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Hooper R, Quintin O, Kasza J. Efficient designs for three-sequence stepped wedge trials with continuous recruitment. Clin Trials 2024:17407745241251780. [PMID: 38773924 DOI: 10.1177/17407745241251780] [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: 05/24/2024]
Abstract
BACKGROUND/AIMS The standard approach to designing stepped wedge trials that recruit participants in a continuous stream is to divide time into periods of equal length. But the choice of design in such cases is infinitely more flexible: each cluster could cross from the control to the intervention at any point on the continuous time-scale. We consider the case of a stepped wedge design with clusters randomised to just three sequences (designs with small numbers of sequences may be preferred for their simplicity and practicality) and investigate the choice of design that minimises the variance of the treatment effect estimator under different assumptions about the intra-cluster correlation. METHODS We make some simplifying assumptions in order to calculate the variance: in particular that we recruit the same number of participants, m , from each cluster over the course of the trial, and that participants present at regularly spaced intervals. We consider an intra-cluster correlation that decays exponentially with separation in time between the presentation of two individuals from the same cluster, from a value of ρ for two individuals who present at the same time, to a value of ρ τ for individuals presenting at the start and end of the trial recruitment interval. We restrict attention to three-sequence designs with centrosymmetry - the property that if we reverse time and swap the intervention and control conditions then the design looks the same. We obtain an expression for the variance of the treatment effect estimator adjusted for effects of time, using methods for generalised least squares estimation, and we evaluate this expression numerically for different designs, and for different parameter values. RESULTS There is a two-dimensional space of possible three-sequence, centrosymmetric stepped wedge designs with continuous recruitment. The variance of the treatment effect estimator for given ρ and τ can be plotted as a contour map over this space. The shape of this variance surface depends on τ and on the parameter m ρ / ( 1 - ρ ) , but typically indicates a broad, flat region of close-to-optimal designs. The 'standard' design with equally spaced periods and 1:1:1 allocation rarely performs well, however. CONCLUSIONS In many different settings, a relatively simple design can be found (e.g. one based on simple fractions) that offers close-to-optimal efficiency in that setting. There may also be designs that are robustly efficient over a wide range of settings. Contour maps of the kind we illustrate can help guide this choice. If efficiency is offered as one of the justifications for using a stepped wedge design, then it is worth designing with optimal efficiency in mind.
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Affiliation(s)
- Richard Hooper
- Wolfson Institute of Population Health, Queen Mary University of London, London, UK
| | - Olivier Quintin
- Wolfson Institute of Population Health, Queen Mary University of London, London, UK
| | - Jessica Kasza
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
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2
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Wayop IYA, de Vet E, Leerlooijer JN, Wagenaar JA, Speksnijder DC. Using Implementation Mapping to develop an intervention program to support veterinarians' adherence to the guideline on Streptococcus suis clinical practice in weaned pigs. PLoS One 2024; 19:e0299905. [PMID: 38635508 PMCID: PMC11025762 DOI: 10.1371/journal.pone.0299905] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Accepted: 02/17/2024] [Indexed: 04/20/2024] Open
Abstract
Streptococcus suis (S. suis) infections in weaned pigs are common and responsible for a high consumption of antimicrobials, and their presence is assumed to be multi-factorial. A specific evidence-based veterinary guideline to support the control of S. suis in weaned pigs was developed for veterinary practitioners in the Netherlands in 2014. Adherence to the S. suis clinical practice guideline helps veterinary practitioners to prevent and control the disease in a systematical approach and thereby improve antimicrobial stewardship and contribute to the prevention of antimicrobial resistance in animals and humans. The impact of such a clinical practice guideline on (animal) disease management depends not only on its content, but also largely on the extent to which practitioners adhere to the clinical guideline in practice. When the S. suis guideline was published, no specific activities were undertaken to support veterinarians' uptake and implementation, thereby contributing to suboptimal adherence in clinical practice. As the S. suis guideline was comprehensively written by veterinary experts following an evidence-based approach, our aim was not to judge the (scientific) quality of the guideline but to study the possibility to improve the currently low adherence of this guideline in veterinary practice. This paper describes the systematic development, using Implementation Mapping, of a theory-based intervention program to support swine veterinarians' adherence to the S. suis guideline. The knowledge, skills, beliefs about capabilities, and beliefs about consequences domains are addressed in the program, which includes seven evidence-based methods (modelling, tailoring, feedback, discussion, persuasive communication, active learning, and self-monitoring) for use in program activities such as a peer-learning meeting and an e-learning module. The intervention program has been developed for practicing swine veterinarians, lasts eight months, and is evaluated through a stepped-wedge design. The Implementation Mapping approach ensured that all relevant adopters and implementers were involved, and that outcomes, determinants (influencing factors), and objectives were systematically discussed.
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Affiliation(s)
- Isaura Y. A. Wayop
- Faculty of Veterinary Medicine, Department Biomolecular Health Sciences, Division of Infectious Diseases and Immunology, Utrecht University, Utrecht, The Netherlands
| | - Emely de Vet
- Consumption and Healthy Lifestyles Group, Wageningen University and Research, Wageningen, The Netherlands
| | - Joanne N. Leerlooijer
- Knowledge, Technology and Innovation, Wageningen University and Research, Wageningen, The Netherlands
| | - Jaap A. Wagenaar
- Faculty of Veterinary Medicine, Department Biomolecular Health Sciences, Division of Infectious Diseases and Immunology, Utrecht University, Utrecht, The Netherlands
- Wageningen Bioveterinary Research, Lelystad, The Netherlands
| | - David C. Speksnijder
- Faculty of Veterinary Medicine, Department Biomolecular Health Sciences, Division of Infectious Diseases and Immunology, Utrecht University, Utrecht, The Netherlands
- University Farm Animal Clinic ULP, Harmelen, The Netherlands
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3
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Nevins P, Ryan M, Davis-Plourde K, Ouyang Y, Macedo JAP, Meng C, Tong G, Wang X, Ortiz-Reyes L, Caille A, Li F, Taljaard M. Adherence to key recommendations for design and analysis of stepped-wedge cluster randomized trials: A review of trials published 2016-2022. Clin Trials 2024; 21:199-210. [PMID: 37990575 PMCID: PMC11003836 DOI: 10.1177/17407745231208397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2023]
Abstract
BACKGROUND/AIMS The stepped-wedge cluster randomized trial (SW-CRT), in which clusters are randomized to a time at which they will transition to the intervention condition - rather than a trial arm - is a relatively new design. SW-CRTs have additional design and analytical considerations compared to conventional parallel arm trials. To inform future methodological development, including guidance for trialists and the selection of parameters for statistical simulation studies, we conducted a review of recently published SW-CRTs. Specific objectives were to describe (1) the types of designs used in practice, (2) adherence to key requirements for statistical analysis, and (3) practices around covariate adjustment. We also examined changes in adherence over time and by journal impact factor. METHODS We used electronic searches to identify primary reports of SW-CRTs published 2016-2022. Two reviewers extracted information from each trial report and its protocol, if available, and resolved disagreements through discussion. RESULTS We identified 160 eligible trials, randomizing a median (Q1-Q3) of 11 (8-18) clusters to 5 (4-7) sequences. The majority (122, 76%) were cross-sectional (almost all with continuous recruitment), 23 (14%) were closed cohorts and 15 (9%) open cohorts. Many trials had complex design features such as multiple or multivariate primary outcomes (50, 31%) or time-dependent repeated measures (27, 22%). The most common type of primary outcome was binary (51%); continuous outcomes were less common (26%). The most frequently used method of analysis was a generalized linear mixed model (112, 70%); generalized estimating equations were used less frequently (12, 8%). Among 142 trials with fewer than 40 clusters, only 9 (6%) reported using methods appropriate for a small number of clusters. Statistical analyses clearly adjusted for time effects in 119 (74%), for within-cluster correlations in 132 (83%), and for distinct between-period correlations in 13 (8%). Covariates were included in the primary analysis of the primary outcome in 82 (51%) and were most often individual-level covariates; however, clear and complete pre-specification of covariates was uncommon. Adherence to some key methodological requirements (adjusting for time effects, accounting for within-period correlation) was higher among trials published in higher versus lower impact factor journals. Substantial improvements over time were not observed although a slight improvement was observed in the proportion accounting for a distinct between-period correlation. CONCLUSIONS Future methods development should prioritize methods for SW-CRTs with binary or time-to-event outcomes, small numbers of clusters, continuous recruitment designs, multivariate outcomes, or time-dependent repeated measures. Trialists, journal editors, and peer reviewers should be aware that SW-CRTs have additional methodological requirements over parallel arm designs including the need to account for period effects as well as complex intracluster correlations.
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Affiliation(s)
- Pascale Nevins
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Mary Ryan
- Department of Biostatistics, Yale School of Public Health, New Haven, CT, USA
| | - Kendra Davis-Plourde
- Department of Biostatistics, Yale School of Public Health, New Haven, CT, USA
- Yale Center for Analytical Sciences, Yale School of Public Health, New Haven, CT, USA
| | - Yongdong Ouyang
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | | | - Can Meng
- Yale Center for Analytical Sciences, Yale School of Public Health, New Haven, CT, USA
| | - Guangyu Tong
- Department of Biostatistics, Yale School of Public Health, New Haven, CT, USA
- Center for Methods in Implementation and Prevention Science, Yale University, New Haven, CT, USA
| | - Xueqi Wang
- Department of Biostatistics, Yale School of Public Health, New Haven, CT, USA
- Section of Geriatrics, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Luis Ortiz-Reyes
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Agnès Caille
- Université de Tours, Université de Nantes, INSERM, SPHERE U1246, Tours, France
- INSERM CIC 1415, CHRU de Tours, Tours, France
| | - Fan Li
- Department of Biostatistics, Yale School of Public Health, New Haven, CT, USA
- Center for Methods in Implementation and Prevention Science, Yale University, New Haven, CT, USA
| | - Monica Taljaard
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
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4
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Wang J, Cao J, Ahn C, Zhang S. A Bayesian adaptive design approach for stepped-wedge cluster randomized trials. Clin Trials 2024:17407745231221438. [PMID: 38240270 PMCID: PMC11261240 DOI: 10.1177/17407745231221438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/24/2024]
Abstract
BACKGROUND The Bayesian group sequential design has been applied widely in clinical studies, especially in Phase II and III studies. It allows early termination based on accumulating interim data. However, to date, there lacks development in its application to stepped-wedge cluster randomized trials, which are gaining popularity in pragmatic trials conducted by clinical and health care delivery researchers. METHODS We propose a Bayesian adaptive design approach for stepped-wedge cluster randomized trials, which makes adaptive decisions based on the predictive probability of declaring the intervention effective at the end of study given interim data. The Bayesian models and the algorithms for posterior inference and trial conduct are presented. RESULTS We present how to determine design parameters through extensive simulations to achieve desired operational characteristics. We further evaluate how various design factors, such as the number of steps, cluster size, random variability in cluster size, and correlation structures, impact trial properties, including power, type I error, and the probability of early stopping. An application example is presented. CONCLUSION This study presents the incorporation of Bayesian adaptive strategies into stepped-wedge cluster randomized trials design. The proposed approach provides the flexibility to stop the trial early if substantial evidence of efficacy or futility is observed, improving the flexibility and efficiency of stepped-wedge cluster randomized trials.
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Affiliation(s)
- Jijia Wang
- Department of Applied Clinical Research, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Jing Cao
- Department of Statistics and Data Science, Southern Methodist University, Dallas, TX, USA
| | - Chul Ahn
- Peter O'Donnell Jr. School of Public Health, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Song Zhang
- Peter O'Donnell Jr. School of Public Health, University of Texas Southwestern Medical Center, Dallas, TX, USA
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5
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Hoppe JA, Ledbetter C, Tolle H, Heard K. Implementation of Electronic Health Record Integration and Clinical Decision Support to Improve Emergency Department Prescription Drug Monitoring Program Use. Ann Emerg Med 2024; 83:3-13. [PMID: 37632496 DOI: 10.1016/j.annemergmed.2023.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 06/30/2023] [Accepted: 07/06/2023] [Indexed: 08/28/2023]
Abstract
STUDY OBJECTIVE(S) To evaluate the implementation of 3 electronic health record (EHR)-based interventions to increase prescription drug monitoring program (PDMP) use in the emergency department (ED): EHR-PDMP integration, addition of a PDMP risk score, and addition of EHR-based clinical decision support alert to review the PDMP when prescribing an opioid. METHODS Three intervention stages were implemented using a prospective stepped-wedge design at 5 university-affiliated EDs split into 3 practice groups. The PDMP use and prescribing rates during the 3 stages were compared with baseline before EHR integration and a sustainability stage where the clinical decision support alert was removed, but EHR integration and risk score remained. Generalized linear mixed model with logit link function and a random intercept for clinicians was analyzed. RESULTS The ED provider PDMP review before opioid prescribing was low in all stages. The highest review rate occurred during interruptive clinical decision support alerts, 23.8% (interquartile range 10.6 to 37.5). Overall, opioid prescribing declined, and PDMP review was not associated with a decrease in opioid prescribing. PDMP review was associated with a reduction in the probability of prescribing an opioid as the number of prior opioid prescriptions increased (odds ratio: 0.92 [95% confidence interval: 0.91 to 0.94] for every additional prescription). CONCLUSION The EHR-PDMP integration did not increase PDMP use in the ED, but a PDMP risk score and a clinical decision support alert were associated with modest increases in the probability of PDMP review. When the PDMP is reviewed, ED clinicians are less likely to prescribe opioids to patients with a high number of prior opioid prescriptions.
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Affiliation(s)
- Jason A Hoppe
- Department of Emergency Medicine, University of Colorado, Aurora, CO.
| | - Caroline Ledbetter
- Center for Innovative Design and Analysis, the Colorado School of Public Health, Aurora, CO
| | - Heather Tolle
- Department of Emergency Medicine, University of Colorado, Aurora, CO
| | - Kennon Heard
- Department of Emergency Medicine, University of Colorado, Aurora, CO
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6
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Maleyeff L, Li F, Haneuse S, Wang R. Assessing exposure-time treatment effect heterogeneity in stepped-wedge cluster randomized trials. Biometrics 2023; 79:2551-2564. [PMID: 36416302 PMCID: PMC10203056 DOI: 10.1111/biom.13803] [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: 12/18/2021] [Accepted: 11/16/2022] [Indexed: 11/24/2022]
Abstract
A stepped-wedge cluster randomized trial (CRT) is a unidirectional crossover study in which timings of treatment initiation for clusters are randomized. Because the timing of treatment initiation is different for each cluster, an emerging question is whether the treatment effect depends on the exposure time, namely, the time duration since the initiation of treatment. Existing approaches for assessing exposure-time treatment effect heterogeneity either assume a parametric functional form of exposure time or model the exposure time as a categorical variable, in which case the number of parameters increases with the number of exposure-time periods, leading to a potential loss in efficiency. In this article, we propose a new model formulation for assessing treatment effect heterogeneity over exposure time. Rather than a categorical term for each level of exposure time, the proposed model includes a random effect to represent varying treatment effects by exposure time. This allows for pooling information across exposure-time periods and may result in more precise average and exposure-time-specific treatment effect estimates. In addition, we develop an accompanying permutation test for the variance component of the heterogeneous treatment effect parameters. We conduct simulation studies to compare the proposed model and permutation test to alternative methods to elucidate their finite-sample operating characteristics, and to generate practical guidance on model choices for assessing exposure-time treatment effect heterogeneity in stepped-wedge CRTs.
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Affiliation(s)
- Lara Maleyeff
- Department of Biostatistics, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Fan Li
- Department of Biostatistics, Yale School of Public Health, New Haven, Connecticut, USA
- Center for Methods in Implementation and Prevention Science, Yale School of Public Health, New Haven, Connecticut, USA
| | - Sebastien Haneuse
- Department of Biostatistics, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Rui Wang
- Department of Biostatistics, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, USA
- Department of Population Medicine, Harvard Pilgrim Health Care Institute and Harvard Medical School, Boston, Massachusetts, USA
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7
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King KM, Yeng S, Brennan C, Creel D, Ames JW, Cotes G, Bann CM, Black MM. Integrated Early Childhood Development in Cambodia: Protocol of a Cluster Stepped-Wedge Trial. Pediatrics 2023; 151:191224. [PMID: 37125891 DOI: 10.1542/peds.2023-060221n] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/17/2023] [Indexed: 05/02/2023] Open
Abstract
OBJECTIVES Limited evidence is available on mechanisms linking integrated, multisector interventions with early childhood development. The Integrated Early Childhood Development program aims to improve children's development by promoting targeted caregiving behaviors beginning prenatally through age 5 years, in partnership with the Royal Government of Cambodia. METHODS This cluster stepped-wedge trial is being conducted in Cambodia among 3 cohorts, encompassing 339 villages and 1790 caregivers who are pregnant or caring for a child aged <5 years. The 12- to 15-month intervention is delivered to each cohort using a staggered stepped-wedge design. Among all cohorts, enrollment evaluations will be followed by 3 data collection waves. Targeted caregiving interventions are provided through community, group, and home-visiting platforms. Child development is measured using the Caregiver Reported Early Development Instrument and the Early Childhood Development Index 2030. The evaluation assesses mediation through targeted caregiving behaviors: responsive caregiving, nutrition, health and hygiene, and household stability and support; moderation by household wealth, caregiver education, and child birth weight; and sustainability after the intervention concludes. CONCLUSIONS This protocol article describes the plans for a cluster randomized controlled trial to measure the impact of an integrated, multisector intervention on children's development. By partnering with the Royal Government of Cambodia and addressing intervention pathways and moderators, this trial will provide guidance for policies and programs to promote early childhood development using principles of implementation science and equity, including increased investment for vulnerable families.
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Affiliation(s)
| | - Seng Yeng
- RTI International, Phnom Penh, Cambodia
| | - Claire Brennan
- RTI International, Research Triangle Park, North Carolina
| | - Darryl Creel
- RTI International, Research Triangle Park, North Carolina
| | | | | | - Carla M Bann
- RTI International, Research Triangle Park, North Carolina
| | - Maureen M Black
- RTI International, Research Triangle Park, North Carolina
- University of Maryland School of Medicine, Baltimore, Maryland
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8
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Davis-Plourde K, Taljaard M, Li F. Sample size considerations for stepped wedge designs with subclusters. Biometrics 2023; 79:98-112. [PMID: 34719017 PMCID: PMC9054939 DOI: 10.1111/biom.13596] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Revised: 10/12/2021] [Accepted: 10/21/2021] [Indexed: 12/12/2022]
Abstract
The stepped wedge cluster randomized trial (SW-CRT) is an increasingly popular design for evaluating health service delivery or policy interventions. An essential consideration of this design is the need to account for both within-period and between-period correlations in sample size calculations. Especially when embedded in health care delivery systems, many SW-CRTs may have subclusters nested in clusters, within which outcomes are collected longitudinally. However, existing sample size methods that account for between-period correlations have not allowed for multiple levels of clustering. We present computationally efficient sample size procedures that properly differentiate within-period and between-period intracluster correlation coefficients in SW-CRTs in the presence of subclusters. We introduce an extended block exchangeable correlation matrix to characterize the complex dependencies of outcomes within clusters. For Gaussian outcomes, we derive a closed-form sample size expression that depends on the correlation structure only through two eigenvalues of the extended block exchangeable correlation structure. For non-Gaussian outcomes, we present a generic sample size algorithm based on linearization and elucidate simplifications under canonical link functions. For example, we show that the approximate sample size formula under a logistic linear mixed model depends on three eigenvalues of the extended block exchangeable correlation matrix. We provide an extension to accommodate unequal cluster sizes and validate the proposed methods via simulations. Finally, we illustrate our methods in two real SW-CRTs with subclusters.
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Affiliation(s)
- Kendra Davis-Plourde
- Department of Biostatistics, Yale School of Public Health, New Haven, Connecticut, USA
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
- Center for Methods in Implementation and Prevention Science, Yale University, New Haven, Connecticut, USA
| | - Monica Taljaard
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- School of Epidemiology and Public Heath, University of Ottawa, Ottawa, Ontario, Canada
| | - Fan Li
- Department of Biostatistics, Yale School of Public Health, New Haven, Connecticut, USA
- Center for Methods in Implementation and Prevention Science, Yale University, New Haven, Connecticut, USA
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9
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Davis-Plourde K, Taljaard M, Li F. Power analyses for stepped wedge designs with multivariate continuous outcomes. Stat Med 2023; 42:559-578. [PMID: 36565050 PMCID: PMC9985483 DOI: 10.1002/sim.9632] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Revised: 10/13/2022] [Accepted: 12/08/2022] [Indexed: 12/25/2022]
Abstract
Multivariate outcomes are common in pragmatic cluster randomized trials. While sample size calculation procedures for multivariate outcomes exist under parallel assignment, none have been developed for a stepped wedge design. In this article, we present computationally efficient power and sample size procedures for stepped wedge cluster randomized trials (SW-CRTs) with multivariate outcomes that differentiate the within-period and between-period intracluster correlation coefficients (ICCs). Under a multivariate linear mixed model, we derive the joint distribution of the intervention test statistics which can be used for determining power under different hypotheses and provide an example using the commonly utilized intersection-union test for co-primary outcomes. Simplifications under a common treatment effect and common ICCs across endpoints and an extension to closed-cohort designs are also provided. Finally, under the common ICC across endpoints assumption, we formally prove that the multivariate linear mixed model leads to a more efficient treatment effect estimator compared to the univariate linear mixed model, providing a rigorous justification on the use of the former with multivariate outcomes. We illustrate application of the proposed methods using data from an existing SW-CRT and present extensive simulations to validate the methods.
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Affiliation(s)
- Kendra Davis-Plourde
- Department of Biostatistics, Yale School of Public Health, New Haven, Connecticut, USA
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
- Center for Methods in Implementation and Prevention Science, Yale School of Public Health, New Haven, Connecticut, USA
| | - Monica Taljaard
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- School of Epidemiology and Public Heath, University of Ottawa, Ottawa, Ontario, Canada
| | - Fan Li
- Department of Biostatistics, Yale School of Public Health, New Haven, Connecticut, USA
- Center for Methods in Implementation and Prevention Science, Yale School of Public Health, New Haven, Connecticut, USA
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10
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Zhang Y, Preisser JS, Turner EL, Rathouz PJ, Toles M, Li F. A general method for calculating power for GEE analysis of complete and incomplete stepped wedge cluster randomized trials. Stat Methods Med Res 2023; 32:71-87. [PMID: 36253078 DOI: 10.1177/09622802221129861] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Stepped wedge designs have uni-directional crossovers at randomly assigned time points (steps) where clusters switch from control to intervention condition. Incomplete stepped wedge designs are increasingly used in cluster randomized trials of health care interventions and have periods without data collection due to logistical, resource and patient-centered considerations. The development of sample size formulae for stepped wedge trials has primarily focused on complete designs and continuous responses. Addressing this gap, a general, fast, non-simulation based power procedure is proposed for generalized estimating equations analysis of complete and incomplete stepped wedge designs and its predicted power is compared to simulated power for binary and continuous responses. An extensive set of simulations for six and twelve clusters is based upon the Connect-Home trial with an incomplete stepped wedge design. Results show that empirical test size is well controlled using a t-test with bias-corrected sandwich variance estimator for as few as six clusters. Analytical power agrees well with a simulated power in scenarios with twelve clusters. For six clusters, analytical power is similar to simulated power with estimation using the correctly specified model-based variance estimator. To explore the impact of study design choice on power, the proposed fast GEE power method is applied to the Connect-Home trial design, four alternative incomplete stepped wedge designs and one complete design.
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Affiliation(s)
- Ying Zhang
- Department of Biostatistics, University of North Carolina, Chapel Hill, NC, USA
| | - John S Preisser
- Department of Biostatistics, University of North Carolina, Chapel Hill, NC, USA
| | - Elizabeth L Turner
- Department of Biostatistics and Bioinformatics, Duke University, Durham, NC, USA
| | - Paul J Rathouz
- Department of Population Health, The University of Texas at Austin, Austin, TX, USA
| | - Mark Toles
- School of Nursing, University of North Carolina, Chapel Hill, NC, USA
| | - Fan Li
- Department of Biostatistics, Yale School of Public Health, New Haven, CT, USA
- Center for Methods in Implementation and Prevention Science, Yale School of Public Health, New Haven, CT, USA
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11
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Gallis JA, Wang X, Rathouz PJ, Preisser JS, Li F, Turner EL. power swgee: GEE-based power calculations in stepped wedge cluster randomized trials. THE STATA JOURNAL 2022; 22:811-841. [PMID: 36968149 PMCID: PMC10035664 DOI: 10.1177/1536867x221140953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/18/2023]
Abstract
Stepped wedge cluster randomized trials are increasingly being used to evaluate interventions in medical, public health, educational, and social science contexts. With the longitudinal and crossover nature of a SW-CRT, complex analysis techniques are often needed which makes appropriately powering SW-CRTs challenging. In this paper, we introduce a newly-developed SW-CRT power calculator, embedded within the power command in Stata. The power calculator assumes a marginal model (i.e., generalized estimating equations [GEE]) for the primary analysis of SW-CRTs, for which other currently available SW-CRT power calculators may not be suitable. The program accommodates complete cross-sectional and closed-cohort designs, and includes multilevel correlation structures appropriate for such designs. We discuss the methods and formulae underlying our SW-CRT calculator, and provide illustrative examples of the use of power swgee. We provide suggestions about the choice of parameters in power swgee, and conclude by discussing areas of future research which may improve the program.
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Affiliation(s)
- John A Gallis
- Department of Biostatistics, Duke University, Duke Global Health Institute, Durham, NC
| | - Xueqi Wang
- Department of Biostatistics, Duke University, Duke Global Health Institute, Durham, NC
| | - Paul J Rathouz
- Department of Population Health, University of Texas at Austin, Dell Medical School, Austin, TX
| | - John S Preisser
- Department of Biosttistics, University of North Carolina at Chapel Hill, Gillings School of Global Public Health, Chapel Hill, NC
| | - Fan Li
- Department of Biostatistics, Yale School of Public Health, Center for Methods in Implementation, Prevention Science, New Haven, CT
| | - Elizabeth L Turner
- Department of Biostatistics, Duke University, Duke Global Health Institute, Durham, NC
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12
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Hsiao CY, Wu JC, Lin PC, Yang PY, Liao F, Guo SL, Hou WH. Effectiveness of interprofessional shared decision-making training: A mixed-method study. PATIENT EDUCATION AND COUNSELING 2022; 105:3287-3297. [PMID: 35927112 DOI: 10.1016/j.pec.2022.07.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Revised: 07/04/2022] [Accepted: 07/15/2022] [Indexed: 06/15/2023]
Abstract
OBJECTIVE This study evaluated the learning effects and examined the participants' perceptions of an interprofessional shared decision-making (IP-SDM) training program. METHODS This mixed-method study used a quasi-experimental pretest-posttest design in the quantitative phase and semi-structured interviews in the qualitative phase. The 6-week curriculum design, based on Kolb's experiential learning cycle, consisted of two simulated objective structured clinical examinations with standardized patients and blended teaching methods through various course modules. RESULTS A total of 39 multidisciplinary healthcare personnel completed the 6-week training program, and 32 of them participated in qualitative interviews. The IP-SDM training program effectively improved the SDM process competency of the participants from the perspectives of the participants, standardized patients, and clinical teachers. The interviews illustrated how the curriculum design enhanced learning; the effectiveness results indicated improvements in learners' attitude, knowledge, skills, and teamwork. CONCLUSION This IP-SDM training program improved multidisciplinary healthcare personnel's competency, self-efficacy, and intention to engage in IP-SDM. PRACTICE IMPLICATIONS Applying Kolb's experiential learning cycle and blended teaching methods to develop and implement the IP-SDM training program can improve multidisciplinary healthcare personnel's knowledge, attitude, skills, and teamwork in IP-SDM.
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Affiliation(s)
- Chih-Yin Hsiao
- School of Gerontology and Long-Term Care, College of Nursing, Taipei Medical University, Taipei, Taiwan
| | - Jeng-Cheng Wu
- Department of Urology, Taipei Medical University Hospital, Taipei, Taiwan; Department of Education, Taipei Medical University Hospital, Taipei, Taiwan; Department of Urology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan; TMU Research Center of Urology and Kidney, Taipei Medical University, Taipei, Taiwan; Department of Health Promotion and Health Education, College of Education, National Taiwan Normal University, Taipei, Taiwan
| | - Pi-Chu Lin
- School of Gerontology and Long-Term Care, College of Nursing, Taipei Medical University, Taipei, Taiwan; Department of Nursing & Graduate Institute of Nursing, Asia University, Taichung, Taiwan; Department of Nursing, Meiho University, Pingtung, Taiwan
| | - Pang-Yuan Yang
- School of Gerontology and Long-Term Care, College of Nursing, Taipei Medical University, Taipei, Taiwan
| | - Faith Liao
- Department of Education, Taipei Medical University Hospital, Taipei, Taiwan; Graduate Institute of Humanities in Medicine, College of Humanities and Social Sciences, Taipei Medical University, Taipei, Taiwan; Department of Humanities in Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan; School of Nursing, College of Nursing, Taipei Medical University, Taipei, Taiwan
| | - Shu-Liu Guo
- School of Nursing, College of Nursing, Taipei Medical University, Taipei, Taiwan; Department of Nursing, Taipei Medical University Hospital, Taipei, Taiwan
| | - Wen-Hsuan Hou
- School of Gerontology and Long-Term Care, College of Nursing, Taipei Medical University, Taipei, Taiwan; Department of Education, Taipei Medical University Hospital, Taipei, Taiwan; Department of Physical Medicine and Rehabilitation & Geriatrics and Gerontology, Taipei Medical University Hospital, Taipei, Taiwan; College of Medicine, National Cheng Kung University, Tainan, Taiwan.
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13
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Gauci J, Bloomfield J, Lawn S, Towns S, Hobbs A, Steinbeck K. A randomized controlled trial evaluating the effectiveness of a self-management program for adolescents with a chronic condition: a study protocol. Trials 2022; 23:850. [PMID: 36199075 PMCID: PMC9532816 DOI: 10.1186/s13063-022-06740-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Accepted: 09/13/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Self-management support is increasingly viewed as an integral part of chronic condition management in adolescence. It is well recognized that markers of chronic illness control deteriorate during adolescence. Due to the increasing prevalence of long-term chronic health conditions in childhood and improved survival rates of previously life-limiting conditions in children and adolescents, significant numbers of adolescents are having to manage their chronic condition effectively as they transition to adult health care. Therapy adherence has been identified as a major challenge for young people living with a chronic condition such as cystic fibrosis, diabetes, or asthma requiring long-term pharmacological therapy and/or lifestyle modifications. Most systematic reviews on self-management interventions address adult populations. Very few intervention studies are directed at adolescents with a chronic condition who are transitioning to adult health services. This protocol describes a prospective randomized controlled trial of a standardized self-management intervention program delivered to adolescents aged 15-18 years prior to their transfer to adult care. This study has been designed to provide evidence regarding self-management programs for adolescents and is the first study to use the Flinders Program with this important, under-researched age group. METHODS A randomized controlled trial is used to investigate the effectiveness of a modified adolescent-friendly version of an adult self-management program. This program is directed at improving self-management in an adolescent cohort 15-18 years of age with a chronic condition being treated in a specialist pediatric hospital. Participants will be randomized to either usual care or the modified Flinders Program plus usual care. Data collection will include measures of specific illness control, unscheduled hospital admissions, and questionnaires to record self-management competencies, quality of life, self-efficacy, and outcome measures specific to the chronic condition at baseline, 3 months, 6 months, and 12 months after delivery. DISCUSSION This study will provide a better understanding of the elements required for effective self-management programs in adolescents with a chronic condition and address some important knowledge gaps in current literature. The study will be carried out in collaboration with the Discipline of Behavioural Health at Flinders University, Adelaide, Australia, in order to inform the development of an adolescent version of the successful and validated Flinders Program™. TRIAL REGISTRATION Australian and New Zealand Clinical Trials Registry (ACTRN12621000390886). Registered on April 8, 2021.
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Affiliation(s)
- Jaunna Gauci
- Department of Adolescent Medicine, The Children's Hospital at Westmead, Locked Bag 4001, Westmead, Sydney, NSW, 2145, Australia. .,Discipline of Child & Adolescent Health, Sydney Medical School, The University of Sydney, Sydney, Australia.
| | - Jacqueline Bloomfield
- Susan Wakil School of Nursing and Midwifery, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Sharon Lawn
- College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia
| | - Susan Towns
- Department of Adolescent Medicine, The Children's Hospital at Westmead, Locked Bag 4001, Westmead, Sydney, NSW, 2145, Australia.,Discipline of Child & Adolescent Health, Sydney Medical School, The University of Sydney, Sydney, Australia
| | - Annabelle Hobbs
- The Academic Department of Adolescent Medicine, The Children's Hospital at Westmead, Sydney, Australia
| | - Katharine Steinbeck
- Discipline of Child & Adolescent Health, Sydney Medical School, The University of Sydney, Sydney, Australia.,The Academic Department of Adolescent Medicine, The Children's Hospital at Westmead, Sydney, Australia
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14
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Young LW, Ounpraseuth S, Merhar SL, Simon AE, Das A, Greenberg RG, Higgins RD, Lee J, Poindexter BB, Smith PB, Walsh M, Snowden J, Devlin LA. Eating, Sleeping, Consoling for Neonatal Opioid Withdrawal (ESC-NOW): a Function-Based Assessment and Management Approach study protocol for a multi-center, stepped-wedge randomized controlled trial. Trials 2022; 23:638. [PMID: 35945598 PMCID: PMC9361241 DOI: 10.1186/s13063-022-06445-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Accepted: 06/02/2022] [Indexed: 12/05/2022] Open
Affiliation(s)
- Leslie W. Young
- Department of Pediatrics, Larner College of Medicine at the University of Vermont, 111 Colchester Ave Smith 5, Burlington, VT 05401 USA
| | - Songthip Ounpraseuth
- University of Arkansas for Medical Sciences, 4301 W. Markham St., Little Rock, AR 72205 USA
| | - Stephanie L. Merhar
- Department of Pediatrics, University of Cincinnati, 3333 Burnet Ave ML7009, Cincinnati, OH 45229 USA
| | - Alan E. Simon
- Environmental Influences on Child Health Outcomes (ECHO) Program, Office of the Director, the National Institutes of Health, Three White Flint North 11601 Landsdown Street, Office 3D16, North Bethesda, MD 20852 USA
| | - Abhik Das
- RTI International, 3040 East Cornwallis Road, Research Triangle Park, NC 27709-2194 USA
| | - Rachel G. Greenberg
- Duke University School of Medicine Duke Clinical Research Institute, 300 W. Morgan St, Durham, NC 27701 USA
| | - Rosemary D. Higgins
- College of Health and Human Services George Mason University, 4400 University Drive 2G7 Peterson Family Health Science Hall Room 5415 Fairfax, Virginia, 22030 USA
| | - Jeannette Lee
- University of Arkansas for Medical Sciences, 4301 West Markham, #781 COPH Room 3234, Little Rock, Arkansas 72205-7199 USA
| | - Brenda B. Poindexter
- Emory University School of Medicine, 2015 Uppergate Dr. NE, Suite 304, Atlanta, GA 30322 USA
| | - P. Brian Smith
- Duke University School of Medicine Duke Clinical Research Institute, 300 W. Morgan St, Durham, NC 27701 USA
| | - Michele Walsh
- Pregnancy and Perinatology Branch of the Eunice Kennedy Shriver National Institute of Child Health and Human Development, 6710 Rockledge Dr. Wing B, Rm2321-D, Bethesda, MD 20892-7002 USA
| | - Jessica Snowden
- Arkansas Children’s Research Institute, University of Arkansas for Medical Sciences, 13 Children’s Way, ACRI Slot 512-35, Little Rock, AR 72202 USA
| | - Lori A. Devlin
- Department of Pediatrics, University of Louisville School of Medicine, 571 South Floyd Street Suite 342, Louisville, KY 40202 USA
| | - for the Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network and the NIH Environmental influences on Child Health Outcomes (ECHO) Program Institutional Development Awards States Pediatric Clinical Trials Network
- Department of Pediatrics, Larner College of Medicine at the University of Vermont, 111 Colchester Ave Smith 5, Burlington, VT 05401 USA
- University of Arkansas for Medical Sciences, 4301 W. Markham St., Little Rock, AR 72205 USA
- Department of Pediatrics, University of Cincinnati, 3333 Burnet Ave ML7009, Cincinnati, OH 45229 USA
- Environmental Influences on Child Health Outcomes (ECHO) Program, Office of the Director, the National Institutes of Health, Three White Flint North 11601 Landsdown Street, Office 3D16, North Bethesda, MD 20852 USA
- RTI International, 3040 East Cornwallis Road, Research Triangle Park, NC 27709-2194 USA
- Duke University School of Medicine Duke Clinical Research Institute, 300 W. Morgan St, Durham, NC 27701 USA
- College of Health and Human Services George Mason University, 4400 University Drive 2G7 Peterson Family Health Science Hall Room 5415 Fairfax, Virginia, 22030 USA
- University of Arkansas for Medical Sciences, 4301 West Markham, #781 COPH Room 3234, Little Rock, Arkansas 72205-7199 USA
- Emory University School of Medicine, 2015 Uppergate Dr. NE, Suite 304, Atlanta, GA 30322 USA
- Pregnancy and Perinatology Branch of the Eunice Kennedy Shriver National Institute of Child Health and Human Development, 6710 Rockledge Dr. Wing B, Rm2321-D, Bethesda, MD 20892-7002 USA
- Arkansas Children’s Research Institute, University of Arkansas for Medical Sciences, 13 Children’s Way, ACRI Slot 512-35, Little Rock, AR 72202 USA
- Department of Pediatrics, University of Louisville School of Medicine, 571 South Floyd Street Suite 342, Louisville, KY 40202 USA
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15
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Li F, Yu H, Rathouz PJ, Turner EL, Preisser JS. Marginal modeling of cluster-period means and intraclass correlations in stepped wedge designs with binary outcomes. Biostatistics 2022; 23:772-788. [PMID: 33527999 PMCID: PMC9291643 DOI: 10.1093/biostatistics/kxaa056] [Citation(s) in RCA: 15] [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: 06/09/2020] [Accepted: 11/30/2020] [Indexed: 01/09/2023] Open
Abstract
Stepped wedge cluster randomized trials (SW-CRTs) with binary outcomes are increasingly used in prevention and implementation studies. Marginal models represent a flexible tool for analyzing SW-CRTs with population-averaged interpretations, but the joint estimation of the mean and intraclass correlation coefficients (ICCs) can be computationally intensive due to large cluster-period sizes. Motivated by the need for marginal inference in SW-CRTs, we propose a simple and efficient estimating equations approach to analyze cluster-period means. We show that the quasi-score for the marginal mean defined from individual-level observations can be reformulated as the quasi-score for the same marginal mean defined from the cluster-period means. An additional mapping of the individual-level ICCs into correlations for the cluster-period means further provides a rigorous justification for the cluster-period approach. The proposed approach addresses a long-recognized computational burden associated with estimating equations defined based on individual-level observations, and enables fast point and interval estimation of the intervention effect and correlations. We further propose matrix-adjusted estimating equations to improve the finite-sample inference for ICCs. By providing a valid approach to estimate ICCs within the class of generalized linear models for correlated binary outcomes, this article operationalizes key recommendations from the CONSORT extension to SW-CRTs, including the reporting of ICCs.
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Affiliation(s)
- Fan Li
- To whom correspondence should be addressed.
| | - Hengshi Yu
- Department of Biostatistics, University of Michigan, 1415 Washington Heights, Ann Arbor, MI 48109, USA
| | - Paul J Rathouz
- Department of Population Health, The University of Texas at Austin, Dell Medical School, 1601 Trinity St, Bldg. B, Austin, TX 78712, USA
| | - Elizabeth L Turner
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, 2424 Erwin Rd, Durham, NC 27710, USA
| | - John S Preisser
- Department of Biostatistics, University of North Carolina at Chapel Hill, 135 Dauer Drive, Chapel Hill, NC 27514, USA
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16
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Stepped Wedge Cluster Randomized Trials: A Methodological Overview. World Neurosurg 2022; 161:323-330. [PMID: 35505551 PMCID: PMC9074087 DOI: 10.1016/j.wneu.2021.10.136] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Revised: 10/17/2021] [Accepted: 10/18/2021] [Indexed: 11/21/2022]
Abstract
BACKGROUND Stepped wedge cluster randomized trials enable rigorous evaluations of health intervention programs in pragmatic settings. In the present study, we aimed to update neurosurgeon scientists on the design of stepped wedge randomized trials. METHODS We have presented an overview of recent methodological developments for stepped wedge designs and included an update on the newer associated methodological tools to aid with future study designs. RESULTS We defined the stepped wedge trial design and reviewed the indications for the design in depth. In addition, key considerations, including mainstream methods of analysis and sample size determination, were discussed. CONCLUSIONS Stepped wedge designs can be attractive for study intervention programs aiming to improve the delivery of patient care, especially when examining a small number of heterogeneous clusters.
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17
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Grantham KL, Kasza J, Heritier S, Carlin JB, Forbes AB. Evaluating the performance of Bayesian and restricted maximum likelihood estimation for stepped wedge cluster randomized trials with a small number of clusters. BMC Med Res Methodol 2022; 22:112. [PMID: 35418034 PMCID: PMC9009029 DOI: 10.1186/s12874-022-01550-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Accepted: 02/02/2022] [Indexed: 11/25/2022] Open
Abstract
Background Stepped wedge trials are an appealing and potentially powerful cluster randomized trial design. However, they are frequently implemented with a small number of clusters. Standard analysis methods for these trials such as a linear mixed model with estimation via maximum likelihood or restricted maximum likelihood (REML) rely on asymptotic properties and have been shown to yield inflated type I error when applied to studies with a small number of clusters. Small-sample methods such as the Kenward-Roger approximation in combination with REML can potentially improve estimation of the fixed effects such as the treatment effect. A Bayesian approach may also be promising for such multilevel models but has not yet seen much application in cluster randomized trials. Methods We conducted a simulation study comparing the performance of REML with and without a Kenward-Roger approximation to a Bayesian approach using weakly informative prior distributions on the intracluster correlation parameters. We considered a continuous outcome and a range of stepped wedge trial configurations with between 4 and 40 clusters. To assess method performance we calculated bias and mean squared error for the treatment effect and correlation parameters and the coverage of 95% confidence/credible intervals and relative percent error in model-based standard error for the treatment effect. Results Both REML with a Kenward-Roger standard error and degrees of freedom correction and the Bayesian method performed similarly well for the estimation of the treatment effect, while intracluster correlation parameter estimates obtained via the Bayesian method were less variable than REML estimates with different relative levels of bias. Conclusions The use of REML with a Kenward-Roger approximation may be sufficient for the analysis of stepped wedge cluster randomized trials with a small number of clusters. However, a Bayesian approach with weakly informative prior distributions on the intracluster correlation parameters offers a viable alternative, particularly when there is interest in the probability-based inferences permitted within this paradigm. Supplementary Information The online version contains supplementary material available at (10.1186/s12874-022-01550-8).
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Affiliation(s)
- Kelsey L Grantham
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Jessica Kasza
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Stephane Heritier
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - John B Carlin
- Clinical Epidemiology and Biostatistics Unit, Murdoch Children's Research Institute, Parkville, Australia.,Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, Carlton, Australia
| | - Andrew B Forbes
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia.
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18
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Federico CA, Heagerty PJ, Lantos J, O'Rourke P, Rahimzadeh V, Sugarman J, Weinfurt K, Wendler D, Wilfond BS, Magnus D. Ethical and epistemic issues in the design and conduct of pragmatic stepped-wedge cluster randomized clinical trials. Contemp Clin Trials 2022; 115:106703. [PMID: 35176501 PMCID: PMC9272561 DOI: 10.1016/j.cct.2022.106703] [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: 10/01/2021] [Revised: 01/27/2022] [Accepted: 02/02/2022] [Indexed: 11/27/2022]
Abstract
Stepped-wedge cluster randomized trial (SW-CRT) designs are increasingly employed in pragmatic research; they differ from traditional parallel cluster randomized trials in which an intervention is delivered to a subset of clusters, but not to all. In a SW-CRT, all clusters receive the intervention under investigation by the end of the study. This approach is thought to avoid ethical concerns about the denial of a desired intervention to participants in control groups. Such concerns have been cited in the literature as a primary motivation for choosing SW-CRT design, however SW-CRTs raise additional ethical concerns related to the delayed implementation of an intervention and consent. Yet, PCT investigators may choose SW-CRT designs simply because they are concerned that other study designs are infeasible. In this paper, we examine justifications for the use of SW-CRT study design, over other designs, by drawing on the experience of the National Institutes of Health's Health Care Systems Research Collaboratory (NIH Collaboratory) with five pragmatic SW-CRTs. We found that decisions to use SW-CRT design were justified by practical and epistemic reasons rather than ethical ones. These include concerns about feasibility, the heterogeneity of cluster characteristics, and the desire for simultaneous clinical evaluation and implementation. In this paper we compare the potential benefits of SW-CRTs against the ethical and epistemic challenges brought forth by the design and suggest that the choice of SW-CRT design must balance epistemic, feasibility and ethical justifications. Moreover, given their complexity, such studies need rigorous and informed ethical oversight.
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Affiliation(s)
- Carole A Federico
- Stanford Center for Biomedical Ethics, Stanford University, Stanford, CA 94305, USA
| | - Patrick J Heagerty
- Department of Biostatistics, University of Washington, Seattle, WA 98185, USA
| | - John Lantos
- Children's Mercy Hospital Bioethics Center, University of Missouri-Kansas City, Kansas City, MO 64108, USA
| | | | - Vasiliki Rahimzadeh
- Stanford Center for Biomedical Ethics, Stanford University, Stanford, CA 94305, USA
| | - Jeremy Sugarman
- Berman Institute of Bioethics, Johns Hopkins University, Baltimore, MD 21218, USA
| | - Kevin Weinfurt
- Center for Health Measurement, Duke University, Durham, NC 27701, USA
| | - David Wendler
- Department of Bioethics, NIH Clinical Center, Bethesda, MD 20892, USA
| | - Benjamin S Wilfond
- Treuman Katz Center for Pediatric Bioethics, Seattle Children's Research Institute, Seattle, WA 98185, USA
| | - David Magnus
- Stanford Center for Biomedical Ethics, Stanford University, Stanford, CA 94305, USA.
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19
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Grayling MJ, Wason JMS, Villar SS. Response adaptive intervention allocation in stepped-wedge cluster randomized trials. Stat Med 2022; 41:1081-1099. [PMID: 35064595 PMCID: PMC7612601 DOI: 10.1002/sim.9317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Revised: 11/30/2021] [Accepted: 12/22/2021] [Indexed: 11/09/2022]
Abstract
BACKGROUND Stepped-wedge cluster randomized trial (SW-CRT) designs are often used when there is a desire to provide an intervention to all enrolled clusters, because of a belief that it will be effective. However, given there should be equipoise at trial commencement, there has been discussion around whether a pre-trial decision to provide the intervention to all clusters is appropriate. In pharmaceutical drug development, a solution to a similar desire to provide more patients with an effective treatment is to use a response adaptive (RA) design. METHODS We introduce a way in which RA design could be incorporated in an SW-CRT, permitting modification of the intervention allocation during the trial. The proposed framework explicitly permits a balance to be sought between power and patient benefit considerations. A simulation study evaluates the methodology. RESULTS In one scenario, for one particular RA design, the proportion of cluster-periods spent in the intervention condition was observed to increase from 32.2% to 67.9% as the intervention effect was increased. A cost of this was a 6.2% power drop compared to a design that maximized power by fixing the proportion of time in the intervention condition at 45.0%, regardless of the intervention effect. CONCLUSIONS An RA approach may be most applicable to settings for which the intervention has substantial individual or societal benefit considerations, potentially in combination with notable safety concerns. In such a setting, the proposed methodology may routinely provide the desired adaptability of the roll-out speed, with only a small cost to the study's power.
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Affiliation(s)
- Michael J Grayling
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - James M S Wason
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Sofía S Villar
- MRC Biostatistics Unit, School of Clinical Medicine, University of Cambridge, Cambridge, UK
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20
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Abstract
BACKGROUND This article identifies the most influential methods reports for group-randomized trials and related designs published through 2020. Many interventions are delivered to participants in real or virtual groups or in groups defined by a shared interventionist so that there is an expectation for positive correlation among observations taken on participants in the same group. These interventions are typically evaluated using a group- or cluster-randomized trial, an individually randomized group treatment trial, or a stepped wedge group- or cluster-randomized trial. These trials face methodological issues beyond those encountered in the more familiar individually randomized controlled trial. METHODS PubMed was searched to identify candidate methods reports; that search was supplemented by reports known to the author. Candidate reports were reviewed by the author to include only those focused on the designs of interest. Citation counts and the relative citation ratio, a new bibliometric tool developed at the National Institutes of Health, were used to identify influential reports. The relative citation ratio measures influence at the article level by comparing the citation rate of the reference article to the citation rates of the articles cited by other articles that also cite the reference article. RESULTS In total, 1043 reports were identified that were published through 2020. However, 55 were deemed to be the most influential based on their relative citation ratio or their citation count using criteria specific to each of the three designs, with 32 group-randomized trial reports, 7 individually randomized group treatment trial reports, and 16 stepped wedge group-randomized trial reports. Many of the influential reports were early publications that drew attention to the issues that distinguish these designs from the more familiar individually randomized controlled trial. Others were textbooks that covered a wide range of issues for these designs. Others were "first reports" on analytic methods appropriate for a specific type of data (e.g. binary data, ordinal data), for features commonly encountered in these studies (e.g. unequal cluster size, attrition), or for important variations in study design (e.g. repeated measures, cohort versus cross-section). Many presented methods for sample size calculations. Others described how these designs could be applied to a new area (e.g. dissemination and implementation research). Among the reports with the highest relative citation ratios were the CONSORT statements for each design. CONCLUSIONS Collectively, the influential reports address topics of great interest to investigators who might consider using one of these designs and need guidance on selecting the most appropriate design for their research question and on the best methods for design, analysis, and sample size.
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Affiliation(s)
- David M Murray
- Office of Disease Prevention, National Institutes of Health, North Bethesda, MD, USA
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21
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Xia F, Hughes JP, Voldal EC, Heagerty PJ. Power and sample size calculation for stepped-wedge designs with discrete outcomes. Trials 2021; 22:598. [PMID: 34488848 PMCID: PMC8419932 DOI: 10.1186/s13063-021-05542-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Accepted: 08/13/2021] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Stepped-wedge designs (SWD) are increasingly used to evaluate the impact of changes to the process of care within health care systems. However, to generate definitive evidence, a correct sample size calculation is crucial to ensure such studies are properly powered. The seminal work of Hussey and Hughes (Contemp Clin Trials 28(2):182-91, 2004) provides an analytical formula for power calculations with normal outcomes using a linear model and simple random effects. However, minimal development and evaluation have been done for power calculation with non-normal outcomes on their natural scale (e.g., logit, log). For example, binary endpoints are common, and logistic regression is the natural multilevel model for such clustered data. METHODS We propose a power calculation formula for SWD with either normal or non-normal outcomes in the context of generalized linear mixed models by adopting the Laplace approximation detailed in Breslow and Clayton (J Am Stat Assoc 88(421):9-25, 1993) to obtain the covariance matrix of the estimated parameters. RESULTS We compare the performance of our proposed method with simulation-based sample size calculation and demonstrate its use on a study of patient-delivered partner therapy for STI treatment and a study that assesses the impact of providing additional benchmark prevalence information in a radiologic imaging report. To facilitate adoption of our methods we also provide a function embedded in the R package "swCRTdesign" for sample size and power calculation for multilevel stepped-wedge designs. CONCLUSIONS Our method requires minimal computational power. Therefore, the proposed procedure facilitates rapid dynamic updates of sample size calculations and can be used to explore a wide range of design options or assumptions.
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Affiliation(s)
- Fan Xia
- National Alzheimer's Coordinating Center, University of Washington, Seattle, WA, USA.
| | - James P Hughes
- Department of Biostatistics, University of Washington, Seattle, WA, USA
| | - Emily C Voldal
- Department of Biostatistics, University of Washington, Seattle, WA, USA
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22
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Li F, Hughes JP, Hemming K, Taljaard M, Melnick ER, Heagerty PJ. Mixed-effects models for the design and analysis of stepped wedge cluster randomized trials: An overview. Stat Methods Med Res 2021; 30:612-639. [PMID: 32631142 PMCID: PMC7785651 DOI: 10.1177/0962280220932962] [Citation(s) in RCA: 86] [Impact Index Per Article: 28.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The stepped wedge cluster randomized design has received increasing attention in pragmatic clinical trials and implementation science research. The key feature of the design is the unidirectional crossover of clusters from the control to intervention conditions on a staggered schedule, which induces confounding of the intervention effect by time. The stepped wedge design first appeared in the Gambia hepatitis study in the 1980s. However, the statistical model used for the design and analysis was not formally introduced until 2007 in an article by Hussey and Hughes. Since then, a variety of mixed-effects model extensions have been proposed for the design and analysis of these trials. In this article, we explore these extensions under a unified perspective. We provide a general model representation and regard various model extensions as alternative ways to characterize the secular trend, intervention effect, as well as sources of heterogeneity. We review the key model ingredients and clarify their implications for the design and analysis. The article serves as an entry point to the evolving statistical literatures on stepped wedge designs.
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Affiliation(s)
- Fan Li
- Department of Biostatistics, Yale School of Public Health, New Haven, CT, USA
- Center for Methods in Implementation and Preventive Science, Yale University, New Haven, CT, USA
| | - James P Hughes
- Department of Biostatistics, School of Public Health, University of Washington, Seattle, WA, USA
| | - Karla Hemming
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Monica Taljaard
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Edward R. Melnick
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Patrick J Heagerty
- Department of Biostatistics, School of Public Health, University of Washington, Seattle, WA, USA
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23
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Zhang P, Shoben A, Jackson R, Fernandez S. Variance formulae for multiphase stepped wedge cluster randomized trial. Stat Med 2020; 39:4147-4168. [PMID: 32808315 DOI: 10.1002/sim.8716] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Revised: 07/04/2020] [Accepted: 07/14/2020] [Indexed: 11/11/2022]
Abstract
In a multiphase stepped wedge cluster randomized trial (MSW-CRT), more than one intervention will be initiated on each sequence in a fixed order. Hence, with the MSW-CRT design, the effect of the first intervention can be evaluated when compared to control, as well as the added-on effects of the subsequent interventions. Studies that use MSW-CRT have been proposed, but properties of this design have not been explicitly studied. We derive closed-form variance formulae to test the interventions' effects, which can be readily used for sample size and power calculation. Additionally, we provide relationships between variances to test the interventions' effects and design parameters. Under special conditions, some important properties include: (i) the variances to test different interventions' effects (ie, the first intervention effect and the second intervention effect) may be same; (ii) as the cluster-period mean autocorrelation increases, the variance to test an intervention effect may first increase and then decrease; (iii) as the amount of periods between the initiations of two interventions (ie, lag) increases, the variance to test an intervention effect may remain unchanged. We illustrate the relationships between power and design parameters using the variance formulae. From a few illustrative examples, we observe that the statistical test that uses data only relevant to a specific intervention has inferior power (relative power loss <15%) compared to the test when using all the study data. Also, power is reduced when both the total number of periods and lag are decreased simultaneously (relative power loss <20%).
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Affiliation(s)
- Pengyue Zhang
- Department of Biomedical Informatics, Ohio State University, Columbus, Ohio, USA
| | - Abigail Shoben
- Division of Biostatistics, College of Public Health, Ohio State University, Columbus, Ohio, USA
| | - Rebecca Jackson
- Departments of Physical Medicine and Rehabilitation, Internal Medicine/Endocrinology, and Diabetes and Metabolism, Ohio State University, Columbus, Ohio, USA
| | - Soledad Fernandez
- Department of Biomedical Informatics, Ohio State University, Columbus, Ohio, USA
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24
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Zhao Y, Izadnegahdar M, Lee MK, Kavsak PA, Singer J, Scheuermeyer F, Udell JA, Robinson S, Norris CM, Lyon AW, Pilote L, Cox J, Hassan A, Rychtera A, Johnson D, Mills NL, Christenson J, Humphries KH. High-Sensitivity Cardiac Troponin-Optimizing the Diagnosis of Acute Myocardial Infarction/Injury in Women (CODE-MI): Rationale and design for a multicenter, stepped-wedge, cluster-randomized trial. Am Heart J 2020; 229:18-28. [PMID: 32916606 DOI: 10.1016/j.ahj.2020.06.013] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Accepted: 06/17/2020] [Indexed: 10/24/2022]
Abstract
Despite evidence that high-sensitivity cardiac troponin (hs-cTn) levels in women are lower than in men, a single threshold based on the 99th percentile upper reference limit of the overall reference population is commonly used to diagnose myocardial infarction in clinical practice. This trial aims to determine whether the use of a lower female-specific hs-cTn threshold would improve the diagnosis, treatment, and outcomes of women presenting to the emergency department with symptoms suggestive of myocardial ischemia. METHODS/DESIGN: CODE-MI (hs-cTn-Optimizing the Diagnosis of Acute Myocardial Infarction/Injury in Women) is a multicenter, stepped-wedge, cluster-randomized trial of 30 secondary and tertiary care hospitals across 8 Canadian provinces, with the unit of randomization being the hospital. All adults (≥20 years of age) presenting to the emergency department with symptoms suggestive of myocardial ischemia and at least 1 hs-cTn test are eligible for inclusion. Over five, 5-month intervals, hospitals will be randomized to implement lower female hs-cTn thresholds according to the assay being used at each site. Men will continue to be assessed using the overall thresholds throughout. Women with a peak hs-cTn value between the female-specific and the overall thresholds will form our primary cohort. The primary outcome, a 1-year composite of all-cause mortality or readmission for nonfatal myocardial infarction, incident heart failure, or emergent/urgent coronary revascularization, will be compared before and after the implementation of female thresholds using mixed-effects logistic regression models. The cohort and outcomes will be obtained from routinely collected administrative data. The trial is designed to detect a 20% relative risk difference in the primary outcome, or a 2.2% absolute difference, with 82% power. CONCLUSIONS: This pragmatic trial will assess whether adopting lower female hs-cTn thresholds leads to appropriate assessment of women with symptoms suggestive of myocardial infarction, thereby improving treatment and outcomes.
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25
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Annett RD, Chervinskiy S, Chun TH, Cowan K, Foster K, Goodrich N, Hirschfeld M, Hsia DS, Jarvis JD, Kulbeth K, Madden C, Nesmith C, Raissy H, Ross J, Saul JP, Shiramizu B, Smith P, Sullivan JE, Tucker L, Atz AM. IDeA States Pediatric Clinical Trials Network for Underserved and Rural Communities. Pediatrics 2020; 146:peds.2020-0290. [PMID: 32943534 PMCID: PMC7786822 DOI: 10.1542/peds.2020-0290] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/16/2020] [Indexed: 01/19/2023] Open
Abstract
The National Institutes of Health's Environmental Influences on Child Health Outcomes (ECHO) program aims to study high-priority and high-impact pediatric conditions. This broad-based health initiative is unique in the National Institutes of Health research portfolio and involves 2 research components: (1) a large group of established centers with pediatric cohorts combining data to support longitudinal studies (ECHO cohorts) and (2) pediatric trials program for institutions within Institutional Development Awards states, known as the ECHO Institutional Development Awards States Pediatric Clinical Trials Network (ISPCTN). In the current presentation, we provide a broad overview of the ISPCTN and, particularly, its importance in enhancing clinical trials capabilities of pediatrician scientists through the support of research infrastructure, while at the same time implementing clinical trials that inform future health care for children. The ISPCTN research mission is aligned with the health priority conditions emphasized in the ECHO program, with a commitment to bringing state-of-the-science trials to children residing in underserved and rural communities. ISPCTN site infrastructure is critical to successful trial implementation and includes research training for pediatric faculty and coordinators. Network sites exist in settings that have historically had limited National Institutes of Health funding success and lacked pediatric research infrastructure, with the initial funding directed to considerable efforts in professional development, implementation of regulatory procedures, and engagement of communities and families. The Network has made considerable headway with these objectives, opening two large research studies during its initial 18 months as well as producing findings that serve as markers of success that will optimize sustainability.
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Affiliation(s)
- Robert D. Annett
- Department of Pediatrics, University of Mississippi Medical Center, Jackson, Mississippi
| | - Sheva Chervinskiy
- Data Coordinating and Operations Center, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Thomas H. Chun
- Departments of Emergency Medicine and Pediatrics, Brown University, Providence, Rhode Island
| | - Kelly Cowan
- University of Vermont Medical Center, Burlington, Vermont
| | | | | | | | - Daniel S. Hsia
- Pennington Biomedical Research Center, Baton Rouge, Louisiana
| | | | - Kurtis Kulbeth
- Data Coordinating and Operations Center, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Christi Madden
- The Children’s Hospital at University of Oklahoma Medical Center, Oklahoma City, Oklahoma
| | | | - Hengameh Raissy
- University of New Mexico Health Sciences Center, Albuquerque, New Mexico
| | - Judith Ross
- Nemours/Alfred I. duPont Hospital for Children, Wilmington, Delaware
| | - J. Philip Saul
- Department of Pediatrics, West Virginia University, Morgantown, West Virginia
| | - Bruce Shiramizu
- Departments of Tropical Medicine, Pediatrics, and Medicine, University of Hawai’i, Honolulu, Hawaii
| | - Paul Smith
- Department of Pediatrics, University of Montana, Missoula, Montana
| | - Janice E. Sullivan
- Department of Pediatrics, University of Louisville, Louisville, Kentucky; and
| | - Lauren Tucker
- Department of Pediatrics, University of Mississippi Medical Center, Jackson, Mississippi
| | - Andrew M. Atz
- Medical University of South Carolina, Charleston, South Carolina
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26
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Yan X, Li Y, Su H, Xing Y, Zhang B, Lu Z, Jia Z. Protect MSM from HIV and other sexually transmitted diseases by providing mobile health services of partner notification: protocol for a pragmatic stepped wedge cluster randomized controlled trial. BMC Public Health 2020; 20:1107. [PMID: 32664934 PMCID: PMC7362655 DOI: 10.1186/s12889-020-09162-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Accepted: 06/22/2020] [Indexed: 11/30/2022] Open
Abstract
Background Recently, more and more men who have sex with men (MSM) look for casual partners through online dating platforms in China. However, most are unable to know their partners’ HIV and other sexually transmitted diseases (STD) statuses, leading to the rapid increase in HIV infection among Chinese MSM. Effective partner notification is urgently needed to increase the risk awareness of MSM and prevent HIV and other STDs transmission. However, the traditional intervention mainly targets to the HIV-positive MSM and the effect is not promising. Our study aims to provide Internet-based partner notification, along with a series of health services for HIV-negative MSM to protect them from HIV and other STDs. Methods A pragmatic stepped wedge cluster randomized controlled trial design is used to evaluate the effectiveness of a new intervention paradigm, which aims to reduce HIV and other STDs incidences among MSM in China. Through integrating a mobile health (mHealth) service application (app) to the current HIV and other STDs prevention and control methods, the new paradigm provides partner notification of HIV, syphilis, hepatitis B, and hepatitis C statuses. A total of 6172 MSM in 16 districts of Beijing, China will be recruited and randomized to sequentially receive partner notification intervention through the app at 6-month intervals. The primary outcomes are HIV incidence and the additional cost of the intervention. The secondary outcomes include incidences of syphilis, hepatitis B, and hepatitis C, disease transmission social networks, testing adherence, knowledge of HIV and STDs control, health self-responsibility awareness, changes of high risk behaviors and other related outcomes. The generalized linear mixed models (GLMM) will be used to analyze the differences of outcomes in the control period and in the intervention period. Discussion We expect that the HIV incidence will be significantly lower and the secondary outcomes will also be improved with providing health service of partner notification through mhealth intervention. The feasible and affordable public health intervention paradigm will have implications for HIV and STDs prevention and control among MSM and other key populations. Trial registration ClinicalTrials.gov, NCT04349748. Registered on 16 April 2020.
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Affiliation(s)
- Xiangyu Yan
- Department of Epidemiology and Biostatistics, School of Public Health, Peking University, Beijing, China.,National Institute on Drug Dependence, Peking University, 38 Xueyuan Rd, Haidian District, Beijing, 100191, China
| | - Yongjie Li
- Department of Epidemiology and Biostatistics, School of Public Health, Peking University, Beijing, China.,National Institute on Drug Dependence, Peking University, 38 Xueyuan Rd, Haidian District, Beijing, 100191, China
| | - Hexuan Su
- Department of Epidemiology and Biostatistics, School of Public Health, Peking University, Beijing, China.,Medical Informatics Center, Peking University, Beijing, China
| | - Yi Xing
- Institute of Child and Adolescent Health, School of Public Health, Peking University, Beijing, China
| | - Bo Zhang
- Department of Epidemiology and Biostatistics, School of Public Health, Peking University, Beijing, China.,National Institute on Drug Dependence, Peking University, 38 Xueyuan Rd, Haidian District, Beijing, 100191, China
| | - Zuhong Lu
- State Key Laboratory for Bioelectronics, School of Biological Science and Medical Engineering, Southeast University, Nanjing, China
| | - Zhongwei Jia
- Department of Epidemiology and Biostatistics, School of Public Health, Peking University, Beijing, China. .,National Institute on Drug Dependence, Peking University, 38 Xueyuan Rd, Haidian District, Beijing, 100191, China. .,Center for Drug Abuse Control and Prevention, National Institute of Health Data Science, Peking University, Beijing, China. .,Center for Technology and Policy Research on Infectious Disease Prevention and Control, Global Health Research Institute, Peking University, Beijing, China.
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27
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Ouyang Y, Karim ME, Gustafson P, Field TS, Wong H. Explaining the variation in the attained power of a stepped-wedge trial with unequal cluster sizes. BMC Med Res Methodol 2020; 20:166. [PMID: 32580698 PMCID: PMC7315519 DOI: 10.1186/s12874-020-01036-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Accepted: 05/27/2020] [Indexed: 02/08/2023] Open
Abstract
Background In a cross-sectional stepped-wedge trial with unequal cluster sizes, attained power in the trial depends on the realized allocation of the clusters. This attained power may differ from the expected power calculated using standard formulae by averaging the attained powers over all allocations the randomization algorithm can generate. We investigated the effect of design factors and allocation characteristics on attained power and developed models to predict attained power based on allocation characteristics. Method Based on data simulated and analyzed using linear mixed-effects models, we evaluated the distribution of attained powers under different scenarios with varying intraclass correlation coefficient (ICC) of the responses, coefficient of variation (CV) of the cluster sizes, number of cluster-size groups, distributions of group sizes, and number of clusters. We explored the relationship between attained power and two allocation characteristics: the individual-level correlation between treatment status and time period, and the absolute treatment group imbalance. When computational time was excessive due to a scenario having a large number of possible allocations, we developed regression models to predict attained power using the treatment-vs-time period correlation and absolute treatment group imbalance as predictors. Results The risk of attained power falling more than 5% below the expected or nominal power decreased as the ICC or number of clusters increased and as the CV decreased. Attained power was strongly affected by the treatment-vs-time period correlation. The absolute treatment group imbalance had much less impact on attained power. The attained power for any allocation was predicted accurately using a logistic regression model with the treatment-vs-time period correlation and the absolute treatment group imbalance as predictors. Conclusion In a stepped-wedge trial with unequal cluster sizes, the risk that randomization yields an allocation with inadequate attained power depends on the ICC, the CV of the cluster sizes, and number of clusters. To reduce the computational burden of simulating attained power for allocations, the attained power can be predicted via regression modeling. Trial designers can reduce the risk of low attained power by restricting the randomization algorithm to avoid allocations with large treatment-vs-time period correlations.
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Affiliation(s)
- Yongdong Ouyang
- School of Population and Public Health, University of British Columbia, 2206 E Mall, Vancouver, BC, V6T 1Z3, Canada. .,Centre for Health Evaluation and Outcome Sciences, 588-1081 Burrard Street, St Paul's Hospital, Vancouver, BC, V6Z 1Y6, Canada.
| | - Mohammad Ehsanul Karim
- School of Population and Public Health, University of British Columbia, 2206 E Mall, Vancouver, BC, V6T 1Z3, Canada.,Centre for Health Evaluation and Outcome Sciences, 588-1081 Burrard Street, St Paul's Hospital, Vancouver, BC, V6Z 1Y6, Canada
| | - Paul Gustafson
- Department of Statistics, University of British Columbia, 3182 Earth Science Building, 2207 Main Mall, Vancouver, BC, V6T 1Z4, Canada
| | - Thalia S Field
- Vancouver Stroke Program, Faculty of Medicine, University of British Columbia, S169-2211 Wesbrook Mall, Vancouver, BC, V6T 2B5, Canada
| | - Hubert Wong
- School of Population and Public Health, University of British Columbia, 2206 E Mall, Vancouver, BC, V6T 1Z3, Canada.,Centre for Health Evaluation and Outcome Sciences, 588-1081 Burrard Street, St Paul's Hospital, Vancouver, BC, V6Z 1Y6, Canada
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28
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Hooper R, Eldridge SM. Cutting edge or blunt instrument: how to decide if a stepped wedge design is right for you. BMJ Qual Saf 2020; 30:245-250. [PMID: 32546592 PMCID: PMC7907557 DOI: 10.1136/bmjqs-2020-011620] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Accepted: 05/26/2020] [Indexed: 12/20/2022]
Affiliation(s)
- Richard Hooper
- Institute of Population Health Sciences, Queen Mary University of London, London, UK
| | - Sandra M Eldridge
- Institute of Population Health Sciences, Queen Mary University of London, London, UK
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29
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Hemming K, Taljaard M. Reflection on modern methods: when is a stepped-wedge cluster randomized trial a good study design choice? Int J Epidemiol 2020; 49:1043-1052. [PMID: 32386407 PMCID: PMC7394949 DOI: 10.1093/ije/dyaa077] [Citation(s) in RCA: 56] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Accepted: 04/08/2020] [Indexed: 12/25/2022] Open
Abstract
The stepped-wedge cluster randomized trial (SW-CRT) involves the sequential transition of clusters (such as hospitals, public health units or communities) from control to intervention conditions in a randomized order. The use of the SW-CRT is growing rapidly. Yet the SW-CRT is at greater risks of bias compared with the conventional parallel cluster randomized trial (parallel-CRT). For this reason, the CONSORT extension for SW-CRTs requires that investigators provide a clear justification for the choice of study design. In this paper, we argue that all other things being equal, the SW-CRT is at greater risk of bias due to misspecification of the secular trends at the analysis stage. This is particularly problematic for studies randomizing a small number of heterogeneous clusters. We outline the potential conditions under which an SW-CRT might be an appropriate choice. Potentially appropriate and often overlapping justifications for conducting an SW-CRT include: (i) the SW-CRT provides a means to conduct a randomized evaluation which otherwise would not be possible; (ii) the SW-CRT facilitates cluster recruitment as it enhances the acceptability of a randomized evaluation either to cluster gatekeepers or other stakeholders; (iii) the SW-CRT is the only feasible design due to pragmatic and logistical constraints (for example the roll-out of a scare resource); and (iv) the SW-CRT has increased statistical power over other study designs (which will include situations with a limited number of clusters). As the number of arguments in favour of an SW-CRT increases, the likelihood that the benefits of using the SW-CRT, as opposed to a parallel-CRT, outweigh its risks also increases. We argue that the mere popularity and novelty of the SW-CRT should not be a factor in its adoption. In situations when a conventional parallel-CRT is feasible, it is likely to be the preferred design.
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Affiliation(s)
- Karla Hemming
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Monica Taljaard
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
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30
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Graziadio S, Winter A, Lendrem BC, Suklan J, Jones WS, Urwin SG, O’Leary RA, Dickinson R, Halstead A, Kurowska K, Green K, Sims A, Simpson AJ, Power HM, Allen AJ. How to Ease the Pain of Taking a Diagnostic Point of Care Test to the Market: A Framework for Evidence Development. MICROMACHINES 2020; 11:mi11030291. [PMID: 32164393 PMCID: PMC7142698 DOI: 10.3390/mi11030291] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Revised: 03/06/2020] [Accepted: 03/07/2020] [Indexed: 01/08/2023]
Abstract
Bringing a diagnostic point of care test (POCT) to a healthcare market can be a painful experience as it requires the manufacturer to meet considerable technical, financial, managerial, and regulatory challenges. In this opinion article we propose a framework for developing the evidence needed to support product development, marketing, and adoption. We discuss each step in the evidence development pathway from the invention phase to the implementation of a new POCT in the healthcare system. We highlight the importance of articulating the value propositions and documenting the care pathway. We provide guidance on how to conduct care pathway analysis as little has been published on this. We summarize the clinical, economic and qualitative studies to be considered for developing evidence, and provide useful links to relevant software, on-line applications, websites, and give practical advice. We also provide advice on patient and public involvement and engagement (PPIE), and on product management. Our aim is to help device manufacturers to understand the concepts and terminology used in evaluation of in vitro diagnostics (IVDs) so that they can communicate effectively with evaluation methodologists, statisticians, and health economists. Manufacturers of medical tests and devices can use the proposed framework to plan their evidence development strategy in alignment with device development, applications for regulatory approval, and publication.
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Affiliation(s)
- Sara Graziadio
- NIHR Newcastle In Vitro Diagnostics Co-operative, The Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne NE1 4LP, UK; (S.G.); (A.W.); (S.G.U.); (R.A.O.); (R.D.); (A.S.)
| | - Amanda Winter
- NIHR Newcastle In Vitro Diagnostics Co-operative, The Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne NE1 4LP, UK; (S.G.); (A.W.); (S.G.U.); (R.A.O.); (R.D.); (A.S.)
| | - B. Clare Lendrem
- NIHR Newcastle In Vitro Diagnostics Co-operative, Room M2.088, Translational and Clinical Research Institute, William Leech Building, Medical School, Newcastle University, Newcastle NE2 4HH, UK; (B.C.L.); (J.S.); (W.S.J.); (A.H.); (K.K.); (K.G.); (A.J.S.); (H.M.P.)
| | - Jana Suklan
- NIHR Newcastle In Vitro Diagnostics Co-operative, Room M2.088, Translational and Clinical Research Institute, William Leech Building, Medical School, Newcastle University, Newcastle NE2 4HH, UK; (B.C.L.); (J.S.); (W.S.J.); (A.H.); (K.K.); (K.G.); (A.J.S.); (H.M.P.)
| | - William S. Jones
- NIHR Newcastle In Vitro Diagnostics Co-operative, Room M2.088, Translational and Clinical Research Institute, William Leech Building, Medical School, Newcastle University, Newcastle NE2 4HH, UK; (B.C.L.); (J.S.); (W.S.J.); (A.H.); (K.K.); (K.G.); (A.J.S.); (H.M.P.)
| | - Samuel G. Urwin
- NIHR Newcastle In Vitro Diagnostics Co-operative, The Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne NE1 4LP, UK; (S.G.); (A.W.); (S.G.U.); (R.A.O.); (R.D.); (A.S.)
| | - Rachel A. O’Leary
- NIHR Newcastle In Vitro Diagnostics Co-operative, The Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne NE1 4LP, UK; (S.G.); (A.W.); (S.G.U.); (R.A.O.); (R.D.); (A.S.)
| | - Rachel Dickinson
- NIHR Newcastle In Vitro Diagnostics Co-operative, The Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne NE1 4LP, UK; (S.G.); (A.W.); (S.G.U.); (R.A.O.); (R.D.); (A.S.)
| | - Anna Halstead
- NIHR Newcastle In Vitro Diagnostics Co-operative, Room M2.088, Translational and Clinical Research Institute, William Leech Building, Medical School, Newcastle University, Newcastle NE2 4HH, UK; (B.C.L.); (J.S.); (W.S.J.); (A.H.); (K.K.); (K.G.); (A.J.S.); (H.M.P.)
| | - Kasia Kurowska
- NIHR Newcastle In Vitro Diagnostics Co-operative, Room M2.088, Translational and Clinical Research Institute, William Leech Building, Medical School, Newcastle University, Newcastle NE2 4HH, UK; (B.C.L.); (J.S.); (W.S.J.); (A.H.); (K.K.); (K.G.); (A.J.S.); (H.M.P.)
| | - Kile Green
- NIHR Newcastle In Vitro Diagnostics Co-operative, Room M2.088, Translational and Clinical Research Institute, William Leech Building, Medical School, Newcastle University, Newcastle NE2 4HH, UK; (B.C.L.); (J.S.); (W.S.J.); (A.H.); (K.K.); (K.G.); (A.J.S.); (H.M.P.)
| | - Andrew Sims
- NIHR Newcastle In Vitro Diagnostics Co-operative, The Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne NE1 4LP, UK; (S.G.); (A.W.); (S.G.U.); (R.A.O.); (R.D.); (A.S.)
| | - A. John Simpson
- NIHR Newcastle In Vitro Diagnostics Co-operative, Room M2.088, Translational and Clinical Research Institute, William Leech Building, Medical School, Newcastle University, Newcastle NE2 4HH, UK; (B.C.L.); (J.S.); (W.S.J.); (A.H.); (K.K.); (K.G.); (A.J.S.); (H.M.P.)
| | - H. Michael Power
- NIHR Newcastle In Vitro Diagnostics Co-operative, Room M2.088, Translational and Clinical Research Institute, William Leech Building, Medical School, Newcastle University, Newcastle NE2 4HH, UK; (B.C.L.); (J.S.); (W.S.J.); (A.H.); (K.K.); (K.G.); (A.J.S.); (H.M.P.)
| | - A. Joy Allen
- NIHR Newcastle In Vitro Diagnostics Co-operative, Room M2.088, Translational and Clinical Research Institute, William Leech Building, Medical School, Newcastle University, Newcastle NE2 4HH, UK; (B.C.L.); (J.S.); (W.S.J.); (A.H.); (K.K.); (K.G.); (A.J.S.); (H.M.P.)
- Correspondence: ; Tel.: +44-(0)-191-208-3708
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31
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Brown SP, Shoben AB. Information growth for sequential monitoring of clinical trials with a stepped wedge cluster randomized design and unknown intracluster correlation. Clin Trials 2020; 17:176-183. [DOI: 10.1177/1740774520901488] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background/aims In a stepped wedge study design, study clusters usually start with the baseline treatment and then cross over to the intervention at randomly determined times. Such designs are useful when the intervention must be delivered at the cluster level and are becoming increasingly common in practice. In these trials, if the outcome is death or serious morbidity, one may have an ethical imperative to monitor the trial and stop before maximum enrollment if the new therapy is proven to be beneficial. In addition, because formal monitoring allows for the stoppage of trials when a significant benefit for new therapy has been ruled out, their use can make a research program more efficient. However, use of the stepped wedge cluster randomized study design complicates the implementation of standard group sequential monitoring methods. Both the correlation of observations introduced by the clustered randomization and the timing of crossover from one treatment to the other impact the rate of information growth, an important component of an interim analysis. Methods We simulated cross-sectional stepped wedge study data in order to evaluate the impact of sequential monitoring on the Type I error and power when the true intracluster correlation is unknown. We studied the impact of varying intracluster correlations, treatment effects, methods of estimating the information growth, and boundary shapes. Results While misspecified information growth can impact both the Type I error and power of a study in some settings, we observed little inflation of the Type I error and only moderate reductions in power across a range of misspecified information growth patterns in our simulations. Conclusion Taking the study design into account and using either an estimate of the intracluster correlation from the ongoing study or other data in the same clusters should allow for easy implementation of group sequential methods in future stepped wedge designs.
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Affiliation(s)
- Siobhan P Brown
- Department of Biostatistics, University of Washington, Seattle, WA, USA
| | - Abigail B Shoben
- Division of Biostatistics, The Ohio State University, Columbus, OH, USA
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32
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Murray DM, Taljaard M, Turner EL, George SM. Essential Ingredients and Innovations in the Design and Analysis of Group-Randomized Trials. Annu Rev Public Health 2019; 41:1-19. [PMID: 31869281 DOI: 10.1146/annurev-publhealth-040119-094027] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
This article reviews the essential ingredients and innovations in the design and analysis of group-randomized trials. The methods literature for these trials has grown steadily since they were introduced to the biomedical research community in the late 1970s, and we summarize those developments. We review, in addition to the group-randomized trial, methods for two closely related designs, the individually randomized group treatment trial and the stepped-wedge group-randomized trial. After describing the essential ingredients for these designs, we review the most important developments in the evolution of their methods using a new bibliometric tool developed at the National Institutes of Health. We then discuss the questions to be considered when selecting from among these designs or selecting the traditional randomized controlled trial. We close with a review of current methods for the analysis of data from these designs, a case study to illustrate each design, and a brief summary.
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Affiliation(s)
- David M Murray
- Office of Disease Prevention, National Institutes of Health, North Bethesda, Maryland 20892, USA; ,
| | - Monica Taljaard
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, The Ottawa Hospital, Civic Campus, Ottawa, Ontario K1Y 4E9, Canada; .,School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario K1Y 4E9, Canada
| | - Elizabeth L Turner
- Department of Biostatistics and Bioinformatics, and Duke Global Health Institute, Duke University, Durham, North Carolina 27710, USA;
| | - Stephanie M George
- Office of Disease Prevention, National Institutes of Health, North Bethesda, Maryland 20892, USA; ,
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Hemming K, Taljaard M, Marshall T, Goldstein CE, Weijer C. Stepped-wedge trials should be classified as research for the purpose of ethical review. Clin Trials 2019; 16:580-588. [PMID: 31818147 DOI: 10.1177/1740774519873322] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND All studies classified as research involving human participants require research ethics review. Most regulation and guidance on ethical oversight of research involving human participants was written for pharmacotherapy interventions. Interpretation of such guidance for cluster-randomized trials and stepped-wedge trials, which commonly evaluate complex non-therapeutic interventions such as knowledge translation, public health, or health service delivery interventions, can pose challenges to researchers and regulators. CURRENT GUIDANCE The Ottawa Statement on the Ethical Design and Conduct of Cluster-Randomized Trials provides guidance on the ethical oversight and consent procedures for cluster-randomized trials, and while not explicit, this includes stepped-wedge trials. Yet, stepped-wedge trials have unique characteristics that differentiate them from standard cluster-randomized trials. In particular, they can be used to evaluate knowledge translation interventions within the context of a routine health system rollout; they may have a non-randomized design; and the decision to implement the intervention is not always made by the researcher. Many stepped-wedge trials do not undergo ethical review and do not report trial registration. This suggests that those undertaking these studies and research ethics committees perceive them as non-research activities. RECOMMENDATIONS Through an ethical analysis of two case studies, we argue that stepped-wedge trials, like parallel arm cluster trials, are systematic investigations designed to produce generalizable knowledge. We contend that stepped-wedge trials usually include human research participants, which may be patients, health care providers, or both. Stepped-wedge trials are therefore research involving human participants for the purpose of ethical review. Nevertheless, the use of a waiver or alteration of consent may be appropriate in many stepped-wedge trials due to the infeasibility of obtaining informed consent and the low-risk nature of the interventions. To ensure that traditional ethical principles such as respect for persons are upheld, these studies must undergo research ethics review.
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Affiliation(s)
- Karla Hemming
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Monica Taljaard
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada.,School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Tom Marshall
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Cory E Goldstein
- Rotman Institute of Philosophy, Western University, London, ON, Canada
| | - Charles Weijer
- Rotman Institute of Philosophy, Western University, London, ON, Canada
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Li F. Design and analysis considerations for cohort stepped wedge cluster randomized trials with a decay correlation structure. Stat Med 2019; 39:438-455. [PMID: 31797438 DOI: 10.1002/sim.8415] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Revised: 08/21/2019] [Accepted: 10/07/2019] [Indexed: 01/08/2023]
Abstract
A stepped wedge cluster randomized trial is a type of longitudinal cluster design that sequentially switches clusters to intervention over time until all clusters are treated. While the traditional posttest-only parallel design requires adjustment for a single intraclass correlation coefficient, the stepped wedge design allows multiple outcome measurements from the same cluster and so additional correlation parameters are necessary to characterize the within-cluster correlation structure. Although a number of studies have differentiated between the concepts of within-period and between-period correlations, only a few studies have allowed the between-period correlation to decay over time. In this article, we consider the proportional decay correlation structure for a cohort stepped wedge design, and provide a matrix-adjusted quasi-least squares approach to accurately estimate the correlation parameters along with the marginal intervention effect. We further develop the sample size and power procedures accounting for the correlation decay, and investigate the accuracy of the power procedure with continuous outcomes in a simulation study. We show that the empirical power agrees well with the prediction even with as few as nine clusters, when data are analyzed with matrix-adjusted quasi-least squares concurrently with a suitable bias-corrected sandwich variance. Two trial examples are provided to illustrate the new sample size procedure.
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Affiliation(s)
- Fan Li
- Department of Biostatistics, Yale University, New Haven, Connecticut.,Center for Methods in Implementation and Prevention Science, Yale University, New Haven, Connecticut
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Binik A. Delaying and withholding interventions: ethics and the stepped wedge trial. JOURNAL OF MEDICAL ETHICS 2019; 45:662-667. [PMID: 31341013 DOI: 10.1136/medethics-2018-105138] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Revised: 06/12/2019] [Accepted: 07/01/2019] [Indexed: 06/10/2023]
Abstract
Ethics has been identified as a central reason for choosing the stepped wedge trial over other kinds of trial designs. The potential advantage of the stepped wedge design is that it provides all arms of the trial with the active intervention over the course of the study. Some groups receive it later than others, but the study intervention is not withheld from any group. This feature of the stepped wedge design seems particularly ethically advantageous in two instances: (1) when the study intervention appears especially likely to be effective and (2) when the consequences of not receiving the intervention may be dire. But despite an increase in the use of the stepped wedge design and appeals to its ethical superiority as the motivation for its selection, there has been limited attention to the stepped wedge trial in the ethics literature. In the following, I examine whether there are persuasive ethical reasons to prefer or to require a stepped wedge trial. I argue that while the stepped wedge design is ethically permissible, it is not morally superior to other kinds of trials. To this end, I examine the ethical justification for providing, withholding, and delaying interventions in research.
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Affiliation(s)
- Ariella Binik
- Department of Philosophy, McMaster University, Hamilton, Ontario, Canada
- Institute on Ethics & Policy for Innovation, McMaster University, Hamilton, Ontario, Canada
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Iyer SN, Shah J, Boksa P, Lal S, Joober R, Andersson N, Fuhrer R, Abdel-Baki A, Beaton AM, Reaume-Zimmer P, Hutt-MacLeod D, Levasseur MA, Chandrasena R, Rousseau C, Torrie J, Etter M, Vallianatos H, Abba-Aji A, Bighead S, MacKinnon A, Malla AK. A minimum evaluation protocol and stepped-wedge cluster randomized trial of ACCESS Open Minds, a large Canadian youth mental health services transformation project. BMC Psychiatry 2019; 19:273. [PMID: 31488144 PMCID: PMC6729084 DOI: 10.1186/s12888-019-2232-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Accepted: 08/07/2019] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Many Canadian adolescents and young adults with mental health problems face delayed detection, long waiting lists, poorly accessible services, care of inconsistent quality and abrupt or absent inter-service transitions. To address these issues, ACCESS Open Minds, a multi-stakeholder network, is implementing and systematically evaluating a transformation of mental health services for youth aged 11 to 25 at 14 sites across Canada. The transformation plan has five key foci: early identification, rapid access, appropriate care, the elimination of age-based transitions between services, and the engagement of youth and families. METHODS The ACCESS Open Minds Research Protocol has multiple components including a minimum evaluation protocol and a stepped-wedge cluster randomized trial, that are detailed in this paper. Additional components include qualitative methods and cost-effectiveness analyses. The services transformation is being evaluated at all sites via a minimum evaluation protocol. Six sites are participating in the stepped-wedge trial whereby the intervention (a service transformation along the key foci) was rolled out in three waves, each commencing six months apart. Two sites, one high-population and one low-population, were randomly assigned to each of the three waves, i.e., randomization was stratified by population size. Our primary hypotheses pertain to increased referral numbers, and reduced wait times to initial assessment and to the commencement of appropriate care. Secondary hypotheses pertain to simplified pathways to care; improved clinical, functional and subjective outcomes; and increased satisfaction among youth and families. Quantitative measures addressing these hypotheses are being used to determine the effectiveness of the intervention. DISCUSSION Data from our overall research strategy will help test the effectiveness of the ACCESS Open Minds transformation, refine it further, and inform its scale-up. The process by which our research strategy was developed has implications for the practice of research itself in that it highlights the need to actively engage all stakeholder groups and address unique considerations in designing evaluations of complex healthcare interventions in multiple, diverse contexts. Our approach will generate both concrete evidence and nuanced insights, including about the challenges of conducting research in real-world settings. More such innovative approaches are needed to advance youth mental health services research. TRIAL REGISTRATION NUMBER Clinicaltrials.gov, ISRCTN23349893 (Retrospectively registered: 16/02/2017).
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Affiliation(s)
- Srividya N. Iyer
- Department of Psychiatry, McGill University, Montréal, Québec Canada
- ACCESS Open Minds (Pan-Canadian Youth Mental Health Services Research Network), Douglas Mental Health University Institute, Montréal, Québec Canada
- Prevention and Early Intervention Program for Psychosis (PEPP), Douglas Mental Health University Institute, Montréal, Québec Canada
- Douglas Mental Health University Institute, Montréal, Québec Canada
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montréal, Québec Canada
| | - Jai Shah
- Department of Psychiatry, McGill University, Montréal, Québec Canada
- ACCESS Open Minds (Pan-Canadian Youth Mental Health Services Research Network), Douglas Mental Health University Institute, Montréal, Québec Canada
- Prevention and Early Intervention Program for Psychosis (PEPP), Douglas Mental Health University Institute, Montréal, Québec Canada
- Douglas Mental Health University Institute, Montréal, Québec Canada
| | - Patricia Boksa
- Department of Psychiatry, McGill University, Montréal, Québec Canada
- ACCESS Open Minds (Pan-Canadian Youth Mental Health Services Research Network), Douglas Mental Health University Institute, Montréal, Québec Canada
- Douglas Mental Health University Institute, Montréal, Québec Canada
| | - Shalini Lal
- ACCESS Open Minds (Pan-Canadian Youth Mental Health Services Research Network), Douglas Mental Health University Institute, Montréal, Québec Canada
- School of Rehabilitation, Faculty of Medicine, Université de Montréal, Montréal, Québec Canada
- Centre de recherche du Centre hospitalier de l’Universite de Montreal (CRCHUM), Montréal, Québec Canada
| | - Ridha Joober
- Department of Psychiatry, McGill University, Montréal, Québec Canada
- ACCESS Open Minds (Pan-Canadian Youth Mental Health Services Research Network), Douglas Mental Health University Institute, Montréal, Québec Canada
- Prevention and Early Intervention Program for Psychosis (PEPP), Douglas Mental Health University Institute, Montréal, Québec Canada
- Douglas Mental Health University Institute, Montréal, Québec Canada
| | - Neil Andersson
- ACCESS Open Minds (Pan-Canadian Youth Mental Health Services Research Network), Douglas Mental Health University Institute, Montréal, Québec Canada
- Department of Family Medicine, Community Information and Epidemiological Technologies (CIET) Institute and Participatory Research at McGill (PRAM), McGill University, Montréal, Québec Canada
- McGill University Institute for Human Development and Well-being, Montréal, Québec Canada
| | - Rebecca Fuhrer
- ACCESS Open Minds (Pan-Canadian Youth Mental Health Services Research Network), Douglas Mental Health University Institute, Montréal, Québec Canada
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montréal, Québec Canada
| | - Amal Abdel-Baki
- ACCESS Open Minds (Pan-Canadian Youth Mental Health Services Research Network), Douglas Mental Health University Institute, Montréal, Québec Canada
- Centre de recherche du Centre hospitalier de l’Universite de Montreal (CRCHUM), Montréal, Québec Canada
- Department of Psychiatry, Université de Montréal, Montréal, Québec Canada
- Centre hospitalier de l’Université de Montréal (CHUM), CRCHUM, Montréal, Québec Canada
| | - Ann M. Beaton
- ACCESS Open Minds (Pan-Canadian Youth Mental Health Services Research Network), Douglas Mental Health University Institute, Montréal, Québec Canada
- School of Psychology, Faculty of Health Sciences and Community Services, Université de Moncton, Moncton, New Brunswick, Canada
| | - Paula Reaume-Zimmer
- ACCESS Open Minds (Pan-Canadian Youth Mental Health Services Research Network), Douglas Mental Health University Institute, Montréal, Québec Canada
- Mental Health and Addictions Services, Bluewater Health and Canadian Mental Health Association, Lambton Kent, Ontario, Canada
| | - Daphne Hutt-MacLeod
- ACCESS Open Minds (Pan-Canadian Youth Mental Health Services Research Network), Douglas Mental Health University Institute, Montréal, Québec Canada
- Eskasoni Mental Health Services, Eskasoni First Nation, Nova Scotia, Canada
| | - Mary Anne Levasseur
- ACCESS Open Minds (Pan-Canadian Youth Mental Health Services Research Network), Douglas Mental Health University Institute, Montréal, Québec Canada
- ACCESS Open Minds Family and Carers Council, Douglas Mental Health University Institute, Montréal, Québec Canada
| | - Ranjith Chandrasena
- ACCESS Open Minds (Pan-Canadian Youth Mental Health Services Research Network), Douglas Mental Health University Institute, Montréal, Québec Canada
- Schulich School of Medicine, Western University, London, Ontario Canada
| | - Cécile Rousseau
- Department of Psychiatry, McGill University, Montréal, Québec Canada
- ACCESS Open Minds (Pan-Canadian Youth Mental Health Services Research Network), Douglas Mental Health University Institute, Montréal, Québec Canada
- Centre de recherche SHERPA, Institut Universitaire au regard des communautés ethno culturelles, Centre intégré universitaire de santé et de services sociaux (CIUSSS) du Centre-Ouest-de-l’Île-de-Montreal, Montréal, Québec Canada
| | - Jill Torrie
- ACCESS Open Minds (Pan-Canadian Youth Mental Health Services Research Network), Douglas Mental Health University Institute, Montréal, Québec Canada
- Public Health Department, Cree Board of Health and Social Services of James Bay, Cree Nation of Mistissini, Québec Canada
| | - Meghan Etter
- ACCESS Open Minds (Pan-Canadian Youth Mental Health Services Research Network), Douglas Mental Health University Institute, Montréal, Québec Canada
- Counselling Services, Inuvialuit Regional Corporation, Inuvik, Northwest Territories, Canada
| | - Helen Vallianatos
- ACCESS Open Minds (Pan-Canadian Youth Mental Health Services Research Network), Douglas Mental Health University Institute, Montréal, Québec Canada
- Department of Anthropology, University of Alberta, Edmonton, Alberta Canada
| | - Adam Abba-Aji
- ACCESS Open Minds (Pan-Canadian Youth Mental Health Services Research Network), Douglas Mental Health University Institute, Montréal, Québec Canada
- Alberta Health Services, Edmonton Zone, Edmonton, Alberta Canada
- Department of Psychiatry, University of Alberta, Edmonton, Alberta Canada
| | - Shirley Bighead
- ACCESS Open Minds (Pan-Canadian Youth Mental Health Services Research Network), Douglas Mental Health University Institute, Montréal, Québec Canada
- Sturgeon Lake Health Centre, Sturgeon Lake First Nation, Saskatchewan, Canada
| | - Aileen MacKinnon
- ACCESS Open Minds (Pan-Canadian Youth Mental Health Services Research Network), Douglas Mental Health University Institute, Montréal, Québec Canada
- Saqijuq Project, Nunavik, Québec Canada
| | - Ashok K. Malla
- Department of Psychiatry, McGill University, Montréal, Québec Canada
- ACCESS Open Minds (Pan-Canadian Youth Mental Health Services Research Network), Douglas Mental Health University Institute, Montréal, Québec Canada
- Prevention and Early Intervention Program for Psychosis (PEPP), Douglas Mental Health University Institute, Montréal, Québec Canada
- Douglas Mental Health University Institute, Montréal, Québec Canada
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montréal, Québec Canada
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Li J, Zhang Y, Myers LJ, Bravata DM. Power calculation in stepped-wedge cluster randomized trial with reduced intervention sustainability effect. J Biopharm Stat 2019; 29:663-674. [PMID: 31317805 DOI: 10.1080/10543406.2019.1633658] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
The stepped-wedge design for pragmatic clinical trials has received increased attention in health service-related research seeking to evaluate the effect of interventions. Compared with the parallel design, the stepped-wedge design is preferred when there is prior knowledge supporting the effectiveness and harmlessness of the intervention, and/or when practical or financial constraints exist such that the intervention can only be implemented sequentially on a fraction of clusters. In some health service studies, the study period may consist of two parts: an active implementation followed by a sustainability phase, where the intervention effect is possibly reduced. There is a gap in current literature of the stepped-wedge design for cluster randomization trials for dealing with this specific scenario. We aim to provide an analytical formula for power analysis under this situation to aid the stepped-wedge design of an ongoing PREVENT trial.
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Affiliation(s)
- Jing Li
- a Department of Biostatistics, Richard M. Fairbanks School of Public Health, Indiana University , Indianapolis , IN , USA
| | - Ying Zhang
- b Department of Biostatistics, College of Public Health, University of Nebraska Medical Center , Omaha , NE , USA
| | - Laura J Myers
- c Health Services Research Service, Richard L. Roudebush VA Medical Center , Indianapolis , IN , USA.,d Department of Internal Medicine, Indiana University School of Medicine , Indianapolis , IN , USA
| | - Dawn M Bravata
- c Health Services Research Service, Richard L. Roudebush VA Medical Center , Indianapolis , IN , USA.,d Department of Internal Medicine, Indiana University School of Medicine , Indianapolis , IN , USA.,e Center for Health Services Research, Regenstrief Institute , Indianapolis , IN , USA
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Hooper R, Copas A. Stepped wedge trials with continuous recruitment require new ways of thinking. J Clin Epidemiol 2019; 116:161-166. [PMID: 31272885 DOI: 10.1016/j.jclinepi.2019.05.037] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Accepted: 05/29/2019] [Indexed: 10/26/2022]
Abstract
OBJECTIVES There is substantial variation in the design of stepped wedge trials. Many recruit participants continuously over time, although the methodological literature has tended not to differentiate closely between continuous recruitment and discrete sampling. We argue for a deeper understanding of the special features of stepped wedge trials with continuous recruitment. STUDY DESIGN AND SETTING This is a commentary and informal review. RESULTS We discuss the scheduling of recruitment and implementation in continuous time and how contamination might be avoided. We also offer some suggestions on reporting and terminology for stepped wedge trials with continuous recruitment and comment on issues for analysis. CONCLUSION Repeated cross-section and continuous recruitment stepped wedge trials are not the same thing. More work is needed to develop the theory and practice of stepped wedge designs with continuous recruitment. Thoughtful approaches to design and clarity of reporting are vital.
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Affiliation(s)
- Richard Hooper
- Centre for Primary Care & Public Health, Queen Mary University of London, London, UK.
| | - Andrew Copas
- MRC Clinical Trials Unit, University College London, London, UK
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Gould GS, Bovill M, Pollock L, Bonevski B, Gruppetta M, Atkins L, Carson-Chahhoud K, Boydell KM, Gribbin GR, Oldmeadow C, Hall A, Bar-Zeev Y, Bar-Zeev Y. Feasibility and acceptability of Indigenous Counselling and Nicotine (ICAN) QUIT in Pregnancy multicomponent implementation intervention and study design for Australian Indigenous pregnant women: A pilot cluster randomised step-wedge trial. Addict Behav 2019; 90:176-190. [PMID: 30412909 DOI: 10.1016/j.addbeh.2018.10.036] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Revised: 10/22/2018] [Accepted: 10/25/2018] [Indexed: 02/03/2023]
Abstract
BACKGROUND Many health providers (HPs) lack knowledge, confidence, optimism and skills in addressing smoking with pregnant women. This study aimed to explore the feasibility and acceptability of a) a co-designed multi-component intervention for HPs at Aboriginal Medical Services (AMSs) in culturally-targeted pregnancy-specific smoking cessation care and b) the study design. METHODS Using a randomised step-wedge cluster design, the Indigenous Counselling And Nicotine (ICAN) QUIT in Pregnancy Trial was evaluated across six AMSs in three Australian states. HPs were provided educational resource packages including live interactive webinars, treatment manuals, patient resources, carbon monoxide (CO) meters, and oral Nicotine Replacement Therapy (NRT). Feasibility was assessed through recruitment and retention rates of both pregnant women (12-weeks) and HPs (end of study) as well as the potential to improve women's quit rates. Qualitative interviews with staff post-trial explored acceptability of the intervention and study, based on capability, opportunity and motivation from the Behaviour Change Wheel. RESULTS Pregnant women (n = 22; 47% (95% CI: 32%, 63%) eligible) and HPs (n = 50; 54% (95% CI: 44%, 64%) eligible) were recruited over 6 months with retention rates of 77% (95% CI: 57%, 90%) and 40% (95% CI: 28%, 54%) respectively. Self-reported 12-week 7-day point-prevalence abstinence was 13.6% (n = 3) and validated abstinent with CO readings ≤6 ppm. Staff interviewed regarding intervention implementation highlighted the importance of provision and use of resources, including training materials, patient resources, CO meters and oral NRT. Resources helped increase capability and opportunity, restructure the environment, and provided social comparison and modelling. Staff were motivated by greater engagement with pregnant women and seeing the women's reductions in CO readings. Having the intervention at the AMSs improved organisational capacity to engage with pregnant women. Staff reported changes to their routine practice that were potentially sustainable. Recommendations for improvement to the implementation of the intervention and research included reducing training length and the tasks related to conducting the study. CONCLUSION ICAN QUIT in Pregnancy was a pilot study with the ability to enrol Indigenous women. It was feasible to implement and acceptable to most staff of the AMSs in three states, with modifications recommended. Smoking in pregnancy is a key challenge for Indigenous health. The intervention needs to be evaluated through a methodologically rigorous fully-powered study to determine the efficacy of outcomes for women. TRIAL REGISTRATION Australian and New Zealand Clinical Trials Registry, ACTRN12616001603404. Registered 21 November 2016 - retrospectively registered, https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=371778.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | - Yael Bar-Zeev
- University of Newcastle, University Drive, Callaghan, New South Wales 2308, Australia.
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Hemming K, Carroll K, Thompson J, Forbes A, Taljaard M. Quality of stepped-wedge trial reporting can be reliably assessed using an updated CONSORT: crowd-sourcing systematic review. J Clin Epidemiol 2019; 107:77-88. [PMID: 30500405 DOI: 10.1016/j.jclinepi.2018.11.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Revised: 10/03/2018] [Accepted: 11/19/2018] [Indexed: 12/29/2022]
Abstract
OBJECTIVES The Consolidated Standards of Reporting Trials extension for the stepped-wedge cluster randomized trial (SW-CRT) is a recently published reporting guideline for SW-CRTs. We assess the quality of reporting of a recent sample of SW-CRTs. STUDY DESIGN AND SETTING Quality of reporting was asssessed according to the 26 items in the new guideline using a novel crowd sourcing methodology conducted independently and in duplicate, with random assignment, by 50 reviewers. We assessed reliability of the quality assessments, proposing this as a novel way to assess robustness of items in reporting guidelines. RESULTS Several items were well reported. Some items were very poorly reported, including several items that have unique requirements for the SW-CRT, such as the rationale for use of the design, description of the design, identification and recruitment of participants within clusters, and concealment of cluster allocation (not reported in more than 50% of the reports). Agreement across items was moderate (median percentage agreement was 76% [IQR 64 to 86]). Agreement was low for several items including the description of the trial design and why trial ended or stopped for example. CONCLUSIONS When reporting SW-CRTs, authors should pay particular attention to ensure clear reporting on the exact format of the design with justification, as well as how clusters and individuals were identified for inclusion in the study, and whether this was done before or after randomization of the clusters, which are crucial for risk of bias assessments. Some items, including why the trial ended, might either not be relevant to SW-CRTs or might be unclearly described in the statement.
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Affiliation(s)
- Karla Hemming
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK.
| | - Kelly Carroll
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, 501 Smyth Road, Ottawa, Ontario, Canada
| | - Jennifer Thompson
- Tropical Epidemiology Group, London School of Hygiene and Tropical Medicine, London, UK
| | - Andrew Forbes
- Biostatistics, Monash University, Melbourne, Australia
| | - Monica Taljaard
- School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa, Ottawa, Canada
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Roberts NA, Mudge A, Alexander K, Wyld D, Janda M. The iPROMOS protocol: a stepped-wedge study to implement routine patient-reported outcomes in a medical oncology outpatient setting. BMJ Open 2019; 9:e027046. [PMID: 30804038 PMCID: PMC6443070 DOI: 10.1136/bmjopen-2018-027046] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Patient-reported outcome measures (PROMs) are data capture tools that collect information directly from patients. Several large research studies provide evidence that the use of PROMs in routine care provides benefits to mortality and morbidity outcomes in medical oncology patients. Despite this, implementation of PROMs in daily clinical routine is slow and challenging. METHODS AND ANALYSIS This study will use a stepped-wedge design to assess the implementation of a PROM intervention in highly frequented medical oncology outpatient clinics. During a lead-in period of 4 weeks, control data will be collected. The intervention will then be implemented for 4 weeks in Clinic 1 initially, then in Clinic 2 for another 4 weeks. 500 patient encounters will be measured over the 12 weeks in total. The process of implementation will be informed and evaluated using the Medical Research Council Guidelines for Implementing Complex Interventions. The study will be guided by the Promoting Action Research in Health Services framework approach for implementation. The intervention and implementation outcomes will be measured using qualitative and quantitative data. ETHICS AND DISSEMINATION Ethical approval has been obtained, approval number HREC/16/QRBW/100 by the Royal Brisbane and Women's Hospital Human Research Ethics Committee. Results will be disseminated in peer-reviewed journals and at scientific meetings. TRIAL REGISTRATION ACTRN12618000398202. Trial Status: Opened on 25 March 2018 and will continue until 12 months after the last PROMs reporting encounter.
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Affiliation(s)
- Natasha Anne Roberts
- Faculty of Health, Queensland University of Technology, Kelvin Grove, Queensland, Australia
- Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
| | - Alison Mudge
- Department of Internal Medicine and Aged Care, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
| | - Kim Alexander
- Faculty of Health, School of Nursing, Queensland University of Technology, Kelvin Grove, Queensland, Australia
| | - David Wyld
- Cancer Care Services, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
| | - Monika Janda
- Faculty of Medicine, Centre of Health Services Research, University of Queensland, Brisbane, Queensland, Australia
- School of Public Health and Social Work, Institute for Health and Biomedical Innovation, Queensland University of Technology, Brisbane, Queensland, Australia
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Sánchez A, Thomas C, Deeken F, Wagner S, Klöppel S, Kentischer F, von Arnim CAF, Denkinger M, Conzelmann LO, Biermann-Stallwitz J, Joos S, Sturm H, Metz B, Auer R, Skrobik Y, Eschweiler GW, Rapp MA. Patient safety, cost-effectiveness, and quality of life: reduction of delirium risk and postoperative cognitive dysfunction after elective procedures in older adults-study protocol for a stepped-wedge cluster randomized trial (PAWEL Study). Trials 2019; 20:71. [PMID: 30665435 PMCID: PMC6341754 DOI: 10.1186/s13063-018-3148-8] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Accepted: 12/18/2018] [Indexed: 12/20/2022] Open
Abstract
Background Postoperative delirium is a common disorder in older adults that is associated with higher morbidity and mortality, prolonged cognitive impairment, development of dementia, higher institutionalization rates, and rising healthcare costs. The probability of delirium after surgery increases with patients’ age, with pre-existing cognitive impairment, and with comorbidities, and its diagnosis and treatment is dependent on the knowledge of diagnostic criteria, risk factors, and treatment options of the medical staff. In this study, we will investigate whether a cross-sectoral and multimodal intervention for preventing delirium can reduce the prevalence of delirium and postoperative cognitive decline (POCD) in patients older than 70 years undergoing elective surgery. Additionally, we will analyze whether the intervention is cost-effective. Methods The study will be conducted at five medical centers (with two or three surgical departments each) in the southwest of Germany. The study employs a stepped-wedge design with cluster randomization of the medical centers. Measurements are performed at six consecutive points: preadmission, preoperative, and postoperative with daily delirium screening up to day 7 and POCD evaluations at 2, 6, and 12 months after surgery. Recruitment goals are to enroll 1500 patients older than 70 years undergoing elective operative procedures (cardiac, thoracic, vascular, proximal big joints and spine, genitourinary, gastrointestinal, and general elective surgery procedures). Discussion Results of the trial should form the basis of future standards for preventing delirium and POCD in surgical wards. Key aims are the improvement of patient safety and quality of life, as well as the reduction of the long-term risk of conversion to dementia. Furthermore, from an economic perspective, we expect benefits and decreased costs for hospitals, patients, and healthcare insurances. Trial registration German Clinical Trials Register, DRKS00013311. Registered on 10 November 2017. Electronic supplementary material The online version of this article (10.1186/s13063-018-3148-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Alba Sánchez
- Department of Social and Preventive Medicine, University of Potsdam, Am Neuen Palais 10, 14469, Potsdam, Germany
| | - Christine Thomas
- Department of Old Age Psychiatry and Psychotherapy, Klinikum Stuttgart, Stuttgart, Germany
| | - Friederike Deeken
- Department of Social and Preventive Medicine, University of Potsdam, Am Neuen Palais 10, 14469, Potsdam, Germany
| | - Sören Wagner
- Department of Anaesthesiology and Intensive Care, Katharinenhospital, Klinikum Stuttgart, Stuttgart, Germany
| | - Stefan Klöppel
- Center for Geriatrics and Gerontology, University Medical Center Freiburg, Freiburg, Germany.,University Hospital of Old Age Psychiatry, University of Bern, Bern, Switzerland
| | - Felix Kentischer
- Department of Surgery, Medical Center-University of Freiburg, Freiburg, Germany
| | | | - Michael Denkinger
- Agaplesion Bethesda Clinic, Geriatric Center Ulm University, Ulm, Germany
| | | | | | - Stefanie Joos
- Institute for General Practice and Interprofessional Care, University Hospital Tübingen, Tübingen, Germany
| | - Heidrun Sturm
- Institute for General Practice and Interprofessional Care, University Hospital Tübingen, Tübingen, Germany
| | - Brigitte Metz
- Geriatric Center Karlsruhe, ViDia Christian Clinics Karlsruhe, Karlsruhe, Germany
| | - Ramona Auer
- Allgemeine Ortskrankenkasse (AOK) Baden-Württemberg, Stuttgart, Germany
| | - Yoanna Skrobik
- Department of Medicine, McGill University Health Center, Glen Campus, Montreal, QC, Canada
| | | | - Michael A Rapp
- Department of Social and Preventive Medicine, University of Potsdam, Am Neuen Palais 10, 14469, Potsdam, Germany.
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Hemming K, Taljaard M, Grimshaw J. Introducing the new CONSORT extension for stepped-wedge cluster randomised trials. Trials 2019; 20:68. [PMID: 30658677 PMCID: PMC6339370 DOI: 10.1186/s13063-018-3116-3] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Accepted: 12/07/2018] [Indexed: 11/18/2022] Open
Abstract
The use of the stepped-wedge cluster randomised trial (SW-CRT) is on the increase, and although there are still relatively few SW-CRTs currently published its use is bound to show an increase in the near future. An extension of the CONSORT reporting guideline for SW-CRTs has recently been developed. By making reporting guidelines for this innovative design available relatively early in its development, it is possible that the methodological conduct and reporting of future SW-CRTs will not be at the same risk of low-quality of reporting as is the case with many other study designs. We provide a brief overview of this reporting guideline and encourage authors to use it appropriately; and for journal editors to endorse its use.
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Affiliation(s)
- Karla Hemming
- Institute of Applied Health Research, University of Birmingham, Birmingham, B15 2TT, UK.
| | - Monica Taljaard
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, 1053 Carling Avenue, Ottawa, ON, K1Y4E9, Canada.,School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
| | - Jeremy Grimshaw
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, 1053 Carling Avenue, Ottawa, ON, K1Y4E9, Canada.,Department of Medicine, University of Ottawa, Ottawa, ON, Canada
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44
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Kristunas CA, Hemming K, Eborall H, Eldridge S, Gray LJ. The current use of feasibility studies in the assessment of feasibility for stepped-wedge cluster randomised trials: a systematic review. BMC Med Res Methodol 2019; 19:12. [PMID: 30630416 PMCID: PMC6327386 DOI: 10.1186/s12874-019-0658-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Accepted: 01/02/2019] [Indexed: 11/12/2022] Open
Abstract
Background Stepped-wedge cluster randomised trials (SW-CRTs) are a pragmatic trial design, providing an unprecedented opportunity to increase the robustness of evidence underpinning implementation and quality improvement interventions. Given the complexity of the SW-CRT, the likelihood of trials not delivering on their objectives will be mitigated if a feasibility study precedes the definitive trial. It is not currently known if feasibility studies are being conducted for SW-CRTs nor what the objectives of these studies are. Methods Searches were conducted of several databases to identify published feasibility studies which were designed to inform a future SW-CRT. For each eligible study, data were extracted on the characteristics of and rationale for the feasibility study; the process for determining progression to the main trial; how the feasibility study informed the main trial; and whether the main trial went ahead. A narrative synthesis and descriptive analysis are presented. Results Eleven feasibility studies were identified, which included eight completed study reports and three protocols. Three studies used a stepped-wedge design and these were the only studies to be randomised. Studies were predominantly of a mixed-methods design. Only one study assessed specific features related to the feasibility of using a SW-CRT and one investigated the time taken to complete the study procedures. The other studies were mostly assessing the feasibility and acceptability of the intervention. Conclusion Published feasibility studies for SW-CRTs are scarce and those that are being reported do not investigate issues specific to the complexities of the trial design. When conducting feasibility studies in advance of a definitive SW-CRT, researchers should consider assessing the feasibility of study procedures, particularly those specific to the SW-CRT design, and ensure that the findings are published for the benefit of other researchers. Electronic supplementary material The online version of this article (10.1186/s12874-019-0658-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
| | - Karla Hemming
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Helen Eborall
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Sandra Eldridge
- Centre for Primary Care and Public Health, Queen Mary University of London, London, UK
| | - Laura J Gray
- Department of Health Sciences, University of Leicester, Leicester, UK
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45
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Zhu H, Chen S, Xie P, Yang G, Zhong Z, Zhang H, Du Y. Quality of Reporting in Oncology Randomized Controlled Trials: From 2011 to 2015. Cancer Control 2018; 25:1073274818781309. [PMID: 29895186 PMCID: PMC6028167 DOI: 10.1177/1073274818781309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Randomized controlled trials (RCTs) are important for evidence-based medicine; however, their quality of reporting remains to be evaluated. The aim of this study was to assess the quality of the report concerning solid tumor medication. Articles were searched in PubMed to identify all oncology phase III RCTs published from 2011 to 2015, and the results were classified manually through Endnote X7.0 software. Registration rate, primary end point (PEP) consistency, positive result rate, enrollment time point, outcome feedback in the registry, and publish time zone were extracted and assessed. The overall registration rate was higher than years before; nevertheless, a portion of trials showed PEP discrepancies and enrolled patients before registration in either journal formats. Trials published in top 5 general medical journals paid more attention to results feedback on registration websites and were more prompt with publication after study accomplishment. Our data suggested general medical journals may be more rigorous compared to oncology journals but identified a preference for positive results. On the whole, RCTs published between 2011 and 2015 seemed fairly standardized. Surveillance in registry and outcome feedback still needs to be strengthened for the stringency and reliability of clinical trials in solid tumor medication territory.
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Affiliation(s)
- Huiyun Zhu
- 1 Department of Gastroenterology, Changhai Hospital, Second Military Medical University/Naval Medical University, Shanghai, China
| | - Si Chen
- 2 Department of Respiratory and Critical Care Medicine, Changhai Hospital, Second Military Medical University/Naval Medical University, Shanghai, China
| | - Pei Xie
- 1 Department of Gastroenterology, Changhai Hospital, Second Military Medical University/Naval Medical University, Shanghai, China
| | - Geliang Yang
- 3 Department of Integrative Oncology, Changhai Hospital of Traditional Chinese Medicine, Second Military Medical University/Naval Medical University, Shanghai, China
| | - Zhenqiang Zhong
- 4 Department of Laboratory, Fengcheng Hospital, Shanghai, People's Republic of China
| | - Huiqing Zhang
- 3 Department of Integrative Oncology, Changhai Hospital of Traditional Chinese Medicine, Second Military Medical University/Naval Medical University, Shanghai, China
| | - Yiqi Du
- 1 Department of Gastroenterology, Changhai Hospital, Second Military Medical University/Naval Medical University, Shanghai, China
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46
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Hemming K, Taljaard M, McKenzie JE, Hooper R, Copas A, Thompson JA, Dixon-Woods M, Aldcroft A, Doussau A, Grayling M, Kristunas C, Goldstein CE, Campbell MK, Girling A, Eldridge S, Campbell MJ, Lilford RJ, Weijer C, Forbes AB, Grimshaw JM. Reporting of stepped wedge cluster randomised trials: extension of the CONSORT 2010 statement with explanation and elaboration. BMJ 2018; 363:k1614. [PMID: 30413417 PMCID: PMC6225589 DOI: 10.1136/bmj.k1614] [Citation(s) in RCA: 220] [Impact Index Per Article: 36.7] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/20/2018] [Indexed: 12/14/2022]
Affiliation(s)
- Karla Hemming
- Institute of Applied Health Research, University of Birmingham, Birmingham B15 2TT, UK
| | - Monica Taljaard
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
| | - Joanne E McKenzie
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Richard Hooper
- Centre for Primary Care and Public Health, Queen Mary University of London, London, UK
| | - Andrew Copas
- London Hub for Trials Methodology Research, MRC Clinical Trials Unit at University College London, London, UK
| | - Jennifer A Thompson
- London Hub for Trials Methodology Research, MRC Clinical Trials Unit at University College London, London, UK
- Department for Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Mary Dixon-Woods
- The Healthcare Improvement Studies Institute, University of Cambridge, Cambridge Biomedical Campus, Cambridge, UK
| | | | - Adelaide Doussau
- Biomedical Ethics Unit, McGill University School of Medicine, Montreal, QC, Canada
| | | | | | - Cory E Goldstein
- Rotman Institute of Philosophy, Western University, London, ON, Canada
| | | | - Alan Girling
- Institute of Applied Health Research, University of Birmingham, Birmingham B15 2TT, UK
| | - Sandra Eldridge
- Centre for Primary Care and Public Health, Queen Mary University of London, London, UK
| | | | | | - Charles Weijer
- Rotman Institute of Philosophy, Western University, London, ON, Canada
| | - Andrew B Forbes
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Jeremy M Grimshaw
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada
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Grayling MJ, Mander AP, Wason JMS. Blinded and unblinded sample size reestimation procedures for stepped-wedge cluster randomized trials. Biom J 2018; 60:903-916. [PMID: 30073685 PMCID: PMC6175439 DOI: 10.1002/bimj.201700125] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2017] [Revised: 06/26/2018] [Accepted: 06/27/2018] [Indexed: 11/05/2022]
Abstract
The ability to accurately estimate the sample size required by a stepped-wedge (SW) cluster randomized trial (CRT) routinely depends upon the specification of several nuisance parameters. If these parameters are misspecified, the trial could be overpowered, leading to increased cost, or underpowered, enhancing the likelihood of a false negative. We address this issue here for cross-sectional SW-CRTs, analyzed with a particular linear-mixed model, by proposing methods for blinded and unblinded sample size reestimation (SSRE). First, blinded estimators for the variance parameters of a SW-CRT analyzed using the Hussey and Hughes model are derived. Following this, procedures for blinded and unblinded SSRE after any time period in a SW-CRT are detailed. The performance of these procedures is then examined and contrasted using two example trial design scenarios. We find that if the two key variance parameters were underspecified by 50%, the SSRE procedures were able to increase power over the conventional SW-CRT design by up to 41%, resulting in an empirical power above the desired level. Thus, though there are practical issues to consider, the performance of the procedures means researchers should consider incorporating SSRE in to future SW-CRTs.
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Affiliation(s)
- Michael J. Grayling
- MRC Biostatistics UnitCambridge Institute of Public Health, Forvie Site, Robinson WayCambridge Biomedical CampusCambridgeUK
| | - Adrian P. Mander
- MRC Biostatistics UnitCambridge Institute of Public Health, Forvie Site, Robinson WayCambridge Biomedical CampusCambridgeUK
| | - James M. S. Wason
- MRC Biostatistics UnitCambridge Institute of Public Health, Forvie Site, Robinson WayCambridge Biomedical CampusCambridgeUK
- Institute of Health and SocietyNewcastle UniversityBaddiley‐Clark BuildingNewcastle upon TyneUK
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48
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Casadei R, Ricci C, Taffurelli G, Pacilio CA, Santini D, Di Marco M, Minni F. Multicolour versus monocolour inking specimens after pancreaticoduodenectomy for periampullary cancer: A single centre prospective randomised clinical trial. Int J Surg 2018; 51:63-70. [PMID: 29367035 DOI: 10.1016/j.ijsu.2018.01.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2017] [Revised: 01/08/2018] [Accepted: 01/14/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND R status represents an important prognostic factors in periampullary cancers. Thus, it is useful to verify if it can be influenced by different techniques of margination. METHODS Single-centre, randomised clinical trial of patients affected by periampullary cancer who underwent pancreaticoduodenectomies which included two different types of margination: arm A (multicolour inking) and arm B (monocolour inking). The primary endpoint was the overall R1 resection rate and its difference between the two arms. The secondary endpoints were the R1 resection rate in each margin and its difference between the two arms, and the impact of margin status on survival. RESULTS Fifty patients were randomised, 41 analysed: 22 in arm A, 19 arm B. The overall R1 status was 61%, without significant differences between the two arms. The margin most commonly involved was the superior mesenteric artery (SMA) (36.6%). A trend in favour of arm B was shown for the superior mesenteric artery margin (arm A = 22.7% versus arm B = 52.6%; P = 0.060). The anterior surface (P = 0.015), SMA (P = 0.047) and pancreatic remnant (P = 0.018) margins significantly influenced disease-free survival. CONCLUSIONS The R status was not influenced by different techniques of margination using a standardised pathological protocol. The SMA margin seemed to be the most important margin for evaluating both R status and disease-free survival.
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Affiliation(s)
- Riccardo Casadei
- Department of Medical and Surgical Sciences-DIMEC, S.Orsola-Malpighi Hospital, Alma Mater Studiorum, University of Bologna, Italy.
| | - Claudio Ricci
- Department of Medical and Surgical Sciences-DIMEC, S.Orsola-Malpighi Hospital, Alma Mater Studiorum, University of Bologna, Italy
| | - Giovanni Taffurelli
- Department of Medical and Surgical Sciences-DIMEC, S.Orsola-Malpighi Hospital, Alma Mater Studiorum, University of Bologna, Italy
| | - Carlo Alberto Pacilio
- Department of Medical and Surgical Sciences-DIMEC, S.Orsola-Malpighi Hospital, Alma Mater Studiorum, University of Bologna, Italy
| | - Donatella Santini
- Department of Specialist, Diagnostic and Experimental Medicine (DIMES), S.Orsola-Malpighi Hospital, Alma Mater Studiorum, University of Bologna, Italy
| | - Mariacristina Di Marco
- Department of Specialist, Diagnostic and Experimental Medicine (DIMES), S.Orsola-Malpighi Hospital, Alma Mater Studiorum, University of Bologna, Italy
| | - Francesco Minni
- Department of Medical and Surgical Sciences-DIMEC, S.Orsola-Malpighi Hospital, Alma Mater Studiorum, University of Bologna, Italy
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Abstract
OBJECTIVES To investigate the extent to which cluster sizes vary in stepped-wedge cluster randomised trials (SW-CRT) and whether any variability is accounted for during the sample size calculation and analysis of these trials. SETTING Any, not limited to healthcare settings. PARTICIPANTS Any taking part in an SW-CRT published up to March 2016. PRIMARY AND SECONDARY OUTCOME MEASURES The primary outcome is the variability in cluster sizes, measured by the coefficient of variation (CV) in cluster size. Secondary outcomes include the difference between the cluster sizes assumed during the sample size calculation and those observed during the trial, any reported variability in cluster sizes and whether the methods of sample size calculation and methods of analysis accounted for any variability in cluster sizes. RESULTS Of the 101 included SW-CRTs, 48% mentioned that the included clusters were known to vary in size, yet only 13% of these accounted for this during the calculation of the sample size. However, 69% of the trials did use a method of analysis appropriate for when clusters vary in size. Full trial reports were available for 53 trials. The CV was calculated for 23 of these: the median CV was 0.41 (IQR: 0.22-0.52). Actual cluster sizes could be compared with those assumed during the sample size calculation for 14 (26%) of the trial reports; the cluster sizes were between 29% and 480% of that which had been assumed. CONCLUSIONS Cluster sizes often vary in SW-CRTs. Reporting of SW-CRTs also remains suboptimal. The effect of unequal cluster sizes on the statistical power of SW-CRTs needs further exploration and methods appropriate to studies with unequal cluster sizes need to be employed.
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Affiliation(s)
| | - Tom Morris
- Leicester Clinical Trials Unit, University of Leicester, Leicester, UK
| | - Laura Gray
- Department of Health Sciences, University of Leicester, Leicester, UK
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50
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Abstract
BACKGROUND/AIMS The stepped-wedge cluster randomised trial design has received substantial attention in recent years. Although various extensions to the original design have been proposed, no guidance is available on the design of stepped-wedge cluster randomised trials with interim analyses. In an individually randomised trial setting, group sequential methods can provide notable efficiency gains and ethical benefits. We address this by discussing how established group sequential methodology can be adapted for stepped-wedge designs. METHODS Utilising the error spending approach to group sequential trial design, we detail the assumptions required for the determination of stepped-wedge cluster randomised trials with interim analyses. We consider early stopping for efficacy, futility, or efficacy and futility. We describe first how this can be done for any specified linear mixed model for data analysis. We then focus on one particular commonly utilised model and, using a recently completed stepped-wedge cluster randomised trial, compare the performance of several designs with interim analyses to the classical stepped-wedge design. Finally, the performance of a quantile substitution procedure for dealing with the case of unknown variance is explored. RESULTS We demonstrate that the incorporation of early stopping in stepped-wedge cluster randomised trial designs could reduce the expected sample size under the null and alternative hypotheses by up to 31% and 22%, respectively, with no cost to the trial's type-I and type-II error rates. The use of restricted error maximum likelihood estimation was found to be more important than quantile substitution for controlling the type-I error rate. CONCLUSION The addition of interim analyses into stepped-wedge cluster randomised trials could help guard against time-consuming trials conducted on poor performing treatments and also help expedite the implementation of efficacious treatments. In future, trialists should consider incorporating early stopping of some kind into stepped-wedge cluster randomised trials according to the needs of the particular trial.
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Affiliation(s)
- Michael J Grayling
- MRC Biostatistics Unit Hub for Trials Methodology Research, Cambridge Institute of Public Health, Cambridge, UK
| | - James MS Wason
- MRC Biostatistics Unit Hub for Trials Methodology Research, Cambridge Institute of Public Health, Cambridge, UK
| | - Adrian P Mander
- MRC Biostatistics Unit Hub for Trials Methodology Research, Cambridge Institute of Public Health, Cambridge, UK
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