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Parsons NR, Basu J, Stallard N. Group sequential designs for pragmatic clinical trials with early outcomes: methods and guidance for planning and implementation. BMC Med Res Methodol 2024; 24:42. [PMID: 38365621 PMCID: PMC10870612 DOI: 10.1186/s12874-024-02174-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Accepted: 02/06/2024] [Indexed: 02/18/2024] Open
Abstract
BACKGROUND Group sequential designs are one of the most widely used methodologies for adaptive design in randomized clinical trials. In settings where early outcomes are available, they offer large gains in efficiency compared to a fixed design. However, such designs are underused and used predominantly in therapeutic areas where there is expertise and experience in implementation. One barrier to their greater use is the requirement to undertake simulation studies at the planning stage that require considerable knowledge, coding experience and additional costs. Based on some modest assumptions about the likely patterns of recruitment and the covariance structure of the outcomes, some simple analytic expressions are presented that negate the need to undertake simulations. METHODS A model for longitudinal outcomes with an assumed approximate multivariate normal distribution and three contrasting simple recruitment models are described, based on fixed, increasing and decreasing rates. For assumed uniform and exponential correlation models, analytic expressions for the variance of the treatment effect and the effects of the early outcomes on reducing this variance at the primary outcome time-point are presented. Expressions for the minimum and maximum values show how the correlations and timing of the early outcomes affect design efficiency. RESULTS Simulations showed how patterns of information accrual varied between correlation and recruitment models, and consequentially to some general guidance for planning a trial. Using a previously reported group sequential trial as an exemplar, it is shown how the analytic expressions given here could have been used as a quick and flexible planning tool, avoiding the need for extensive simulation studies based on individual participant data. CONCLUSIONS The analytic expressions described can be routinely used at the planning stage of a putative trial, based on some modest assumptions about the likely number of outcomes and when they might occur and the expected recruitment patterns. Numerical simulations showed that these models behaved sensibly and allowed a range of design options to be explored in a way that would have been difficult and time-consuming if the previously described method of simulating individual trial participant data had been used.
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Affiliation(s)
- Nick R Parsons
- Warwick Clinical Trials Unit (WCTU), Warwick Medical School, University of Warwick, CV4 7AL, Coventry, UK.
| | - Joydeep Basu
- Warwick Clinical Trials Unit (WCTU), Warwick Medical School, University of Warwick, CV4 7AL, Coventry, UK
| | - Nigel Stallard
- Warwick Clinical Trials Unit (WCTU), Warwick Medical School, University of Warwick, CV4 7AL, Coventry, UK
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Davies A, Ormel I, Bernier A, Harriss E, Mumba N, Gobat N, Schwartz L, Cheah PY. A rapid review of community engagement and informed consent processes for adaptive platform trials and alternative design trials for public health emergencies. Wellcome Open Res 2023; 8:194. [PMID: 37654739 PMCID: PMC10465998 DOI: 10.12688/wellcomeopenres.19318.1] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/19/2023] [Indexed: 09/02/2023] Open
Abstract
Background : Public Health Emergencies (PHE) demand expeditious research responses to evaluate new or repurposed therapies and prevention strategies. Alternative Design Trials (ADTs) and Adaptive Platform Trials (APTs) have enabled efficient large-scale testing of biomedical interventions during recent PHEs. Design features of these trials may have implications for engagement and/or informed consent processes. We aimed to rapidly review evidence on engagement and informed consent for ADTs and APTs during PHE to consider what (if any) recommendations can inform practice. Method : In 2022, we searched 8 prominent databases for relevant peer reviewed publications and guidelines for ADTs/APTs in PHE contexts. Articles were selected based on pre-identified inclusion and exclusion criteria. We reviewed protocols and informed consent documents for a sample of large platform trials and consulted with key informants from ADTs/APT trial teams. Data were extracted and summarised using narrative synthesis. Results : Of the 49 articles included, 10 were guidance documents, 14 discussed engagement, 10 discussed informed consent, and 15 discussed both. Included articles addressed ADTs delivered during the West African Ebola epidemic and APTs delivered during COVID-19. PHE clinical research guidance documents highlight the value of ADTs/APTs and the importance of community engagement, but do not provide practice-specific guidance for engagement or informed consent. Engagement and consent practice for ADTs conducted during the West African Ebola epidemic have been well-documented. For COVID-19, engagement and consent practice was described for APTs primarily delivered in high income countries with well-developed health service structures. A key consideration is strong communication of the complexity of trial design in clear, accessible ways. Conclusion: We highlight key considerations for best practice in community engagement and informed consent relevant to ADTs and APTs for PHEs which may helpfully be included in future guidance. Protocol: The review protocol is published online at Prospero on 15/06/2022: registration number CRD42022334170.
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Affiliation(s)
- Alun Davies
- Health Systems Collaborative, Nuffield Department of Medicine, University of Oxford, Oxford, England, UK
| | - Ilja Ormel
- Faculty of Health Sciences, Department of Health Research Methods, Evidence & Impact, McMaster University, Hamilton, Ontario, Canada
| | - Alexe Bernier
- Faculty of Social Sciences, School of Social Work, McMaster University, Hamilton, Ontario, Canada
| | - Eli Harriss
- Bodleian Health Care Libraries, University of Oxford, Oxford, England, UK
| | - Noni Mumba
- The KEMRI-Wellcome Trust Research Programme, Kilifi, 80108, Kenya
| | - Nina Gobat
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, England, UK
| | - Lisa Schwartz
- Faculty of Health Sciences, Department of Health Research Methods, Evidence & Impact, McMaster University, Hamilton, Ontario, Canada
| | - Phaik Yeong Cheah
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Salaya, Nakhon Pathom, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, England, UK
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3
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Group sequential designs in pragmatic trials: feasibility and assessment of utility using data from a number of recent surgical RCTs. BMC Med Res Methodol 2022; 22:256. [PMID: 36183085 PMCID: PMC9526271 DOI: 10.1186/s12874-022-01734-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Accepted: 09/16/2022] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Assessing the long term effects of many surgical interventions tested in pragmatic RCTs may require extended periods of participant follow-up to assess effectiveness and use patient-reported outcomes that require large sample sizes. Consequently the RCTs are often perceived as being expensive and time-consuming, particularly if the results show the test intervention is not effective. Adaptive, and particularly group sequential, designs have great potential to improve the efficiency and cost of testing new and existing surgical interventions. As a means to assess the potential utility of group sequential designs, we re-analyse data from a number of recent high-profile RCTs and assess whether using such a design would have caused the trial to stop early. METHODS Many pragmatic RCTs monitor participants at a number of occasions (e.g. at 6, 12 and 24 months after surgery) during follow-up as a means to assess recovery and also to keep participants engaged with the trial process. Conventionally one of the outcomes is selected as the primary (final) outcome, for clinical reasons, with others designated as either early or late outcomes. In such settings, novel group sequential designs that use data from not only the final outcome but also from early outcomes at interim analyses can be used to inform stopping decisions. We describe data from seven recent surgical RCTs (WAT, DRAFFT, WOLLF, FASHION, CSAW, FIXDT, TOPKAT), and outline possible group sequential designs that could plausibly have been proposed at the design stage. We then simulate how these group sequential designs could have proceeded, by using the observed data and dates to replicate how information could have accumulated and decisions been made for each RCT. RESULTS The results of the simulated group sequential designs showed that for two of the RCTs it was highly likely that they would have stopped for futility at interim analyses, potentially saving considerable time (15 and 23 months) and costs and avoiding patients being exposed to interventions that were either ineffective or no better than standard care. We discuss the characteristics of RCTs that are important in order to use the methodology we describe, particularly the value of early outcomes and the window of opportunity when early stopping decisions can be made and how it is related to the length of recruitment period and follow-up. CONCLUSIONS The results for five of the RCTs tested showed that group sequential designs using early outcome data would have been feasible and likely to provide designs that were at least as efficient, and possibly more efficient, than the original fixed sample size designs. In general, the amount of information provided by the early outcomes was surprisingly large, due to the strength of correlations with the primary outcome. This suggests that the methods described here are likely to provide benefits more generally across the range of surgical trials and more widely in other application areas where trial designs, outcomes and follow-up patterns are structured and behave similarly.
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Aqib A, Lebouché B, Engler K, Schuster T. Feasibility of a Platform Trial Design for the Development of Mobile Health Applications: A Review. Telemed J E Health 2022; 29:501-509. [PMID: 35951018 DOI: 10.1089/tmj.2021.0620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: A novel adaptive trial design called platform trials (PTs) may offer an effective, efficient, and unbiased approach to evaluate different developer versions of mobile health (m-health) apps. However, the feasibility of their use for this purpose is yet to be explored. Objective: This literature review aims to explore the reported challenges associated with the adaptive PT design to assess its feasibility for the development of m-health apps. Methods: A descriptive literature review using two databases (MEDLINE and Embase) was conducted. Documents published in English between 1947 and September 20, 2020, were eligible for inclusion. Results: The titles and abstracts of 758 records were screened after which 179 full-text articles were assessed for eligibility. A total of 41 articles were included in the synthesis, all published after the year 2000. The synthesis yielded eight distinct categories of challenging issues with PTs relevant to their application in m-health app development, along with potential solutions. These categories are ethical issues (e.g., related to informed consent, equipoise, justice) (with 19 articles contributing content), biases (7 articles), temporal drift (4 articles), miscellaneous statistical issues (3 articles), logistical issues (e.g., cost and human resources, frequent amendments; 6 articles), sample size and power conflict (2 articles), generalizability of the results (2 articles), and operational challenges (1 article). Conclusion: Although PT designs are relatively new, they have promising feasibility for the seamless evaluation of interventions that undergo continuous development, including m-health apps; however, various challenges may hinder their successful implementation.
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Affiliation(s)
- Asma Aqib
- Department of Family Medicine, Faculty of Medicine and Health Sciences, McGill University, Montreal, Canada.,Department of Internal Medicine, University of Alabama, Montgomery, Alabama, USA
| | - Bertrand Lebouché
- Department of Family Medicine, Faculty of Medicine and Health Sciences, McGill University, Montreal, Canada.,Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Center, Montreal, Canada.,Chronic Viral Illness Service, Royal Victoria Hospital, McGill University Health Centre, Montreal, Canada
| | - Kim Engler
- Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Center, Montreal, Canada
| | - Tibor Schuster
- Department of Family Medicine, Faculty of Medicine and Health Sciences, McGill University, Montreal, Canada
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Wason JMS, Dimairo M, Biggs K, Bowden S, Brown J, Flight L, Hall J, Jaki T, Lowe R, Pallmann P, Pilling MA, Snowdon C, Sydes MR, Villar SS, Weir CJ, Wilson N, Yap C, Hancock H, Maier R. Practical guidance for planning resources required to support publicly-funded adaptive clinical trials. BMC Med 2022; 20:254. [PMID: 35945610 PMCID: PMC9364623 DOI: 10.1186/s12916-022-02445-7] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 06/20/2022] [Indexed: 11/15/2022] Open
Abstract
Adaptive designs are a class of methods for improving efficiency and patient benefit of clinical trials. Although their use has increased in recent years, research suggests they are not used in many situations where they have potential to bring benefit. One barrier to their more widespread use is a lack of understanding about how the choice to use an adaptive design, rather than a traditional design, affects resources (staff and non-staff) required to set-up, conduct and report a trial. The Costing Adaptive Trials project investigated this issue using quantitative and qualitative research amongst UK Clinical Trials Units. Here, we present guidance that is informed by our research, on considering the appropriate resourcing of adaptive trials. We outline a five-step process to estimate the resources required and provide an accompanying costing tool. The process involves understanding the tasks required to undertake a trial, and how the adaptive design affects them. We identify barriers in the publicly funded landscape and provide recommendations to trial funders that would address them. Although our guidance and recommendations are most relevant to UK non-commercial trials, many aspects are relevant more widely.
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Affiliation(s)
- James M S Wason
- Biostatistics Research Group, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK.
| | - Munyaradzi Dimairo
- School of Health and Related Research, Clinical Trials Research Unit, University of Sheffield, Sheffield, UK
| | - Katie Biggs
- School of Health and Related Research, Clinical Trials Research Unit, University of Sheffield, Sheffield, UK
| | - Sarah Bowden
- Cancer Research UK Clinical Trials Unit (CRCTU), University of Birmingham, Birmingham, UK
| | - Julia Brown
- Cancer Research UK CTU, University of Leeds, Leeds, UK
| | - Laura Flight
- School of Health and Related Research, Health Economics and Decision Science, University of Sheffield, Sheffield, UK
| | - Jamie Hall
- School of Health and Related Research, Clinical Trials Research Unit, University of Sheffield, Sheffield, UK
| | - Thomas Jaki
- MRC Biostatistics Unit, University of Cambridge, Cambridge, UK
- Department of Mathematics and Statistics, Lancaster University, Lancaster, UK
| | - Rachel Lowe
- Centre for Trials Research, Cardiff University, Cardiff, UK
| | | | - Mark A Pilling
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Claire Snowdon
- The Institute of Cancer Research Clinical Trials & Statistics Unit, London, UK
| | | | - Sofía S Villar
- MRC Biostatistics Unit, University of Cambridge, Cambridge, UK
| | - Christopher J Weir
- Edinburgh Clinical Trials Unit, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Nina Wilson
- Biostatistics Research Group, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Christina Yap
- The Institute of Cancer Research Clinical Trials & Statistics Unit, London, UK
| | - Helen Hancock
- Newcastle Clinical Trials Unit, Newcastle University, Newcastle upon Tyne, UK
| | - Rebecca Maier
- Newcastle Clinical Trials Unit, Newcastle University, Newcastle upon Tyne, UK
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Factors influencing the statistical planning, design, conduct, analysis and reporting of trials in health care: A systematic review. Contemp Clin Trials Commun 2022; 26:100897. [PMID: 35198793 PMCID: PMC8842005 DOI: 10.1016/j.conctc.2022.100897] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Revised: 11/24/2021] [Accepted: 01/24/2022] [Indexed: 11/23/2022] Open
Abstract
Background Trials in health care are prospective human research studies designed to test the effectiveness and safety of health care interventions, such as medications, surgeries, medical devices and other treatment or prevention interventions. Statistics is an important and powerful tool in trials. Inappropriately designed trials and/or inappropriate statistical analysis produce unreliable results and a lack of transparency when reported, with limited clinical use. Aim This systematic literature review aimed to identify, describe and synthesise factors contributing to or influencing the statistical planning, design, conduct, analysis and reporting of trials. Methods Information sources were retrieved from the following electronic citation databases: PubMed, Web of Science, PsycINFO, and CINAHL and the grey literature repository: OpenGrey. 90 articles and guidelines were included in this review. A narrative, thematic synthesis identified the key factors influencing the statistical planning, design, conduct, analysis and reporting of trials in health care. Findings and conclusion We identified three analytical themes within which factors are grouped. These are: “what makes a statistician?“, “the need for dynamic statistical involvement and collaboration throughout a trial – it's not just about the numbers”, “and the “accountability of statisticians in ensuring the safety of trial participants and the integrity of trial data”. While important insights emerged about the qualifications, training, roles, and responsibilities of statisticians and their collaboration with other team members in a trial, further empirical research is warranted to elicit the perceptions of trial team members at the centre of statistics in trials.
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Wilson N, Biggs K, Bowden S, Brown J, Dimairo M, Flight L, Hall J, Hockaday A, Jaki T, Lowe R, Murphy C, Pallmann P, Pilling MA, Snowdon C, Sydes MR, Villar SS, Weir CJ, Welburn J, Yap C, Maier R, Hancock H, Wason JMS. Costs and staffing resource requirements for adaptive clinical trials: quantitative and qualitative results from the Costing Adaptive Trials project. BMC Med 2021; 19:251. [PMID: 34696781 PMCID: PMC8545558 DOI: 10.1186/s12916-021-02124-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Accepted: 09/13/2021] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Adaptive designs offer great promise in improving the efficiency and patient-benefit of clinical trials. An important barrier to further increased use is a lack of understanding about which additional resources are required to conduct a high-quality adaptive clinical trial, compared to a traditional fixed design. The Costing Adaptive Trials (CAT) project investigated which additional resources may be required to support adaptive trials. METHODS We conducted a mock costing exercise amongst seven Clinical Trials Units (CTUs) in the UK. Five scenarios were developed, derived from funded clinical trials, where a non-adaptive version and an adaptive version were described. Each scenario represented a different type of adaptive design. CTU staff were asked to provide the costs and staff time they estimated would be needed to support the trial, categorised into specified areas (e.g. statistics, data management, trial management). This was calculated separately for the non-adaptive and adaptive version of the trial, allowing paired comparisons. Interviews with 10 CTU staff who had completed the costing exercise were conducted by qualitative researchers to explore reasons for similarities and differences. RESULTS Estimated resources associated with conducting an adaptive trial were always (moderately) higher than for the non-adaptive equivalent. The median increase was between 2 and 4% for all scenarios, except for sample size re-estimation which was 26.5% (as the adaptive design could lead to a lengthened study period). The highest increase was for statistical staff, with lower increases for data management and trial management staff. The percentage increase in resources varied across different CTUs. The interviews identified possible explanations for differences, including (1) experience in adaptive trials, (2) the complexity of the non-adaptive and adaptive design, and (3) the extent of non-trial specific core infrastructure funding the CTU had. CONCLUSIONS This work sheds light on additional resources required to adequately support a high-quality adaptive trial. The percentage increase in costs for supporting an adaptive trial was generally modest and should not be a barrier to adaptive designs being cost-effective to use in practice. Informed by the results of this research, guidance for investigators and funders will be developed on appropriately resourcing adaptive trials.
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Affiliation(s)
- Nina Wilson
- Population Health Sciences Institute, Newcastle University, Baddiley-Clark Building, Richardson Road, Newcastle upon Tyne, NE2 4AX, UK
| | - Katie Biggs
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Sarah Bowden
- Cancer Research UK Clinical Trials Unit (CRCTU), University of Birmingham, Birmingham, UK
| | - Julia Brown
- Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Munyaradzi Dimairo
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Laura Flight
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Jamie Hall
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Anna Hockaday
- Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Thomas Jaki
- MRC Biostatistics Unit, University of Cambridge, Cambridge, UK
- Department of Mathematics and Statistics, Lancaster University, Lancaster, UK
| | - Rachel Lowe
- Centre for Trials Research, Cardiff University, Cardiff, UK
| | - Caroline Murphy
- King's College Trials Unit, King's College London, London, UK
| | | | - Mark A Pilling
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Claire Snowdon
- The Institute of Cancer Research Clinical Trials & Statistics Unit, London, UK
| | | | - Sofía S Villar
- MRC Biostatistics Unit, University of Cambridge, Cambridge, UK
| | - Christopher J Weir
- Edinburgh Clinical Trials Unit, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Jessica Welburn
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Christina Yap
- The Institute of Cancer Research Clinical Trials & Statistics Unit, London, UK
| | - Rebecca Maier
- Population Health Sciences Institute, Newcastle University, Baddiley-Clark Building, Richardson Road, Newcastle upon Tyne, NE2 4AX, UK
- Newcastle Clinical Trials Unit, Newcastle University, Newcastle upon Tyne, UK
| | - Helen Hancock
- Population Health Sciences Institute, Newcastle University, Baddiley-Clark Building, Richardson Road, Newcastle upon Tyne, NE2 4AX, UK
- Newcastle Clinical Trials Unit, Newcastle University, Newcastle upon Tyne, UK
| | - James M S Wason
- Population Health Sciences Institute, Newcastle University, Baddiley-Clark Building, Richardson Road, Newcastle upon Tyne, NE2 4AX, UK.
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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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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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10
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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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Madani Kia T, Marshall JC, Murthy S. Stakeholder perspectives on adaptive clinical trials: a scoping review. Trials 2020; 21:539. [PMID: 32552852 PMCID: PMC7301522 DOI: 10.1186/s13063-020-04466-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2019] [Accepted: 05/29/2020] [Indexed: 11/10/2022] Open
Abstract
Background Adaptive clinical trials (ACTs) represent an emerging approach to trial design where accumulating data are used to make decisions about future conduct. Adaptations can include comparisons of multiple dose tiers, response-adaptive randomization, sample size re-estimation, and efficacy/futility stopping rules. The objective of this scoping review is to assess stakeholder attitudes, perspectives, and understanding of adaptive trials. Methods We conducted a review of articles examining stakeholders encompassing the broad medical trial community’s perspectives of adaptive designs (ADs). A computerized search was conducted of four electronic databases with relevant search terms. Following screening of articles, the primary findings of each included article were coded for study design, population studied, purpose, and primary implications. Results Our team retrieved 167 peer-reviewed titles in total from the database search and 5 additional titles through searching web-based search engines for gray literature. Of those 172 titles, 152 were non-duplicate citations. Of these, 119 were not given full-text reviews, as their titles and abstracts indicated that they did not meet the inclusion criteria. Thirty-three articles were carefully examined for relevance, and of those, 18 were chosen to be part of the analysis; the other 15 were excluded, as they were not relevant upon closer inspection. Perceived advantages to ADs included limiting ineffective treatments and efficiency in answering the research question; −perceived barriers included insufficient sample size for secondary outcomes, challenges of consent, potential for bias, risk of type 1 error, cost and time to adaptively design trials, unclear rationales for using Ads, and, most importantly, a lack of education regarding ADs among stakeholders within the clinical trial community. Perceptions among different types of stakeholders varied from sector to sector, with patient perspectives being noticeably absent from the literature. Conclusion There are diverse perceptions regarding ADs among stakeholders. Further training, guidelines, and toolkits on the proper use of ADs are needed at all levels to overcome many of these perceived barriers. While education for principal investigators is important, it is also crucial to educate other groups in the community, such as patients, as well as clinicians and staff involved in their daily implementation.
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Affiliation(s)
- Tina Madani Kia
- BC Children's Hospital Research Institute, 4500 Oak Street, Vancouver, BC, Canada.
| | - John C Marshall
- Li Ka Shing Knowledge Institute, Unity Health Toronto, University of Toronto, Toronto, ON, Canada
| | - Srinivas Murthy
- BC Children's Hospital Research Institute, 4500 Oak Street, Vancouver, BC, Canada
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12
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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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13
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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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14
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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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15
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Wason JMS, Brocklehurst P, Yap C. When to keep it simple - adaptive designs are not always useful. BMC Med 2019; 17:152. [PMID: 31370839 PMCID: PMC6676635 DOI: 10.1186/s12916-019-1391-9] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Accepted: 07/15/2019] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Adaptive designs are a wide class of methods focused on improving the power, efficiency and participant benefit of clinical trials. They do this through allowing information gathered during the trial to be used to make changes in a statistically robust manner - the changes could include which treatment arms patients are enrolled to (e.g. dropping non-promising treatment arms), the allocation ratios, the target sample size or the enrolment criteria of the trial. Generally, we are enthusiastic about adaptive designs and advocate their use in many clinical situations. However, they are not always advantageous. In some situations, they provide little efficiency advantage or are even detrimental to the quality of information provided by the trial. In our experience, factors that reduce the efficiency of adaptive designs are routinely downplayed or ignored in methodological papers, which may lead researchers into believing they are more beneficial than they actually are. MAIN TEXT In this paper, we discuss situations where adaptive designs may not be as useful, including situations when the outcomes take a long time to observe, when dropping arms early may cause issues and when increased practical complexity eliminates theoretical efficiency gains. CONCLUSION Adaptive designs often provide notable efficiency benefits. However, it is important for investigators to be aware that they do not always provide an advantage. There should always be careful consideration of the potential benefits and disadvantages of an adaptive design.
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Affiliation(s)
- James M S Wason
- Institute of Health and Society, Newcastle University, Baddiley-Clark Building, Richardson Road, Newcastle upon Tyne, NE2 4AX, UK.
- MRC Biostatistics Unit, University of Cambridge, Cambridge, UK.
| | - Peter Brocklehurst
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Christina Yap
- Cancer Research UK Clinical Trials Unit, University of Birmingham, Birmingham, UK
- Clinical Trials and Statistics Unit, The Institute of Cancer Research, London, UK
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16
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Dimairo M, Coates E, Pallmann P, Todd S, Julious SA, Jaki T, Wason J, Mander AP, Weir CJ, Koenig F, Walton MK, Biggs K, Nicholl J, Hamasaki T, Proschan MA, Scott JA, Ando Y, Hind D, Altman DG. Development process of a consensus-driven CONSORT extension for randomised trials using an adaptive design. BMC Med 2018; 16:210. [PMID: 30442137 PMCID: PMC6238302 DOI: 10.1186/s12916-018-1196-2] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Accepted: 10/23/2018] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Adequate reporting of adaptive designs (ADs) maximises their potential benefits in the conduct of clinical trials. Transparent reporting can help address some obstacles and concerns relating to the use of ADs. Currently, there are deficiencies in the reporting of AD trials. To overcome this, we have developed a consensus-driven extension to the CONSORT statement for randomised trials using an AD. This paper describes the processes and methods used to develop this extension rather than detailed explanation of the guideline. METHODS We developed the guideline in seven overlapping stages: 1) Building on prior research to inform the need for a guideline; 2) A scoping literature review to inform future stages; 3) Drafting the first checklist version involving an External Expert Panel; 4) A two-round Delphi process involving international, multidisciplinary, and cross-sector key stakeholders; 5) A consensus meeting to advise which reporting items to retain through voting, and to discuss the structure of what to include in the supporting explanation and elaboration (E&E) document; 6) Refining and finalising the checklist; and 7) Writing-up and dissemination of the E&E document. The CONSORT Executive Group oversaw the entire development process. RESULTS Delphi survey response rates were 94/143 (66%), 114/156 (73%), and 79/143 (55%) in rounds 1, 2, and across both rounds, respectively. Twenty-seven delegates from Europe, the USA, and Asia attended the consensus meeting. The main checklist has seven new and nine modified items and six unchanged items with expanded E&E text to clarify further considerations for ADs. The abstract checklist has one new and one modified item together with an unchanged item with expanded E&E text. The E&E document will describe the scope of the guideline, the definition of an AD, and some types of ADs and trial adaptations and explain each reporting item in detail including case studies. CONCLUSIONS We hope that making the development processes, methods, and all supporting information that aided decision-making transparent will enhance the acceptability and quick uptake of the guideline. This will also help other groups when developing similar CONSORT extensions. The guideline is applicable to all randomised trials with an AD and contains minimum reporting requirements.
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Affiliation(s)
- Munyaradzi Dimairo
- School of Health and Related Research, University of Sheffield, Regent Court, 30 Regent Street, Sheffield, S1 4DA, UK.
| | - Elizabeth Coates
- School of Health and Related Research, University of Sheffield, Regent Court, 30 Regent Street, Sheffield, S1 4DA, UK
| | | | | | - Steven A Julious
- School of Health and Related Research, University of Sheffield, Regent Court, 30 Regent Street, Sheffield, S1 4DA, UK
| | | | - James Wason
- MRC Biostatistics Unit, University of Cambridge, Cambridge, UK
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | - Adrian P Mander
- MRC Biostatistics Unit, University of Cambridge, Cambridge, 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
| | - Katie Biggs
- School of Health and Related Research, University of Sheffield, Regent Court, 30 Regent Street, Sheffield, S1 4DA, UK
| | - Jon Nicholl
- School of Health and Related Research, University of Sheffield, Regent Court, 30 Regent Street, 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, White Oak, USA
| | - Yuki Ando
- Pharmaceuticals and Medical Devices Agency, Tokyo, Japan
| | - Daniel Hind
- School of Health and Related Research, University of Sheffield, Regent Court, 30 Regent Street, Sheffield, S1 4DA, UK
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17
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Pickles T, Christensen R, Tam LS, Simon LS, Choy EH. Early phase and adaptive design clinical trials in rheumatoid arthritis: a systematic review of early phase trials. Rheumatol Adv Pract 2018; 2:rky045. [PMID: 31431982 PMCID: PMC6649924 DOI: 10.1093/rap/rky045] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2018] [Revised: 09/17/2018] [Indexed: 12/21/2022] Open
Abstract
Objective Adaptive designs can enable highly sophisticated and efficient early phase trials, but the clinical inference from these trials is surrounded by complexity, and currently there is a paucity but steadily increasing amount of use of these designs in all fields of medicine. We aim to review early phase trials in RA to discover those that have used adaptive designs and benchmark trial characteristics. Methods From an OVID search for journal articles reporting the results of early phase trials in rheumatology, 35 studies were found, with 9 subsequently excluded; 11 were added from manual searches and 19 from searching the references. Study characteristics were extracted from the 56 papers (describing 62 trials), including the number of arms, number of patients, the primary outcome and when it was measured. Result One early phase trial using an adaptive design was found. The benchmark early phase trial in RA is a phase II double-blinded randomized trial, with four arms (one control and three intervention), each with 34 patients, and ACR20 measured at 16 weeks as the primary outcome. Conclusion The one adaptive design reviewed here, and a simulation study found in the search, both indicate that adaptive designs can be applied to early phase trials in RA. We have described the benchmark, which the efficiency of early phase trials using an adaptive design needs to exceed. These efficient designs could drive down numbers required, time for data collection and thus cost. Changes have been suggested, but more needs to be done.
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Affiliation(s)
- Tim Pickles
- Cardiff Regional Experimental Arthritis Treatment and Evaluation (CREATE) Centre, Division of Infection and Immunity, School of Medicine, College of Biomedical and Life Sciences, Cardiff University.,Centre for Trials Research, College of Biomedical and Life Sciences, Cardiff University, Cardiff, UK
| | - Robin Christensen
- Musculoskeletal Statistics Unit, The Parker Institute, Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark
| | - Lai-Shan Tam
- Department of Medicine & Therapeutics, Faculty of Medicine, The Chinese University of Hong Kong, Shatin, Hong Kong SAR, China
| | | | - Ernest H Choy
- Cardiff Regional Experimental Arthritis Treatment and Evaluation (CREATE) Centre, Division of Infection and Immunity, School of Medicine, College of Biomedical and Life Sciences, Cardiff University
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Pallmann P, Bedding AW, Choodari-Oskooei B, Dimairo M, Flight L, Hampson LV, Holmes J, Mander AP, Odondi L, Sydes MR, Villar SS, Wason JMS, Weir CJ, Wheeler GM, Yap C, Jaki T. Adaptive designs in clinical trials: why use them, and how to run and report them. BMC Med 2018; 16:29. [PMID: 29490655 PMCID: PMC5830330 DOI: 10.1186/s12916-018-1017-7] [Citation(s) in RCA: 361] [Impact Index Per Article: 60.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2017] [Accepted: 01/30/2018] [Indexed: 12/11/2022] Open
Abstract
Adaptive designs can make clinical trials more flexible by utilising results accumulating in the trial to modify the trial's course in accordance with pre-specified rules. Trials with an adaptive design are often more efficient, informative and ethical than trials with a traditional fixed design since they often make better use of resources such as time and money, and might require fewer participants. Adaptive designs can be applied across all phases of clinical research, from early-phase dose escalation to confirmatory trials. The pace of the uptake of adaptive designs in clinical research, however, has remained well behind that of the statistical literature introducing new methods and highlighting their potential advantages. We speculate that one factor contributing to this is that the full range of adaptations available to trial designs, as well as their goals, advantages and limitations, remains unfamiliar to many parts of the clinical community. Additionally, the term adaptive design has been misleadingly used as an all-encompassing label to refer to certain methods that could be deemed controversial or that have been inadequately implemented.We believe that even if the planning and analysis of a trial is undertaken by an expert statistician, it is essential that the investigators understand the implications of using an adaptive design, for example, what the practical challenges are, what can (and cannot) be inferred from the results of such a trial, and how to report and communicate the results. This tutorial paper provides guidance on key aspects of adaptive designs that are relevant to clinical triallists. We explain the basic rationale behind adaptive designs, clarify ambiguous terminology and summarise the utility and pitfalls of adaptive designs. We discuss practical aspects around funding, ethical approval, treatment supply and communication with stakeholders and trial participants. Our focus, however, is on the interpretation and reporting of results from adaptive design trials, which we consider vital for anyone involved in medical research. We emphasise the general principles of transparency and reproducibility and suggest how best to put them into practice.
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Affiliation(s)
- Philip Pallmann
- Department of Mathematics & Statistics, Lancaster University, Lancaster, LA1 4YF UK
| | | | - Babak Choodari-Oskooei
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, University College London, London, UK
| | | | - Laura Flight
- Medical Statistics Group, University of Sheffield, Sheffield, UK
| | - Lisa V. Hampson
- Department of Mathematics & Statistics, Lancaster University, Lancaster, LA1 4YF UK
- Statistical Innovation Group, Advanced Analytics Centre, AstraZeneca, Cambridge, UK
| | - Jane Holmes
- Centre for Statistics in Medicine, University of Oxford, Oxford, UK
| | | | - Lang’o Odondi
- Centre for Statistics in Medicine, University of Oxford, Oxford, UK
| | - Matthew R. Sydes
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, University College London, London, UK
| | - Sofía S. Villar
- MRC Biostatistics Unit, University of Cambridge, Cambridge, UK
| | - James M. S. Wason
- MRC Biostatistics Unit, University of Cambridge, Cambridge, UK
- Institute of Health and Society, Newcastle University, Newcastle, UK
| | - Christopher J. Weir
- Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
| | - Graham M. Wheeler
- MRC Biostatistics Unit, University of Cambridge, Cambridge, UK
- Cancer Research UK & UCL Cancer Trials Centre, University College London, London, UK
| | - Christina Yap
- Cancer Research UK Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Thomas Jaki
- Department of Mathematics & Statistics, Lancaster University, Lancaster, LA1 4YF UK
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Abstract
OBJECTIVES This review investigates characteristics of implemented adaptive design clinical trials and provides examples of regulatory experience with such trials. DESIGN Review of adaptive design clinical trials in EMBASE, PubMed, Cochrane Registry of Controlled Clinical Trials, Web of Science and ClinicalTrials.gov. Phase I and seamless Phase I/II trials were excluded. Variables extracted from trials included basic study characteristics, adaptive design features, size and use of independent data monitoring committees (DMCs) and blinded interim analyses. We also examined use of the adaptive trials in new drug submissions to the Food and Drug Administration (FDA) and European Medicines Agency (EMA) and recorded regulators' experiences with adaptive designs. RESULTS 142 studies met inclusion criteria. There has been a recent growth in publicly reported use of adaptive designs among researchers around the world. The most frequently appearing types of adaptations were seamless Phase II/III (57%), group sequential (21%), biomarker adaptive (20%), and adaptive dose-finding designs (16%). About one-third (32%) of trials reported an independent DMC, while 6% reported blinded interim analysis. We found that 9% of adaptive trials were used for FDA product approval consideration, and 12% were used for EMA product approval consideration. International regulators had mixed experiences with adaptive trials. Many product applications with adaptive trials had extensive correspondence between drug sponsors and regulators regarding the adaptive designs, in some cases with regulators requiring revisions or alterations to research designs. CONCLUSIONS Wider use of adaptive designs will necessitate new drug application sponsors to engage with regulatory scientists during planning and conduct of the trials. Investigators need to more consistently report protections intended to preserve confidentiality and minimise potential operational bias during interim analysis.
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Affiliation(s)
- Laura E Bothwell
- Program on Regulation, Therapeutics, and Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Jerry Avorn
- Program on Regulation, Therapeutics, and Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Nazleen F Khan
- Program on Regulation, Therapeutics, and Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Aaron S Kesselheim
- Program on Regulation, Therapeutics, and Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
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Love SB, Brown S, Weir CJ, Harbron C, Yap C, Gaschler-Markefski B, Matcham J, Caffrey L, McKevitt C, Clive S, Craddock C, Spicer J, Cornelius V. Embracing model-based designs for dose-finding trials. Br J Cancer 2017; 117:332-339. [PMID: 28664918 PMCID: PMC5537496 DOI: 10.1038/bjc.2017.186] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2017] [Revised: 04/27/2017] [Accepted: 05/31/2017] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Dose-finding trials are essential to drug development as they establish recommended doses for later-phase testing. We aim to motivate wider use of model-based designs for dose finding, such as the continual reassessment method (CRM). METHODS We carried out a literature review of dose-finding designs and conducted a survey to identify perceived barriers to their implementation. RESULTS We describe the benefits of model-based designs (flexibility, superior operating characteristics, extended scope), their current uptake, and existing resources. The most prominent barriers to implementation of a model-based design were lack of suitable training, chief investigators' preference for algorithm-based designs (e.g., 3+3), and limited resources for study design before funding. We use a real-world example to illustrate how these barriers can be overcome. CONCLUSIONS There is overwhelming evidence for the benefits of CRM. Many leading pharmaceutical companies routinely implement model-based designs. Our analysis identified barriers for academic statisticians and clinical academics in mirroring the progress industry has made in trial design. Unified support from funders, regulators, and journal editors could result in more accurate doses for later-phase testing, and increase the efficiency and success of clinical drug development. We give recommendations for increasing the uptake of model-based designs for dose-finding trials in academia.
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Affiliation(s)
- Sharon B Love
- Oxford Clinical Trials Research Unit, Centre for Statistics in Medicine, NDORMS, University of Oxford, Botnar Research Centre, Windmill Road, Oxford OX3 7LD, UK
| | - Sarah Brown
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds LS2 9JT, UK
| | - Christopher J Weir
- Edinburgh Clinical Trials Unit, Usher Institute of Population Health Sciences and Informatics, University of Edinburgh Medical School, Teviot Place, Edinburgh EH8 9AG, UK
| | - Chris Harbron
- Roche Pharmaceuticals, 6 Falcon Way, Shire Park, Welwyn Garden City AL7 1TW, UK
| | - Christina Yap
- Cancer Research UK Clinical Trials Unit, Institute of Cancer and Genomic Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham B15 2TT, UK
| | - Birgit Gaschler-Markefski
- Boehringer Ingelheim Pharma GmbH & Co. KG, Biostatistics and Data Sciences, Birkendorfer Strasse 65, Biberach an der Riss 88400, Germany
| | - James Matcham
- AstraZeneca, DaVinci Building, Melbourn Science Park, Royston SG8 6HB, UK
| | - Louise Caffrey
- School of Social Work and Social Policy, Trinity College Dublin, College Green, Dublin 2, Ireland
| | - Christopher McKevitt
- Division of Health and Social Care Research, Faculty of Life Sciences and Medicine, King’s College London, London, UK
| | - Sally Clive
- Edinburgh Cancer Centre, Western General Hospital, Edinburgh EX4 2XU, UK
| | - Charlie Craddock
- Centre for Clinical Haematology, Haematology – University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Queen Elizabeth Medical Centre, Birmingham B15 2TH, UK
| | - James Spicer
- Division of Cancer Studies, Bermondsey Wing, Guy’s Hospital, Great Maze Pond, London SE1 9RT, UK
| | - Victoria Cornelius
- Imperial Clinical Trials Unit, Imperial College London, Stadium House, 68 Wood Lane, London W12 7RH, UK
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21
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Curtin F, Heritier S. The role of adaptive trial designs in drug development. Expert Rev Clin Pharmacol 2017; 10:727-736. [DOI: 10.1080/17512433.2017.1321985] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Affiliation(s)
- François Curtin
- Division of Clinical Pharmacology and Toxicology, University of Geneva, Geneva, Switzerland
- Research Center for Statistics, Geneva School of Economics and Management, University of Geneva, Geneva, Switzerland
- Geneuro SA, Geneva, Switzerland
| | - Stephane Heritier
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
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22
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Mawocha SC, Fetters MD, Legocki LJ, Guetterman TC, Frederiksen S, Barsan WG, Lewis RJ, Berry DA, Meurer WJ. A conceptual model for the development process of confirmatory adaptive clinical trials within an emergency research network. Clin Trials 2017; 14:246-254. [PMID: 28135827 DOI: 10.1177/1740774516688900] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Adaptive clinical trials use accumulating data from enrolled subjects to alter trial conduct in pre-specified ways based on quantitative decision rules. In this research, we sought to characterize the perspectives of key stakeholders during the development process of confirmatory-phase adaptive clinical trials within an emergency clinical trials network and to build a model to guide future development of adaptive clinical trials. METHODS We used an ethnographic, qualitative approach to evaluate key stakeholders' views about the adaptive clinical trial development process. Stakeholders participated in a series of multidisciplinary meetings during the development of five adaptive clinical trials and completed a Strengths-Weaknesses-Opportunities-Threats questionnaire. In the analysis, we elucidated overarching themes across the stakeholders' responses to develop a conceptual model. RESULTS Four major overarching themes emerged during the analysis of stakeholders' responses to questioning: the perceived statistical complexity of adaptive clinical trials and the roles of collaboration, communication, and time during the development process. Frequent and open communication and collaboration were viewed by stakeholders as critical during the development process, as were the careful management of time and logistical issues related to the complexity of planning adaptive clinical trials. CONCLUSION The Adaptive Design Development Model illustrates how statistical complexity, time, communication, and collaboration are moderating factors in the adaptive design development process. The intensity and iterative nature of this process underscores the need for funding mechanisms for the development of novel trial proposals in academic settings.
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Affiliation(s)
- Samkeliso C Mawocha
- 1 Department of Emergency Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Michael D Fetters
- 2 Department of Family Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Laurie J Legocki
- 2 Department of Family Medicine, University of Michigan, Ann Arbor, MI, USA
| | | | - Shirley Frederiksen
- 1 Department of Emergency Medicine, University of Michigan, Ann Arbor, MI, USA
| | - William G Barsan
- 1 Department of Emergency Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Roger J Lewis
- 3 Department of Emergency Medicine, Los Angeles Biomedical Research Institute, David Geffen School of Medicine at UCLA, Harbor-UCLA Medical Center, Torrance, CA, USA.,4 Berry Consultants, Austin, TX, USA
| | | | - William J Meurer
- 1 Department of Emergency Medicine, University of Michigan, Ann Arbor, MI, USA.,5 Department of Neurology, University of Michigan, Ann Arbor, MI, USA
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Biomarker-Guided Non-Adaptive Trial Designs in Phase II and Phase III: A Methodological Review. J Pers Med 2017; 7:jpm7010001. [PMID: 28125057 PMCID: PMC5374391 DOI: 10.3390/jpm7010001] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2016] [Revised: 12/06/2016] [Accepted: 01/11/2017] [Indexed: 01/22/2023] Open
Abstract
Biomarker-guided treatment is a rapidly developing area of medicine, where treatment choice is personalised according to one or more of an individual’s biomarker measurements. A number of biomarker-guided trial designs have been proposed in the past decade, including both adaptive and non-adaptive trial designs which test the effectiveness of a biomarker-guided approach to treatment with the aim of improving patient health. A better understanding of them is needed as challenges occur both in terms of trial design and analysis. We have undertaken a comprehensive literature review based on an in-depth search strategy with a view to providing the research community with clarity in definition, methodology and terminology of the various biomarker-guided trial designs (both adaptive and non-adaptive designs) from a total of 211 included papers. In the present paper, we focus on non-adaptive biomarker-guided trial designs for which we have identified five distinct main types mentioned in 100 papers. We have graphically displayed each non-adaptive trial design and provided an in-depth overview of their key characteristics. Substantial variability has been observed in terms of how trial designs are described and particularly in the terminology used by different authors. Our comprehensive review provides guidance for those designing biomarker-guided trials.
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24
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Flight L, Julious SA, Goodacre S. Can emergency medicine research benefit from adaptive design clinical trials? Emerg Med J 2016; 34:243-248. [DOI: 10.1136/emermed-2016-206046] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2016] [Accepted: 10/03/2016] [Indexed: 11/04/2022]
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25
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Hatfield I, Allison A, Flight L, Julious SA, Dimairo M. Adaptive designs undertaken in clinical research: a review of registered clinical trials. Trials 2016; 17:150. [PMID: 26993469 PMCID: PMC4799596 DOI: 10.1186/s13063-016-1273-9] [Citation(s) in RCA: 60] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2015] [Accepted: 03/02/2016] [Indexed: 12/25/2022] Open
Abstract
Adaptive designs have the potential to improve efficiency in the evaluation of new medical treatments in comparison to traditional fixed sample size designs. However, they are still not widely used in practice in clinical research. Little research has been conducted to investigate what adaptive designs are being undertaken. This review highlights the current state of registered adaptive designs and their characteristics. The review looked at phase II, II/III and III trials registered on ClinicalTrials.gov from 29 February 2000 to 1 June 2014, supplemented with trials from the National Institute for Health Research register and known adaptive trials. A range of adaptive design search terms were applied to the trials extracted from each database. Characteristics of the adaptive designs were then recorded including funder, therapeutic area and type of adaptation. The results in the paper suggest that the use of adaptive designs has increased. They seem to be most often used in phase II trials and in oncology. In phase III trials, the most popular form of adaptation is the group sequential design. The review failed to capture all trials with adaptive designs, which suggests that the reporting of adaptive designs, such as in clinical trials registers, needs much improving. We recommend that clinical trial registers should contain sections dedicated to the type and scope of the adaptation and that the term 'adaptive design' should be included in the trial title or at least in the brief summary or design sections.
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Affiliation(s)
- Isabella Hatfield
- />School of Mathematics & Statistics, Newcastle University, Herschel Building, Newcastle upon Tyne, NE1 7RU UK
- />ScHARR, University of Sheffield, 30 Regent Street, Sheffield, S1 4DA UK
| | - Annabel Allison
- />ScHARR, University of Sheffield, 30 Regent Street, Sheffield, S1 4DA UK
- />MRC Biostatistics Unit, Cambridge Institute of Public Health, Forvie Site, Robinson Way, Cambridge Biomedical Campus, Cambridge, CB2 0SR UK
| | - Laura Flight
- />ScHARR, University of Sheffield, 30 Regent Street, Sheffield, S1 4DA UK
| | - Steven A. Julious
- />ScHARR, University of Sheffield, 30 Regent Street, Sheffield, S1 4DA UK
| | - Munyaradzi Dimairo
- />ScHARR, University of Sheffield, 30 Regent Street, Sheffield, S1 4DA UK
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26
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Antoniou M, Jorgensen AL, Kolamunnage-Dona R. Biomarker-Guided Adaptive Trial Designs in Phase II and Phase III: A Methodological Review. PLoS One 2016; 11:e0149803. [PMID: 26910238 PMCID: PMC4766245 DOI: 10.1371/journal.pone.0149803] [Citation(s) in RCA: 68] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2015] [Accepted: 02/04/2016] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Personalized medicine is a growing area of research which aims to tailor the treatment given to a patient according to one or more personal characteristics. These characteristics can be demographic such as age or gender, or biological such as a genetic or other biomarker. Prior to utilizing a patient's biomarker information in clinical practice, robust testing in terms of analytical validity, clinical validity and clinical utility is necessary. A number of clinical trial designs have been proposed for testing a biomarker's clinical utility, including Phase II and Phase III clinical trials which aim to test the effectiveness of a biomarker-guided approach to treatment; these designs can be broadly classified into adaptive and non-adaptive. While adaptive designs allow planned modifications based on accumulating information during a trial, non-adaptive designs are typically simpler but less flexible. METHODS AND FINDINGS We have undertaken a comprehensive review of biomarker-guided adaptive trial designs proposed in the past decade. We have identified eight distinct biomarker-guided adaptive designs and nine variations from 107 studies. Substantial variability has been observed in terms of how trial designs are described and particularly in the terminology used by different authors. We have graphically displayed the current biomarker-guided adaptive trial designs and summarised the characteristics of each design. CONCLUSIONS Our in-depth overview provides future researchers with clarity in definition, methodology and terminology for biomarker-guided adaptive trial designs.
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Affiliation(s)
- Miranta Antoniou
- MRC North West Hub For Trials Methodology Research, Liverpool, United Kingdom
- Department of Biostatistics, Institute of Translational Medicine, University of Liverpool, L69 3GL, Liverpool, United Kingdom
- * E-mail:
| | - Andrea L Jorgensen
- MRC North West Hub For Trials Methodology Research, Liverpool, United Kingdom
- Department of Biostatistics, Institute of Translational Medicine, University of Liverpool, L69 3GL, Liverpool, United Kingdom
| | - Ruwanthi Kolamunnage-Dona
- MRC North West Hub For Trials Methodology Research, Liverpool, United Kingdom
- Department of Biostatistics, Institute of Translational Medicine, University of Liverpool, L69 3GL, Liverpool, United Kingdom
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27
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Dimairo M, Julious SA, Todd S, Nicholl JP, Boote J. Cross-sector surveys assessing perceptions of key stakeholders towards barriers, concerns and facilitators to the appropriate use of adaptive designs in confirmatory trials. Trials 2015; 16:585. [PMID: 26700741 PMCID: PMC4690427 DOI: 10.1186/s13063-015-1119-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2015] [Accepted: 12/14/2015] [Indexed: 11/10/2022] Open
Abstract
Background Appropriately conducted adaptive designs (ADs) offer many potential advantages over conventional trials. They make better use of accruing data, potentially saving time, trial participants, and limited resources compared to conventional, fixed sample size designs. However, one can argue that ADs are not implemented as often as they should be, particularly in publicly funded confirmatory trials. This study explored barriers, concerns, and potential facilitators to the appropriate use of ADs in confirmatory trials among key stakeholders. Methods We conducted three cross-sectional, online parallel surveys between November 2014 and January 2015. The surveys were based upon findings drawn from in-depth interviews of key research stakeholders, predominantly in the UK, and targeted Clinical Trials Units (CTUs), public funders, and private sector organisations. Response rates were as follows: 30(55 %) UK CTUs, 17(68 %) private sector, and 86(41 %) public funders. A Rating Scale Model was used to rank barriers and concerns in order of perceived importance for prioritisation. Results Top-ranked barriers included the lack of bridge funding accessible to UK CTUs to support the design of ADs, limited practical implementation knowledge, preference for traditional mainstream designs, difficulties in marketing ADs to key stakeholders, time constraints to support ADs relative to competing priorities, lack of applied training, and insufficient access to case studies of undertaken ADs to facilitate practical learning and successful implementation. Associated practical complexities and inadequate data management infrastructure to support ADs were reported as more pronounced in the private sector. For funders of public research, the inadequate description of the rationale, scope, and decision-making criteria to guide the planned AD in grant proposals by researchers were all viewed as major obstacles. Conclusions There are still persistent and important perceptions of individual and organisational obstacles hampering the use of ADs in confirmatory trials research. Stakeholder perceptions about barriers are largely consistent across sectors, with a few exceptions that reflect differences in organisations’ funding structures, experiences and characterisation of study interventions. Most barriers appear connected to a lack of practical implementation knowledge and applied training, and limited access to case studies to facilitate practical learning. Electronic supplementary material The online version of this article (doi:10.1186/s13063-015-1119-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Munyaradzi Dimairo
- ScHARR, Regent Court, University of Sheffield, 30 Regent Street, S1 4DA, Sheffield, UK.
| | - Steven A Julious
- ScHARR, Regent Court, University of Sheffield, 30 Regent Street, S1 4DA, Sheffield, UK.
| | - Susan Todd
- Department of Mathematics and Statistics, University of Reading, Whiteknights, Reading, RG6 6AX, UK.
| | - Jonathan P Nicholl
- ScHARR, Regent Court, University of Sheffield, 30 Regent Street, S1 4DA, Sheffield, UK.
| | - Jonathan Boote
- ScHARR, Regent Court, University of Sheffield, 30 Regent Street, S1 4DA, Sheffield, UK. .,Centre for Research in Primary and Community Care, University of Hertfordshire, Hatfield, AL109AB, Hertfordshire, UK.
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28
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Snowdon C. Qualitative and mixed methods research in trials. Trials 2015; 16:558. [PMID: 26646545 PMCID: PMC4672490 DOI: 10.1186/s13063-015-1084-4] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2015] [Accepted: 11/26/2015] [Indexed: 11/15/2022] Open
Affiliation(s)
- Claire Snowdon
- London School of Hygiene and Tropical Medicine, London, UK.
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29
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Stevely A, Dimairo M, Todd S, Julious SA, Nicholl J, Hind D, Cooper CL. An Investigation of the Shortcomings of the CONSORT 2010 Statement for the Reporting of Group Sequential Randomised Controlled Trials: A Methodological Systematic Review. PLoS One 2015; 10:e0141104. [PMID: 26528812 PMCID: PMC4631356 DOI: 10.1371/journal.pone.0141104] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2015] [Accepted: 10/04/2015] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND It can be argued that adaptive designs are underused in clinical research. We have explored concerns related to inadequate reporting of such trials, which may influence their uptake. Through a careful examination of the literature, we evaluated the standards of reporting of group sequential (GS) randomised controlled trials, one form of a confirmatory adaptive design. METHODS We undertook a systematic review, by searching Ovid MEDLINE from the 1st January 2001 to 23rd September 2014, supplemented with trials from an audit study. We included parallel group, confirmatory, GS trials that were prospectively designed using a Frequentist approach. Eligible trials were examined for compliance in their reporting against the CONSORT 2010 checklist. In addition, as part of our evaluation, we developed a supplementary checklist to explicitly capture group sequential specific reporting aspects, and investigated how these are currently being reported. RESULTS Of the 284 screened trials, 68(24%) were eligible. Most trials were published in "high impact" peer-reviewed journals. Examination of trials established that 46(68%) were stopped early, predominantly either for futility or efficacy. Suboptimal reporting compliance was found in general items relating to: access to full trials protocols; methods to generate randomisation list(s); details of randomisation concealment, and its implementation. Benchmarking against the supplementary checklist, GS aspects were largely inadequately reported. Only 3(7%) trials which stopped early reported use of statistical bias correction. Moreover, 52(76%) trials failed to disclose methods used to minimise the risk of operational bias, due to the knowledge or leakage of interim results. Occurrence of changes to trial methods and outcomes could not be determined in most trials, due to inaccessible protocols and amendments. DISCUSSION AND CONCLUSIONS There are issues with the reporting of GS trials, particularly those specific to the conduct of interim analyses. Suboptimal reporting of bias correction methods could potentially imply most GS trials stopping early are giving biased results of treatment effects. As a result, research consumers may question credibility of findings to change practice when trials are stopped early. These issues could be alleviated through a CONSORT extension. Assurance of scientific rigour through transparent adequate reporting is paramount to the credibility of findings from adaptive trials. Our systematic literature search was restricted to one database due to resource constraints.
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Affiliation(s)
- Abigail Stevely
- The Medical School, University of Sheffield, Sheffield, United Kingdom
| | - Munyaradzi Dimairo
- School of Health and Related Research, University of Sheffield, Sheffield, United Kingdom
| | - Susan Todd
- Department of Mathematics and Statistics, University of Reading, Reading, United Kingdom
| | - Steven A. Julious
- School of Health and Related Research, University of Sheffield, Sheffield, United Kingdom
| | - Jonathan Nicholl
- School of Health and Related Research, University of Sheffield, Sheffield, United Kingdom
| | - Daniel Hind
- School of Health and Related Research, University of Sheffield, Sheffield, United Kingdom
| | - Cindy L. Cooper
- School of Health and Related Research, University of Sheffield, Sheffield, United Kingdom
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