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Landi A, Heg D, Frigoli E, Tonino PAL, Vranckx P, Pourbaix S, Chevalier B, Iñiguez A, Pinar E, Lesiak M, Kala P, Donahue M, Windecker S, Roffi M, Smits PC, Valgimigli M. Consecutive or selectively included high bleeding risk patients in the MASTER DAPT screening log and trial. Eur J Intern Med 2024; 126:89-94. [PMID: 38704291 DOI: 10.1016/j.ejim.2024.04.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Revised: 04/10/2024] [Accepted: 04/22/2024] [Indexed: 05/06/2024]
Abstract
AIMS Screening logs have the potential to appraise the actual prevalence and distribution of predefined patient subsets, avoiding selection biases, which are inevitably and potentially present in randomised trials and real-world registries, respectively. We aimed to assess the prevalence of high bleeding risk (HBR) characteristics in the real world and the external validity of the MASTER DAPT trial. METHODS AND RESULTS All consecutive patients who underwent percutaneous coronary intervention (PCI) for at least two consecutive weeks across 65 sites participating in the trial were entered into a screening log. Of 2,847 consecutive patients, 1,098 (38.6 %) were HBR and 109 (9.9 %) consented for trial participation. PRECISE-DAPT score ≥ 25 was the most frequent HBR feature, followed by advanced age, use of oral anticoagulation (OAC) and anaemia. Compared with consecutive HBR patients, consenting patients were older (≥ 75 years: 69 % versus 62 %, absolute standardized difference [SD] 0.16), more frequently male (78 % versus 71 %, absolute SD 0.18), had higher use of OAC (38 % versus 20 %, absolute SD 0.39), treatment with steroids or nonsteroidal anti-inflammatory drugs (10 % versus 5 %, SD 0.16), and prior cerebrovascular events (10 % versus 6 %, absolute SD 0.18) but lower PRECISE DAPT score ≥ 25 (54 % versus 66 %, absolute SD 0.24). CONCLUSIONS The HBR criteria distribution differed between consecutive versus selectively included HBR patients, suggesting the existence of selection biases in the trial population.
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Affiliation(s)
- Antonio Landi
- Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale (EOC), Università della Svizzera Italiana, CH-6900, Lugano, Switzerland; The Faculty of Biomedical Sciences, University of Italian Switzerland (USI), CH-6900 Lugano, Switzerland
| | - Dik Heg
- The Department of Clinical Research (DCR), University of Bern, Bern, Switzerland
| | - Enrico Frigoli
- Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale (EOC), Università della Svizzera Italiana, CH-6900, Lugano, Switzerland
| | - Pim A L Tonino
- The Department of Cardiology, Catharina Hospital, Eindhoven, the Netherlands
| | - Pascal Vranckx
- The Faculty of Medicine and Life Sciences, Hasselt University, Hasselt, Belgium
| | | | - Bernard Chevalier
- the Ramsay Générale de Santé, Interventional Cardiology Department, Institut Cardiovasculaire Paris Sud, Massy, France
| | | | | | - Maciej Lesiak
- The First Department of Cardiology, University of Medical Sciences, Poznan, Poland
| | - Petr Kala
- The University Hospital Brno, Medical Faculty of Masaryk University Brno, Czech Republic
| | - Michael Donahue
- The Interventional Cardiology Unit, Policlinico Casilino, Rome, Italy
| | - Stephan Windecker
- The Department of Cardiology, Bern University Hospital, Bern, Switzerland
| | - Marco Roffi
- The Division of Cardiology, Geneva University Hospitals, Geneva Switzerland
| | - Pieter C Smits
- The Department of Cardiology, Maasstad Hospital, Rotterdam, the Netherlands
| | - Marco Valgimigli
- Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale (EOC), Università della Svizzera Italiana, CH-6900, Lugano, Switzerland; The Faculty of Biomedical Sciences, University of Italian Switzerland (USI), CH-6900 Lugano, Switzerland; The University of Bern, Bern, Switzerland.
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Innes K, Ahmed I, Hudson J, Hernández R, Gillies K, Bruce R, Bell V, Avenell A, Blazeby J, Brazzelli M, Cotton S, Croal B, Forrest M, MacLennan G, Murchie P, Wileman S, Ramsay C. Laparoscopic cholecystectomy versus conservative management for adults with uncomplicated symptomatic gallstones: the C-GALL RCT. Health Technol Assess 2024; 28:1-151. [PMID: 38943314 PMCID: PMC11228691 DOI: 10.3310/mnby3104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/01/2024] Open
Abstract
Background Gallstone disease is a common gastrointestinal disorder in industrialised societies. The prevalence of gallstones in the adult population is estimated to be approximately 10-15%, and around 80% remain asymptomatic. At present, cholecystectomy is the default option for people with symptomatic gallstone disease. Objectives To assess the clinical and cost-effectiveness of observation/conservative management compared with laparoscopic cholecystectomy for preventing recurrent symptoms and complications in adults presenting with uncomplicated symptomatic gallstones in secondary care. Design Parallel group, multicentre patient randomised superiority pragmatic trial with up to 24 months follow-up and embedded qualitative research. Within-trial cost-utility and 10-year Markov model analyses. Development of a core outcome set for uncomplicated symptomatic gallstone disease. Setting Secondary care elective settings. Participants Adults with symptomatic uncomplicated gallstone disease referred to a secondary care setting were considered for inclusion. Interventions Participants were randomised 1: 1 at clinic to receive either laparoscopic cholecystectomy or observation/conservative management. Main outcome measures The primary outcome was quality of life measured by area under the curve over 18 months using the Short Form-36 bodily pain domain. Secondary outcomes included the Otago gallstones' condition-specific questionnaire, Short Form-36 domains (excluding bodily pain), area under the curve over 24 months for Short Form-36 bodily pain domain, persistent symptoms, complications and need for further treatment. No outcomes were blinded to allocation. Results Between August 2016 and November 2019, 434 participants were randomised (217 in each group) from 20 United Kingdom centres. By 24 months, 64 (29.5%) in the observation/conservative management group and 153 (70.5%) in the laparoscopic cholecystectomy group had received surgery, median time to surgery of 9.0 months (interquartile range, 5.6-15.0) and 4.7 months (interquartile range 2.6-7.9), respectively. At 18 months, the mean Short Form-36 norm-based bodily pain score was 49.4 (standard deviation 11.7) in the observation/conservative management group and 50.4 (standard deviation 11.6) in the laparoscopic cholecystectomy group. The mean area under the curve over 18 months was 46.8 for both groups with no difference: mean difference -0.0, 95% confidence interval (-1.7 to 1.7); p-value 0.996; n = 203 observation/conservative, n = 205 cholecystectomy. There was no evidence of differences in quality of life, complications or need for further treatment at up to 24 months follow-up. Condition-specific quality of life at 24 months favoured cholecystectomy: mean difference 9.0, 95% confidence interval (4.1 to 14.0), p < 0.001 with a similar pattern for the persistent symptoms score. Within-trial cost-utility analysis found observation/conservative management over 24 months was less costly than cholecystectomy (mean difference -£1033). A non-significant quality-adjusted life-year difference of -0.019 favouring cholecystectomy resulted in an incremental cost-effectiveness ratio of £55,235. The Markov model continued to favour observation/conservative management, but some scenarios reversed the findings due to uncertainties in longer-term quality of life. The core outcome set included 11 critically important outcomes from both patients and healthcare professionals. Conclusions The results suggested that in the short term (up to 24 months) observation/conservative management may be a cost-effective use of National Health Service resources in selected patients, but subsequent surgeries in the randomised groups and differences in quality of life beyond 24 months could reverse this finding. Future research should focus on longer-term follow-up data and identification of the cohort of patients that should be routinely offered surgery. Trial registration This trial is registered as ISRCTN55215960. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 14/192/71) and is published in full in Health Technology Assessment; Vol. 28, No. 26. See the NIHR Funding and Awards website for further award information.
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Affiliation(s)
- Karen Innes
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Irfan Ahmed
- Department of Surgery, NHS Grampian, Aberdeen, UK
| | - Jemma Hudson
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Rodolfo Hernández
- Health Economics Research Unit, University of Aberdeen, Aberdeen, UK
| | - Katie Gillies
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Rebecca Bruce
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Victoria Bell
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Alison Avenell
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Jane Blazeby
- Center for Surgical Research, NIHR Bristol and Western Biomedical Research Centre, University of Bristol, Bristol, UK
| | - Miriam Brazzelli
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Seonaidh Cotton
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | | | - Mark Forrest
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Graeme MacLennan
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Peter Murchie
- Academic Primary Care, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
| | - Samantha Wileman
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Craig Ramsay
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
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Chandra S, Prakash PKS, Samanta S, Chilukuri S. ClinicalGAN: powering patient monitoring in clinical trials with patient digital twins. Sci Rep 2024; 14:12236. [PMID: 38806536 PMCID: PMC11133486 DOI: 10.1038/s41598-024-62567-1] [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: 07/11/2023] [Accepted: 05/19/2024] [Indexed: 05/30/2024] Open
Abstract
Conducting clinical trials is becoming increasingly challenging lately due to spiraling costs, increased time to market, and high failure rates. Patient recruitment and retention is one of the key challenges that impact 90% of the trials directly. While a lot of attention has been given to optimizing patient recruitment, limited progress has been made towards developing comprehensive clinical trial monitoring systems to determine patients at risk and potentially improve patient retention through the right intervention at the right time. Earlier research in patient retention primarily focused on using deterministic frameworks to model the inherently stochastic patient journey process. Existing generative approaches to model temporal data such as TimeGAN or CRBM , face challenges and fail to address key requirements such as personalized generation, variable patient journey, and multi-variate time-series needed to model patient digital twin. In response to these challenges, current research proposes ClinicalGAN to enable patient level generation, effectively creating a patient's digital twin. ClinicalGAN provides capabilities for: (a) patient-level personalized generation by utilizing patient meta-data for conditional generation; (b) dynamic termination prediction to enable pro-active patient monitoring for improved patient retention; (c) multi-variate time-series training to incorporate relationship and dependencies among different tests measures captured during patient journey. The proposed solution is validated on two Alzheimer's clinical trial datasets and the results are benchmarked across multiple dimensions of generation quality. Empirical results demonstrate that the proposed ClinicalGAN outperforms the SOTA approach by 3-4 × on average across all the generation quality metrics. Furthermore, the proposed architecture is shown to outperform predictive methods at the task of drop-off prediction significantly (5-10% MAPE scores).
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Affiliation(s)
- Shantanu Chandra
- ZS, 2nd Floor, MFAR Manyta Tech park, Phase IV, Manayata Tech Park, Nagavara, Bengaluru, Karnataka, India.
| | - P K S Prakash
- ZS, 2nd Floor, MFAR Manyta Tech park, Phase IV, Manayata Tech Park, Nagavara, Bengaluru, Karnataka, India
| | - Subhrajit Samanta
- ZS, 2nd Floor, MFAR Manyta Tech park, Phase IV, Manayata Tech Park, Nagavara, Bengaluru, Karnataka, India
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Hasan N, Mehrotra K, Danzig CJ, Eichenbaum DA, Ewald A, Regillo C, Momenaei B, Sheth VS, Lally DR, Chhablani J. Screen Failures in Clinical Trials in Retina. Ophthalmol Retina 2024:S2468-6530(24)00263-X. [PMID: 38810882 DOI: 10.1016/j.oret.2024.05.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2024] [Revised: 05/16/2024] [Accepted: 05/21/2024] [Indexed: 05/31/2024]
Abstract
PURPOSE Disparities in clinical trials are a major problem because of significant underrepresentation of certain gender, racial, and ethnic groups. Several factors including stringent eligibility criteria and recruitment strategies hinder our understanding of retinal disease. Thus, we aimed to study the various reasons of screen failures and specific patient and study characteristics among screen failures. DESIGN This is a cross-sectional retrospective study. METHODS Screening data of 87 trials from 6 centers were analyzed. Study characteristics (disease studied, phase of trial, and route of drug administration) and patient demographics (age, gender, race, ethnicity, and employment status) were compared among different causes of screen failures. Screen failures were broadly classified into 6 categories: exclusion because of vision-based criteria, exclusion because of imaging findings, exclusion because of other factors, patient-related criteria, physician-related criteria, and miscellaneous. Descriptive statistics, Pearson chi-square test, and analysis of variance were used for statistical analysis. MAIN OUTCOME MEASURES Prevalence of various reasons for screen failures in multiple trials and its trend among different study and patient characteristics. RESULTS Among 87 trials and 962 patients, 465 (48.2%) patients were successfully randomized and 497 (51.8%) patients were classified as screen failures. The trials were conducted for various retinal diseases. Mean age was 76.50 ±10.45 years and 59.4% were females. Predominantly White patients (93.4%) and unemployed/retired patients (66.6%) were screened. Of the 497 screen failures, most were because of patients not meeting inclusion criteria of imaging findings (n = 221 [44.5%]) followed by inclusion of vision-based criteria (n = 73 [14.7%]), exclusion because of other factors (n = 75 [15.1%]), patient-related (n = 34 [6.8%]), physician-related (n = 28 [5.6%]), and miscellaneous reasons (n = 39 [7.8%]). Reason for screen failure was not available for 27 (5.4%) patients. A higher proportion of patients screened for surgical trials (15%) declined to participate in the study compared with noninvasive trials involving topical drugs and photobiomodulation (0%) (P = 0.02). CONCLUSIONS Patients not meeting the imaging and vision-cased criteria were the most common reasons for screen failures. White patients and unemployed patients predominantly participated in clinical trials. Patients are more inclined to continue participation in noninvasive clinical trials compared with surgical trials. Better recruitment strategies and careful consideration of study criteria can aid in decreasing the rate of screen failures.
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Affiliation(s)
- Nasiq Hasan
- Department of Ophthalmology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Kunaal Mehrotra
- Department of Ophthalmology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | | | - David A Eichenbaum
- Retina Vitreous Associates of Florida, Saint Petersburg, Florida; Department of Ophthalmology, Morsani College of Medicine at the University of South Florida, Tampa, Florida
| | - Amy Ewald
- Retina Vitreous Associates of Florida, Saint Petersburg, Florida; Department of Ophthalmology, Morsani College of Medicine at the University of South Florida, Tampa, Florida
| | - Carl Regillo
- Retina Service, Wills Eye Hospital, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Bita Momenaei
- Retina Service, Wills Eye Hospital, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Veeral S Sheth
- University Retina and Macula Associates PC, Oak Forest, Illinois
| | - David R Lally
- New England Retina Associates, Springfield, Massachusetts
| | - Jay Chhablani
- Department of Ophthalmology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.
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Schroeck FR, Grubb R, MacKenzie TA, Ould Ismail AA, Jensen L, Tsongalis GJ, Lotan Y. Clinical Trial Protocol for "Replace Cysto": Replacing Invasive Cystoscopy with Urine Testing for Non-muscle-invasive Bladder Cancer Surveillance-A Multicenter, Randomized, Phase 2 Healthcare Delivery Trial Comparing Quality of Life During Cancer Surveillance with Xpert Bladder Cancer Monitor or Bladder EpiCheck Urine Testing Versus Frequent Cystoscopy. EUR UROL SUPPL 2024; 63:19-30. [PMID: 38558761 PMCID: PMC10981003 DOI: 10.1016/j.euros.2024.02.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/28/2024] [Indexed: 04/04/2024] Open
Abstract
"Replace Cysto" is a multisite randomized phase 2 trial including 240 participants with low-grade intermediate-risk non-muscle-invasive bladder cancer, in which participants will be randomized 1:1:1 to one of two urine marker-based approaches alternating a urine marker test (Xpert Bladder Cancer Monitor or Bladder EpiCheck) with cystoscopy or to frequent scheduled cystoscopy. The primary objective is to determine whether urinary quality of life after surveillance is significantly improved in the urine marker arms. The primary outcome will be the patient-reported urinary quality of life domain score of the validated QLQ-NMIBC24 instrument, measured 1-3 d after surveillance. Exploratory outcomes include discomfort after surveillance, the number of invasive procedures that participants undergo per 1000 person years, complications from these procedures per 1000 person years, nonurinary quality of life, acceptability of surveillance, and bladder cancer recurrence and progression. Comparators include surveillance using (1) the Xpert Bladder Cancer Monitor test, (2) the Bladder EpiCheck urinary marker, or (3) frequent cystoscopy alone. After a negative cystoscopy ≤4 mo following bladder tumor resection, all the participants will undergo surveillance at 6, 12, 18, and 24 mo (with time zero defined as the date of the most recent bladder tumor resection). In the urine marker arms, surveillance at 6 and 18 mo will be performed with the marker. Regardless of the arm, participants will undergo cystoscopy at 12 and 24 mo. End of study for each participant will be their 24-mo cystoscopy. Overall trial duration is estimated at 5 yr from when the study opens to enrollment until completion of data analyses. The trial is registered at clinicaltrials.gov (NCT05796375).
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Affiliation(s)
- Florian R. Schroeck
- White River Junction VA Medical Center, White River Junction, VT, USA
- Section of Urology, Dartmouth Hitchcock Medical Center, Lebanon, NH, USA
- Norris Cotton Cancer Center, Dartmouth Hitchcock Medical Center, Lebanon, NH, USA
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth College, Lebanon, NH, USA
| | - Robert Grubb
- Department of Urology, Medical University of South Carolina, Charleston, SC, USA
| | - Todd A. MacKenzie
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth College, Lebanon, NH, USA
- Department of Biomedical Data Science, Dartmouth College, Lebanon, NH, USA
| | | | - Laura Jensen
- White River Junction VA Medical Center, White River Junction, VT, USA
| | - Gregory J. Tsongalis
- Department of Pathology and Laboratory Medicine, Dartmouth Hitchcock Medical Center, Lebanon, NH, USA
| | - Yair Lotan
- Department of Urology, University of Texas Southwestern, Dallas, TX, USA
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Wade J, Farrar N, Realpe AX, Donovan JL, Forsyth L, Harkness KA, Hutchinson PJ, Kitchen N, Lewis SC, Loan JJ, Stephen J, Al-Shahi Salman R. Addressing barriers and identifying facilitators to support informed consent and recruitment in the Cavernous malformations A Randomised Effectiveness (CARE) pilot phase trial: insights from the integrated QuinteT recruitment intervention (QRI). EClinicalMedicine 2024; 71:102557. [PMID: 38813441 PMCID: PMC11133797 DOI: 10.1016/j.eclinm.2024.102557] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Revised: 03/04/2024] [Accepted: 03/05/2024] [Indexed: 05/31/2024] Open
Abstract
Background It was anticipated that recruitment to the Cavernous malformations: A Randomised Effectiveness (CARE) pilot randomised trial would be challenging. The trial compared medical management and surgery (neurosurgical resection or stereotactic radiosurgery) with medical management alone, for people with symptomatic cerebral cavernous malformation (ISRCTN41647111). Previous trials comparing surgical and medical management for intracranial vascular malformations failed to recruit to target. A QuinteT Recruitment Intervention was integrated during trial accrual, September 2021-April 2023 inclusive, to improve informed consent and recruitment. Methods The QuinteT Recruitment Intervention combined iterative collection and analysis of quantitative data (28 trial site screening logs recording numbers/proportions screened, eligible, approached and randomised) and qualitative data (79 audio-recorded recruitment discussions, 19 interviews with healthcare professionals, 11 interviews with patients, 2 investigator workshops, and observations of study meetings, all subject to thematic, content or conversation analysis). We triangulated quantitative and qualitative data to identify barriers and facilitators to recruitment and how and why these arose. Working with the chief investigators and trial management group, we addressed barriers and facilitators with corresponding actions to improve informed consent and recruitment. Findings Barriers identified included how usual care practices made equipoise challenging, multi-disciplinary teams sometimes overrode recruiter equipoise and logistical issues rendered symptomatic cavernoma diagnosis and assessment for stereotactic radiosurgery challenging. Facilitators identified included the preparedness of some neurosurgeons' to offer surgery to people otherwise offered medical management alone, multi-disciplinary team equipoise, and effective information provision presenting participation as a solution to equipoise regarding management. Actions, before and during recruitment, to improve inclusivity of site screening, approach and effectiveness of information provision resulted in 72 participants recruited following a 5-month extension, exceeding the target of 60 participants. Interpretation QuinteT Recruitment Intervention insights revealed barriers and facilitators, enabling identification of remedial actions. Recruitment to a definitive trial would benefit from further training/support to encourage clinicians to be comfortable approaching patients to whom medical management is usually offered, and broadening the pool of neurosurgeons and multi-disciplinary team members prepared to offer surgery, particularly stereotactic radiosurgery. Funding National Institute for Health and Care Research.
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Affiliation(s)
- Julia Wade
- Bristol Medical School, University of Bristol, 39 Whatley Road, Bristol, BS8 2PS, UK
| | - Nicola Farrar
- Bristol Medical School, University of Bristol, 39 Whatley Road, Bristol, BS8 2PS, UK
| | - Alba X. Realpe
- Bristol Medical School, University of Bristol, 39 Whatley Road, Bristol, BS8 2PS, UK
| | - Jenny L. Donovan
- Bristol Medical School, University of Bristol, 39 Whatley Road, Bristol, BS8 2PS, UK
| | - Laura Forsyth
- Edinburgh Clinical Trials Unit, Usher Institute, University of Edinburgh, NINE Edinburgh BioQuarter, 9 Little France Road, EH16 4UK, UK
| | - Kirsty A. Harkness
- Department of Neurology, The Royal Hallamshire Hospital, Glossop Road, Sheffield, S10 2JF, UK
| | - Peter J.A. Hutchinson
- Department of Clinical Neurosciences, University of Cambridge, Cambridge Biomedical Campus, CB3 0QQ, UK
| | - Neil Kitchen
- Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, University College London Hospitals NHS Foundation Trust, Queen's Square, London, WC1N 3BG, UK
| | - Steff C. Lewis
- Edinburgh Clinical Trials Unit, Usher Institute, University of Edinburgh, NINE Edinburgh BioQuarter, 9 Little France Road, EH16 4UK, UK
| | - James J.M. Loan
- Centre for Clinical Brain Sciences, University of Edinburgh, 49 Little France Crescent, Edinburgh, EH16 4SB, UK
| | - Jacqueline Stephen
- Edinburgh Clinical Trials Unit, Usher Institute, University of Edinburgh, NINE Edinburgh BioQuarter, 9 Little France Road, EH16 4UK, UK
| | - Rustam Al-Shahi Salman
- Centre for Clinical Brain Sciences, University of Edinburgh, 49 Little France Crescent, Edinburgh, EH16 4SB, UK
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Popplewell MA, Meecham L, Davies HOB, Kelly L, Ellis T, Bate GR, Moakes CA, Bradbury AW. Editor's Choice - Bypass versus Angioplasty for Severe Ischaemia of the Leg (BASIL) Prospective Cohort Study and the Generalisability of the BASIL-2 Randomised Controlled Trial. Eur J Vasc Endovasc Surg 2024; 67:146-152. [PMID: 37778500 DOI: 10.1016/j.ejvs.2023.09.041] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Revised: 09/14/2023] [Accepted: 09/24/2023] [Indexed: 10/03/2023]
Abstract
OBJECTIVE The Bypass versus Angioplasty in Severe Ischaemia of the Leg-2 (BASIL-2) randomised controlled trial has shown that, for patients with chronic limb threatening ischaemia (CLTI) who require an infrapopliteal (IP) revascularisation a vein bypass (VB) first revascularisation strategy led to a 35% increased risk of major amputation or death when compared with a best endovascular treatment (BET) first revascularisation strategy. The study aims are to place the BASIL-2 trial within the context of the CLTI patient population as a whole and to investigate the generalisability of the BASIL-2 outcome data. METHODS This was an observational, single centre prospective cohort study. Between 24 June 2014 and 31 July 2018, the BASIL Prospective Cohort Study (PCS) was performed which used BASIL-2 trial case record forms to document the characteristics, initial and subsequent management, and outcomes of 471 consecutive CLTI patients admitted to an academic vascular centre. Ethical approval was obtained, and all patients provided fully informed written consent. Follow up data were censored on 14 December 2022. RESULTS Of the 238 patients who required an infrainguinal revascularisation, 75 (32%) had either IP bypass (39 patients) or IP BET (36 patients) outside BASIL-2. Seventeen patients were initially randomised to BASIL-2. A further three patients who did not have an IP revascularisation as their initial management were later randomised in BASIL-2. Therefore, 95/471 (20%) of patients had IP revascularisation (16% outside, 4% inside BASIL-2). Differences in amputation free survival, overall survival, and limb salvage between IP bypass and IP BET performed outside BASIL-2 were not subject to hypothesis testing due to the small sample size. Reasons for non-randomisation into the trial were numerous, but often due to anatomical and technical considerations. CONCLUSION CLTI patients who required an IP revascularisation procedure and were subsequently randomised into BASIL-2 accounted for a small subset of the CLTI population as a whole. For a wide range of patient, limb, anatomical and operational reasons, most patients in this cohort were deemed unsuitable for randomisation in BASIL-2. The results of BASIL-2 should be interpreted in this context.
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Affiliation(s)
| | | | | | - Lisa Kelly
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Tracy Ellis
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Gareth R Bate
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Catherine A Moakes
- Birmingham Clinical Trial Unit, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Andrew W Bradbury
- Institute of Cardiovascular Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
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Littlewood C, Moffatt M, Beckhelling J, Davis D, Burden A, Pitt L, Lalande S, Maddocks C, Stephens G, Tunnicliffe H, Pawson J, Lloyd J, Manca A, Wade J, Foster NE. Physiotherapist-led exercise versus usual care (waiting-list) control for patients awaiting rotator cuff repair surgery: A pilot randomised controlled trial (POWER). Musculoskelet Sci Pract 2023; 68:102874. [PMID: 37926065 DOI: 10.1016/j.msksp.2023.102874] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 10/16/2023] [Accepted: 10/19/2023] [Indexed: 11/07/2023]
Abstract
BACKGROUND Once a decision to undergo rotator cuff repair surgery is made, patients are placed on the waiting list. It can take weeks or months to receive surgery. There has been a call to move from waiting lists to 'preparation' lists to better prepare patients for surgery and to ensure it remains an appropriate treatment option for them. OBJECTIVE To evaluate the feasibility, as measured by recruitment rates, treatment fidelity and follow-up rates, of a future multi-centre randomised controlled trial to compare the clinical and cost-effectiveness of undertaking a physiotherapist-led exercise programme while waiting for surgery versus usual care (waiting-list control). DESIGN Two-arm, multi-centre pilot randomised controlled trial with feasibility objectives in six NHS hospitals in England. METHOD Adults (n = 76) awaiting rotator cuff repair surgery were recruited and randomly allocated to a programme of physiotherapist-led exercise (n = 38) or usual care control (n = 38). RESULTS Of 302 eligible patients, 76 (25%) were randomised. Of 38 participants randomised to physiotherapist-led exercise, 28 (74%) received the exercise programme as intended. 51/76 (67%) Shoulder Pain and Disability Index questionnaires were returned at 6-months. Of 76 participants, 32 had not received surgery after 6-months (42%). Of those 32, 20 were allocated to physiotherapist-led exercise; 12 to usual care control. CONCLUSIONS A future multi-centre randomised controlled trial is feasible but would require planning for variable recruitment rates between sites, measures to improve treatment fidelity and opportunity for surgical exit, and optimisation of follow-up. A fully powered, randomised controlled trial is now needed to robustly inform clinical decision-making.
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Affiliation(s)
- Chris Littlewood
- Faculty of Health, Social Care & Medicine, Edge Hill University, St Helen's Road, Ormskirk, Lancashire, L39 4QP, UK.
| | - Maria Moffatt
- Faculty of Health, Social Care & Medicine, Edge Hill University, St Helen's Road, Ormskirk, Lancashire, L39 4QP, UK
| | - Jacqueline Beckhelling
- Derby Clinical Trials Support Unit, University Hospitals Derby & Burton NHS Foundation Trust, Royal Derby Hospital, Derby, DE22 3NE, UK
| | - Daniel Davis
- Derby Clinical Trials Support Unit, University Hospitals Derby & Burton NHS Foundation Trust, Royal Derby Hospital, Derby, DE22 3NE, UK
| | | | - Lisa Pitt
- University Hospitals Derby & Burton NHS Foundation Trust, Royal Derby Hospital, Derby, DE22 3NE, UK
| | - Stacey Lalande
- Airedale NHS Foundation Trust, Airedale General Hospital, Skipton Rd, Steeton, Keighley, BD20 6TD, UK
| | - Catrin Maddocks
- Robert Jones & Agnes Hunt Orthopaedic Hospital, Gobowen, Oswestry, SY10 7AG, UK
| | - Gareth Stephens
- The Royal Orthopaedic Hospital NHS Foundation Trust, Bristol Road South, Northfield, Birmingham, B31 2AP, UK
| | - Helen Tunnicliffe
- University Hospitals of Leicester NHS Trust, Leicester Royal Infirmary, Infirmary Square, LE1 5WW, UK
| | - Jessica Pawson
- Barts Health NHS Trust, Royal London Hospital, Whitechapel, E1 1FR, UK
| | - James Lloyd
- Barts Health NHS Trust, Royal London Hospital, Whitechapel, E1 1FR, UK
| | - Andrea Manca
- Centre for Health Economics, University of York, York, YO10 5DD, UK
| | - Julia Wade
- Population Health Sciences, Bristol Medical School, University of Bristol, 39 Whatley Road, Bristol, BS8 2PS, UK
| | - Nadine E Foster
- STARS Education and Research Alliance, Surgical, Treatment and Rehabilitation Service (STARS), The University of Queensland and Metro North Health, Queensland, QLD 4029, Australia
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9
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Lewis A, Clout M, Benger J, Braude P, Turner N, Gagg J, Gendall E, Holloway S, Ingram J, Kandiyali R, Maskell N, Shipway D, Smith JE, Taylor J, Darweish-Medniuk A, Carlton E. The Randomised Evaluation of early topical Lidocaine patches In Elderly patients admitted to hospital with rib Fractures (RELIEF): feasibility trial protocol. NIHR OPEN RESEARCH 2023; 3:38. [PMID: 37881461 PMCID: PMC10593328 DOI: 10.3310/nihropenres.13438.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Accepted: 09/22/2023] [Indexed: 10/27/2023]
Abstract
Background Topical lidocaine patches, applied over rib fractures, have been suggested as a non-invasive method of local anaesthetic delivery to improve respiratory function, reduce opioid consumption and consequently reduce pulmonary complications. Older patients may gain most benefit from improved analgesic regimens yet lidocaine patches are untested as an early intervention in the Emergency Department (ED). The aim of this trial is to investigate uncertainties around trial design and conduct, to establish whether a definitive randomised trial of topical lidocaine patches in older patients with rib fractures is feasible. Methods RELIEF is an open label, multicentre, parallel group, individually randomised, feasibility randomised controlled trial with economic scoping and nested qualitative study. Patients aged ≥ 65 years presenting to the ED with traumatic rib fracture(s) requiring admission will be randomised 1:1 to lidocaine patches (intervention), in addition to standard clinical management, or standard clinical management alone. Lidocaine patches will be applied immediately after diagnosis in ED and continued daily for 72 hours or until discharge. Feasibility outcomes will focus on recruitment, adherence and follow-up data with a total sample size of 100. Clinical outcomes, such as 30-day pulmonary complications, and resource use will be collected to understand feasibility of data collection. Qualitative interviews will explore details of the trial design, trial acceptability and recruitment processes. An evaluation of the feasibility of measuring health economics outcomes data will be completed. Discussion Interventions to improve outcomes in elderly patients with rib fractures are urgently required. This feasibility trial will test a novel early intervention which has the potential of fulfilling this unmet need. The Randomised Evaluation of early topical Lidocaine patches In Elderly patients admitted to hospital with rib Fractures (RELIEF) feasibility trial will determine whether a definitive trial is feasible. ISRCTN Registration ISRCTN14813929 (22/04/2021).
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Affiliation(s)
- Amanda Lewis
- Bristol Trials Centre (BTC), Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, England, UK
| | - Madeleine Clout
- Bristol Trials Centre (BTC), Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, England, UK
| | - Jonathan Benger
- Emergency Care, Faculty of Health and Applied Sciences, University of the West of England, Bristol, England, UK
| | - Philip Braude
- Department of Elderly Care Medicine, Southmead Hospital, North Bristol NHS Trust, Bristol, England, UK
| | - Nicholas Turner
- Bristol Trials Centre (BTC), Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, England, UK
| | - James Gagg
- Department of Emergency Medicine, Musgrove Park Hospital, Taunton, England, UK
| | - Emma Gendall
- Research and Innovation, Southmead Hospital, North Bristol NHS Trust, Bristol, England, UK
| | - Simon Holloway
- Pharmacy Clinical Trials and Research, Southmead Hospital, North Bristol NHS Trust, Bristol, England, UK
| | - Jenny Ingram
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, England, UK
| | - Rebecca Kandiyali
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Warwick, England, UK
| | - Nick Maskell
- Academic Respiratory Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, England, UK
| | - David Shipway
- Department of Elderly Care Medicine, Southmead Hospital, North Bristol NHS Trust, Bristol, England, UK
| | - Jason E Smith
- Emergency Department, Derriford Hospital, University Hospitals Plymouth NHS Trust, Plymouth, UK
| | - Jodi Taylor
- Bristol Trials Centre (BTC), Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, England, UK
| | - Alia Darweish-Medniuk
- Department of Anaesthesia and Pain Medicine, Southmead Hospital, North Bristol NHS Trust, Bristol, England, UK
| | - Edward Carlton
- Department of Emergency Medicine, Southmead Hospital, North Bristol NHS Trust, Bristol, England, UK
- Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, England, UK
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10
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Koutoukidis DA, Jebb SA, Foster C, Wheatstone P, Horne A, Hill TM, Taylor A, Realpe A, Achana F, Buczacki SJA. CARE: Protocol of a randomised trial evaluating the feasibility of preoperative intentional weight loss to support postoperative recovery in patients with excess weight and colorectal cancer. Colorectal Dis 2023; 25:1910-1920. [PMID: 37525408 DOI: 10.1111/codi.16687] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Revised: 06/12/2023] [Accepted: 06/19/2023] [Indexed: 08/02/2023]
Abstract
AIM Excess weight increases the risk of morbidity following colorectal cancer surgery. Weight loss may improve morbidity, but it is uncertain whether patients can follow an intensive weight loss intervention while waiting for surgery and there are concerns about muscle mass loss. The aim of this trial is to assess the feasibility of intentional weight loss in this setting and determine progression to a definitive trial. METHODS CARE is a prospectively registered, multicentre, feasibility, parallel, randomised controlled trial with embedded evaluation and optimisation of the recruitment process. Participants with excess weight awaiting curative colorectal resection for cancer are randomised 1:1 to care as usual or a low-energy nutritionally-replete total diet replacement programme with weekly remote behavioural support by a dietitian. Progression criteria will be based on the recruitment, engagement, adherence, and retention rates. Data will be collected on the 30-day postoperative morbidity, the typical primary outcome of prehabilitation trials. Secondary outcomes will include, among others, length of hospital stay, health-related quality of life, and body composition. Qualitative interviews will be used to understand patients' experiences of and attitudes towards trial participation and intervention engagement and adherence. CONCLUSION CARE will evaluate the feasibility of intensive intentional weight loss as prehabilitation before colorectal cancer surgery. The results will determine the planning of a definitive trial.
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Affiliation(s)
- Dimitrios A Koutoukidis
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
- NIHR Oxford Biomedical Research Centre, Oxford, UK
| | - Susan A Jebb
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
- NIHR Oxford Biomedical Research Centre, Oxford, UK
| | - Claire Foster
- Centre for Psychosocial Research in Cancer: CentRIC+ in Health Sciences, University of Southampton, Southampton, UK
| | | | - Alison Horne
- Surgical Intervention Trials Unit, Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - T Martyn Hill
- Surgical Intervention Trials Unit, Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - Amy Taylor
- Surgical Intervention Trials Unit, Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - Alba Realpe
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- NIHR Bristol Biomedical Research Centre, Bristol, UK
| | - Felix Achana
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Simon J A Buczacki
- NIHR Oxford Biomedical Research Centre, Oxford, UK
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
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11
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Loan JJM, Bacon A, van Beijnum J, Bhatt P, Bjornson A, Broomes N, Bullen A, Bulters D, Cahill J, Chavredakis E, Colombo F, Danciut M, Digpal R, Edwards RJ, Ferguson L, Forsyth L, Fouyas I, Ganesan V, Grover P, Gurusinghe N, Hall PS, Harkness K, Harris LS, Hayton T, Helmy A, Holsgrove D, Hutchinson PJ, Israni A, Kinsella E, Lewis S, Majeed S, Mallucci C, Mukerji N, Nair R, Neilson AR, Papadopoulos MC, Radatz M, Rossdeutsch A, Raza-Knight S, Stephen J, Stoddart A, Teo M, Turner C, Wade J, Walsh D, White D, White P, Wildman J, Wroe Wright O, Uff C, Ushewokunze S, Vindlacheruvu R, Kitchen N, Al-Shahi Salman R. Feasibility of comparing medical management and surgery (with neurosurgery or stereotactic radiosurgery) with medical management alone in people with symptomatic brain cavernoma - protocol for the Cavernomas: A Randomised Effectiveness (CARE) pilot trial. BMJ Open 2023; 13:e075187. [PMID: 37558454 PMCID: PMC10414059 DOI: 10.1136/bmjopen-2023-075187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Accepted: 06/29/2023] [Indexed: 08/11/2023] Open
Abstract
INTRODUCTION The top research priority for cavernoma, identified by a James Lind Alliance Priority setting partnership was 'Does treatment (with neurosurgery or stereotactic radiosurgery) or no treatment improve outcome for people diagnosed with a cavernoma?' This pilot randomised controlled trial (RCT) aims to determine the feasibility of answering this question in a main phase RCT. METHODS AND ANALYSIS We will perform a pilot phase, parallel group, pragmatic RCT involving approximately 60 children or adults with mental capacity, resident in the UK or Ireland, with an unresected symptomatic brain cavernoma. Participants will be randomised by web-based randomisation 1:1 to treatment with medical management and with surgery (neurosurgery or stereotactic radiosurgery) versus medical management alone, stratified by prerandomisation preference for type of surgery. In addition to 13 feasibility outcomes, the primary clinical outcome is symptomatic intracranial haemorrhage or new persistent/progressive focal neurological deficit measured at 6 monthly intervals. An integrated QuinteT Recruitment Intervention (QRI) evaluates screening logs, audio recordings of recruitment discussions, and interviews with recruiters and patients/parents/carers to identify and address barriers to participation. A Patient Advisory Group has codesigned the study and will oversee its progress. ETHICS AND DISSEMINATION This study was approved by the Yorkshire and The Humber-Leeds East Research Ethics Committee (21/YH/0046). We will submit manuscripts to peer-reviewed journals, describing the findings of the QRI and the Cavernomas: A Randomised Evaluation (CARE) pilot trial. We will present at national specialty meetings. We will disseminate a plain English summary of the findings of the CARE pilot trial to participants and public audiences with input from, and acknowledgement of, the Patient Advisory Group. TRIAL REGISTRATION NUMBER ISRCTN41647111.
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Affiliation(s)
- James J M Loan
- Centre for Clinical Brain Sciences, The University of Edinburgh, Edinburgh, UK
- Department of Clinical Neurosciences, Royal Infirmary of Edinburgh, Edinburgh, UK
| | | | | | | | | | - Nicole Broomes
- University Hospital Southampton NHS Foundation Trust Wessex Neurological Centre, Southampton, UK
| | - Alistair Bullen
- Edinburgh Clinical Trials Unit, The University of Edinburgh Usher Institute of Population Health Sciences and Informatics, Edinburgh, UK
| | - Diederik Bulters
- University Hospital Southampton NHS Foundation Trust Wessex Neurological Centre, Southampton, UK
| | - Julian Cahill
- National Centre for Stereotactic Radiosurgery, Royal Hallamshire Hospital, Sheffield, UK
| | | | | | | | - Ronneil Digpal
- University Hospital Southampton NHS Foundation Trust Wessex Neurological Centre, Southampton, UK
| | | | | | - Laura Forsyth
- Edinburgh Clinical Trials Unit, The University of Edinburgh Usher Institute of Population Health Sciences and Informatics, Edinburgh, UK
| | - Ioannis Fouyas
- Department of Clinical Neurosciences, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Vijeya Ganesan
- Developmental Neurosciences Department, Great Ormond Street Hospital for Children, London, UK
| | - Patrick Grover
- The National Hospital for Neurology & Neurosurgery, London, UK
| | | | - Peter S Hall
- Institute of Genetics and Cancer, University of Edinburgh, Edinburgh, UK
| | | | | | - Tom Hayton
- Queen Elizabeth Hospital, Birmingham, UK
| | - Adel Helmy
- Clinical Neurosciences, University of Cambridge, Cambridge, UK
- Addenbrooke's Hospital, Cambridge, UK
| | - Daniel Holsgrove
- Centre for Clinical Neurosciences, Salford Royal Hospital Manchester, Salford, UK
| | - Peter J Hutchinson
- Clinical Neurosciences, University of Cambridge, Cambridge, UK
- Addenbrooke's Hospital, Cambridge, UK
| | - Anil Israni
- Alder Hey Children's Hospital, Liverpool, UK
| | - Elaine Kinsella
- Edinburgh Clinical Trials Unit, The University of Edinburgh Usher Institute of Population Health Sciences and Informatics, Edinburgh, UK
| | - Steff Lewis
- Edinburgh Clinical Trials Unit, The University of Edinburgh Usher Institute of Population Health Sciences and Informatics, Edinburgh, UK
| | | | | | | | | | - Aileen R Neilson
- Edinburgh Clinical Trials Unit, The University of Edinburgh Usher Institute of Population Health Sciences and Informatics, Edinburgh, UK
| | | | - Matthias Radatz
- National Centre for Stereotactic Radiosurgery, Royal Hallamshire Hospital, Sheffield, UK
| | | | | | - Jacqueline Stephen
- Edinburgh Clinical Trials Unit, The University of Edinburgh Usher Institute of Population Health Sciences and Informatics, Edinburgh, UK
| | - Andrew Stoddart
- Edinburgh Clinical Trials Unit, The University of Edinburgh Usher Institute of Population Health Sciences and Informatics, Edinburgh, UK
| | - Mario Teo
- Department of Neurosurgery, Southmead Hospital, Bristol, UK
| | - Carole Turner
- Clinical Neurosciences, University of Cambridge, Cambridge, UK
- Addenbrooke's Hospital, Cambridge, UK
| | - Julia Wade
- Population Health Science, Bristol Medical School, University of Bristol, Bristol, UK
| | - Daniel Walsh
- King's College Hospital, London, UK
- Institute of Psychiatry Psychology & Neuroscience, King's College London, London, UK
| | | | - Phil White
- Newcastle University Translational and Clinical Research Institute, Newcastle upon Tyne, UK
| | - Jack Wildman
- Department of Neurosurgery, Southmead Hospital, Bristol, UK
| | | | | | | | | | - Neil Kitchen
- The National Hospital for Neurology & Neurosurgery, London, UK
| | - Rustam Al-Shahi Salman
- Centre for Clinical Brain Sciences, The University of Edinburgh, Edinburgh, UK
- Department of Clinical Neurosciences, Royal Infirmary of Edinburgh, Edinburgh, UK
- Edinburgh Clinical Trials Unit, The University of Edinburgh Usher Institute of Population Health Sciences and Informatics, Edinburgh, UK
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12
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Saadoun S, Grassner L, Belci M, Cook J, Knight R, Davies L, Asif H, Visagan R, Gallagher MJ, Thomé C, Hutchinson PJ, Zoumprouli A, Wade J, Farrar N, Papadopoulos MC. Duroplasty for injured cervical spinal cord with uncontrolled swelling: protocol of the DISCUS randomized controlled trial. Trials 2023; 24:497. [PMID: 37550727 PMCID: PMC10405486 DOI: 10.1186/s13063-023-07454-2] [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: 04/26/2023] [Accepted: 06/13/2023] [Indexed: 08/09/2023] Open
Abstract
BACKGROUND Cervical traumatic spinal cord injury is a devastating condition. Current management (bony decompression) may be inadequate as after acute severe TSCI, the swollen spinal cord may become compressed against the surrounding tough membrane, the dura. DISCUS will test the hypothesis that, after acute, severe traumatic cervical spinal cord injury, the addition of dural decompression to bony decompression improves muscle strength in the limbs at 6 months, compared with bony decompression alone. METHODS This is a prospective, phase III, multicenter, randomized controlled superiority trial. We aim to recruit 222 adults with acute, severe, traumatic cervical spinal cord injury with an American Spinal Injury Association Impairment Scale grade A, B, or C who will be randomized 1:1 to undergo bony decompression alone or bony decompression with duroplasty. Patients and outcome assessors are blinded to study arm. The primary outcome is change in the motor score at 6 months vs. admission; secondary outcomes assess function (grasp, walking, urinary + anal sphincters), quality of life, complications, need for further surgery, and mortality, at 6 months and 12 months from randomization. A subgroup of at least 50 patients (25/arm) also has observational monitoring from the injury site using a pressure probe (intraspinal pressure, spinal cord perfusion pressure) and/or microdialysis catheter (cord metabolism: tissue glucose, lactate, pyruvate, lactate to pyruvate ratio, glutamate, glycerol; cord inflammation: tissue chemokines/cytokines). Patients are recruited from the UK and internationally, with UK recruitment supported by an integrated QuinteT recruitment intervention to optimize recruitment and informed consent processes. Estimated study duration is 72 months (6 months set-up, 48 months recruitment, 12 months to complete follow-up, 6 months data analysis and reporting results). DISCUSSION We anticipate that the addition of duroplasty to standard of care will improve muscle strength; this has benefits for patients and carers, as well as substantial gains for health services and society including economic implications. If the addition of duroplasty to standard treatment is beneficial, it is anticipated that duroplasty will become standard of care. TRIAL REGISTRATION IRAS: 292031 (England, Wales, Northern Ireland) - Registration date: 24 May 2021, 296518 (Scotland), ISRCTN: 25573423 (Registration date: 2 June 2021); ClinicalTrials.gov number : NCT04936620 (Registration date: 21 June 2021); NIHR CRN 48627 (Registration date: 24 May 2021).
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Affiliation(s)
- Samira Saadoun
- Academic Neurosurgery, Molecular and Clinical Sciences, St. George's, University of London, London, UK.
| | - Lukas Grassner
- Department of Neurosurgery, Christian Doppler Clinic, Paracelsus Medical University, Salzburg, Austria
- Institute of Molecular Regenerative Medicine, Spinal Cord Injury and Tissue Regeneration Center Salzburg, Paracelsus Medical University, Salzburg, Austria
| | - Maurizio Belci
- National Spinal Injury Centre, Stoke Mandeville Hospital, Buckinghamshire Healthcare NHS Trust, Aylesbury, Bucks, UK
| | - Jonathan Cook
- Oxford Clinical Trials Research Unit, Botnar Research Centre, University of Oxford, Oxford, UK
| | - Ruth Knight
- Liverpool Clinical Trials Centre, University of Liverpool, Liverpool, UK
| | - Lucy Davies
- Surgical Intervention Trials Unit, University of Oxford, Oxford, UK
| | - Hasan Asif
- Academic Neurosurgery, Molecular and Clinical Sciences, St. George's, University of London, London, UK
| | - Ravindran Visagan
- Academic Neurosurgery, Molecular and Clinical Sciences, St. George's, University of London, London, UK
| | - Mathew J Gallagher
- Academic Neurosurgery, Molecular and Clinical Sciences, St. George's, University of London, London, UK
| | - Claudius Thomé
- Department of Neurosurgery, Innsbruck Medical University, Innsbruck, Austria
| | | | - Argyro Zoumprouli
- Neuro-Intensive Care Unit, Atkinson Morley Wing, St. George's Hospital NHS Foundation Trust, London, UK
| | - Julia Wade
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Nicola Farrar
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Marios C Papadopoulos
- Academic Neurosurgery, Molecular and Clinical Sciences, St. George's, University of London, London, UK
- Neurosurgery, Atkinson Morley Wing, St. George's Hospital NHS Foundation Trust, London, UK
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13
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Airody A, Baseler HA, Seymour J, Allgar V, Mukherjee R, Downey L, Dhar-Munshi S, Mahmood S, Balaskas K, Empeslidis T, Hanson RLW, Dorey T, Szczerbicki T, Sivaprasad S, Gale RP. The MATE trial: a multicentre, mixed-methodology, pilot, randomised controlled trial in neovascular age-related macular degeneration. Pilot Feasibility Stud 2023; 9:63. [PMID: 37081576 PMCID: PMC10116669 DOI: 10.1186/s40814-023-01288-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Accepted: 03/30/2023] [Indexed: 04/22/2023] Open
Abstract
BACKGROUND/OBJECTIVES In healthcare research investigating complex interventions, gaps in understanding of processes can be filled by using qualitative methods alongside a quantitative approach. The aim of this mixed-methods pilot trial was to provide feasibility evidence comparing two treatment regimens for neovascular age-related macular degeneration (nAMD) to inform a future large-scale randomised controlled trial (RCT). SUBJECTS/METHODS Forty-four treatment-naïve nAMD patients were followed over 24 months and randomised to one of two treatment regimens: standard care (SC) or treat and extend (T&E). The primary objective evaluated feasibility of the MATE trial via evaluations of screening logs for recruitment rates, nonparticipation and screen fails, whilst qualitative in-depth interviews with key study staff evaluated the recruitment phase and running of the trial. The secondary objective assessed changes in visual acuity and central retinal thickness (CRT) between the two treatment arms. RESULTS The overall recruitment rate was 3.07 participants per month with a 40.8% non-participation rate, 18.51% screen-failure rate and 15% withdrawal/non-completion rate. Key themes in the recruitment phase included human factors, protocol-related issues, recruitment processes and challenges. Both treatment regimens showed a trend towards a visual acuity gain at month 12 which was not maintained at month 24, whilst CRT reduced similarly in both regimens over the same time period. These were achieved with one less treatment following a T&E regimen. CONCLUSION This mixed-methodology, pilot RCT achieved its pre-defined recruitment, nonparticipation and screen failure rates, thus deeming it a success. With some minor protocol amendments, progression to a large-scale RCT will be achievable.
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Affiliation(s)
- Archana Airody
- Academic Unit of Ophthalmology, York & Scarborough Teaching Hospitals NHS Foundation Trust, York, YO31 8HE, UK.
| | - Heidi A Baseler
- Department of Psychology, University of York, York, UK
- Hull York Medical School, University of York, York, UK
| | - Julie Seymour
- Hull York Medical School, University of Hull, Hull, UK
| | - Victoria Allgar
- Peninsula Medical School, University of Plymouth, Plymouth, UK
| | | | | | - Sushma Dhar-Munshi
- Kings Mill Hospital, Sherwood Forest Hospitals NHS Foundation Trust, Sutton-in-Ashfield, UK
| | | | - Konstantinos Balaskas
- NIHR Moorfields Biomedical Research Centre, Moorfields Eye Hospital NHS Foundation Trust, London, UK
| | - Theo Empeslidis
- Leicester Royal Infirmary, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Rachel L W Hanson
- Academic Unit of Ophthalmology, York & Scarborough Teaching Hospitals NHS Foundation Trust, York, YO31 8HE, UK
| | - Tracey Dorey
- Research and Development, York & Scarborough Teaching Hospitals NHS Foundation Trust, York, UK
| | - Tom Szczerbicki
- Research and Development, York & Scarborough Teaching Hospitals NHS Foundation Trust, York, UK
| | - Sobha Sivaprasad
- NIHR Moorfields Biomedical Research Centre, Moorfields Eye Hospital NHS Foundation Trust, London, UK
| | - Richard P Gale
- Academic Unit of Ophthalmology, York & Scarborough Teaching Hospitals NHS Foundation Trust, York, YO31 8HE, UK
- Hull York Medical School, University of York, York, UK
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14
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Lim E, Harris RA, McKeon HE, Batchelor TJ, Dunning J, Shackcloth M, Anikin V, Naidu B, Belcher E, Loubani M, Zamvar V, Dabner L, Brush T, Stokes EA, Wordsworth S, Paramasivan S, Realpe A, Elliott D, Blazeby J, Rogers CA. Impact of video-assisted thoracoscopic lobectomy versus open lobectomy for lung cancer on recovery assessed using self-reported physical function: VIOLET RCT. Health Technol Assess 2022; 26:1-162. [PMID: 36524582 PMCID: PMC9791462 DOI: 10.3310/thbq1793] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Lung cancer is the leading cause of cancer death. Surgery remains the main method of managing early-stage disease. Minimal-access video-assisted thoracoscopic surgery results in less tissue trauma than open surgery; however, it is not known if it improves patient outcomes. OBJECTIVE To compare the clinical effectiveness and cost-effectiveness of video-assisted thoracoscopic surgery lobectomy with open surgery for the treatment of lung cancer. DESIGN, SETTING AND PARTICIPANTS A multicentre, superiority, parallel-group, randomised controlled trial with blinding of participants (until hospital discharge) and outcome assessors conducted in nine NHS hospitals. Adults referred for lung resection for known or suspected lung cancer, with disease suitable for both surgeries, were eligible. Participants were followed up for 1 year. INTERVENTIONS Participants were randomised 1 : 1 to video-assisted thoracoscopic surgery lobectomy or open surgery. Video-assisted thoracoscopic surgery used one to four keyhole incisions without rib spreading. Open surgery used a single incision with rib spreading, with or without rib resection. MAIN OUTCOME MEASURES The primary outcome was self-reported physical function (using the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire Core 30) at 5 weeks. Secondary outcomes included upstaging to pathologic node stage 2 disease, time from surgery to hospital discharge, pain in the first 2 days, prolonged pain requiring analgesia at > 5 weeks, adverse health events, uptake of adjuvant treatment, overall and disease-free survival, quality of life (Quality of Life Questionnaire Core 30, Quality of Life Questionnaire Lung Cancer 13 and EQ-5D) at 2 and 5 weeks and 3, 6 and 12 months, and cost-effectiveness. RESULTS A total of 503 patients were randomised between July 2015 and February 2019 (video-assisted thoracoscopic surgery, n = 247; open surgery, n = 256). One participant withdrew before surgery. The mean age of patients was 69 years; 249 (49.5%) patients were men and 242 (48.1%) did not have a confirmed diagnosis. Lobectomy was performed in 453 of 502 (90.2%) participants and complete resection was achieved in 429 of 439 (97.7%) participants. Quality of Life Questionnaire Core 30 physical function was better in the video-assisted thoracoscopic surgery group than in the open-surgery group at 5 weeks (video-assisted thoracoscopic surgery, n = 247; open surgery, n = 255; mean difference 4.65, 95% confidence interval 1.69 to 7.61; p = 0.0089). Upstaging from clinical node stage 0 to pathologic node stage 1 and from clinical node stage 0 or 1 to pathologic node stage 2 was similar (p ≥ 0.50). Pain scores were similar on day 1, but lower in the video-assisted thoracoscopic surgery group on day 2 (mean difference -0.54, 95% confidence interval -0.99 to -0.09; p = 0.018). Analgesic consumption was 10% lower (95% CI -20% to 1%) and the median hospital stay was less (4 vs. 5 days, hazard ratio 1.34, 95% confidence interval 1.09, 1.65; p = 0.006) in the video-assisted thoracoscopic surgery group than in the open-surgery group. Prolonged pain was also less (relative risk 0.82, 95% confidence interval 0.72 to 0.94; p = 0.003). Time to uptake of adjuvant treatment, overall survival and progression-free survival were similar (p ≥ 0.28). Fewer participants in the video-assisted thoracoscopic surgery group than in the open-surgery group experienced complications before and after discharge from hospital (relative risk 0.74, 95% confidence interval 0.66 to 0.84; p < 0.001 and relative risk 0.81, 95% confidence interval 0.66 to 1.00; p = 0.053, respectively). Quality of life to 1 year was better across several domains in the video-assisted thoracoscopic surgery group than in the open-surgery group. The probability that video-assisted thoracoscopic surgery is cost-effective at a willingness-to-pay threshold of £20,000 per quality-adjusted life-year is 1. LIMITATIONS Ethnic minorities were under-represented compared with the UK population (< 5%), but the cohort reflected the lung cancer population. CONCLUSIONS Video-assisted thoracoscopic surgery lobectomy was associated with less pain, fewer complications and better quality of life without any compromise to oncologic outcome. Use of video-assisted thoracoscopic surgery is highly likely to be cost-effective for the NHS. FUTURE WORK Evaluation of the efficacy of video-assisted thoracoscopic surgery with robotic assistance, which is being offered in many hospitals. TRIAL REGISTRATION This trial is registered as ISRCTN13472721. FUNDING This project was funded by the National Institute for Health and Care Research ( NIHR ) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 48. See the NIHR Journals Library website for further project information.
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15
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Pérez-Muñoz A, Horn TL, Graber J, Chowdhury SMR, Bursac Z, Krukowski RA. Recruitment strategies for a post cessation weight management trial: A comparison of strategy cost-effectiveness and sample diversity. Contemp Clin Trials Commun 2022; 30:101037. [DOI: 10.1016/j.conctc.2022.101037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Revised: 09/28/2022] [Accepted: 11/07/2022] [Indexed: 11/09/2022] Open
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16
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Da JLW, Merker VL, Jordan JT, Ly KI, Muzikansky A, Parsons M, Wolters PL, Xu L, Styren S, Brown MT, Plotkin SR. Design of a randomized, placebo-controlled, phase 2 study evaluating the safety and efficacy of tanezumab for treatment of schwannomatosis-related pain. Contemp Clin Trials 2022; 121:106900. [PMID: 36038003 DOI: 10.1016/j.cct.2022.106900] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Revised: 08/22/2022] [Accepted: 08/23/2022] [Indexed: 01/27/2023]
Abstract
BACKGROUND Schwannomatosis (SWN) is a rare tumor suppressor syndrome that predisposes affected individuals to develop multiple schwannomas and, less often, meningiomas. The most common symptom is chronic, severe pain. No medications are broadly effective in treating SWN-associated pain. The clinical trial described in this manuscript is a phase 2, randomized, double-blind, placebo-controlled study investigating the safety and efficacy of tanezumab - a humanized monoclonal antibody that inhibits nerve growth factor - for treatment of SWN-related pain. As the first therapeutic trial for SWN-related pain, it also aims to evaluate trial endpoints, understand recruitment patterns, and improve clinical trial design in this rare disease. AIMS The primary objective of this trial is to assess the analgesic efficacy of subcutaneous tanezumab 10 mg in subjects with SWN who continue pre-existing pain therapy (excluding non-steroidal anti-inflammatory drugs). The secondary objective is to assess safety in this population. Exploratory objectives include assessment of pain features, quality of life, and predictive biomarkers. METHODS The study is comprised of four periods (pre-treatment, double-blind treatment, single-arm treatment, safety follow-up) across 10 months with a delayed-start trial design to allow all participants to receive tanezumab. Forty-six participants will be enrolled and randomized 1:1 to receive either tanezumab or placebo subcutaneously in the double-blind treatment period; all participants receive tanezumab during the single-arm treatment period. CONCLUSIONS This study is the first therapeutic trial for SWN patients and targets a biological driver of SWN-related pain. It aims to establish a model for future pain studies in SWN and other rare diseases. CLINICAL TRIAL REGISTRATION NCT04163419 on ClinicalTrials.gov.
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Affiliation(s)
- Jennifer L W Da
- Department of Neurology and Cancer Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Vanessa L Merker
- Department of Neurology and Cancer Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Justin T Jordan
- Department of Neurology and Cancer Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - K Ina Ly
- Department of Neurology and Cancer Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Alona Muzikansky
- MGH Biostatistics Center, Massachusetts General Hospital, Boston, MA, USA
| | - Michael Parsons
- Department of Neurology and Cancer Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Pamela L Wolters
- Pediatric Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Lei Xu
- Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | | | | | - Scott R Plotkin
- Department of Neurology and Cancer Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
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17
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Clark L, Fitzgerald B, Noble S, MacNeill S, Paramasivan S, Cotterill N, Hashim H, Jha S, Toozs-Hobson P, Greenwell T, Thiruchelvam N, Agur W, White A, Garner V, Cobos-Arrivabene M, Clement C, Cochrane M, Liu Y, Lewis AL, Taylor J, Lane JA, Drake MJ, Pope C. Proper understanding of recurrent stress urinary incontinence treatment in women (PURSUIT): a randomised controlled trial of endoscopic and surgical treatment. Trials 2022; 23:628. [PMID: 35922823 PMCID: PMC9347071 DOI: 10.1186/s13063-022-06546-9] [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: 06/09/2022] [Accepted: 07/13/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Women with stress urinary incontinence (SUI) experience urine leakage with physical activity. Currently, the interventional treatments for SUI are surgical, or endoscopic bulking injection(s). However, these procedures are not always successful, and symptoms can persist or come back after treatment, categorised as recurrent SUI. There are longstanding symptoms and distress associated with a failed primary treatment, and currently, there is no consensus on how best to treat women with recurrent, or persistent, SUI. METHODS A two-arm trial, set in at least 20 National Health Service (NHS) urology and urogynaecology referral units in the UK, randomising 250 adult women with recurrent or persistent SUI 1:1 to receive either an endoscopic intervention (endoscopic bulking injections) or a standard NHS surgical intervention, currently colposuspension, autologous fascial sling or artificial urinary sphincter. The aim of the trial is to determine whether surgical treatment is superior to endoscopic bulking injections in terms of symptom severity at 1 year after randomisation. This primary outcome will be measured using the patient-reported International Consultation on Incontinence Questionnaire - Urinary Incontinence - Short Form (ICIQ-UI-SF). Secondary outcomes include assessment of longer-term clinical impact, improvement of symptoms, safety, operative assessments, sexual function, cost-effectiveness and an evaluation of patients' and clinicians' views and experiences of the interventions. DISCUSSION There is a lack of high-quality, randomised, scientific evidence for which treatment is best for women presenting with recurrent SUI. The PURSUIT study will benefit healthcare professionals and patients and provide robust evidence to guide further treatment and improve symptoms and quality of life for women with this condition. TRIAL REGISTRATION International Standard Randomised Controlled Trials Number (ISRCTN) registry ISRCTN12201059. Registered on 09 January 2020.
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Affiliation(s)
- L Clark
- Department of Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - B Fitzgerald
- Department of Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - S Noble
- Department of Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - S MacNeill
- Department of Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - S Paramasivan
- Department of Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - N Cotterill
- Bristol Urological Institute, Southmead Hospital, North Bristol NHS Trust, Bristol, UK
| | - H Hashim
- Bristol Urological Institute, Southmead Hospital, North Bristol NHS Trust, Bristol, UK
| | - S Jha
- Department of Urogynaecology, Sheffield Teaching Hospitals NHS Foundation Trust, Jessop Wing, Tree Root Walk, Sheffield, UK
| | - P Toozs-Hobson
- Department of Urogynaecology, Birmingham Women's & Children's Hospital NHS Foundation Trust, Birmingham, UK
| | - T Greenwell
- Department of Urology, University College London Hospital, London, UK
| | - N Thiruchelvam
- Department of Urology, Cambridge University Hospitals NHS Trust, Cambridge, UK
| | - W Agur
- Department of Obstetrics and Gynaecology, NHS Ayrshire and Arran, University Hospital Crosshouse, Kilmarnock, UK
| | - A White
- Patient and Public Involvement (PPI) Representative, Bristol, UK
| | - V Garner
- Bristol Urological Institute, Southmead Hospital, North Bristol NHS Trust, Bristol, UK
| | - M Cobos-Arrivabene
- Bristol Urological Institute, Southmead Hospital, North Bristol NHS Trust, Bristol, UK
| | - C Clement
- Bristol Trials Centre (BTC), University of Bristol, Bristol, UK
| | - M Cochrane
- Department of Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Y Liu
- Department of Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - A L Lewis
- Department of Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK.,Bristol Trials Centre (BTC), University of Bristol, Bristol, UK
| | - J Taylor
- Department of Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK.,Bristol Trials Centre (BTC), University of Bristol, Bristol, UK
| | - J A Lane
- Department of Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK.,Bristol Trials Centre (BTC), University of Bristol, Bristol, UK
| | - M J Drake
- Bristol Urological Institute, Southmead Hospital, North Bristol NHS Trust, Bristol, UK. .,Department of Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK.
| | - C Pope
- Department of Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK.,Bristol Trials Centre (BTC), University of Bristol, Bristol, UK
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18
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Sooriakumaran P, Wilson C, Rombach I, Hassanali N, Aning J, D Lamb A, Cathcart P, Eden C, Ahmad I, Rajan P, Sridhar A, Bryant RJ, Elhage O, Cook J, Leung H, Soomro N, Kelly J, Nathan S, Donovan JL, Hamdy FC. Feasibility and safety of radical prostatectomy for oligo-metastatic prostate cancer: the Testing Radical prostatectomy in men with prostate cancer and oligo-Metastases to the bone (TRoMbone) trial. BJU Int 2022; 130:43-53. [PMID: 34878715 DOI: 10.1111/bju.15669] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To test the feasibility of randomisation to radical prostatectomy (RP) plus pelvic lymphadenectomy in addition to standard-of-care (SOC) systemic therapy in men with newly diagnosed oligo-metastatic prostate cancer. PATIENTS AND METHODS A prospective, randomised, non-blinded, feasibility clinical trial with an embedded QuinteT Recruitment Intervention (QRI) to optimise recruitment was conducted in nine nationwide tertiary care centres undertaking high-volume robotic surgery. We aimed to randomise 50 men with synchronous oligo-metastatic prostate cancer within an 18-month recruitment period to SOC systemic therapy vs SOC plus RP (intervention arm). The main outcome measures were: ability to randomise patients, optimised by a QRI; EuroQoL five Dimensions five Levels (EQ-5D-5L) questionnaires to capture quality-of-life (QoL) data at baseline and 3 months post-randomisation; routine clinicopathological assessment to capture adverse events and prostate-specific antigen in both arms, plus standard perioperative parameters in the surgical arm. RESULTS A total of 51 men were randomised within 14 months (one was subsequently deemed ineligible), with 60-83% accrual rate in centres that recruited at least two patients. All patients completed the trial follow-up; one patient in the intervention arm subsequently did not undergo the surgical intervention and one in the SOC arm refused all therapies. The QRI positively impacted recruitment. QoL data showed similarly high functioning in both study arms. Surgery for men with oligo-metastatic prostate cancer was found to be safe and had similar impact on early functional outcomes as surgery for standard indication. CONCLUSION It is feasible to randomise men with synchronous oligo-metastatic prostate cancer to a surgical intervention in addition to standard systemic therapies. While surgery appeared safe with no substantial impact on QoL in this feasibility study, a large randomised controlled trial is now warranted to examine treatment effectiveness of this additional component in the multimodality management of oligo-metastatic prostate cancer.
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Affiliation(s)
- Prasanna Sooriakumaran
- Department of Uro-oncology, University College London Hospitals NHS Foundation Trust, London, UK
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - Caroline Wilson
- Department of Population Health Sciences, University of Bristol, Bristol, UK
| | - Ines Rombach
- Centre for Statistics in Medicine, University of Oxford, Oxford, UK
| | - Neelam Hassanali
- Oxford Clinical Trials Research Unit, University of Oxford, Oxford, UK
| | - Jonathan Aning
- The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle, UK
| | - Alastair D Lamb
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - Paul Cathcart
- Guy's and St Thomas' NHS Foundation Trust, London, UK
| | | | - Imran Ahmad
- The Queen Elizabeth University Hospital Glasgow, Glasgow, UK
| | - Prabhakar Rajan
- Department of Uro-oncology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Ashwin Sridhar
- Department of Uro-oncology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Richard J Bryant
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | | | - Jonathan Cook
- Centre for Statistics in Medicine, University of Oxford, Oxford, UK
| | - Hing Leung
- The Queen Elizabeth University Hospital Glasgow, Glasgow, UK
| | - Naeem Soomro
- The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle, UK
| | - John Kelly
- Department of Uro-oncology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Senthil Nathan
- Department of Uro-oncology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Jenny L Donovan
- Department of Population Health Sciences, University of Bristol, Bristol, UK
| | - Freddie C Hamdy
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
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19
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Rafee A, Riepenhausen S, Neuhaus P, Meidt A, Dugas M, Varghese J. ELaPro, a LOINC-mapped core dataset for top laboratory procedures of eligibility screening for clinical trials. BMC Med Res Methodol 2022; 22:141. [PMID: 35568796 PMCID: PMC9107639 DOI: 10.1186/s12874-022-01611-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Accepted: 04/20/2022] [Indexed: 12/21/2022] Open
Abstract
Background Screening for eligible patients continues to pose a great challenge for many clinical trials. This has led to a rapidly growing interest in standardizing computable representations of eligibility criteria (EC) in order to develop tools that leverage data from electronic health record (EHR) systems. Although laboratory procedures (LP) represent a common entity of EC that is readily available and retrievable from EHR systems, there is a lack of interoperable data models for this entity of EC. A public, specialized data model that utilizes international, widely-adopted terminology for LP, e.g. Logical Observation Identifiers Names and Codes (LOINC®), is much needed to support automated screening tools. Objective The aim of this study is to establish a core dataset for LP most frequently requested to recruit patients for clinical trials using LOINC terminology. Employing such a core dataset could enhance the interface between study feasibility platforms and EHR systems and significantly improve automatic patient recruitment. Methods We used a semi-automated approach to analyze 10,516 screening forms from the Medical Data Models (MDM) portal’s data repository that are pre-annotated with Unified Medical Language System (UMLS). An automated semantic analysis based on concept frequency is followed by an extensive manual expert review performed by physicians to analyze complex recruitment-relevant concepts not amenable to automatic approach. Results Based on analysis of 138,225 EC from 10,516 screening forms, 55 laboratory procedures represented 77.87% of all UMLS laboratory concept occurrences identified in the selected EC forms. We identified 26,413 unique UMLS concepts from 118 UMLS semantic types and covered the vast majority of Medical Subject Headings (MeSH) disease domains. Conclusions Only a small set of common LP covers the majority of laboratory concepts in screening EC forms which supports the feasibility of establishing a focused core dataset for LP. We present ELaPro, a novel, LOINC-mapped, core dataset for the most frequent 55 LP requested in screening for clinical trials. ELaPro is available in multiple machine-readable data formats like CSV, ODM and HL7 FHIR. The extensive manual curation of this large number of free-text EC as well as the combining of UMLS and LOINC terminologies distinguishes this specialized dataset from previous relevant datasets in the literature. Supplementary Information The online version contains supplementary material available at 10.1186/s12874-022-01611-y.
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Affiliation(s)
- Ahmed Rafee
- Institute of Medical Informatics, University of Münster, Münster, Germany. .,Department of Internal Medicine (D), University Hospital of Münster, Münster, Germany.
| | - Sarah Riepenhausen
- Institute of Medical Informatics, University of Münster, Münster, Germany
| | - Philipp Neuhaus
- Institute of Medical Informatics, University of Münster, Münster, Germany
| | - Alexandra Meidt
- Institute of Medical Informatics, University of Münster, Münster, Germany
| | - Martin Dugas
- Institute of Medical Informatics, Heidelberg University Hospital, Heidelberg, Germany
| | - Julian Varghese
- Institute of Medical Informatics, University of Münster, Münster, Germany.
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20
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Donovan JL, Jepson M, Rooshenas L, Paramasivan S, Mills N, Elliott D, Wade J, Reda D, Blazeby JM, Moghanaki D, Hwang ES, Davies L. Development of a new adapted QuinteT Recruitment Intervention (QRI-Two) for rapid application to RCTs underway with enrolment shortfalls—to identify previously hidden barriers and improve recruitment. Trials 2022; 23:258. [PMID: 35379301 PMCID: PMC8978173 DOI: 10.1186/s13063-022-06187-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 03/19/2022] [Indexed: 11/30/2022] Open
Abstract
Background Many randomised controlled trials (RCTs) struggle to recruit, despite valiant efforts. The QRI (QuinteT Recruitment Intervention) uses innovative research methods to optimise recruitment by revealing previously hidden barriers related to the perceptions and experiences of recruiters and patients, and targeting remedial actions. It was designed to be integrated with RCTs anticipating difficulties at the outset. A new version of the intervention (QRI-Two) was developed for RCTs already underway with enrolment shortfalls. Methods QRIs in 12 RCTs with enrolment shortfalls during 2007–2017 were reviewed to document which of the research methods used could be rapidly applied to successfully identify recruitment barriers. These methods were then included in the new streamlined QRI-Two intervention which was applied in 20 RCTs in the USA and Europe during 2018–2019. The feasibility of the QRI-Two was investigated, recruitment barriers and proposed remedial actions were documented, and the QRI-Two protocol was finalised. Results The review of QRIs from 2007 to 2017 showed that previously unrecognised recruitment barriers could be identified but data collection for the full QRI required time and resources usually unavailable to ongoing RCTs. The streamlined QRI-Two focussed on analysis of screening/accrual data and RCT documents (protocol, patient-information), with discussion of newly diagnosed barriers and potential remedial actions in a workshop with the RCT team. Four RCTs confirmed the feasibility of the rapid application of the QRI-Two. When the QRI-Two was applied to 14 RCTs underway with enrolment shortfalls, an array of previously unknown/underestimated recruitment barriers related to issues such as equipoise, intervention preferences, or study presentation was identified, with new insights into losses of eligible patients along the recruitment pathway. The QRI-Two workshop enabled discussion of the newly diagnosed barriers and potential remedial actions to improve recruitment in collaboration with the RCT team. As expected, the QRI-Two performed less well in six RCTs at the start-up stage before commencing enrolment. Conclusions The QRI-Two can be applied rapidly, diagnose previously unrecognised recruitment barriers, and suggest remedial actions in RCTs underway with enrolment shortfalls, providing opportunities for RCT teams to develop targeted actions to improve recruitment. The effectiveness of the QRI-Two in improving recruitment requires further evaluation. Supplementary Information The online version contains supplementary material available at 10.1186/s13063-022-06187-y.
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21
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The challenge of equipoise: qualitative interviews exploring the views of health professionals and women with multiple ipsilateral breast cancer on recruitment to a surgical randomised controlled feasibility trial. Pilot Feasibility Stud 2022; 8:46. [PMID: 35227311 PMCID: PMC8883693 DOI: 10.1186/s40814-022-01007-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Accepted: 02/17/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
A multicentre feasibility trial (MIAMI), comparing outcomes and quality of life of women with multiple ipsilateral breast cancer randomised to therapeutic mammoplasty or mastectomy, was conducted from September 2018 to March 2020. The MIAMI surgical trial aimed to investigate recruitment of sufficient numbers of women. Multidisciplinary teams at 10 breast care centres in the UK identified 190 with MIBC diagnosis; 20 were eligible for trial participation but after being approached only four patients were recruited. A nested qualitative study sought to understand the reasons for this lack of recruitment.
Methods
Interviews were conducted from November 2019 to September 2020 with 17 staff from eight hospital-based breast care centres that recruited and attempted to recruit to MIAMI; and seven patients from four centres, comprising all patients who were recruited to the trial and some who declined to take part. Interviews were audio-recorded, anonymised and analysed using thematic methods of building codes into themes and sub-themes using the process of constant comparison.
Results
Overarching themes of (1) influences on equipoise and recruitment and (2) effects of a lack of equipoise were generated. Within these themes, health professional themes described the barriers to recruitment as ‘the treatment landscape has changed’, ‘staff preferences and beliefs’ which influenced equipoise and patient advice; and how different the treatments were for patients. Patient themes of ‘altruism and timing of trial approach’, ‘influences from consultants and others’ and ‘diagnostic journey doubts’ all played a part in whether patients agreed to take part in the trial.
Conclusions
Barriers to recruiting to breast cancer surgical trials can be significant, especially where there are substantial differences between the treatments being offered and a lack of equipoise communicated by healthcare professionals to patients. Patients can become overwhelmed by numerous requests for participation in research trials and inappropriate timing of trial discussions. Alternative study designs to the gold standard randomised control trial for surgical interventions may be required to provide the high-quality evidence on which to base practice.
Trial registration
ISRCTN (ISRCTN17987569) registered on April 20, 2018, and ClinicalTrials.gov (NCT03514654).
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22
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Verschuur CVM, Donovan JL, de Bie RMA. Review of the recruitment process for a large investigator-initiated trial in early Parkinson’s disease. Trials 2022; 23:141. [PMID: 35164821 PMCID: PMC8842530 DOI: 10.1186/s13063-022-06052-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Accepted: 01/27/2022] [Indexed: 11/22/2022] Open
Abstract
Introduction Organizing and executing a large clinical trial is a complex process, and often recruitment targets are not met. We describe the organization of the Levodopa in the Early Parkinson’s disease (LEAP) trial and the results of an external assessment of the recruitment process. Methods Several strategies were used to ensure that recruitment for the trial was effective and efficient. We analyzed the patterns in referrals, inclusions, and non-inclusions to investigate whether there were bottlenecks in the referral and inclusion process. For the external assessment of the recruitment process, the QuinteT Recruitment Intervention (QRI-Two) was used retrospectively, focusing on finding possible issues impeding recruitment that are less easily recognized. Results Recruitment took 57 months, which was 27 months longer than initially expected. 6.8% of the estimated eligible patients in the Netherlands were included. The number of referrals differed widely between participating centers and regions in the Netherlands, with the region of the principal study center having the most referrals. Reasons of exclusion varied across regions, as in some regions more patients already started, wanted to start, or did not want to start with Parkinson medication compared to other regions. Discussion Executing a large, investigator-initiated clinical trial on a limited budget still remains possible by focusing on minimizing administrative and organizational procedures. Our study suggests that centers with closer institutional ties to a principal study center tend to have a higher referral rate. The review of the LEAP trial recruitment strategies and data using the QRI-Two suggested that the variations in referrals and reasons of non-inclusion could indicate the presence of issues related to clinical equipoise, patient eligibility, or study presentation. Integrating a recruitment intervention could have explored issues with study presentation and equipoise that might have increased recruitment efficiency. Trial registration ISRCTN ISRCTN30518857. The registration was initiated on 02/08/2011 and finalized on 25/08/2011. Recruitment started on 17/08/2011, after the initiation of public registration.
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23
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Bricca A, Swithenbank Z, Scott N, Treweek S, Johnston M, Black N, Hartmann-Boyce J, West R, Michie S, de Bruin M. Predictors of recruitment and retention in randomized controlled trials of behavioural smoking cessation interventions: a systematic review and meta-regression analysis. Addiction 2022; 117:299-311. [PMID: 34159677 DOI: 10.1111/add.15614] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 04/06/2021] [Accepted: 06/09/2021] [Indexed: 01/10/2023]
Abstract
AIM To investigate predictors of participant eligibility, recruitment and retention in behavioural randomized controlled trials (RCTs) for smoking cessation. METHOD Systematic review and pre-specified meta-regression analysis of behavioural RCTs for smoking cessation including adult (≥ 18-year-old) smokers. The pre-specified predictors were identified through a literature review and experts' consultation and included participant, trial and intervention characteristics and recruitment and retention strategies. Outcome measures included eligibility rates (proportion of people eligible for the trials), recruitment rates, retention rates and differential retention rates. RESULTS A total of 172 RCTs with 89 639 participants. Eligibility [median 57.6%; interquartile range (IQR) = 34.7-83.7], recruitment (median 66.4%; IQR = 42.7-85.2) and retention rates (median 80.5%; IQR = 68.5-89.5) varied considerably across studies. For eligibility rates, the recruitment strategy appeared not to be associated with eligibility rates. For recruitment rates, use of indirect recruitment strategies (e.g. public announcements) [odds ratio (OR) = 0.30, 95% confidence interval (CI) = 0.11-0.82] and self-help interventions (OR = 0.14, 95% CI = 0.03-0.67) were associated with lower recruitment rates. For retention rates, higher retention was seen if the sample had ongoing physical health condition/s (OR = 1.66, 95% CI = 1.04-2.63), whereas lower retention was seen amongst primarily female samples (OR = 0.83, 95% CI = 0.71-0.98) and those motivated to quit smoking (OR = 0.74, 95% CI = 0.55-0.99) when indirect recruitment methods were used (OR = 0.60, 95% CI = 0.38-0.97) and at longer follow-up assessments (OR = 0.83, 95% CI = 0.79-0.87). For differential retention, higher retention in the intervention group occurred when the intervention but not comparator group received financial incentives for smoking cessation (OR = 1.35, 95% CI = 1.02-1.77). CONCLUSIONS In randomized controlled trials of behavioural smoking cessation interventions, recruitment and retention rates appear to be higher for smoking cessation interventions that include a person-to-person rather than at-a-distance contact; male participants, smokers with chronic conditions, smokers not initially motivated to quit and shorter follow-up assessments seems to be associated with improved retention; financial incentive interventions improve retention in groups receiving them relative to comparison groups.
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Affiliation(s)
- Alessio Bricca
- Health Psychology Group, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, Scotland, UK
- Research Unit for Musculoskeletal Function and Physiotherapy, Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark
- The Research Unit PROgrez, Department of Physiotherapy and Occupational Therapy, Naestved-Slagelse-Ringsted Hospitals, Slagelse, Denmark, Slagelse, Denmark
| | - Zoe Swithenbank
- Health Psychology Group, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, Scotland, UK
- Public Health Institute, Liverpool John Moores University, Liverpool, UK
| | - Neil Scott
- Medical Statistics Team, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, Scotland, UK
| | - Shaun Treweek
- Health Services Research Unit, University of Aberdeen, Aberdeen, Scotland, UK
| | - Marie Johnston
- Health Psychology Group, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, Scotland, UK
| | - Nicola Black
- Health Psychology Group, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, Scotland, UK
- Technology Addiction Team, Brain and Mind Centre, University of Sydney, Sydney, Australia
| | - Jamie Hartmann-Boyce
- Nuffield Department of Primary Care Health Sciences and National Institute for Health Research Oxford Biomedical Research Centre, University of Oxford, Oxford, UK
| | - Robert West
- Health Behaviour Research Centre, Department of Epidemiology and Public Health, University College London, London, UK
| | - Susan Michie
- Centre for Behaviour Change, University College London, London, UK
| | - Marijn de Bruin
- Health Psychology Group, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, Scotland, UK
- Radboud Institute for Health Sciences, IQ Healthcare, Radboud University Medical Centre, Nijmegen, the Netherlands
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Kaye DK. Navigating ethical challenges of conducting randomized clinical trials on COVID-19. Philos Ethics Humanit Med 2022; 17:2. [PMID: 35086524 PMCID: PMC8794733 DOI: 10.1186/s13010-022-00115-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Accepted: 01/10/2022] [Indexed: 06/14/2023] Open
Abstract
BACKGROUND The contemporary frameworks for clinical research require informed consent for research participation that includes disclosure of material information, comprehension of disclosed information and voluntary consent to research participation. There is thus an urgent need to test, and an ethical imperative, to test, modify or refine medications or healthcare plans that could reduce patient morbidity, lower healthcare costs or strengthen healthcare systems. METHODS Conceptual review. DISCUSSION Although some allocation principles seem better than others, no single moral principle allocates interventions justly, necessitating combining the moral principles into multiprinciple allocation systems. The urgency notwithstanding, navigating ethical challenges related to conducting corona virus disease (COVID-19) clinical trials is mandatory, in order to safeguard the safety and welfare of research participants, ensure autonomy of participants, reduce possibilities for exploitation and ensure opportunities for research participation. The ethical challenges to can be categorized as challenges in allocation of resources for research; challenges of clinical equipoise in relation to the research questions; challenges of understanding disclosed information in potential participants; and challenges in obtaining informed consent. CONCLUSION To navigate these challenges, stakeholders need a delicate balance of moral principles during allocation of resources for research. Investigators need to apply information processing theories to aid decision-making about research participation or employ acceptable modifications to improve the informed consent process. Research and ethics committees should strengthen research review and oversight to ensure rigor, responsiveness and transparency.
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Affiliation(s)
- Dan Kabonge Kaye
- College of Health Sciences, Department of Obstetrics and Gynecology, Makerere University, P.O. Box 7072, Kampala, Uganda.
- Johns Hopkins Berman Institute of Bioethics, Deering Hall, 1809 Ashland Avenue, Baltimore, MD, 21205, USA.
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Roberts K, Mills N, Metcalfe C, Lane A, Clement C, Hollingworth W, Taylor J, Holcombe C, Skillman J, Fairhurst K, Whisker L, Cutress R, Thrush S, Fairbrother P, Potter S. Best-BRA (Is subpectoral or prepectoral implant placement best in immediate breast reconstruction?): a protocol for a pilot randomised controlled trial of subpectoral versus prepectoral immediate implant-based breast reconstruction in women following mastectomy. BMJ Open 2021; 11:e050886. [PMID: 34848516 PMCID: PMC8634330 DOI: 10.1136/bmjopen-2021-050886] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Implant-based breast reconstruction (IBBR) is the most commonly performed reconstructive procedure following mastectomy. IBBR techniques are evolving rapidly, with mesh-assisted subpectoral reconstruction becoming the standard of care and more recently, prepectoral techniques being introduced. These muscle-sparing techniques may reduce postoperative pain, avoid implant animation and improve cosmetic outcomes and have been widely adopted into practice. Although small observational studies have failed to demonstrate any differences in the clinical or patient-reported outcomes of prepectoral or subpectoral reconstruction, high-quality comparative evidence of clinical or cost-effectiveness is lacking. A well-designed, adequately powered randomised controlled trial (RCT) is needed to compare the techniques, but breast reconstruction RCTs are challenging. We, therefore, aim to undertake an external pilot RCT (Best-BRA) with an embedded QuinteT Recruitment Intervention (QRI) to determine the feasibility of undertaking a trial comparing prepectoral and subpectoral techniques. METHODS AND ANALYSIS Best-BRA is a pragmatic, two-arm, external pilot RCT with an embedded QRI and economic scoping for resource use. Women who require a mastectomy for either breast cancer or risk reduction, elect to have an IBBR and are considered suitable for both prepectoral and subpectoral reconstruction will be recruited and randomised 1:1 between the techniques.The QRI will be implemented in two phases: phase 1, in which sources of recruitment difficulties are rapidly investigated to inform the delivery in phase 2 of tailored interventions to optimise recruitment of patients.Primary outcomes will be (1) recruitment of patients, (2) adherence to trial allocation and (3) outcome completion rates. Outcomes will be reviewed at 12 months to determine the feasibility of a definitive trial. ETHICS AND DISSEMINATION The study has been approved by the National Health Service (NHS) Wales REC 6 (20/WA/0338). Findings will be presented at conferences and in peer-reviewed journals. TRIAL REGISTRATION NUMBER ISRCTN10081873.
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Affiliation(s)
- Kirsty Roberts
- Population Health Sciences, University of Bristol Medical School, Bristol, UK
| | - Nicola Mills
- Population Health Sciences, University of Bristol Medical School, Bristol, UK
| | - Chris Metcalfe
- Population Health Sciences, University of Bristol Medical School, Bristol, UK
| | - Athene Lane
- Population Health Sciences, University of Bristol Medical School, Bristol, UK
| | - Clare Clement
- Population Health Sciences, University of Bristol Medical School, Bristol, UK
| | | | - Jodi Taylor
- Population Health Sciences, University of Bristol Medical School, Bristol, UK
| | - Chris Holcombe
- Linda McCartney Centre, Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, UK
| | - Joanna Skillman
- Department of Plastic Surgery, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Katherine Fairhurst
- Population Health Sciences, University of Bristol Medical School, Bristol, UK
| | - Lisa Whisker
- Nottingham Breast Institute, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Ramsey Cutress
- Cancer Sciences Academic Unit, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Steven Thrush
- Breast Unit, Worcestershire Acute Hospitals NHS Trust, Worcester, Worcestershire, UK
| | | | - Shelley Potter
- Population Health Sciences, University of Bristol Medical School, Bristol, UK
- Bristol Breast Care Centre, North Bristol NHS Trust, Westbury on Trym, UK
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Cragg WJ, McMahon K, Oughton JB, Sigsworth R, Taylor C, Napp V. Clinical trial recruiters' experiences working with trial eligibility criteria: results of an exploratory, cross-sectional, online survey in the UK. Trials 2021; 22:736. [PMID: 34689802 PMCID: PMC8542410 DOI: 10.1186/s13063-021-05723-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Accepted: 10/13/2021] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Eligibility criteria are a fundamental element of clinical trial design, defining who can and who should not participate in a trial. Problems with the design or application of criteria are known to occur and pose risks to participants' safety and trial integrity, sometimes also negatively impacting on trial recruitment and generalisability. We conducted a short, exploratory survey to gather evidence on UK recruiters' experiences interpreting and applying eligibility criteria and their views on how criteria are communicated and developed. METHODS Our survey included topics informed by a wider programme of work at the Clinical Trials Research Unit, University of Leeds, on assuring eligibility criteria quality. Respondents were asked to answer based on all their trial experience, not only on experiences with our trials. The survey was disseminated to recruiters collaborating on trials run at our trials unit, and via other mailing lists and social media. The quantitative responses were descriptively analysed, with inductive analysis of free-text responses to identify themes. RESULTS A total of 823 eligible respondents participated. In total, 79% of respondents reported finding problems with eligibility criteria in some trials, and 9% in most trials. The main themes in the types of problems experienced were criteria clarity (67% of comments), feasibility (34%), and suitability (14%). In total, 27% of those reporting some level of problem said these problems had led to patients being incorrectly included in trials; 40% said they had led to incorrect exclusions. Most respondents (56%) reported accessing eligibility criteria mainly in the trial protocol. Most respondents (74%) supported the idea of recruiter review of eligibility criteria earlier in the protocol development process. CONCLUSIONS Our survey corroborates other evidence about the existence of suboptimal trial eligibility criteria. Problems with clarity were the most often reported, but the number of comments on feasibility and suitability suggest some recruiters feel eligibility criteria and associated assessments can hinder recruitment to trials. Our proposal for more recruiter involvement in protocol development has strong support and some potential benefits, but questions remain about how best to implement this. We invite other trialists to consider our other suggestions for how to assure quality in trial eligibility criteria.
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Affiliation(s)
- William J Cragg
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, LS2 9JT, UK.
| | - Kathryn McMahon
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, LS2 9JT, UK
| | - Jamie B Oughton
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, LS2 9JT, UK
| | - Rachel Sigsworth
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, LS2 9JT, UK
| | - Christopher Taylor
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, LS2 9JT, UK
| | - Vicky Napp
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, LS2 9JT, UK
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Al-Shahi Salman R, Keerie C, Stephen J, Lewis S, Norrie J, Dennis MS, Newby DE, Wardlaw JM, Lip GY, Parry-Jones A, White PM, Baigent C, Lasserson D, Oliver C, O'Mahony F, Amoils S, Bamford J, Armitage J, Emberson J, Rinkel GJ, Lowe G, Innes K, Adamczuk K, Dinsmore L, Drever J, Milne G, Walker A, Hutchison A, Williams C, Fraser R, Anderson R, Covil K, Stewart K, Rees J, Hall P, Bullen A, Stoddart A, Moullaali TJ, Palmer J, Sakka E, Perthen J, Lyttle N, Samarasekera N, MacRaild A, Burgess S, Teasdale J, Coakley M, Taylor P, Blair G, Whiteley W, Shenkin S, Clancy U, Macleod M, Sutherland R, Moullaali T, Barugh A, Lerpiniere C, Moreton F, Fethers N, Anjum T, Krishnan M, Slade P, Storton S, Williams M, Davies C, Connor L, Gainard G, Murphy C, Barber M, Esson D, Choulerton J, Shaw L, Lucas S, Hierons S, Avis J, Stone A, Gbadamoshi L, Costa T, Pearce L, Harkness K, Richards E, Howe J, Kamara C, Lindert R, Ali A, Rehan J, Chapman S, Edwards M, Bathula R, Cohen D, Devine J, Mpelembue M, Yesupatham P, Chhabra S, Adewetan G, Ballantine R, Brooks D, Smith G, Rogers G, Marsden S, Clark S, Wilkinson A, Brown E, Stephenson L, Nyo K, Abraham A, Pai Y, Shim G, Baliga V, Nair A, Robinson M, Hawksworth C, Greig J, Alam I, Nortcliffe T, Ramiz R, Shaw R, Parry-Jones A, Lee S, Marsden T, Perez J, Birleson E, Yadava R, Sangombe M, Stafford S, Hughes T, Knibbs L, Morse B, Schwarz S, Jelley B, White S, Richard B, Lawson H, Moseley S, Tayler M, Edwards M, Triscott C, Wallace R, Hall A, Dell A, Rashed K, Board S, Buckley C, Tanate A, Pitt-Kerby T, Beesley K, Perry J, Hellyer C, Guyler P, Menon N, Tysoe S, Prabakaran R, Cooper M, Rajapakse A, Wynter I, Smith S, Weir N, Boxall C, Yates H, Smith S, Crawford P, Marigold J, Smith F, Harvey J, Evans S, Baldwin L, Hammond S, Mudd P, Bowring A, Keenan S, Thorpe K, Haque M, Taaffe J, Temple N, Peachey T, Wells K, Haines F, Butterworth-Cowin N, Horne Z, Licenik R, Boughton H, England T, Hedstrom A, Menezes B, Davies R, Johnson V, Whittingham-Jones S, Werring D, Obarey S, Watchurst C, Ashton A, Feerick S, Francia N, Banaras A, Epstein D, Marinescu M, Williams A, Robinson A, Humphries F, Anwar I, Annamalai A, Crawford S, Collins V, Shepherd L, Siddle E, Penge J, Epstein D, Qureshi S, Krishnamurthy V, Papavasileiou V, Waugh D, Veraque E, Douglas N, Khan N, Ramachandran S, Sommerville P, Rudd A, Kullane S, Bhalla A, Birns J, Ahmed R, Gibbons M, Klamerus E, Cendreda B, Muir K, Day N, Welch A, Smith W, Elliot J, Eltawil S, Mahmood A, Hatherley K, Mitchell S, Bains H, Quinn L, Teal R, Gbinigie I, Harston G, Mathieson P, Ford G, Schulz U, Kennedy J, Nagaratnam K, Bangalore K, Bhupathiraju N, Wharton C, Fotherby K, Nasar A, Stevens A, Willberry A, Evans R, Rai B, Blake C, Thavanesan K, Hann G, Changuion T, Nix S, Whiting A, Dharmasiri M, Mallon L, Keltos M, Smyth N, Eglinton C, Duffy J, Tone E, Sykes L, Porter E, Fitton C, Kirkineziadis N, Cluckie G, Kennedy K, Trippier S, Williams R, Hayter E, Rackie J, Patel B, Rita G, Blight A, Jones V, Zhang L, Choy L, Pereira A, Clarke B, Al-Hussayni S, Dixon L, Young A, Bergin A, Broughton D, Raghunathan S, Jackson B, Appleton J, Wilkes G, Buck A, Richardson C, Clarke J, Fleming L, Squires G, Law Z, Hutchinson C, Cvoro V, Couser M, McGregor A, McAuley S, Pound S, Cochrane P, Holmes C, Murphy P, Devitt N, Osborn M, Steele A, Guthrie LB, Smith E, Hewitt J, Chaston N, Myint M, Smith A, Fairlie L, Davis M, Atkinson B, Woodward S, Hogg V, Fawcett M, Finlay L, Dixit A, Cameron E, Keegan B, Kelly J, Concannon D, Dutta D, Ward D, Glass J, O'Connell S, Ngeh J, O'Kelly A, Williams E, Ragab S, Jenkinson D, Dube J, Gleave L, Leggett J, Kissoon N, Southern L, Naghotra U, Bokhari M, McClelland B, Adie K, Mate A, Harrington F, James A, Swanson E, Chant T, Naccache M, Coutts A, Courtauld G, Whurr S, Webber S, Shead E, Luder R, Bhargava M, Murali E, Cuenoud L, Pasco K, Speirs O, Chapman L, Inskip L, Kavanagh L, Srinivasan M, Motherwell N, Mukherjee I, Tonks L, Donaldson D, Button H, Wilcox R, Hurford F, Logan R, Taylor A, Arden T, Carpenter M, Datta P, Zahoor T, Jackson L, Needle A, Stanners A, Ghouri I, Exley D, Akhtar S, Brooke H, Beadle S, O'Brien E, Francis J, McGee J, Amis E, Mitchell J, Finlay S, Sinha D, Manoczki C, King S, Tarka J, Choudhary S, Premaruban J, Sutton D, Kumar P, Culmsee C, Winckley C, Davies H, Thatcher H, Vasileiadis E, Aweid B, Holden M, Mason C, Hlaing T, Madzamba G, Ingram T, Linforth M, Cullen C, Thomas N, France J, Saulat A, Bhaskaran B, Fitzell P, Horan K, Manyoni C, Garfield-Smith J, Griffin H, Atkins S, Redome J, Muddegowda G, Maguire H, Barry A, Abano N, Varquez R, Hiden J, Lyjko S, Remegoso A, Finney K, Butler A, Strecker M, MaCleod MJ, Irvine J, Nelson S, Guzmangutierrez G, Furnace J, Taylor V, Ramadan H, Storton K, Hassan S, Abdus Sami E, Bellfield R, Stewart K, Quinn O, Patterson C, Emsley H, Gregary B, Ahmed S, Patel S, Raj S, Sultan S, Wright F, Langhorne P, Graham R, Quinn T, McArthur K. Effects of oral anticoagulation for atrial fibrillation after spontaneous intracranial haemorrhage in the UK: a randomised, open-label, assessor-masked, pilot-phase, non-inferiority trial. Lancet Neurol 2021; 20:842-853. [PMID: 34487722 DOI: 10.1016/s1474-4422(21)00264-7] [Citation(s) in RCA: 43] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Revised: 08/03/2021] [Accepted: 08/04/2021] [Indexed: 01/19/2023]
Abstract
BACKGROUND Oral anticoagulation reduces the rate of systemic embolism for patients with atrial fibrillation by two-thirds, but its benefits for patients with previous intracranial haemorrhage are uncertain. In the Start or STop Anticoagulants Randomised Trial (SoSTART), we aimed to establish whether starting is non-inferior to avoiding oral anticoagulation for survivors of intracranial haemorrhage who have atrial fibrillation. METHODS SoSTART was a prospective, randomised, open-label, assessor-masked, parallel-group, pilot phase trial done at 67 hospitals in the UK. We recruited adults (aged ≥18 years) who had survived at least 24 h after symptomatic spontaneous intracranial haemorrhage, had atrial fibrillation, and had a CHA2DS2-VASc score of at least 2. Web-based computerised randomisation incorporating a minimisation algorithm allocated participants (1:1) to start or avoid long-term (≥1 year) full treatment dose open-label oral anticoagulation. The participants assigned to start oral anticoagulation received either a direct oral anticoagulant or vitamin K antagonist, and the group assigned to avoid oral anticoagulation received standard clinical practice (antiplatelet agent or no antithrombotic agent). The primary outcome was recurrent symptomatic spontaneous intracranial haemorrhage, and was adjudicated by an individual masked to treatment allocation. All outcomes were ascertained for at least 1 year after randomisation and assessed in the intention-to-treat population of all randomly assigned participants, using Cox proportional hazards regression adjusted for minimisation covariates. We planned a sample size of 190 participants (one-sided p=0·025, power 90%, allowing for non-adherence) based on a non-inferiority margin of 12% (or adjusted hazard ratio [HR] of 3·2). This trial is registered with ClinicalTrials.gov (NCT03153150) and is complete. FINDINGS Between March 29, 2018, and Feb 27, 2020, consent was obtained at 61 sites for 218 participants, of whom 203 were randomly assigned at a median of 115 days (IQR 49-265) after intracranial haemorrhage onset. 101 were assigned to start and 102 to avoid oral anticoagulation. Participants were followed up for median of 1·2 years (IQR 0·97-1·95; completeness 97·2%). Starting oral anticoagulation was not non-inferior to avoiding oral anticoagulation: eight (8%) of 101 in the start group versus four (4%) of 102 in the avoid group had intracranial haemorrhage recurrences (adjusted HR 2·42 [95% CI 0·72-8·09]; p=0·152). Serious adverse events occurred in 17 (17%) participants in the start group and 15 (15%) in the avoid group. 22 (22%) patients in the start group and 11 (11%) patients in the avoid group died during the study. INTERPRETATION Whether starting oral anticoagulation was non-inferior to avoiding it for people with atrial fibrillation after intracranial haemorrhage was inconclusive, although rates of recurrent intracranial haemorrhage were lower than expected. In view of weak evidence from analyses of three composite secondary outcomes, the possibility that oral anticoagulation might be superior for preventing symptomatic major vascular events should be investigated in adequately powered randomised trials. FUNDING British Heart Foundation, Medical Research Council, Chest Heart & Stroke Scotland.
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Parental Views on the Non-Operative Management of Simple Appendicitis in Children: Results of a Cross-Sectional Survey. World J Surg 2021; 46:274-287. [PMID: 34557942 DOI: 10.1007/s00268-021-06305-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/07/2021] [Indexed: 12/31/2022]
Abstract
BACKGROUND To determine parental attitudes for the non-operative management of simple appendicitis and determine willingness to participate in research evaluating different management options. METHOD Voluntary cross-sectional survey of parents/guardians presenting to paediatric outpatient department. Likert scale of 0-10 (strongly disagree-strongly agree) was utilised, analysis by individual question responses. Results are presented as medians [IQR], paired t test, the Mann-Whitney U test and Kruskal-Wallis test analysis as appropriate. A p value of < 0.05 is considered significant. RESULTS Of 311 respondents, 81% (252/311) completed all the questions. The majority (73%, 220/303) believed that appendicitis needed an urgent operation, and 88% (264/299) believed that perforated appendicitis was a life-threatening condition. Fifty-two per cent (131/252) preferred operative management, and 48% (121/252) preferred antibiotic treatment. The most important factors influencing treatment choice were removal of pain (84%, 246/293), removal of infection (83%, 244/293) and minimising complications (54%, 162/293). Concerns regarding antibiotic treatment included the potential for recurrence (75%, 204/271), the risk of progression (63%, 170/271) and the potential of future surgery (53%, 145/271). The perceived beneficial factors of antibiotic treatment included avoiding surgery, 64% (173/269) and surgical complications 68% (184/269). When asked to consider whether they would participate in clinical research evaluating the two treatment options, parents were equally in favour (39%), against (26%) or unsure (35%). CONCLUSION Our study demonstrates equipoise in the parental acceptance of antibiotics as a treatment simple appendicitis in children, or participation in research evaluating this topic. However, the important factors that may influence this decision have been identified to guide future conversations.
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Jepson M, Lazaroo M, Pathak S, Blencowe N, Collingwood J, Clout M, Toogood G, Blazeby J. Making large-scale surgical trials possible: collaboration and the role of surgical trainees. Trials 2021; 22:567. [PMID: 34446065 PMCID: PMC8390009 DOI: 10.1186/s13063-021-05536-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Accepted: 08/11/2021] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Recruitment to surgical randomised controlled trials (RCTs) can be challenging. The Sunflower study is a large-scale multi-centre RCT that seeks to establish the clinical and cost effectiveness of pre-operative imaging versus expectant management in patients with symptomatic gallstones undergoing laparoscopic cholecystectomy at low or moderate risk of common bile duct stones. Trials such as Sunflower, with a large recruitment target, rely on teamworking. Recruitment can be optimised by embedding a QuinteT Recruitment Intervention (QRI). Additionally, engaging surgical trainees can contribute to successful recruitment, and the NIHR Associate Principal Investigator (API) scheme provides a framework to acknowledge their contributions. METHODS This was a mixed-methods study that formed a component part of an embedded QRI for the Sunflower RCT. The aim of this study was to understand factors that supported and hindered the participation of surgical trainees in a large-scale RCT and their participation in the API scheme. It comprised semi-structured telephone interviews with consultant surgeons and surgical trainees involved in screening and recruitment of patients, and descriptive analysis of screening and recruitment data. Interviews were analysed thematically to explore the perspectives of-and roles undertaken by-surgical trainees. RESULTS Interviews were undertaken with 34 clinicians (17 consultant surgeons, 17 surgical trainees) from 22 UK hospital trusts. Surgical trainees contributed to patient screening, approaches and randomisation, with a major contribution to the randomisation of patients from acute admissions. They were often encouraged to participate in the study by their centre principal investigator, and career development was a typical motivating factor for their participation in the study. The study was registered with the API scheme, and a majority of the trainees interviewed (n = 14) were participating in the scheme. CONCLUSION Surgical trainees can contribute substantial activity to a large-scale multi-centre RCT. Benefits of trainee engagement were identified for trainees themselves, for local sites and for the study as a whole. The API scheme provided a formal framework to acknowledge engagement. Ensuring that training and support for trainees are provided by the trial team is key to optimise success for all stakeholders.
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Affiliation(s)
- Marcus Jepson
- grid.5337.20000 0004 1936 7603QuinteT Research Group, Population Health Sciences, Bristol Medical School, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS UK
| | - Michelle Lazaroo
- grid.5337.20000 0004 1936 7603Clinical Trials and Evaluation Unit, University of Bristol Faculty of Medical and Veterinary Sciences, Bristol, UK
| | - Samir Pathak
- grid.5337.20000 0004 1936 7603Bristol Centre for Surgical Research, Population Health Sciences, Bristol Medical School, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS UK
| | - Natalie Blencowe
- grid.5337.20000 0004 1936 7603Bristol Centre for Surgical Research, Population Health Sciences, Bristol Medical School, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS UK
- grid.410421.20000 0004 0380 7336University Hospitals Bristol and Weston NHS Foundation Trust, Trust Headquarters, Marlborough St, Bristol, BS1 3NU UK
| | - Jane Collingwood
- grid.5337.20000 0004 1936 7603Bristol Centre for Surgical Research, Population Health Sciences, Bristol Medical School, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS UK
| | - Madeleine Clout
- grid.5337.20000 0004 1936 7603Clinical Trials and Evaluation Unit, University of Bristol Faculty of Medical and Veterinary Sciences, Bristol, UK
| | - Giles Toogood
- grid.443984.6Department of Hepatobiliary and Transplantation Surgery, St James’s University Hospital, Leeds, LS9 7TF UK
| | - Jane Blazeby
- grid.5337.20000 0004 1936 7603NIHR Biomedical Research Centre Bristol, University Hospitals Bristol and Weston NHS Foundation Trust, University of Bristol, Oakfield House, Oakfield Grove, Bristol, BS8 2BN UK
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Kettle J, Deery C, Bolt R, Papaioannou D, Marshman Z. Stakeholder perspectives on barriers and enablers to recruiting anxious children undergoing day surgery under general anaesthetic: a qualitative internal pilot study of the MAGIC randomised controlled trial. Trials 2021; 22:458. [PMID: 34271982 PMCID: PMC8285773 DOI: 10.1186/s13063-021-05425-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Accepted: 07/06/2021] [Indexed: 11/29/2022] Open
Abstract
Background The ‘Melatonin for Anxiety prior to General anaesthesia In Children’ (MAGIC) trial was designed to compare midazolam and melatonin as pre-medications for anxious children (aged five to fourteen), undergoing day-case surgical procedures under general anaesthesia. Low recruitment is a challenge for many trials, particularly paediatric trials and those in ‘emergency’ settings. A qualitative study as part of MAGIC aimed to gather stakeholder perspectives on barriers and enablers to recruitment. Methods Sixteen stakeholders from six sites participated in semi-structured interviews about their experiences of setting up the MAGIC trial and recruiting patients as part of the internal pilot. Data was analysed using framework analysis. Results Participants identified barriers and enablers to recruitment. Barriers and enablers related to the study, participants, the population of anxious children, practitioners, collaboration with other health professionals, ethics, specific settings and the context of surgical day units and the wider health system. Attempting to recruit anxious children from a surgical day unit is particularly challenging for several reasons. Issues include the practicalities of dealing with a child experiencing anxiety for parents/guardians; professional unwillingness to make things more difficult for families and clinicians and nurses valuing predictability within a busy and time-sensitive setting. Conclusions Multi-site RCTs face recruitment barriers relating to study-wide and site-specific factors. There are multiple barriers to recruiting anxious children due to undergo day-case surgery. Barriers across domains can interrelate and reinforce each other, reflecting challenges relating to populations and settings. For example, in the case of anxious children, parents and other health professionals are concerned about exacerbating children’s anxiety prior to surgery. They may look for ways to keep things predictable and avoid the uncertainty of an RCT. Pre-trial engagement work could help address concerns among collaborating health professionals. Using rapid ethnography during set-up or an internal pilot to focus on how the protocol will be or has been operationalised in practice may help identify issues. Allowing time to reflect on the findings of internal pilots and implement necessary changes could facilitate higher recruitment during the main phase of a trial. Trial registration NIHR Trial Registration Number: ISRCTN18296119. Registered on October 01, 2019. Supplementary Information The online version contains supplementary material available at 10.1186/s13063-021-05425-z.
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Affiliation(s)
- Jennifer Kettle
- School of Clinical Dentistry, University of Sheffield, 19 Claremont Crescent, Sheffield, S10 2TA, UK.
| | - Chris Deery
- School of Clinical Dentistry, University of Sheffield, 19 Claremont Crescent, Sheffield, S10 2TA, UK
| | - Robert Bolt
- School of Clinical Dentistry, University of Sheffield, 19 Claremont Crescent, Sheffield, S10 2TA, UK
| | - Diana Papaioannou
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Zoe Marshman
- School of Clinical Dentistry, University of Sheffield, 19 Claremont Crescent, Sheffield, S10 2TA, UK
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Jochym N, Lin LY, Merz JF. Path Analysis of RCT Recruitment: Secondary Analysis of Results from a Systematic Review. J Empir Res Hum Res Ethics 2021; 16:418-423. [PMID: 34106783 DOI: 10.1177/15562646211023698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
We examine recruitment processes for 71 pragmatic and comparative effectiveness trials identified in a systematic review, using path analysis to examine rates of refusal to screen, test, and consent to trial participation. Our analysis suggests that refusal rates might be on net slightly higher if potential subjects are screened or asked to undergo physical eligibility tests, but this was not significant in our sample of trials (p = .11 by Mann-Whitney test). We find that rates of refusing to provide informed consent are much lower for trials in which subjects have agreed to screening or testing (odds ratio = 0.40, Wilcoxon rank-sum z = 2.67, p = .008). We also observe that the overwhelming majority of trials examined secured consent after determining eligibility, even in trials involving screening or testing activities. The ethical implications and areas for future research are discussed.
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Affiliation(s)
- Nicole Jochym
- 363994Cooper Medical School of Rowan University, New Jersey, USA
| | - Lisa Y Lin
- Department of Ophthalmology, 1866Massachusetts Eye and Ear Infirmary, Boston, MA, USA
| | - Jon F Merz
- Department of Medical Ethics & Health Policy, 14640Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
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Carcel C, Reeves M. Under-Enrollment of Women in Stroke Clinical Trials: What Are the Causes and What Should Be Done About It? Stroke 2021; 52:452-457. [PMID: 33493049 DOI: 10.1161/strokeaha.120.033227] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The under-representation of women in clinical trials is a commonly recognized and seemingly intractable problem in many different areas of clinical medicine. Discrepancies in the enrollment of women in clinical trials raises concerns about the generalizability of trial evidence, as well as the potential for reduced access and utilization of new therapies in women. Recent studies confirm that the problem of under-enrollment of women continues to exist in stroke clinical trials, even after accounting for the sex ratio of stroke cases in the underlying population. The origins of these disparities are complex, and there remains a relative dearth of stroke studies that have examined the causes in detail. Although caution should be used when generalizing research findings from studies conducted in other medical conditions including cardiology trials, factors that contribute to lower enrollment in women include the use of specific trial eligibility criteria (eg, older age, presence of specific comorbidities), patient attitudes and beliefs (resulting in less interest and more refusals in women), and potentially implicit biases among study personnel. Beyond a general call to prioritize stroke research in this area, we also recommend the greater use of trial screening logs, the use of qualitative studies to understand patient attitudes and beliefs towards stroke research, avoiding the use of age-based exclusion criteria (eg, >80 years), and increasing the number of women who lead stroke clinical trials.
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Affiliation(s)
- Cheryl Carcel
- The George Institute for Global Health, University of New South Wales, Sydney, Australia (C.C.).,The University of Sydney, Sydney School of Public Health, Sydney Medical School, New South Wales, Australia (C.C.)
| | - Mathew Reeves
- Department of Epidemiology and Biostatistics, College of Human Medicine, Michigan State University, East Lansing (M.R.)
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McDermott C, Vennik J, Philpott C, le Conte S, Thomas M, Eyles C, Little P, Blackshaw H, Schilder A, Hopkins C. Maximising recruitment to a randomised controlled trial for chronic rhinosinusitis using qualitative research methods: the MACRO conversation study. Trials 2021; 22:54. [PMID: 33436031 PMCID: PMC7805190 DOI: 10.1186/s13063-020-04993-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Accepted: 12/22/2020] [Indexed: 11/10/2022] Open
Abstract
Background Randomised controlled trials (RCTs) are considered the ‘gold standard’ of medical evidence; however, recruitment can be challenging. The MACRO trial is a NIHR-funded RCT for chronic rhinosinusitis (CRS) addressing the challenge of comparing surgery, antibiotics and placebo. The embedded MACRO conversation study (MCS) used qualitative research techniques pioneered by the University of Bristol QuinteT team to explore recruitment issues during the pilot phase, to maximise recruitment in the main trial. Methods Setting: Five outpatient Ear Nose and Throat (ENT) departments recruiting for the pilot phase of the MACRO trial (ISRCTN Number: 36962030, prospectively registered 17 October 2018). We conducted a thematic analysis of telephone interviews with 18 recruiters and 19 patients and 61 audio-recordings of recruitment conversations. We reviewed screening and recruitment data and mapped patient pathways at participating sites. We presented preliminary findings to individual site teams. Group discussions enabled further exploration of issues, evolving strategies and potential solutions. Findings were reported back to the funder and used together with recruitment data to justify progression to the main trial. Results Recruitment in the MACRO pilot trial began slowly but accelerated in time to progress successfully to the main trial. Research nurse involvement was pivotal to successful recruitment. Engaging the wider network of clinical colleagues emerged as an important factor, ensuring the patient pathway through primary and secondary care did not inadvertently affect trial eligibility. The most common reason for patients declining participation was treatment preference. Good patient-clinician relationships engendered trust and supported patient decision-making. Overall, trial involvement appeared clearly presented by recruiters, possibly influenced by pre-trial training. The weakest area of understanding for patients appeared to be trial medications. A clear presentation of medical and surgical treatment options, together with checking patient understanding, had the potential to allay patient concerns. Conclusion The MACRO conversation study contributed to the learning process of optimising recruitment by helping to identify and address recruitment issues. Although some issues were trial-specific, others have applicability to many clinical trial situations. Using qualitative research techniques to identify/explore barriers and facilitators to recruitment may be valuable during the pilot phase of many RCTs including those with complex designs.
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Affiliation(s)
- Clare McDermott
- Primary Care and Populations Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Jane Vennik
- Primary Care and Populations Sciences, Faculty of Medicine, University of Southampton, Southampton, UK.
| | - Carl Philpott
- Norwich Medical School, University of East Anglia, Norwich, UK.,James Paget University Hospital NHS Foundation Trust, Great Yarmouth, UK
| | - Steffi le Conte
- Surgical Interventional Trials Unit, University of Oxford, Oxford, UK
| | - Mike Thomas
- Primary Care and Populations Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Caroline Eyles
- Primary Care and Populations Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Paul Little
- Primary Care and Populations Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Helen Blackshaw
- evidENT, Ear Institute, University College London, London, UK
| | - Anne Schilder
- evidENT, Ear Institute, University College London, London, UK
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Littlewood C, Wade J, Butler-Walley S, Lewis M, Beard D, Rangan A, Bhabra G, Kalogrianitis S, Kelly C, Mehta S, Singh HP, Smith M, Tambe A, Tyler J, Foster NE. Protocol for a multi-site pilot and feasibility randomised controlled trial: Surgery versus PhysiothErapist-leD exercise for traumatic tears of the rotator cuff (the SPeEDy study). Pilot Feasibility Stud 2021; 7:17. [PMID: 33413664 PMCID: PMC7788278 DOI: 10.1186/s40814-020-00714-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Accepted: 10/27/2020] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Clinically, a distinction is made between types of rotator cuff tear, traumatic and non-traumatic, and this sub-classification currently informs the treatment pathway. It is currently recommended that patients with traumatic rotator cuff tears are fast tracked for surgical opinion. However, there is uncertainty about the most clinically and cost-effective intervention for patients with traumatic rotator cuff tears and further research is required. SPeEDy will assess the feasibility of a fully powered, multi-centre randomised controlled trial (RCT) to test the hypothesis that, compared to surgical repair (and usual post-operative rehabilitation), a programme of physiotherapist-led exercise is not clinically inferior, but is more cost-effective for patients with traumatic rotator cuff tears. METHODS SPeEDy is a two-arm, multi-centre pilot and feasibility RCT with integrated Quintet Recruitment Intervention (QRI) and further qualitative investigation of patient experience. A total of 76 patients with traumatic rotator cuff tears will be recruited from approximately eight UK NHS hospitals and randomly allocated to either surgical repair and usual post-operative rehabilitation or a programme of physiotherapist-led exercise. The QRI is a mixed-methods approach that includes data collection and analysis of screening logs, audio recordings of recruitment consultations, interviews with patients and clinicians involved in recruitment, and review of study documentation as a basis for developing action plans to address identified difficulties whilst recruitment to the RCT is underway. A further sample of patient participants will be purposively sampled from both intervention groups and interviewed to explore reasons for initial participation, treatment acceptability, reasons for non-completion of treatment, where relevant, and any reasons for treatment crossover. DISCUSSION Research to date suggests that there is uncertainty regarding the most clinically and cost-effective interventions for patients with traumatic rotator cuff tears. There is a clear need for a high-quality, fully powered, RCT to better inform clinical practice. Prior to this, we first need to undertake a pilot and feasibility RCT to address current uncertainties about recruitment, retention and number of and reasons for treatment crossover. TRIAL REGISTRATION ClinicalTrials.gov ( NCT04027205 ) - Registered on 19 July 2019. Available via.
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Affiliation(s)
- Chris Littlewood
- School of Primary, Community and Social Care, Keele University, Staffordshire, UK.
- Department of Health Professions, Faculty of Health, Psychology & Social Care, Manchester Metropolitan University, Manchester, UK.
| | - Julia Wade
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Stephanie Butler-Walley
- School of Primary, Community and Social Care, Keele University, Staffordshire, UK
- Keele Clinical Trials Unit, Keele University, Keele, UK
| | - Martyn Lewis
- School of Primary, Community and Social Care, Keele University, Staffordshire, UK
- Keele Clinical Trials Unit, Keele University, Keele, UK
| | - David Beard
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Amar Rangan
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
- Department of Health Sciences & Hull York Medical School, University of York, York, UK
| | - Gev Bhabra
- University Hospitals Coventry & Warwickshire, Coventry, UK
| | - Socrates Kalogrianitis
- Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Cormac Kelly
- The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust, Oswestry, UK
| | - Saurabh Mehta
- Royal Stoke University Hospital, University Hospitals of North Midlands NHS Trust, Stoke, UK
| | - Harvinder Pal Singh
- Leicester Shoulder Unit, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Matthew Smith
- The Liverpool Upper Limb Unit, The Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, UK
| | - Amol Tambe
- Derby Shoulder Unit, University Hospitals Derby & Burton NHS Foundation Trust, Derby, UK
| | - James Tyler
- Airedale General Hospital, Airedale NHS Foundation Trust, Keighley, UK
| | - Nadine E Foster
- School of Primary, Community and Social Care, Keele University, Staffordshire, UK
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Husbands S, Elliott D, Davis TRC, Blazeby JM, Harrison EF, Montgomery AA, Sprange K, Duley L, Karantana A, Hollingworth W, Mills N. Optimising recruitment to the HAND-1 RCT feasibility study: integration of the QuinteT Recruitment Intervention (QRI). Pilot Feasibility Stud 2020; 6:173. [PMID: 33292646 PMCID: PMC7650179 DOI: 10.1186/s40814-020-00710-1] [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: 09/24/2019] [Accepted: 10/16/2020] [Indexed: 12/04/2022] Open
Abstract
Background Recruitment to randomised controlled trials (RCTs) can be challenging, with most trials not reaching recruitment targets. Randomised feasibility studies can be set up prior to a main trial to identify and overcome recruitment obstacles. This paper reports on an intervention—the QuinteT Recruitment Intervention (QRI)—to optimise recruitment within a randomised feasibility study of surgical treatments for patients with Dupuytren’s contracture (the HAND-1 study). Methods The QRI was introduced in 2-phases: phase 1 sought to understand the recruitment challenges by interviewing trial staff, scrutinising screening logs and analysing audio-recorded patient consultations; in phase 2 a tailored plan of action consisting of recruiter feedback and training was delivered to address the identified challenges. Results Two key recruitment obstacles emerged: (1) issues with the recruitment pathway, in particular methods to identify potentially eligible patients and (2) equipoise of recruiters and patients. These were addressed by liaising with centres to share good practice and refine their pathway and by providing bespoke feedback and training on consent discussions to individual recruiters and centres whilst recruitment was ongoing. The HAND-1 study subsequently achieved its recruitment target. Conclusions Transferable lessons learnt from the QRI in the feasibility study will be implemented in the definitive RCT, enabling a “head start” in the tackling of wider issues around screening methods and consent discussions in the set up/early recruitment study phases, with ongoing QRI addressing specific issues with new centres and recruiters. Findings from this study are likely to be relevant to other surgical and similar trials that are anticipated to encounter issues around patient and recruiter equipoise of treatments and variation in recruitment pathways across centres. The study also highlights the value of feasibility studies in fine-tuning design and conduct issues for definitive RCTs. Embedding a QRI in an RCT, at feasibility or main stage, offers an opportunity for a detailed and nuanced understanding of key recruitment challenges and the chance to address them in “real-time” as recruitment proceeds.
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Affiliation(s)
- Samantha Husbands
- Bristol Medical School, University of Bristol, 1-5 Whiteladies Road, Bristol, BS8 1NU, UK.
| | - Daisy Elliott
- Bristol Medical School, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK
| | - Tim R C Davis
- Nottingham University Hospitals NHS Trust, Queen's Medical Centre, Derby Road, Nottingham, NG7 2UH, UK
| | - Jane M Blazeby
- Bristol Medical School, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK
| | - Eleanor F Harrison
- Nottingham Clinical Trials Unit, University of Nottingham, University Park, Nottingham, NG7 2RD, UK
| | - Alan A Montgomery
- Nottingham Clinical Trials Unit, University of Nottingham, University Park, Nottingham, NG7 2RD, UK
| | - Kirsty Sprange
- Nottingham Clinical Trials Unit, University of Nottingham, University Park, Nottingham, NG7 2RD, UK
| | - Lelia Duley
- Nottingham Clinical Trials Unit, University of Nottingham, University Park, Nottingham, NG7 2RD, UK
| | - Alexia Karantana
- Department of Academic Orthopaedics, Trauma and Sports Medicine, School of Medicine, University of Nottingham, Nottingham, NG7 2UH, UK
| | - William Hollingworth
- Bristol Medical School, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK
| | - Nicola Mills
- Bristol Medical School, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK
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Pickard R, Goulao B, Carnell S, Shen J, MacLennan G, Norrie J, Breckons M, Vale L, Whybrow P, Rapley T, Forbes R, Currer S, Forrest M, Wilkinson J, McColl E, Andrich D, Barclay S, Cook J, Mundy A, N'Dow J, Payne S, Watkin N. Open urethroplasty versus endoscopic urethrotomy for recurrent urethral stricture in men: the OPEN RCT. Health Technol Assess 2020; 24:1-110. [PMID: 33228846 PMCID: PMC7750862 DOI: 10.3310/hta24610] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Men who suffer recurrence of bulbar urethral stricture have to decide between endoscopic urethrotomy and open urethroplasty to manage their urinary symptoms. Evidence of relative clinical effectiveness and cost-effectiveness is lacking. OBJECTIVES To assess benefit, harms and cost-effectiveness of open urethroplasty compared with endoscopic urethrotomy as treatment for recurrent urethral stricture in men. DESIGN Parallel-group, open-label, patient-randomised trial of allocated intervention with 6-monthly follow-ups over 24 months. Target sample size was 210 participants providing outcome data. Participants, clinicians and local research staff could not be blinded to allocation. Central trial staff were blinded when needed. SETTING UK NHS with recruitment from 38 hospital sites. PARTICIPANTS A total of 222 men requiring operative treatment for recurrence of bulbar urethral stricture who had received at least one previous intervention for stricture. INTERVENTIONS A centralised randomisation system using random blocks allocated participants 1 : 1 to open urethroplasty (experimental group) or endoscopic urethrotomy (control group). MAIN OUTCOME MEASURES The primary clinical outcome was control of urinary symptoms. Cost-effectiveness was assessed by cost per quality-adjusted life-year (QALY) gained over 24 months. The main secondary outcome was the need for reintervention for stricture recurrence. RESULTS The mean difference in the area under the curve of repeated measurement of voiding symptoms scored from 0 (no symptoms) to 24 (severe symptoms) between the two groups was -0.36 [95% confidence interval (CI) -1.78 to 1.02; p = 0.6]. Mean voiding symptom scores improved between baseline and 24 months after randomisation from 13.4 [standard deviation (SD) 4.5] to 6 (SD 5.5) for urethroplasty group and from 13.2 (SD 4.7) to 6.4 (SD 5.3) for urethrotomy. Reintervention was less frequent and occurred earlier in the urethroplasty group (hazard ratio 0.52, 95% CI 0.31 to 0.89; p = 0.02). There were two postoperative complications requiring reinterventions in the group that received urethroplasty and five, including one death from pulmonary embolism, in the group that received urethrotomy. Over 24 months, urethroplasty cost on average more than urethrotomy (cost difference £2148, 95% CI £689 to £3606) and resulted in a similar number of QALYs (QALY difference -0.01, 95% CI -0.17 to 0.14). Therefore, based on current evidence, urethrotomy is considered to be cost-effective. LIMITATIONS We were able to include only 69 (63%) of the 109 men allocated to urethroplasty and 90 (80%) of the 113 men allocated to urethrotomy in the primary complete-case intention-to-treat analysis. CONCLUSIONS The similar magnitude of symptom improvement seen for the two procedures over 24 months of follow-up shows that both provide effective symptom control. The lower likelihood of further intervention favours urethroplasty, but this had a higher cost over the 24 months of follow-up and was unlikely to be considered cost-effective. FUTURE WORK Formulate methods to incorporate short-term disutility data into cost-effectiveness analysis. Survey pathways of care for men with urethral stricture, including the use of enhanced recovery after urethroplasty. Establish a pragmatic follow-up schedule to allow national audit of outcomes following urethral surgery with linkage to NHS Hospital Episode Statistics. TRIAL REGISTRATION Current Controlled Trials ISRCTN98009168. FUNDING This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 61. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Robert Pickard
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - Beatriz Goulao
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Sonya Carnell
- Newcastle Clinical Trials Unit, Newcastle University, Newcastle upon Tyne, UK
| | - Jing Shen
- Institute of Health & Society, Newcastle University, Newcastle upon Tyne, UK
| | - Graeme MacLennan
- Centre for Healthcare and Randomised Trials, University of Aberdeen, Aberdeen, UK
| | - John Norrie
- Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Matt Breckons
- Institute of Health & Society, Newcastle University, Newcastle upon Tyne, UK
| | - Luke Vale
- Institute of Health & Society, Newcastle University, Newcastle upon Tyne, UK
| | | | - Tim Rapley
- Social Work, Education & Community Wellbeing, University of Northumbria, Newcastle upon Tyne, UK
| | - Rebecca Forbes
- Newcastle Clinical Trials Unit, Newcastle University, Newcastle upon Tyne, UK
| | - Stephanie Currer
- Newcastle Clinical Trials Unit, Newcastle University, Newcastle upon Tyne, UK
| | - Mark Forrest
- Centre for Healthcare and Randomised Trials, University of Aberdeen, Aberdeen, UK
| | - Jennifer Wilkinson
- Newcastle Clinical Trials Unit, Newcastle University, Newcastle upon Tyne, UK
| | - Elaine McColl
- Institute of Health & Society, Newcastle University, Newcastle upon Tyne, UK
| | - Daniela Andrich
- University College London Hospitals NHS Foundation Trust, London, UK
| | | | - Jonathan Cook
- Oxford Clinical Trials Research Unit, Oxford University, Oxford, UK
| | - Anthony Mundy
- University College London Hospitals NHS Foundation Trust, London, UK
| | - James N'Dow
- Academic Urology Unit, University of Aberdeen, Aberdeen, UK
| | - Stephen Payne
- Central Manchester Hospitals NHS Foundation Trust, Manchester, UK
| | - Nick Watkin
- St George's University Hospitals NHS Foundation Trust, London, UK
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Bugge C, Kearney R, Dembinsky M, Khunda A, Graham M, Agur W, Breeman S, Dwyer L, Elders A, Forrest M, Goodman K, Guerrero K, Hemming C, Mason H, McClurg D, Melone L, Norrie J, Thakar R, Hagen S. The TOPSY pessary self-management intervention for pelvic organ prolapse: a study protocol for the process evaluation. Trials 2020; 21:836. [PMID: 33032651 PMCID: PMC7542744 DOI: 10.1186/s13063-020-04729-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Accepted: 09/08/2020] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Process evaluations have become a valued component, alongside clinical trials, of the wider evaluation of complex health interventions. They support understanding of implementation, and fidelity, related to the intervention and provide valuable insights into what is effective in a practical setting by examining the context in which interventions are implemented. The TOPSY study consists of a large multi-centre randomised controlled trial comparing the effectiveness of pessary self-management with clinic-based care in improving women's condition-specific quality of life, and a nested process evaluation. The process evaluation aims to examine and maximise recruitment to the trial, describe intervention fidelity and explore participants' and healthcare professionals' experiences. METHODS The trial will recruit 330 women from approximately 17 UK centres. The process evaluation uses a mixed-methods approach. Semi-structured interviews will be conducted with randomised women (18 per randomised group/n = 36), women who declined trial participation but agreed to interview (non-randomised women) (n = 20) and healthcare professionals recruiting to the trial (n ~ 17) and delivering self-management and clinic-based care (n ~ 17). The six internal pilot centres will be asked to record two to three recruitment discussions each (total n = 12-18). All participating centres will be asked to record one or two self-management teaching appointments (n = 30) and self-management 2-week follow-up telephone calls (n = 30). Process data (quantitative and qualitative) will be gathered in participant completed trial questionnaires. Interviews will be analysed thematically and recordings using an analytic grid to identify fidelity to the intervention. Quantitative analysis will be predefined within the process evaluation analysis plan. DISCUSSION The wide variety of pessary care delivered across the UK for women with pelvic organ prolapse presents specific localised contexts in which the TOPSY interventions will be implemented. Understanding this contextual variance is central to understanding how and in what circumstances pessary self-management can be implemented (should it be effective). The inclusion of non-randomised women provides an innovative way of collecting indispensable information about eligible women who decline trial participation, allowing broader contextualisation and considerations of generalisability of trial findings. Methodological insights from examination of recruitment processes and mechanisms have the potential to inform recruitment mechanisms and future recruitment strategies and study designs. TRIAL REGISTRATION ISRCTN62510577 . Registered on 6 October 2017.
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Affiliation(s)
- Carol Bugge
- Faculty of Health Sciences and Sport, University of Stirling, Stirling, UK.
| | - Rohna Kearney
- The Warrell Unit, St. Mary's Hospital, Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
- Faculty of Biology Medicine and Health, School of Medical Sciences, University of Manchester, Manchester, UK
| | - Melanie Dembinsky
- Faculty of Health Sciences and Sport, University of Stirling, Stirling, UK
| | - Aethele Khunda
- South Tees Hospitals NHS Foundation Trust, James Cook University Hospital, Middlesbrough, UK
| | - Margaret Graham
- Faculty of Health Sciences and Sport, University of Stirling, Stirling, UK
| | - Wael Agur
- NHS Ayrshire & Arran, Crosshouse Hospital, School of Medicine, Dentistry & Nursing, University of Glasgow, Kilmarnock, UK
| | - Suzanne Breeman
- Health Services Research Unit (HSRU), University of Aberdeen, Aberdeen, UK
| | - Lucy Dwyer
- The Warrell Unit, St. Mary's Hospital, Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Andrew Elders
- Nursing, Midwifery and Allied Health Professions Research Unit, Glasgow Caledonian University, Glasgow, UK
| | - Mark Forrest
- Health Services Research Unit (HSRU), University of Aberdeen, Aberdeen, UK
| | - Kirsteen Goodman
- Nursing, Midwifery and Allied Health Professions Research Unit, Glasgow Caledonian University, Glasgow, UK
| | - Karen Guerrero
- Department of Urogynaecology, NHS Greater Glasgow & Clyde, Glasgow, UK
| | - Christine Hemming
- Grampian University Hospitals NHS Trust, Aberdeen Maternity Hospital & Aberdeen Royal Infirmary, Aberdeen, UK
| | - Helen Mason
- Yunus Centre for Social Business and Health, Glasgow Caledonian University, Glasgow, UK
| | - Doreen McClurg
- Nursing, Midwifery and Allied Health Professions Research Unit, Glasgow Caledonian University, Glasgow, UK
| | - Lynn Melone
- Nursing, Midwifery and Allied Health Professions Research Unit, Glasgow Caledonian University, Glasgow, UK
| | - John Norrie
- Usher Institute of Population Health Sciences and Informatics, College of Medicine and Veterinary Medicine, The University of Edinburgh, Edinburgh, UK
| | - Ranee Thakar
- Croydon Health Services NHS Trust, Croydon University Hospital, Croydon, UK
| | - Suzanne Hagen
- Nursing, Midwifery and Allied Health Professions Research Unit, Glasgow Caledonian University, Glasgow, UK
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Chester JD. Unifying Themes in Urothelial Cancers. Eur Urol 2020; 79:80-81. [PMID: 33039204 DOI: 10.1016/j.eururo.2020.09.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Accepted: 09/24/2020] [Indexed: 10/23/2022]
Affiliation(s)
- John D Chester
- Division of Cancer & Genetics, School of Medicine, Cardiff University, Cardiff, UK.
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Crocker JC, Farrar N, Cook JA, Treweek S, Woolfall K, Chant A, Bostock J, Locock L, Rees S, Olszowski S, Bulbulia R. Recruitment and retention of participants in UK surgical trials: survey of key issues reported by trial staff. BJS Open 2020; 4:1238-1245. [PMID: 33016008 PMCID: PMC7709375 DOI: 10.1002/bjs5.50345] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Accepted: 07/21/2020] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Recruitment and retention of participants in surgical trials is challenging. Knowledge of the most common and problematic issues will aid future trial design. This study aimed to identify trial staff perspectives on the main issues affecting participant recruitment and retention in UK surgical trials. METHODS An online survey of UK surgical trial staff was performed. Respondents were asked whether or not they had experienced a range of recruitment and retention issues, and, if yes, how relatively problematic these were (no, mild, moderate or serious problem). RESULTS The survey was completed by 155 respondents including 60 trial managers, 53 research nurses, 20 trial methodologists and 19 chief investigators. The three most common recruitment issues were: patients preferring one treatment over another (81·5 per cent of respondents); clinicians' time constraints (78·1 per cent); and clinicians preferring one treatment over another (76·8 per cent). Seven recruitment issues were rated moderate or serious problems by a majority of respondents, the most problematic being a lack of eligible patients (60·3 per cent). The three most common retention issues were: participants forgetting to return questionnaires (81·4 per cent); participants found to be ineligible for the trial (74·3 per cent); and long follow-up period (70·7 per cent). The most problematic retention issues, rated moderate or serious by the majority of respondents, were participants forgetting to return questionnaires (56·4 per cent) and insufficient research nurse time/funding (53·6 per cent). CONCLUSION The survey identified a variety of common recruitment and retention issues, several of which were rated moderate or serious problems by the majority of participating UK surgical trial staff. Mitigation of these problems may help boost recruitment and retention in surgical trials.
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Affiliation(s)
- J. C. Crocker
- Nuffield Department of Primary Care Health SciencesOxfordUK
- National Institute for Health Research Oxford Biomedical Research CentreOxfordUK
- MRC ConDuCT‐II Hub for Trials Methodology Research, Bristol Medical SchoolBristolUK
| | - N. Farrar
- MRC ConDuCT‐II Hub for Trials Methodology Research, Bristol Medical SchoolBristolUK
- Population Health Sciences, Bristol Medical School, University of BristolBristolUK
| | - J. A. Cook
- Surgical Intervention Trials Unit, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal SciencesOxfordUK
- MRC ConDuCT‐II Hub for Trials Methodology Research, Bristol Medical SchoolBristolUK
| | - S. Treweek
- Health Services Research Unit, University of AberdeenAberdeenUK
| | - K. Woolfall
- Department of Public Health, Policy and Systems, Institute of Population Health and Society, University of LiverpoolLiverpoolUK
- MRC North West Hub for Trials Methodology ResearchLiverpoolUK
| | - A. Chant
- Patient partnerCookham, BerkshireUK
| | - J. Bostock
- Quality Safety and Outcomes Policy Research Unit, University of KentCanterburyUK
- Policy Innovation and Evaluation Research Unit, London School of Hygiene and Tropical MedicineLondonUK
| | - L. Locock
- Health Services Research Unit, University of AberdeenAberdeenUK
| | - S. Rees
- Oxford Academic Health Science NetworkOxfordUK
| | - S. Olszowski
- National Institute for Health Research Oxford Biomedical Research CentreOxfordUK
- SPZ AssociatesLyme RegisUK
| | - R. Bulbulia
- Clinical Trial Service Unit Hub for Trials Methodology ResearchOxfordUK
- Medical Research Council (MRC) Population Health Unit, Nuffield Department of Population Health, University of OxfordOxfordUK
- Cheltenham General Hospital, Gloucestershire Hospitals NHS Foundation TrustCheltenhamUK
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Hamdy FC, Donovan JL, Lane JA, Mason M, Metcalfe C, Holding P, Wade J, Noble S, Garfield K, Young G, Davis M, Peters TJ, Turner EL, Martin RM, Oxley J, Robinson M, Staffurth J, Walsh E, Blazeby J, Bryant R, Bollina P, Catto J, Doble A, Doherty A, Gillatt D, Gnanapragasam V, Hughes O, Kockelbergh R, Kynaston H, Paul A, Paez E, Powell P, Prescott S, Rosario D, Rowe E, Neal D. Active monitoring, radical prostatectomy and radical radiotherapy in PSA-detected clinically localised prostate cancer: the ProtecT three-arm RCT. Health Technol Assess 2020; 24:1-176. [PMID: 32773013 PMCID: PMC7443739 DOI: 10.3310/hta24370] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Prostate cancer is the most common cancer among men in the UK. Prostate-specific antigen testing followed by biopsy leads to overdetection, overtreatment as well as undertreatment of the disease. Evidence of treatment effectiveness has lacked because of the paucity of randomised controlled trials comparing conventional treatments. OBJECTIVES To evaluate the effectiveness of conventional treatments for localised prostate cancer (active monitoring, radical prostatectomy and radical radiotherapy) in men aged 50-69 years. DESIGN A prospective, multicentre prostate-specific antigen testing programme followed by a randomised trial of treatment, with a comprehensive cohort follow-up. SETTING Prostate-specific antigen testing in primary care and treatment in nine urology departments in the UK. PARTICIPANTS Between 2001 and 2009, 228,966 men aged 50-69 years received an invitation to attend an appointment for information about the Prostate testing for cancer and Treatment (ProtecT) study and a prostate-specific antigen test; 82,429 men were tested, 2664 were diagnosed with localised prostate cancer, 1643 agreed to randomisation to active monitoring (n = 545), radical prostatectomy (n = 553) or radical radiotherapy (n = 545) and 997 chose a treatment. INTERVENTIONS The interventions were active monitoring, radical prostatectomy and radical radiotherapy. TRIAL PRIMARY OUTCOME MEASURE Definite or probable disease-specific mortality at the 10-year median follow-up in randomised participants. SECONDARY OUTCOME MEASURES Overall mortality, metastases, disease progression, treatment complications, resource utilisation and patient-reported outcomes. RESULTS There were no statistically significant differences between the groups for 17 prostate cancer-specific (p = 0.48) and 169 all-cause (p = 0.87) deaths. Eight men died of prostate cancer in the active monitoring group (1.5 per 1000 person-years, 95% confidence interval 0.7 to 3.0); five died of prostate cancer in the radical prostatectomy group (0.9 per 1000 person-years, 95% confidence interval 0.4 to 2.2 per 1000 person years) and four died of prostate cancer in the radical radiotherapy group (0.7 per 1000 person-years, 95% confidence interval 0.3 to 2.0 per 1000 person years). More men developed metastases in the active monitoring group than in the radical prostatectomy and radical radiotherapy groups: active monitoring, n = 33 (6.3 per 1000 person-years, 95% confidence interval 4.5 to 8.8); radical prostatectomy, n = 13 (2.4 per 1000 person-years, 95% confidence interval 1.4 to 4.2 per 1000 person years); and radical radiotherapy, n = 16 (3.0 per 1000 person-years, 95% confidence interval 1.9 to 4.9 per 1000 person-years; p = 0.004). There were higher rates of disease progression in the active monitoring group than in the radical prostatectomy and radical radiotherapy groups: active monitoring (n = 112; 22.9 per 1000 person-years, 95% confidence interval 19.0 to 27.5 per 1000 person years); radical prostatectomy (n = 46; 8.9 per 1000 person-years, 95% confidence interval 6.7 to 11.9 per 1000 person-years); and radical radiotherapy (n = 46; 9.0 per 1000 person-years, 95% confidence interval 6.7 to 12.0 per 1000 person years; p < 0.001). Radical prostatectomy had the greatest impact on sexual function/urinary continence and remained worse than radical radiotherapy and active monitoring. Radical radiotherapy's impact on sexual function was greatest at 6 months, but recovered somewhat in the majority of participants. Sexual and urinary function gradually declined in the active monitoring group. Bowel function was worse with radical radiotherapy at 6 months, but it recovered with the exception of bloody stools. Urinary voiding and nocturia worsened in the radical radiotherapy group at 6 months but recovered. Condition-specific quality-of-life effects mirrored functional changes. No differences in anxiety/depression or generic or cancer-related quality of life were found. At the National Institute for Health and Care Excellence threshold of £20,000 per quality-adjusted life-year, the probabilities that each arm was the most cost-effective option were 58% (radical radiotherapy), 32% (active monitoring) and 10% (radical prostatectomy). LIMITATIONS A single prostate-specific antigen test and transrectal ultrasound biopsies were used. There were very few non-white men in the trial. The majority of men had low- and intermediate-risk disease. Longer follow-up is needed. CONCLUSIONS At a median follow-up point of 10 years, prostate cancer-specific mortality was low, irrespective of the assigned treatment. Radical prostatectomy and radical radiotherapy reduced disease progression and metastases, but with side effects. Further work is needed to follow up participants at a median of 15 years. TRIAL REGISTRATION Current Controlled Trials ISRCTN20141297. FUNDING This project was funded by the National Institute for Health Research Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 37. See the National Institute for Health Research Journals Library website for further project information.
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Affiliation(s)
- Freddie C Hamdy
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | | | - J Athene Lane
- Bristol Medical School, University of Bristol, Bristol, UK
| | - Malcolm Mason
- School of Medicine, University of Cardiff, Cardiff, UK
| | - Chris Metcalfe
- Bristol Medical School, University of Bristol, Bristol, UK
| | - Peter Holding
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - Julia Wade
- Bristol Medical School, University of Bristol, Bristol, UK
| | - Sian Noble
- Bristol Medical School, University of Bristol, Bristol, UK
| | | | - Grace Young
- Bristol Medical School, University of Bristol, Bristol, UK
| | - Michael Davis
- Bristol Medical School, University of Bristol, Bristol, UK
| | - Tim J Peters
- Bristol Medical School, University of Bristol, Bristol, UK
| | - Emma L Turner
- Bristol Medical School, University of Bristol, Bristol, UK
| | | | - Jon Oxley
- Department of Cellular Pathology, North Bristol NHS Trust, Bristol, UK
| | - Mary Robinson
- Department of Cellular Pathology, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - John Staffurth
- Division of Cancer and Genetics, School of Medicine, Cardiff University, Cardiff, UK
| | - Eleanor Walsh
- Bristol Medical School, University of Bristol, Bristol, UK
| | - Jane Blazeby
- Bristol Medical School, University of Bristol, Bristol, UK
| | - Richard Bryant
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - Prasad Bollina
- Department of Urology and Surgery, Western General Hospital, University of Edinburgh, Edinburgh, UK
| | - James Catto
- Academic Urology Unit, University of Sheffield, Sheffield, UK
| | - Andrew Doble
- Department of Urology, Addenbrooke's Hospital, Cambridge, UK
| | - Alan Doherty
- Department of Urology, Queen Elizabeth Hospital, Birmingham, UK
| | - David Gillatt
- Department of Urology, Southmead Hospital and Bristol Urological Institute, Bristol, UK
| | | | - Owen Hughes
- Department of Urology, Cardiff and Vale University Health Board, Cardiff, UK
| | - Roger Kockelbergh
- Department of Urology, University Hospitals of Leicester, Leicester, UK
| | - Howard Kynaston
- Department of Urology, Cardiff and Vale University Health Board, Cardiff, UK
| | - Alan Paul
- Department of Urology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Edgar Paez
- Department of Urology, Freeman Hospital, Newcastle upon Tyne, UK
| | - Philip Powell
- Department of Urology, Freeman Hospital, Newcastle upon Tyne, UK
| | - Stephen Prescott
- Department of Urology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Derek Rosario
- Academic Urology Unit, University of Sheffield, Sheffield, UK
| | - Edward Rowe
- Department of Urology, Southmead Hospital and Bristol Urological Institute, Bristol, UK
| | - David Neal
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
- Academic Urology Group, University of Cambridge, Cambridge, UK
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Lewis R, Todd R, Newton M, Jones RJ, Wilson C, Donovan JL, Bryan RT, Birtle A, Hall E. The implementation and utility of patient screening logs in a multicentre randomised controlled oncology trial. Trials 2020; 21:629. [PMID: 32641097 PMCID: PMC7346417 DOI: 10.1186/s13063-020-04559-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Accepted: 06/26/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The utility of patient screening logs and their impact on improving trial recruitment rates are unclear. We conducted a retrospective exploratory analysis of screening data collected within a multicentre randomised controlled trial investigating chemotherapy for upper tract urothelial carcinoma. METHODS Participating centres maintained a record of patients meeting basic screening criteria stipulated in the trial protocol, submitting logs regularly to the clinical trial coordinating centre (CTC). Sites recorded the number of patients ineligible, not approached, declined and randomised. The CTC monitored proportions of eligible patients, approach rate (proportion of eligible patients approached) and acceptance rate (proportion recruited of those approached). Data were retrospectively analysed to identify patterns of screening activity and correlation with recruitment. RESULTS Data were collected between May 2012 and August 2016, during which time 71 sites were activated-a recruitment period of 2768 centre months. A total of 1138 patients were reported on screening logs, with 2300 requests for logs sent by the CTC and 47% of expected logs received. A total of 758 patients were reported as ineligible, 36 eligible patients were not approached and 207 declined trial participation. The approach rate was 91% (344/380), and the acceptance rate was 40% (137/344); these rates remained consistent throughout the data collection. The main reason patients provided for declining (99/207, 48%) was not wanting to receive chemotherapy. There was a moderately strong correlation (r = 0.47) between the number reported on screening logs and the number recruited per site. Considerable variation in data between centres was observed, and 54/191 trial participants (28%) enrolled during this period were not reported on logs. CONCLUSIONS Central collection of screening logs can identify reasons for patients declining trial participation and help monitor trial activity at sites; however, obtaining complete data can be challenging. There was a correlation between the number of patients reported on logs and recruitment; however, this was likely confounded by sites' available patient population. The use of screening logs may not be appropriate for all trials, and their use should be carefully considered in relation to the associated workload. No evidence was found that central collection of screening logs improved recruitment rates in this study, and their continued use warrants further investigation. TRIAL REGISTRATION ISRCTN98387754 . Registered on 31 January 2012.
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Affiliation(s)
- Rebecca Lewis
- Clinical Trials and Statistics Unit at the Institute of Cancer Research (ICR-CTSU), London, SM2 5NG, UK.
| | - Rachel Todd
- Clinical Trials and Statistics Unit at the Institute of Cancer Research (ICR-CTSU), London, SM2 5NG, UK
| | - Michelle Newton
- Clinical Trials and Statistics Unit at the Institute of Cancer Research (ICR-CTSU), London, SM2 5NG, UK
| | - Robert J Jones
- Institute of Cancer Sciences, Beatson West of Scotland Cancer Centre, University of Glasgow, Glasgow, UK
| | - Caroline Wilson
- Population Health Sciences, Bristol Medical School, Bristol, UK
| | - Jenny L Donovan
- Population Health Sciences, Bristol Medical School, Bristol, UK
| | - Richard T Bryan
- Institute of Cancer & Genomic Sciences, University of Birmingham, Birmingham, UK
| | - Alison Birtle
- Royal Preston Hospital, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, UK
| | - Emma Hall
- Clinical Trials and Statistics Unit at the Institute of Cancer Research (ICR-CTSU), London, SM2 5NG, UK
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Michel J, Datay MI, Motsohi TJ, Bärnighausen T, Tediosi F, McIntyre D, Tanner M, Evans D. Achieving universal health coverage in sub-Saharan Africa: the role of leadership development. JOURNAL OF GLOBAL HEALTH REPORTS 2020. [DOI: 10.29392/001c.12855] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Countries world-wide are striving towards Universal Health Coverage (UHC). Financial resources are extremely limited in developing countries and many developing countries are in the midst of multiple interconnected social, economic, epidemiologic, demographic, technological, institutional, environmental and political transitions. According to the World Health Organization (WHO), accelerating progress towards UHC in Africa will require strong leadership. At the recent Global Conference on Primary Health Care (PHC), the Astana Declaration, the world recommitted to comprehensive Primary Health Care as a keystone of Universal Health Coverage. There is evidence that PHC works. Countries that followed the Alma Ata PHC principles have demonstrated population health outcomes and reduced inequalities at low costs as seen in Chile, Cuba, Ethiopia and Rwanda. What seems to be missing is leadership to apply and uphold these PHC principles. There is consensus that if Astana is to be realized, strong political, economic, education, health, science, institutional, and community leaders are needed to make PHC work this time around. Governments and leaders in Africa have been conveying a constant message, that those leading and managing health systems are not sufficiently prepared to succeed in leadership roles they now occupy. Africa has had different leaders with the same results for decades. Leadership development efforts made to date seem not to be producing desired results. Students taken out of Africa to be trained in leadership at western universities, seem to go back home and carry on as usual. Many students have been taken to the West for education, developed great visions and ideas of how they can transfer knowledge learnt, got home and got swallowed by the system. Pumping more money into a health system with no leadership development will not help us achieve ‘Health for All’ in sub-Saharan Africa. How can accountable leadership with a sense of consciousness for social justice be developed successfully in these contexts? If leadership is key for Universal Health Coverage to be achieved in sub-Saharan Africa, is it not high time attention is paid to leadership development approaches.
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Affiliation(s)
- Janet Michel
- Swiss Tropical and Public Health Institute (Swiss TPH), Basel, Switzerland; University of Basel, Basel, Switzerland
| | - M Ishaaq Datay
- Primary Health Care Directorate, University of Cape Town, Cape Town, South Africa
| | | | - Till Bärnighausen
- Institute of Public Health, University of Heidelberg, Heidelberg, Germany; Harvard T. H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Fabrizio Tediosi
- Swiss Tropical and Public Health Institute (Swiss TPH), Basel, Switzerland; University of Basel, Basel, Switzerland
| | - Di McIntyre
- Health Economics Unit, University of Cape Town, Cape Town, South Africa
| | - Marcel Tanner
- Swiss Tropical and Public Health Institute (Swiss TPH), Basel, Switzerland; University of Basel, Basel, Switzerland
| | - David Evans
- World Bank Health Economist, Geneva, Switzerland
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Chaudhari N, Ravi R, Gogtay NJ, Thatte UM. Recruitment and retention of the participants in clinical trials: Challenges and solutions. Perspect Clin Res 2020; 11:64-69. [PMID: 32670830 PMCID: PMC7342338 DOI: 10.4103/picr.picr_206_19] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Revised: 12/31/2019] [Accepted: 01/29/2020] [Indexed: 11/18/2022] Open
Abstract
Drug development is a tedious and expensive procedure and it takes roughly 10 to 15 years to take a potential treatment from bench to bedside and costs the pharmaceutical companies as much as USD ~2 billion for the process. Delay in investigator-initiated studies can cause financial loss to grant providers (either public or private) and investigator's reputation may also be at stake. Participant recruitment and retention are two major bottlenecks in conducting clinical trials and contribute vastly to the delays. They are essential for both scientific validity of the clinical study and economic reasons. Thus, issues in recruitment and retention should be addressed and minimized. A proper recruitment and retention plan incorporating adequate communication between all stakeholders will eventually avoid the delays in drug development and make treatments available to the consumer at an earlier date and at a more affordable price. Awareness of challenges and reviewing strategies that can optimise recruitment and retention will facilitate drug development. The article gives a first-person perspective on challenges and proposed solutions from an experienced clinical study centre in a tertiary care hospital.
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Affiliation(s)
- Nayan Chaudhari
- Department of Clinical Pharmacology, Seth GS Medical College and KEM Hospital, Mumbai, Maharashtra, India
| | - Renju Ravi
- Department of Clinical Pharmacology, Seth GS Medical College and KEM Hospital, Mumbai, Maharashtra, India
| | - Nithya J. Gogtay
- Department of Clinical Pharmacology, Seth GS Medical College and KEM Hospital, Mumbai, Maharashtra, India
| | - Urmila M. Thatte
- Department of Clinical Pharmacology, Seth GS Medical College and KEM Hospital, Mumbai, Maharashtra, India
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Identifying important barriers to recruitment of patients in randomised clinical studies using a questionnaire for study personnel. Trials 2019; 20:618. [PMID: 31666093 PMCID: PMC6822437 DOI: 10.1186/s13063-019-3737-1] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Accepted: 09/19/2019] [Indexed: 11/13/2022] Open
Abstract
Background Many randomised controlled trials (RCT) fail to meet their recruitment goals. Study personnel play a key role in recruitment. The aim of this study was to identify successful strategies that study personnel consider to be important in patient recruitment to RCT. Methods We constructed a questionnaire based on the literature, discussions with colleagues and our own experience as trialists. The survey was named “What is Important for Making a Study Successful questionnaire” (WIMSS-q). Our target group was the study personnel in the ongoing EFFECTS study. The questionnaire was sent out electronically to all physicians and nurses (n = 148). Success factors and barriers were divided according to patient, centre and study level, respectively. Results Responses were received from 94% of the study personnel (139/148). The five most important factors at centre level for enhancing recruitment were that the research question was important (97%), a simple procedure for providing information and gaining consent (92%), a highly engaged local principal investigator and research nurse (both 87%), and that study-related follow-ups are practically feasible and possible to coordinate with the clinical follow-up (87%). The most significant barrier at the local centre was lack of time and resources devoted to research (72%). Important patient-related barriers were fear of side effects (35%) and language problems (30%). Conclusions For recruitment in an RCT to be successful, the research question must be relevant, and the protocol must be simple and easy to implement in the daily routine. Trial registration The protocol for this study was registered at the Northern Ireland Hub for trials methodology research (SWAT ID 64). The EFFECTS study has EudraCT number 2011–006130-16 and was registered 17 February 2016 at ClinicalTrials.gov number NCT02683213.
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Husbands S, Caskey F, Winton H, Gibson A, Donovan JL, Rooshenas L. Pre-trial qualitative work with health care professionals to refine the design and delivery of a randomised controlled trial on kidney care. Trials 2019; 20:224. [PMID: 30992024 PMCID: PMC6469088 DOI: 10.1186/s13063-019-3281-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Accepted: 03/07/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Recruitment to randomised controlled trials (RCTs) is challenging. Pre-trial qualitative research provides insights into the feasibility and acceptability of proposed trial designs and delivery; however, this is rarely conducted. This paper reports on work undertaken in advance of the Prepare for Kidney Care trial (formerly PrepareME), which compares preparing for dialysis with preparing for conservative care for patients with chronic kidney disease. The paper describes how the findings refined plans for the forthcoming trial. METHODS Semi-structured interviews were undertaken with health-care professionals involved in delivering or recruiting to the trial. Interview findings were considered in relation to observations of a patient advisory group workshop and introductory site visits, which were set up to present the trial to professionals involved in the internal pilot phase of the RCT. The use of findings and input from multiple sources was intended to support suggested refinements to the forthcoming trial. The findings were fed back to the trial management group and other expert stakeholders. RESULTS Sixteen health-care professionals were interviewed, and one patient advisory group workshop and six introductory visits to sites involved in the internal pilot were observed. The professionals interviewed included renal consultants, nurses and renal social workers. Key themes identified from the interviews, supported by the observations, were concerns around the eligibility criteria, the feasibility of the trial intervention, imbalances in the presentation of the trial arms, and anticipated recruitment issues arising from patients' and clinicians' preferences for one arm or the other. Changes to the design were made in response, including to the content of the intervention, the presentation of the trial arms and the name of the RCT. CONCLUSIONS This study highlights the value of carrying out pre-trial work with health-care professionals to identify issues with delivering the proposed trial. This work can be particularly valuable in trials of new interventions, for which the barriers to their integration into routine care are unknown. This work has important implications for facilitating the identification of further obstacles in the main RCT. We suggest that pre-trial qualitative work is undertaken to address design issues early on, in addition to ongoing qualitative research to monitor the emergence of obstacles affecting recruitment.
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Affiliation(s)
- Samantha Husbands
- Population Health Sciences, Bristol Medical School, University of Bristol, 1-5 Whiteladies Road, Bristol, BS8 1NU UK
| | - Fergus Caskey
- Population Health Sciences, Bristol Medical School, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS UK
| | - Helen Winton
- Population Health Sciences, Bristol Medical School, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS UK
| | - Andy Gibson
- Department of Health and Applied Social Sciences, University of West of England, Bristol, UK
| | - Jenny L. Donovan
- Population Health Sciences, Bristol Medical School, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS UK
| | - Leila Rooshenas
- Population Health Sciences, Bristol Medical School, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS UK
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Bracken K, Askie L, Keech AC, Hague W, Wittert G. Recruitment strategies in randomised controlled trials of men aged 50 years and older: a systematic review. BMJ Open 2019; 9:e025580. [PMID: 30948584 PMCID: PMC6500287 DOI: 10.1136/bmjopen-2018-025580] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2018] [Revised: 12/17/2018] [Accepted: 02/13/2019] [Indexed: 01/21/2023] Open
Abstract
OBJECTIVES To identify and review evaluations of strategies to recruit men aged 50 years and over to randomised controlled trials (RCTs). DESIGN Systematic review and narrative synthesis. DATA SOURCES MEDLINE, EMBASE, CINAHL and ORRCA databases were searched to 1 December 2017. ELIGIBILITY CRITERIA Studies using quantitative methods to evaluate recruitment strategies to RCTs of men aged 50 years and older. DATA EXTRACTION AND SYNTHESIS A single reviewer extracted data (for each strategy, number of participants approached, screened and randomised, and cost). Study quality was assessed using National Heart, Lung and Blood Institute Quality Assessment Tools and considered study design, description of interventions, description and measurement of outcomes, completeness of outcome reporting, performance of statistical testing and consideration of confounders. Recruitment strategies were categorised by the recruitment stage they addressed. RESULTS Sixteen studies (n >14 000) were included: one good quality, ten fair quality and five poor quality. Studies evaluated strategies to identify prospective participants, and to improve the processes for assessing participant eligibility, providing participant information and seeking consent. In good and fair quality studies, the most effective strategies for identifying participants were referral from an affiliated health service provider (two studies), mass mailing (five studies) and media coverage (two studies). Community outreach activities such as displaying posters and attending local community events were not effective (two studies). Trial-specific training of site recruitment staff, developed using qualitative analysis of recruitment visits (two studies), and provision of study information to prospective participants at a multidisciplinary, group information session (one study) both improved recruitment. CONCLUSION Improved engagement of men aged 50 years and older in RCTs is needed. A gender-sensitised approach to RCT recruitment may help to address this need. We have identified several promising recruitment strategies that merit further evaluation. PROSPERO REGISTRATION NUMBER CRD42017060301.
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Affiliation(s)
- Karen Bracken
- NHMRC Clinical Trials Centre, Camperdown, New South Wales, Australia
| | - Lisa Askie
- NHMRC Clinical Trials Centre, Camperdown, New South Wales, Australia
| | - Anthony C Keech
- NHMRC Clinical Trials Centre, Camperdown, New South Wales, Australia
| | - Wendy Hague
- NHMRC Clinical Trials Centre, Camperdown, New South Wales, Australia
| | - Gary Wittert
- Department of Medicine, University of Adelaide, Adelaide, South Australia, Australia
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Rooshenas L, Paramasivan S, Jepson M, Donovan JL. Intensive Triangulation of Qualitative Research and Quantitative Data to Improve Recruitment to Randomized Trials: The QuinteT Approach. QUALITATIVE HEALTH RESEARCH 2019; 29:672-679. [PMID: 30791819 DOI: 10.1177/1049732319828693] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Abstract
Randomized controlled trials (RCTs) can provide high quality evidence about the comparative effectiveness of health care interventions, but many RCTs struggle with or fail to complete recruitment. RCTs are built on the principles of the experimental method, but their planning, conduct, and interpretation can depend on complex social, behavioral, and cultural factors that may be best understood through qualitative research. Most qualitative studies undertaken alongside RCTs involve interviews that produce data that are used in a supportive or supplicatory role, but there is potential for qualitative research to be more influential. In this article, we describe the research methods underpinning the "QuinteT" (Qualitative Research Integrated Within Trials) approach to understand and address RCT recruitment difficulties. The QuinteT Recruitment Intervention (QRI) brings together multiple qualitative strategies and quantitative data and uses triangulation to understand recruitment issues rapidly. These nuanced understandings are used to inform the implementation of collaborative actions to improve recruitment.
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Elliott D, Hamdy FC, Leslie TA, Rosario D, Dudderidge T, Hindley R, Emberton M, Brewster S, Sooriakumaran P, Catto JW, Emara A, Ahmed H, Whybrow P, le Conte S, Donovan JL. Overcoming difficulties with equipoise to enable recruitment to a randomised controlled trial of partial ablation vs radical prostatectomy for unilateral localised prostate cancer. BJU Int 2018; 122:970-977. [PMID: 29888845 PMCID: PMC6348419 DOI: 10.1111/bju.14432] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
OBJECTIVE To describe how clinicians conceptualised equipoise in the PART (Partial prostate Ablation vs Radical prosTatectomy in intermediate-risk unilateral clinically localised prostate cancer) feasibility study and how this affected recruitment. SUBJECTS AND METHODS PART included a QuinteT Recruitment Intervention (QRI) to optimise recruitment. Phase I aimed to understand recruitment, and included: scrutinising recruitment data, interviewing the trial management group and recruiters (n = 13), and audio-recording recruitment consultations (n = 64). Data were analysed using qualitative content and thematic analysis methods. In Phase II, strategies to improve recruitment were developed and delivered. RESULTS Initially many recruiters found it difficult to maintain a position of equipoise and held preconceptions about which treatment was best for particular patients. They did not feel comfortable about approaching all eligible patients, and when the study was discussed, biases were conveyed through the use of terminology, poorly balanced information, and direct treatment recommendations. Individual and group feedback led to presentations to patients becoming clearer and enabled recruiters to reconsider their sense of equipoise. Although the precise impact of the QRI alone cannot be determined, recruitment increased (from a mean [range] of 1.4 [0-4] to 4.5 [0-12] patients/month) and the feasibility study reached its recruitment target. CONCLUSION Although clinicians find it challenging to recruit patients to a trial comparing different contemporary treatments for prostate cancer, training and support can enable recruiters to become more comfortable with conveying equipoise and providing clearer information to patients.
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Affiliation(s)
- Daisy Elliott
- Population Health SciencesBristol Medical SchoolUniversity of BristolBristolUK
| | - Freddie C. Hamdy
- Nuffield Department of Surgical SciencesUniversity of OxfordOxfordUK
| | - Tom A. Leslie
- Nuffield Department of Surgical SciencesUniversity of OxfordOxfordUK
| | - Derek Rosario
- Department of Oncology and MetabolismUniversity of SheffieldSheffieldUK
| | - Tim Dudderidge
- University Hospital Southampton NHS Foundation TrustSouthamptonUK
| | | | - Mark Emberton
- Division of Surgery and Interventional ScienceUniversity College LondonLondonUK
| | - Simon Brewster
- Nuffield Department of Surgical SciencesUniversity of OxfordOxfordUK
| | | | - James W.F. Catto
- Department of Oncology and MetabolismUniversity of SheffieldSheffieldUK
| | - Amr Emara
- Hampshire Hospitals NHS Foundation TrustBasingstokeUK
| | - Hashim Ahmed
- Imperial UrologyImperial College Healthcare NHS TrustLondonUK
| | - Paul Whybrow
- Population Health SciencesBristol Medical SchoolUniversity of BristolBristolUK
| | - Steffi le Conte
- Nuffield Department of Surgical SciencesUniversity of OxfordOxfordUK
| | - Jenny L. Donovan
- Population Health SciencesBristol Medical SchoolUniversity of BristolBristolUK
- NIHR Collaboration for Leadership in Applied Health Research and Care West at University Hospitals Bristol NHS TrustBristolUK
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