not requiring further explanatory text.The intention is to enhance transparency and improve reporting of AD randomised trials to improve the interpretability of their results and reproducibility of their methods, results and inference. We also hope indirectly to facilitate the much-needed knowledge transfer of innovative trial designs to maximise their potential benefits. In order to encourage its wide dissemination this article is freely accessible on the BMJ and Trials journal websites."To maximise the benefit to society, you need to not just do research but do it well" Douglas G Altman.
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Affiliation(s)
- Munyaradzi Dimairo
- School of Health and Related Research, University of Sheffield, Sheffield, S1 4DA, UK.
| | | | - James Wason
- MRC Biostatistics Unit, University of Cambridge, Cambridge, UK
- Institute of Health and Society, Newcastle University, Newcastle, UK
| | - Susan Todd
- Department of Mathematics and Statistics, University of Reading, Reading, UK
| | - Thomas Jaki
- Department of Mathematics and Statistics, Lancaster University, Lancaster, UK
| | - Steven A Julious
- School of Health and Related Research, University of Sheffield, Sheffield, S1 4DA, UK
| | - Adrian P Mander
- Centre for Trials Research, Cardiff University, Cardiff, UK
- MRC Biostatistics Unit, University of Cambridge, Cambridge, UK
| | - Christopher J Weir
- Edinburgh Clinical Trials Unit, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Franz Koenig
- Centre for Medical Statistics, Informatics, and Intelligent Systems, Medical University of Vienna, Vienna, Austria
| | - Marc K Walton
- Janssen Pharmaceuticals, Titusville, New Jersey, USA
| | - Jon P Nicholl
- School of Health and Related Research, University of Sheffield, Sheffield, S1 4DA, UK
| | - Elizabeth Coates
- School of Health and Related Research, University of Sheffield, Sheffield, S1 4DA, UK
| | - Katie Biggs
- School of Health and Related Research, University of Sheffield, Sheffield, S1 4DA, UK
| | | | - Michael A Proschan
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, USA
| | - John A Scott
- Division of Biostatistics in the Center for Biologics Evaluation and Research, Food and Drug Administration, Rockville, USA
| | - Yuki Ando
- Pharmaceuticals and Medical Devices Agency, Tokyo, Japan
| | - Daniel Hind
- School of Health and Related Research, University of Sheffield, Sheffield, S1 4DA, UK
| | - Douglas G Altman
- Centre for Statistics in Medicine, University of Oxford, Oxford, UK
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17
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Dimairo M, Pallmann P, Wason J, Todd S, Jaki T, Julious SA, Mander AP, Weir CJ, Koenig F, Walton MK, Nicholl JP, Coates E, Biggs K, Hamasaki T, Proschan MA, Scott JA, Ando Y, Hind D, Altman DG. The Adaptive designs CONSORT Extension (ACE) statement: a checklist with explanation and elaboration guideline for reporting randomised trials that use an adaptive design. BMJ 2020; 369:m115. [PMID: 32554564 PMCID: PMC7298567 DOI: 10.1136/bmj.m115] [Citation(s) in RCA: 55] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/19/2019] [Indexed: 12/11/2022]
Abstract
Adaptive designs (ADs) allow pre-planned changes to an ongoing trial without compromising the validity of conclusions and it is essential to distinguish pre-planned from unplanned changes that may also occur. The reporting of ADs in randomised trials is inconsistent and needs improving. Incompletely reported AD randomised trials are difficult to reproduce and are hard to interpret and synthesise. This consequently hampers their ability to inform practice as well as future research and contributes to research waste. Better transparency and adequate reporting will enable the potential benefits of ADs to be realised.This extension to the Consolidated Standards Of Reporting Trials (CONSORT) 2010 statement was developed to enhance the reporting of randomised AD clinical trials. We developed an Adaptive designs CONSORT Extension (ACE) guideline through a two-stage Delphi process with input from multidisciplinary key stakeholders in clinical trials research in the public and private sectors from 21 countries, followed by a consensus meeting. Members of the CONSORT Group were involved during the development process.The paper presents the ACE checklists for AD randomised trial reports and abstracts, as well as an explanation with examples to aid the application of the guideline. The ACE checklist comprises seven new items, nine modified items, six unchanged items for which additional explanatory text clarifies further considerations for ADs, and 20 unchanged items not requiring further explanatory text. The ACE abstract checklist has one new item, one modified item, one unchanged item with additional explanatory text for ADs, and 15 unchanged items not requiring further explanatory text.The intention is to enhance transparency and improve reporting of AD randomised trials to improve the interpretability of their results and reproducibility of their methods, results and inference. We also hope indirectly to facilitate the much-needed knowledge transfer of innovative trial designs to maximise their potential benefits.
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Affiliation(s)
- Munyaradzi Dimairo
- School of Health and Related Research, University of Sheffield, Sheffield S1 4DA, UK
| | | | - James Wason
- MRC Biostatistics Unit, University of Cambridge, UK
- Institute of Health and Society, Newcastle University, UK
| | - Susan Todd
- Department of Mathematics and Statistics, University of Reading, UK
| | - Thomas Jaki
- Department of Mathematics and Statistics, Lancaster University, UK
| | - Steven A Julious
- School of Health and Related Research, University of Sheffield, Sheffield S1 4DA, UK
| | - Adrian P Mander
- Centre for Trials Research, Cardiff University, UK
- MRC Biostatistics Unit, University of Cambridge, UK
| | - Christopher J Weir
- Edinburgh Clinical Trials Unit, Usher Institute, University of Edinburgh, UK
| | - Franz Koenig
- Centre for Medical Statistics, Informatics, and Intelligent Systems, Medical University of Vienna, Austria
| | | | - Jon P Nicholl
- School of Health and Related Research, University of Sheffield, Sheffield S1 4DA, UK
| | - Elizabeth Coates
- School of Health and Related Research, University of Sheffield, Sheffield S1 4DA, UK
| | - Katie Biggs
- School of Health and Related Research, University of Sheffield, Sheffield S1 4DA, UK
| | | | - Michael A Proschan
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, USA
| | - John A Scott
- Division of Biostatistics in the Center for Biologics Evaluation and Research, Food and Drug Administration, USA
| | - Yuki Ando
- Pharmaceuticals and Medical Devices Agency, Japan
| | - Daniel Hind
- School of Health and Related Research, University of Sheffield, Sheffield S1 4DA, UK
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18
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Wang Y, Zhou F, Zhang D, Zhao J, Du R, Hu Y, Cheng Z, Gao L, Jin Y, Luo G, Fu S, Lu Q, Du G, Wang K, Lu Y, Fan G, Zhang Y, Liu Y, Ruan S, Liu W, Jaki T, Hayden FG, Horby PW, Cao B, Wang C. Evaluation of the efficacy and safety of intravenous remdesivir in adult patients with severe COVID-19: study protocol for a phase 3 randomized, double-blind, placebo-controlled, multicentre trial. Trials 2020; 21:422. [PMID: 32448345 PMCID: PMC7245636 DOI: 10.1186/s13063-020-04352-9] [Citation(s) in RCA: 49] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Accepted: 04/27/2020] [Indexed: 12/29/2022] Open
Abstract
Background Coronavirus disease 2019 (COVID-19), caused by a novel corinavirus (later named SARS-CoV-2 virus), was fistly reported in Wuhan, Hubei Province, China towards the end of 2019. Large-scale spread within China and internationally led the World Health Organization to declare a Public Health Emergency of International Concern on 30th January 2020. The clinical manifestations of COVID-19 virus infection include asymptomatic infection, mild upper respiratory symptoms, severe viral pneumonia with respiratory failure, and even death. There are no antivirals of proven clinical efficacy in coronavirus infections. Remdesivir (GS-5734), a nucleoside analogue, has inhibitory effects on animal and human highly pathogenic coronaviruses, including MERS-CoV and SARS-CoV, in in vitro and in vivo experiments. It is also inhibitory against the COVID-19 virus in vitro. The aim of this study is to assess the efficacy and safety of remdesivir in adult patients with severe COVID-19. Methods The protocol is prepared in accordance with the SPIRIT (Standard Protocol Items: Recommendations for Interventional Trials) guidelines. This is a phase 3, randomized, double-blind, placebo-controlled, multicentre trial. Adults (≥ 18 years) with laboratory-confirmed COVID-19 virus infection, severe pneumonia signs or symptoms, and radiologically confirmed severe pneumonia are randomly assigned in a 2:1 ratio to intravenously administered remdesivir or placebo for 10 days. The primary endpoint is time to clinical improvement (censored at day 28), defined as the time (in days) from randomization of study treatment (remdesivir or placebo) until a decline of two categories on a six-category ordinal scale of clinical status (1 = discharged; 6 = death) or live discharge from hospital. One interim analysis for efficacy and futility will be conducted once half of the total number of events required has been observed. Discussion This is the first randomized, placebo-controlled trial in COVID-19. Enrolment began in sites in Wuhan, Hubei Province, China on 6th February 2020. Trial registration ClinicalTrials.gov: NCT04257656. Registered on 6 February 2020.
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Affiliation(s)
- Yeming Wang
- Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, National Clinical Research Center for Respiratory Diseases, China-Japan Friendship Hospital, Beijing, China
| | - Fei Zhou
- Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, National Clinical Research Center for Respiratory Diseases, China-Japan Friendship Hospital, Beijing, China
| | - Dingyu Zhang
- Jin Yin-tan Hospital, Wuhan, Hubei Province, China
| | - Jianping Zhao
- Tongji Hospital, Tongji Medical College of Huazhong University of Science & Technology, Wuhan, China
| | | | - Yi Hu
- The Central Hospital of Wuhan, Wuhan, China
| | | | - Ling Gao
- Renmin Hospital of Wuhan University, Wuhan, China
| | - Yang Jin
- Union Hospital, Tongji Medical College of Huazhong University of Science & Technology, Wuhan, China
| | | | | | | | - Guanhua Du
- Institute of Medicine, Chinese Academy of Medical Sciences, Beijing, China
| | - Ke Wang
- Institute of Medicine, Chinese Academy of Medical Sciences, Beijing, China
| | - Yang Lu
- Institute of Medicine, Chinese Academy of Medical Sciences, Beijing, China
| | - Guohui Fan
- Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, National Clinical Research Center for Respiratory Diseases, China-Japan Friendship Hospital, Beijing, China.,Institute of Clinical Medical Sciences, China-Japan Friendship Hospital, Beijing, China
| | - Yi Zhang
- Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, National Clinical Research Center for Respiratory Diseases, China-Japan Friendship Hospital, Beijing, China
| | - Ying Liu
- Jin Yin-tan Hospital, Wuhan, Hubei Province, China
| | - Shunan Ruan
- Jin Yin-tan Hospital, Wuhan, Hubei Province, China
| | - Wen Liu
- Jin Yin-tan Hospital, Wuhan, Hubei Province, China
| | | | | | | | - Bin Cao
- Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, National Clinical Research Center for Respiratory Diseases, China-Japan Friendship Hospital, Beijing, China. .,Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Beijing, China.
| | - Chen Wang
- Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, National Clinical Research Center for Respiratory Diseases, China-Japan Friendship Hospital, Beijing, China. .,Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Beijing, China. .,Peking Union Medical College, Beijing, China.
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Metcalfe A, Gemperle Mannion E, Parsons H, Brown J, Parsons N, Fox J, Kearney R, Lawrence T, Bush H, McGowan K, Khan I, Mason J, Hutchinson C, Gates S, Stallard N, Underwood M, Drew S. Protocol for a randomised controlled trial of Subacromial spacer for Tears Affecting Rotator cuff Tendons: a Randomised, Efficient, Adaptive Clinical Trial in Surgery (START:REACTS). BMJ Open 2020; 10:e036829. [PMID: 32444433 PMCID: PMC7247380 DOI: 10.1136/bmjopen-2020-036829] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [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 Shoulder pain due to irreparable rotator cuff tears can cause substantial disability, but treatment options are limited. A balloon spacer is a relatively simple addition to a standard arthroscopic debridement procedure, but it is costly and there is no current randomised trial evidence to support its use. This trial will evaluate the clinical and cost-effectiveness of a subacromial balloon spacer for individuals undergoing arthroscopic debridement for irreparable rotator cuff tears.New surgical procedures can provide substantial benefit to patients. Good quality randomised controlled trials (RCTs) are needed, but trials in surgery are typically long and expensive, exposing patients to risk and the healthcare system to substantial costs. One way to improve the efficiency of trials is with an adaptive sample size. Such methods are well established in drug trials but have rarely, if ever, been used in surgical trials. METHODS AND ANALYSIS Subacromial spacer for Tears Affecting Rotator cuff Tendons: a Randomised, Efficient, Adaptive Clinical Trial in Surgery (START:REACTS) is a participant and assessor blinded, adaptive, multicentre RCT comparing arthroscopic debridement with the InSpace balloon (Stryker, USA) to arthroscopic debridement alone for people with a symptomatic irreparable rotator cuff tear. It uses a group sequential adaptive design where interim analyses are performed using all of the 3, 6 and 12-month data that are available at each time point. A maximum of 221 participants will be randomised (1:1 ratio), this will provide 90% power (at the 5% level) for a 6 point difference in the primary outcome; the Oxford Shoulder Score at 12 months. A substudy will use deltoid-active MRI scans in 56 participants to assess the function of the balloon. Analysis will be on an intention-to-treat basis and reported according to principles established in the Consolidated Standards of Reporting Trials statement. ETHICS AND DISSEMINATION NRES number 18/WM/0025. The results will be disseminated via peer-reviewed publications, presentations at conferences, lay summaries and social media. TRIAL REGISTRATION NUMBER ISRCTN17825590.
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Affiliation(s)
- Andrew Metcalfe
- Warwick Medical School, University of Warwick, Coventry, UK
- University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | | | - Helen Parsons
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Jaclyn Brown
- Warwick Medical School, University of Warwick, Coventry, UK
| | | | | | - Rebecca Kearney
- Warwick Medical School, University of Warwick, Coventry, UK
- University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Tom Lawrence
- University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Howard Bush
- University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Kerri McGowan
- University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Iftekhar Khan
- Warwick Medical School, University of Warwick, Coventry, UK
| | - James Mason
- Warwick Medical School, University of Warwick, Coventry, UK
| | | | - Simon Gates
- Warwick Medical School, University of Warwick, Coventry, UK
- Cancer Research UK Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Nigel Stallard
- Warwick Medical School, University of Warwick, Coventry, UK
| | | | - Stephen Drew
- University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
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20
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An overview of platform trials with a checklist for clinical readers. J Clin Epidemiol 2020; 125:1-8. [PMID: 32416336 DOI: 10.1016/j.jclinepi.2020.04.025] [Citation(s) in RCA: 55] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Revised: 04/16/2020] [Accepted: 04/22/2020] [Indexed: 12/23/2022]
Abstract
OBJECTIVES The objective of the study was to outline key considerations for general clinical readers when critically evaluating publications on platform trials and for researchers when designing these types of clinical trials. STUDY DESIGN AND SETTING In this review, we describe key concepts of platform trials with case study discussion of two hallmark platform trials in STAMPEDE and I-SPY2. We provide reader's guide to platform trials with a critical appraisal checklist. RESULTS Platform trials offer flexibilities of dropping ineffective arms early based on interim data and introducing new arms into the trial. For platform trials, it is important to consider how interventions are compared and evaluated throughout and how new interventions are introduced. For intervention comparisons, it is important to consider what the primary analysis is, what and how many interventions are active simultaneously, and allocation between different arms. Interim evaluation considerations should include the number and timing of interim evaluations and outcomes and statistical rules used to drop interventions. New interventions are usually introduced based on scientific merits, so consideration of these merits is important, together with the timing and mechanisms in which new interventions are added. CONCLUSION More efforts are needed to improve the scientific literacy of platform trials. Our review provides an overview of the important concepts of platform trials.
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21
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Flight L, Julious S, Brennan A, Todd S, Hind D. How can health economics be used in the design and analysis of adaptive clinical trials? A qualitative analysis. Trials 2020; 21:252. [PMID: 32143728 PMCID: PMC7060544 DOI: 10.1186/s13063-020-4137-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2019] [Accepted: 02/04/2020] [Indexed: 12/04/2022] Open
Abstract
INTRODUCTION Adaptive designs offer a flexible approach, allowing changes to a trial based on examinations of the data as it progresses. Adaptive clinical trials are becoming a popular choice, as the prudent use of finite research budgets and accurate decision-making are priorities for healthcare providers around the world. The methods of health economics, which aim to maximise the health gained for money spent, could be incorporated into the design and analysis of adaptive clinical trials to make them more efficient. We aimed to understand the perspectives of stakeholders in health technology assessments to inform recommendations for the use of health economics in adaptive clinical trials. METHODS A qualitative study explored the attitudes of key stakeholders-including researchers, decision-makers and members of the public-towards the use of health economics in the design and analysis of adaptive clinical trials. Data were collected using interviews and focus groups (29 participants). A framework analysis was used to identify themes in the transcripts. RESULTS It was considered that answering the clinical research question should be the priority in a clinical trial, notwithstanding the importance of cost-effectiveness for decision-making. Concerns raised by participants included handling the volatile nature of cost data at interim analyses; implementing this approach in global trials; resourcing adaptive trials which are designed and adapted based on health economic outcomes; and training stakeholders in these methods so that they can be implemented and appropriately interpreted. CONCLUSION The use of health economics in the design and analysis of adaptive clinical trials has the potential to increase the efficiency of health technology assessments worldwide. Recommendations are made concerning the development of methods allowing the use of health economics in adaptive clinical trials, and suggestions are given to facilitate their implementation in practice.
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Affiliation(s)
- Laura Flight
- School of Health And Related Research, University of Sheffield, Sheffield, UK
| | - Steven Julious
- School of Health And Related Research, University of Sheffield, Sheffield, UK
| | - Alan Brennan
- School of Health And Related Research, University of Sheffield, Sheffield, UK
| | - Susan Todd
- Department of Mathematics and Statistics, University of Reading, Reading, UK
| | - Daniel Hind
- School of Health And Related Research, University of Sheffield, Sheffield, UK
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22
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Abstract
BACKGROUND/AIMS The increasing cost of the drug development process has seen interest in the use of adaptive trial designs grow substantially. Accordingly, much research has been conducted to identify barriers to increasing the use of adaptive designs in practice. Several articles have argued that the availability of user-friendly software will be an important step in making adaptive designs easier to implement. Therefore, we present a review of the current state of software availability for adaptive trial design. METHODS We review articles from 31 journals published in 2013-2017 that relate to methodology for adaptive trials to assess how often code and software for implementing novel adaptive designs is made available at the time of publication. We contrast our findings against these journals' policies on code distribution. We also search popular code repositories, such as Comprehensive R Archive Network and GitHub, to identify further existing user-contributed software for adaptive designs. From this, we are able to direct interested parties toward solutions for their problem of interest. RESULTS Only 30% of included articles made their code available in some form. In many instances, articles published in journals that had mandatory requirements on code provision still did not make code available. There are several areas in which available software is currently limited or saturated. In particular, many packages are available to address group sequential design, but comparatively little code is present in the public domain to determine biomarker-guided adaptive designs. CONCLUSIONS There is much room for improvement in the provision of software alongside adaptive design publications. In addition, while progress has been made, well-established software for various types of trial adaptation remains sparsely available.
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Affiliation(s)
- Michael John Grayling
- MRC Biostatistics Unit, University of Cambridge, Cambridge, UK.,Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Graham Mark Wheeler
- Cancer Research UK & UCL Cancer Trials Centre, University College London, London, UK
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23
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Grayling MJ, Wason JM. A web application for the design of multi-arm clinical trials. BMC Cancer 2020; 20:80. [PMID: 32005187 PMCID: PMC6995188 DOI: 10.1186/s12885-020-6525-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Accepted: 01/08/2020] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND Multi-arm designs provide an effective means of evaluating several treatments within the same clinical trial. Given the large number of treatments now available for testing in many disease areas, it has been argued that their utilisation should increase. However, for any given clinical trial there are numerous possible multi-arm designs that could be used, and choosing between them can be a difficult task. This task is complicated further by a lack of available easy-to-use software for designing multi-arm trials. RESULTS To aid the wider implementation of multi-arm clinical trial designs, we have developed a web application for sample size calculation when using a variety of popular multiple comparison corrections. Furthermore, the application supports sample size calculation to control several varieties of power, as well as the determination of optimised arm-wise allocation ratios. It is built using the Shiny package in the R programming language, is free to access on any device with an internet browser, and requires no programming knowledge to use. It incorporates a variety of features to make it easier to use, including help boxes and warning messages. Using design parameters motivated by a recently completed phase II oncology trial, we demonstrate that the application can effectively determine and evaluate complex multi-arm trial designs. CONCLUSIONS The application provides the core information required by statisticians and clinicians to review the operating characteristics of a chosen multi-arm clinical trial design. The range of designs supported by the application is broader than other currently available software solutions. Its primary limitation, particularly from a regulatory agency point of view, is its lack of validation. However, we present an approach to efficiently confirming its results via simulation.
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Affiliation(s)
| | - James Ms Wason
- Population Health Sciences Institute, Newcastle, NE2 4AX, UK.,MRC Biostatistics Unit, University of Cambridge, Cambridge, CB2 0SR, UK
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Walter SD, Han H, Guyatt GH, Bassler D, Bhatnagar N, Gloy V, Schandelmaier S, Briel M. A systematic survey of randomised trials that stopped early for reasons of futility. BMC Med Res Methodol 2020; 20:10. [PMID: 31948397 PMCID: PMC6966801 DOI: 10.1186/s12874-020-0899-1] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Accepted: 01/03/2020] [Indexed: 12/17/2022] Open
Abstract
Background Randomised trial protocols may incorporate interim analyses, with the potential to stop the study for futility if early data show insufficient promise of a treatment benefit. Previously, we have shown that this approach will theoretically lead to mis-estimation of the treatment effect. We now wished to ascertain the importance of this phenomenon in practice. Methods We reviewed the methods and results in a set of trials that had stopped for futility, identified through an extensive literature search. We recorded clinical areas, interventions, study design, outcomes, trial setting, sponsorship, planned and actual treatment effects, sample sizes; power; and if there was a data safety monitoring board, or a published protocol. We identified: if interim analyses were pre-specified, and how many analyses actually occurred; what pre-specified criteria might define futility; if a futility analysis formed the basis for stopping; who made the decision to stop; and the conditional power of each study, i.e. the probability of statistically significant results if the study were to continue to its complete sample size. Results We identified 52 eligible trials, covering many clinical areas. Most trials had multiple centres, tested drugs, and 40% were industry sponsored. There were 75% where at least one interim analysis was planned a priori; a majority had only one interim analysis, typically with about half the target total sample size. A majority of trials did not pre-define a stopping rule, and a variety of reasons were given for stopping. Few studies calculated and reported low conditional power to justify the early stop. When conditional power could be calculated, it was typically low, especially under the current trend hypothesis. However, under the original design hypothesis, a few studies had relatively high conditional power. Data collection often continued after the interim analysis. Conclusions Although other factors will typically be involved, we conclude that, from the perspective of conditional power, stopping early for futility was probably reasonable in most cases, but documentation of the basis for stopping was often missing or vague. Interpretation of truncated trials would be enhanced by improved reporting of stopping protocols, and of their actual execution.
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Affiliation(s)
- S D Walter
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, L8N 3Z5, Canada.
| | - H Han
- Mount Sinai Hospital, Toronto, Canada
| | - G H Guyatt
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, L8N 3Z5, Canada
| | - D Bassler
- Department of Neonatology, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - N Bhatnagar
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, L8N 3Z5, Canada
| | - V Gloy
- Basel Institute for Clinical Epidemiology and Biostatistics, Department of Clinical Research, University of Basel and University Hospital Basel, Basel, Switzerland
| | - S Schandelmaier
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, L8N 3Z5, Canada.,Basel Institute for Clinical Epidemiology and Biostatistics, Department of Clinical Research, University of Basel and University Hospital Basel, Basel, Switzerland
| | - M Briel
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, L8N 3Z5, Canada.,Basel Institute for Clinical Epidemiology and Biostatistics, Department of Clinical Research, University of Basel and University Hospital Basel, Basel, Switzerland
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Ryan EG, Lamb SE, Williamson E, Gates S. Bayesian adaptive designs for multi-arm trials: an orthopaedic case study. Trials 2020; 21:83. [PMID: 31937341 PMCID: PMC6961269 DOI: 10.1186/s13063-019-4021-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Accepted: 12/20/2019] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Bayesian adaptive designs can be more efficient than traditional methods for multi-arm randomised controlled trials. The aim of this work was to demonstrate how Bayesian adaptive designs can be constructed for multi-arm phase III clinical trials and assess potential benefits that these designs offer. METHODS We constructed several alternative Bayesian adaptive designs for the Collaborative Ankle Support Trial (CAST), which was a randomised controlled trial that compared four treatments for severe ankle sprain. These designs incorporated response adaptive randomisation (RAR), arm dropping, and early stopping for efficacy or futility. We studied the operating characteristics of the Bayesian designs via simulation. We then virtually re-executed the trial by implementing the Bayesian adaptive designs using patient data sampled from the CAST study to demonstrate the practical applicability of the designs. RESULTS We constructed five Bayesian adaptive designs, each of which had high power and recruited fewer patients on average than the original designs target sample size. The virtual executions showed that most of the Bayesian designs would have led to trials that declared superiority of one of the interventions over the control. Bayesian adaptive designs with RAR or arm dropping were more likely to allocate patients to better performing arms at each interim analysis. Similar estimates and conclusions were obtained from the Bayesian adaptive designs as from the original trial. CONCLUSIONS Using CAST as an example, this case study shows how Bayesian adaptive designs can be constructed for phase III multi-arm trials using clinically relevant decision criteria. These designs demonstrated that they can potentially generate earlier results and allocate more patients to better performing arms. We recommend the wider use of Bayesian adaptive approaches in phase III clinical trials. TRIAL REGISTRATION CAST study registration ISRCTN, ISRCTN37807450. Retrospectively registered on 25 April 2003.
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Affiliation(s)
- Elizabeth G Ryan
- Cancer Research UK Clinical Trials Unit, Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, B15 2TT, UK.
| | - Sarah E Lamb
- Centre for Rehabilitation Research, Nuffield Department of Orthopaedics, Rheumatology & Musculoskeletal Sciences (NDORMS), Botnar Research Centre, University of Oxford, Oxford, OX3 7LD, UK
- College of Medicine and Health, University of Exeter, Exeter, EX1 2LU, UK
| | - Esther Williamson
- Centre for Rehabilitation Research, Nuffield Department of Orthopaedics, Rheumatology & Musculoskeletal Sciences (NDORMS), Botnar Research Centre, University of Oxford, Oxford, OX3 7LD, UK
| | - Simon Gates
- Cancer Research UK Clinical Trials Unit, Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, B15 2TT, UK
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26
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Lanini S, Ioannidis JPA, Vairo F, Pletschette M, Portella G, Di Bari V, Mammone A, Pisapia R, Merler S, Nguhuni B, Langer M, Di Caro A, Edwards SJL, Petrosillo N, Zumla A, Ippolito G. Non-inferiority versus superiority trial design for new antibiotics in an era of high antimicrobial resistance: the case for post-marketing, adaptive randomised controlled trials. THE LANCET. INFECTIOUS DISEASES 2019; 19:e444-e451. [PMID: 31451421 DOI: 10.1016/s1473-3099(19)30284-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Revised: 05/11/2019] [Accepted: 05/23/2019] [Indexed: 12/25/2022]
Abstract
Antimicrobial resistance is one of the most important threats to global health security. A range of Gram-negative bacteria associated with high morbidity and mortality are now resistant to almost all available antibiotics. In this context of urgency to develop novel drugs, new antibiotics for multidrug-resistant Gram-negative bacteria (namely, ceftazidime-avibactam, plazomicin, and meropenem-vaborbactam) have been approved by regulatory authorities based on non-inferiority trials that provided no direct evidence of their efficacy against multidrug-resistant bacteria such as Enterobacteriaceae spp, Pseudomonas aeruginosa, Stenotrophomonas maltophilia, Burkholderia cepacia, and Acinetobacter baumannii. The use of non-inferiority and superiority trials, and selection of appropriate and optimal study designs, remains a major challenge in the development, registration, and post-marketing implementation of new antibiotics. Using an example of the development process of ceftazidime-avibactam, we propose a strategy for a new research framework based on adaptive randomised clinical trials. The operational research strategy has the aim of assessing the efficacy of new antibiotics in special groups of patients, such as those infected with multidrug-resistant bacteria, who were not included in earlier phase studies, and for whom it is important to establish an appropriate standard of care.
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Affiliation(s)
- Simone Lanini
- National Institute for Infectious Diseases (INMI), Lazzaro Spallanzani IRCCS, Rome, Italy
| | - John P A Ioannidis
- Department of Medicine, Stanford Prevention Research Center, Stanford University School of Medicine, Stanford, California, USA; Departments of Health Research and Policy and of Biomedical Data Science, Stanford University School of Medicine, Stanford, California, USA
| | - Francesco Vairo
- National Institute for Infectious Diseases (INMI), Lazzaro Spallanzani IRCCS, Rome, Italy
| | - Michel Pletschette
- Department of Tropical and Infectious Diseases, Medical Center of the University of Munich, Munich, Germany
| | | | - Virginia Di Bari
- National Institute for Infectious Diseases (INMI), Lazzaro Spallanzani IRCCS, Rome, Italy
| | - Alessia Mammone
- National Institute for Infectious Diseases (INMI), Lazzaro Spallanzani IRCCS, Rome, Italy
| | - Raffaella Pisapia
- National Institute for Infectious Diseases (INMI), Lazzaro Spallanzani IRCCS, Rome, Italy
| | - Stefano Merler
- Center for Information Technology, Bruno Kessler Foundation, Trento, Italy
| | - Boniface Nguhuni
- Division of Health, President's Office Regional Administration and Local Government (PORALG), Dodoma, Tanzania
| | | | - Antonino Di Caro
- National Institute for Infectious Diseases (INMI), Lazzaro Spallanzani IRCCS, Rome, Italy
| | | | - Nicola Petrosillo
- National Institute for Infectious Diseases (INMI), Lazzaro Spallanzani IRCCS, Rome, Italy
| | - Alimuddin Zumla
- Division of Infection and Immunity, University College London, London, UK; NIHR Biomedical Research Centre, University College London Hospitals, London, UK
| | - Giuseppe Ippolito
- National Institute for Infectious Diseases (INMI), Lazzaro Spallanzani IRCCS, Rome, Italy.
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