1
|
Cooper LA, Marsteller JA, Carson KA, Dietz KB, Boonyasai RT, Alvarez C, Crews DC, Himmelfarb CRD, Ibe CA, Lubomski L, Miller ER, Wang NY, Avornu GD, Brown D, Hickman D, Simmons M, Stein AA, Yeh HC. Equitable Care for Hypertension: Blood Pressure and Patient-Reported Outcomes of the RICH LIFE Cluster Randomized Trial. Circulation 2024; 150:230-242. [PMID: 39008556 PMCID: PMC11254328 DOI: 10.1161/circulationaha.124.069622] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2024] [Accepted: 06/03/2024] [Indexed: 07/17/2024]
Abstract
BACKGROUND Disparities in hypertension control are well documented but underaddressed. METHODS RICH LIFE (Reducing Inequities in Care of Hypertension: Lifestyle Improvement for Everyone) was a 2-arm, cluster randomized trial comparing the effect on blood pressure (BP) control (systolic BP ≤140 mm Hg, diastolic BP ≤90 mm Hg), patient activation, and disparities in BP control of 2 multilevel interventions, standard of care plus (SCP) and collaborative care/stepped care (CC/SC). SCP included BP measurement standardization, audit and feedback, and equity-leadership training. CC/SC added roles to address social or medical needs. Primary outcomes were BP control and patient activation at 12 months. Generalized estimating equations and mixed-effects regression models with fixed effects of time, intervention, and their interaction compared change in outcomes at 12 months from baseline. RESULTS A total of 1820 adults with uncontrolled BP and ≥1 other risk factors enrolled in the study. Their mean age was 60.3 years, and baseline BP was 152.3/85.5 mm Hg; 59.4% were women; 57.4% were Black, 33.2% were White, and 9.4% were Hispanic; 74% had hyperlipidemia; and 45.1% had type 2 diabetes. CC/SC did not improve BP control rates more than SCP. Both groups achieved statistically and clinically significant BP control rates at 12 months (CC/SC: 57.3% [95% CI, 52.7%-62.0%]; SCP: 56.7% [95% CI, 51.9%-61.5%]). Pairwise comparisons between racial and ethnic groups showed overall no significant differences in BP control at 12 months. Patients with coronary heart disease showed greater achievement of BP control in CC/SC than in SCP (64.0% [95% CI, 54.1%-73.9%] versus 50.8% [95% CI, 42.6%-59.0%]; P=0.04), as did patients in rural areas (67.3% [95% CI, 49.8%-84.8%] versus 47.8% [95% CI, 32.4%-63.2%]; P=0.01). Individuals in both arms experienced statistically and clinically significant reductions in mean systolic BP (CC/SC: -13.8 mm Hg [95% CI, -15.2 to -12.5]; SCP: -14.6 mm Hg [95% CI, -15.9 to -13.2]) and diastolic BP (CC/SC: -6.9 mm Hg [95% CI, -7.8 to -6.1]; SCP: -5.5 mm Hg [95% CI, -6.4 to -4.6]) over time. The difference in diastolic BP reduction between CC/SC and SCP over time was statistically significant (-1.4 mm Hg [95% CI, -2.6 to -0.2). Patient activation did not differ between arms. CC/SC showed greater improvements in patient ratings of chronic illness care (Patient Assessment of Chronic Illness Care score) over 12 months (0.12 [95% CI, 0.02-0.22]). CONCLUSIONS Adding a collaborative care team to enhanced standard of care did not improve BP control but did improve patient ratings of chronic illness care.
Collapse
Affiliation(s)
- Lisa A. Cooper
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Johns Hopkins Center for Health Equity, Johns Hopkins University, Baltimore, Maryland
- The Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Jill A. Marsteller
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Johns Hopkins Center for Health Equity, Johns Hopkins University, Baltimore, Maryland
- The Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Kathryn A. Carson
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Johns Hopkins Center for Health Equity, Johns Hopkins University, Baltimore, Maryland
- The Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Katherine B. Dietz
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Johns Hopkins Center for Health Equity, Johns Hopkins University, Baltimore, Maryland
| | - Romsai T. Boonyasai
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Agency for Healthcare Research and Quality, Rockville, Maryland
| | - Carmen Alvarez
- Johns Hopkins Center for Health Equity, Johns Hopkins University, Baltimore, Maryland
- University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania
| | - Deidra C. Crews
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Johns Hopkins Center for Health Equity, Johns Hopkins University, Baltimore, Maryland
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Cheryl R. Dennison Himmelfarb
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Johns Hopkins Center for Health Equity, Johns Hopkins University, Baltimore, Maryland
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
- Johns Hopkins School of Nursing, Baltimore, Maryland
| | - Chidinma A. Ibe
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Johns Hopkins Center for Health Equity, Johns Hopkins University, Baltimore, Maryland
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Lisa Lubomski
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Johns Hopkins Center for Health Equity, Johns Hopkins University, Baltimore, Maryland
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Edgar R. Miller
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Johns Hopkins Center for Health Equity, Johns Hopkins University, Baltimore, Maryland
- The Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Nae-Yuh Wang
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
- The Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
| | - Gideon D. Avornu
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Deven Brown
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Johns Hopkins Center for Health Equity, Johns Hopkins University, Baltimore, Maryland
| | - Debra Hickman
- Johns Hopkins Center for Health Equity, Johns Hopkins University, Baltimore, Maryland
- Sisters Together and Reaching, Inc., Baltimore, MD
| | - Michelle Simmons
- Johns Hopkins Center for Health Equity, Johns Hopkins University, Baltimore, Maryland
| | - Ariella Apfel Stein
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Johns Hopkins Center for Health Equity, Johns Hopkins University, Baltimore, Maryland
| | - Hsin-Chieh Yeh
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Johns Hopkins Center for Health Equity, Johns Hopkins University, Baltimore, Maryland
- The Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| |
Collapse
|
2
|
Qiu H, Cook AJ, Bobb JF. Evaluating tests for cluster-randomized trials with few clusters under generalized linear mixed models with covariate adjustment: A simulation study. Stat Med 2024; 43:201-215. [PMID: 37933766 PMCID: PMC10872819 DOI: 10.1002/sim.9950] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 10/04/2023] [Accepted: 10/16/2023] [Indexed: 11/08/2023]
Abstract
Generalized linear mixed models (GLMM) are commonly used to analyze clustered data, but when the number of clusters is small to moderate, standard statistical tests may produce elevated type I error rates. Small-sample corrections have been proposed for continuous or binary outcomes without covariate adjustment. However, appropriate tests to use for count outcomes or under covariate-adjusted models remains unknown. An important setting in which this issue arises is in cluster-randomized trials (CRTs). Because many CRTs have just a few clusters (eg, clinics or health systems), covariate adjustment is particularly critical to address potential chance imbalance and/or low power (eg, adjustment following stratified randomization or for the baseline value of the outcome). We conducted simulations to evaluate GLMM-based tests of the treatment effect that account for the small (10) or moderate (20) number of clusters under a parallel-group CRT setting across scenarios of covariate adjustment (including adjustment for one or more person-level or cluster-level covariates) for both binary and count outcomes. We find that when the intraclass correlation is non-negligible (≥ $$ \ge $$ 0.01) and the number of covariates is small (≤ $$ \le $$ 2), likelihood ratio tests with a between-within denominator degree of freedom have type I error rates close to the nominal level. When the number of covariates is moderate (≥ $$ \ge $$ 5), across our simulation scenarios, the relative performance of the tests varied considerably and no method performed uniformly well. Therefore, we recommend adjusting for no more than a few covariates and using likelihood ratio tests with a between-within denominator degree of freedom.
Collapse
Affiliation(s)
- Hongxiang Qiu
- Department of Epiidemiology and Biostatistics, Michigan State University, Michigan, United States
| | - Andrea J. Cook
- Biostatistics unit, Kaiser Permanente Washington Health Research Institute, Washington, United States
- Department of Biostatistics, University of Washington, Washington, United States
| | - Jennifer F. Bobb
- Biostatistics unit, Kaiser Permanente Washington Health Research Institute, Washington, United States
- Department of Biostatistics, University of Washington, Washington, United States
| |
Collapse
|
3
|
Farnsworth von Cederwald A, Lilja JL, Hentati Isacsson N, Kaldo V. Primary Care Behavioral Health in Sweden - a protocol of a cluster randomized trial evaluating outcomes related to implementation, organization, and patients (KAIROS). BMC Health Serv Res 2023; 23:1188. [PMID: 37907899 PMCID: PMC10619326 DOI: 10.1186/s12913-023-10180-9] [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: 08/18/2023] [Accepted: 10/18/2023] [Indexed: 11/02/2023] Open
Abstract
BACKGROUND Providing comprehensive and continuous care for patients whose conditions have mental or behavioral components is a central challenge in primary care and an important part of improving universal health coverage. There is a great need for high and routine availability of psychological interventions, but traditional methods for delivering psychotherapy often result in low reach and long wait times. Primary Care Behavioral Health (PCBH) is a method for organizing primary care in which behavioral health staff provide brief, flexible interventions to a large part of the population in active collaboration with other providers. While PCBH holds promise in addressing important challenges, it has not yet been thoroughly evaluated. METHODS This cluster randomized trial will assess 17 primary care centers (PCCs) that are starting a PCBH implementation process. The PCCs will be divided into two groups, with one starting immediate implementation and the other acting as a control, implementing six months later. The purpose of the study is to strengthen the evidence base for PCBH regarding implementation-, organization-, and patient-level outcomes, taking into consideration that there is a partially dependent relationship between the three levels. Patient outcomes (such as increased daily functioning and reduction of symptoms) may be dependent on organizational changes (such as availability of treatment, waiting times and interprofessional teamwork), which in turn requires change in implementation outcomes (most notably, model fidelity). In addition to the main analysis, five secondary analyses will compare groups based on different combinations of randomization and time periods, specifically before and after each center achieves sufficient PCBH fidelity. DISCUSSION A randomized comparison of PCBH and traditional primary care has, to our knowledge, not been made before. While the naturalistic setting and the intricacies of implementation pose certain challenges, we have designed this study in an effort to evaluate the causal effects of PCBH despite these complex aspects. The results of this project will be helpful in guiding decisions on how to organize the delivery of behavioral interventions and psychological treatment within the context of primary care in Sweden and elsewhere. TRIAL REGISTRATION ClinicalTrials.gov: NCT05335382. Retrospectively registered on March 13th, 2022.
Collapse
Affiliation(s)
| | - Josefine L Lilja
- Department of Psychology, Faculty of Health and Life Sciences, Linnaeus University, Växjö, Sweden
- School of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Närhälsan Research and Development Primary Health Care, Region Västra Götaland, Gothenburg, Sweden
| | - Nils Hentati Isacsson
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, & Stockholm Health Care Services, Region Stockholm, Stockholm, Sweden
| | - Viktor Kaldo
- Department of Psychology, Faculty of Health and Life Sciences, Linnaeus University, Växjö, Sweden
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, & Stockholm Health Care Services, Region Stockholm, Stockholm, Sweden
| |
Collapse
|
4
|
Vilain-Abraham FL, Tavernier E, Dantan E, Desmée S, Caille A. Restricted mean survival time to estimate an intervention effect in a cluster randomized trial. Stat Methods Med Res 2023; 32:2016-2032. [PMID: 37559486 DOI: 10.1177/09622802231192960] [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: 08/11/2023]
Abstract
For time-to-event outcomes, the difference in restricted mean survival time is a measure of the intervention effect, an alternative to the hazard ratio, corresponding to the expected survival duration gain due to the intervention up to a predefined time t*. We extended two existing approaches of restricted mean survival time estimation for independent data to clustered data in the framework of cluster randomized trials: one based on the direct integration of Kaplan-Meier curves and the other based on pseudo-values regression. Then, we conducted a simulation study to assess and compare the statistical performance of the proposed methods, varying the number and size of clusters, the degree of clustering, and the magnitude of the intervention effect under proportional and non-proportional hazards assumption. We found that the extended methods well estimated the variance and controlled the type I error if there was a sufficient number of clusters (≥ 50) under both proportional and non-proportional hazards assumption. For cluster randomized trials with a limited number of clusters (< 50), a permutation test for pseudo-values regression was implemented and corrected the type I error. We also provided a procedure to estimate permutation-based confidence intervals which produced adequate coverage. All the extended methods performed similarly, but the pseudo-values regression offered the possibility to adjust for covariates. Finally, we illustrated each considered method with a cluster randomized trial evaluating the effectiveness of an asthma-control education program.
Collapse
Affiliation(s)
| | - Elsa Tavernier
- INSERM, SPHERE, U1246, Tours University, Nantes University, Tours, France
| | - Etienne Dantan
- INSERM, SPHERE, U1246, Nantes University, Tours University, Nantes, France
| | - Solène Desmée
- INSERM, SPHERE, U1246, Tours University, Nantes University, Tours, France
| | - Agnès Caille
- INSERM, SPHERE, U1246, Tours University, Nantes University, Tours, France
| |
Collapse
|
5
|
Tong G, Li F, Chen X, Hirani SP, Newman SP, Wang W, Harhay MO. A Bayesian Approach for Estimating the Survivor Average Causal Effect When Outcomes Are Truncated by Death in Cluster-Randomized Trials. Am J Epidemiol 2023; 192:1006-1015. [PMID: 36799630 PMCID: PMC10236525 DOI: 10.1093/aje/kwad038] [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: 06/29/2022] [Revised: 01/05/2023] [Accepted: 02/18/2023] [Indexed: 02/18/2023] Open
Abstract
Many studies encounter clustering due to multicenter enrollment and nonmortality outcomes, such as quality of life, that are truncated due to death-that is, missing not at random and nonignorable. Traditional missing-data methods and target causal estimands are suboptimal for statistical inference in the presence of these combined issues, which are especially common in multicenter studies and cluster-randomized trials (CRTs) carried out among the elderly or seriously ill. Using principal stratification, we developed a Bayesian estimator that jointly identifies the always-survivor principal stratum in a clustered/hierarchical data setting and estimates the average treatment effect among them (i.e., the survivor average causal effect (SACE)). In simulations, we observed low bias and good coverage with our method. In a motivating CRT, the SACE and the estimate from complete-case analysis differed in magnitude, but both were small, and neither was incompatible with a null effect. However, the SACE estimate has a clear causal interpretation. The option to assess the rigorously defined SACE estimand in studies with informative truncation and clustering can provide additional insight into an important subset of study participants. Based on the simulation study and CRT reanalysis, we provide practical recommendations for using the SACE in CRTs and software code to support future research.
Collapse
Affiliation(s)
- Guangyu Tong
- Correspondence to Dr. Guangyu Tong, Department of Biostatistics, Yale School of Public Health, 135 College Street, New Haven, CT 06510 (e-mail: )
| | | | | | | | | | | | | |
Collapse
|
6
|
Candel MJJM, van Breukelen GJP. Best (but oft forgotten) practices: Efficient sample sizes for commonly used trial designs. Am J Clin Nutr 2023; 117:1063-1085. [PMID: 37270287 DOI: 10.1016/j.ajcnut.2023.02.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Revised: 02/08/2023] [Accepted: 02/14/2023] [Indexed: 06/05/2023] Open
Abstract
Designing studies such that they have a high level of power to detect an effect or association of interest is an important tool to improve the quality and reproducibility of findings from such studies. Since resources (research subjects, time, and money) are scarce, it is important to obtain sufficient power with minimum use of such resources. For commonly used randomized trials of the treatment effect on a continuous outcome, designs are presented that minimize the number of subjects or the amount of research budget when aiming for a desired power level. This concerns the optimal allocation of subjects to treatments and, in case of nested designs such as cluster-randomized trials and multicenter trials, also the optimal number of centers versus the number of persons per center. Since such optimal designs require knowledge of parameters of the analysis model that are not known in the design stage, in particular outcome variances, maximin designs are presented. These designs guarantee a prespecified power level for plausible ranges of the unknown parameters and minimize research costs for the worst-case values of these parameters. The focus is on a 2-group parallel design, the AB/BA crossover design, and cluster-randomized and multicenter trials with a continuous outcome. How to calculate sample sizes for maximin designs is illustrated for examples from nutrition. Several computer programs that are helpful in calculating sample sizes for optimal and maximin designs are discussed as well as some results on optimal designs for other types of outcomes.
Collapse
Affiliation(s)
- Math J J M Candel
- Department of Methodology and Statistics, Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, Netherlands.
| | - Gerard J P van Breukelen
- Department of Methodology and Statistics, Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, Netherlands; Department of Methodology and Statistics, Graduate School of Psychology and Neuroscience, Maastricht University, Maastricht, Netherlands
| |
Collapse
|
7
|
Gagnon J, Probst S, Chartrand J, Lalonde M. Self-supporting wound care mobile applications for nurses: A scoping review protocol. J Tissue Viability 2023; 32:79-84. [PMID: 36642670 DOI: 10.1016/j.jtv.2023.01.004] [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: 06/28/2022] [Revised: 11/29/2022] [Accepted: 01/07/2023] [Indexed: 01/11/2023]
Abstract
AIM Mobile health (mHealth) is playing an increasingly important role in the computerization of wound care on an international scale with an aim to improve care. The aim of this scoping review protocol is to present a transparent process for how we plan to search and review the existing evidence related to self-supporting mobile wound care applications used by nurses. MATERIALS AND METHODS The scoping review will follow the Joanna Briggs Institute (JBI) methodology. An exploratory search was performed using MEDLINE (Ovid), Embase, CINAHL (Ebsco), to identify concepts, keywords, MeSH terms, and headings to identify study types looking for mobile applications in wound care. The findings of this search will determine the final search strategy. Data sources will include MEDLINE, Embase, CINAHL, Web of Science, LiSSa, Cochrane Wounds (Cochrane Library) and Erudit. The titles and abstracts of the identified articles will be screened independently by two authors for relevance. Full texts will also be screened by two independent reviewers and data extraction will be performed in accordance with a pre-designed extraction form. All types of studies and literature linked to self-supporting mobile wound care application used by nurses will be included (quantitative, qualitative, mixed methods and grey literature). CONCLUSION The results of the scoping review will give an overview of the existing self-supporting mobile applications in wound care used by nurses. These will also help to identify the existing applications, and describe knowledge in nursing about their utilisation, development, and evaluation, as well as synthesize the available literature on their impacts.
Collapse
Affiliation(s)
- Julie Gagnon
- School of Nursing, Faculty of Health Sciences, University of Ottawa, 451 Smyth Road, Ottawa, Ontario, K1H 8L1, Canada.
| | - Sebastian Probst
- HES-SO, University of Applied Sciences and Arts Western Switzerland, 47 Avenue de Champel, 1206, Geneva, Switzerland; University Hospital, Geneva, Switzerland; Faculty of Medicine Nursing and Health Sciences, Monash University, Melbourne, Australia.
| | - Julie Chartrand
- School of Nursing, Faculty of Health Sciences, University of Ottawa, 451 Smyth Road, Ottawa, Ontario, K1H 8L1, Canada; Children's Hospital of Eastern Ontario Research Institute, 401 Smyth Road, Ottawa, Ontario, K1H 8L1, Canada.
| | - Michelle Lalonde
- School of Nursing, Faculty of Health Sciences, University of Ottawa, 451 Smyth Road, Ottawa, Ontario, K1H 8L1, Canada; Institut du Savoir Montfort, Montfort Hospital, 745A Montréal Road, Suite 202, Ottawa, Ontario, Canada.
| |
Collapse
|
8
|
Spencer-Bonilla G, Branda ME, Kunneman M, Bellolio F, Burnett B, Guyatt G, Montori VM. Encounter-based randomization did not result in contamination in a shared decision-making trial: a secondary analysis. J Clin Epidemiol 2022; 152:185-192. [PMID: 36220625 DOI: 10.1016/j.jclinepi.2022.09.017] [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: 02/07/2022] [Revised: 09/07/2022] [Accepted: 09/30/2022] [Indexed: 11/18/2022]
Abstract
OBJECTIVES To estimate the level of contamination in an encounter-randomized trial evaluating a shared decision-making (SDM) tool. STUDY DESIGN AND SETTING We assessed contamination at three levels: (1) tool contamination (whether the tool was physically present in the usual care encounter), (2) functional contamination (whether components of the SDM tool were recreated in the usual care encounters without directly accessing the tool), and (3) learned contamination (whether clinicians "got better at SDM" in the usual care encounters as assessed by the OPTION-12 score). For functional and learned contamination, the interaction with the number of exposures to the tool was assessed. RESULTS We recorded and analyzed 830 of 922 randomized encounters. Of the 411 recorded encounters randomized to usual care, the SDM tool was used in nine (2.2%) encounters. Clinicians discussed at least one patient-important issue in 377 usual care encounters (92%) and the risk of stroke in 214 encounters (52%). We found no significant interaction between number of times the SDM tool was used and subsequent functional or learned contamination. CONCLUSION Despite randomly assigning clinicians to use an SDM tool in some and not other encounters, we found no evidence of contamination in usual care encounters.
Collapse
Affiliation(s)
- Gabriela Spencer-Bonilla
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, MN, USA; Department of Medicine, Stanford University, Stanford, CA, USA
| | - Megan E Branda
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, MN, USA; Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA
| | - Marleen Kunneman
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, MN, USA; Biomedical Data Sciences, Leiden University Medical Center, Leiden, The Netherlands
| | - Fernanda Bellolio
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, MN, USA; Department of Emergency Medicine, Mayo Clinic, Rochester, MN, USA
| | - Bruce Burnett
- Thrombosis Clinic and Anticoagulation Services, Park Nicollet Health Services, St Louis Park, MN, USA
| | - Gordon Guyatt
- Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Victor M Montori
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, MN, USA.
| | | |
Collapse
|
9
|
Ahlstedt Karlsson S, Henoch I, Olofsson Bagge R, Wallengren C. Person-centred support programme (RESPECT intervention) for women with breast cancer treated with endocrine therapy: a feasibility study. BMJ Open 2022; 12:e060946. [PMID: 36198470 PMCID: PMC9535178 DOI: 10.1136/bmjopen-2022-060946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
OBJECTIVE The peRson-cEntred Support Programme EndoCrine Therapy intervention is a complex intervention encompassing a person-centred support programme for patients with breast cancer being treated with endocrine therapy (ET). The aim of this study was to explore the feasibility of the trial design and patient acceptability of the intervention and outcome measures and to provide data to estimate the parameters required to design the final intervention. DESIGN A controlled before-and-after design following the Consolidated Standards of Reporting Trials 2010 statement for feasibility trials. SETTING A surgical outpatient clinic in Sweden. PARTICIPANTS Forty-one patients (aged 47-85) with breast cancer who were treated with ET. INTERVENTIONS Eligible patients were assigned to the control group or intervention group, which included individual education material, an individualised learning plan and a personalised reminder letter using a person-centred approach. The intervention could be delivered as a telephone or digital follow-up during a 12-week follow-up. OUTCOME MEASURES The aims were to determine the recruitment rate, assess the rate of retention, explore whether the intervention was delivered according to the protocol, assess the preferred form of educational support, rate of education sessions, length per education session and length between each education session, determine the distribution of education materials and assess completion rates of patient-reported instruments, including the General Self-efficacy Scale, the Quality of Care from the Patient's Perspective Questionnaire and the Memorial Symptom Assessment Scale. RESULTS Eighty-six per cent of the patients in the intervention group completed the intervention and questionnaires 3 months after their inclusion. The call attendance was 90%. During the intervention, the contact nurse complied with the intervention protocol. For self-efficacy, symptoms and quality of care, there were no differences in effect size between the control and intervention groups. CONCLUSIONS This intervention seems to be feasible and acceptable among patients.
Collapse
Affiliation(s)
| | - Ingela Henoch
- Institute of Health and Care Sciences, Gothenburg University, Gothenburg, Sweden
| | | | | |
Collapse
|
10
|
Abstract
BACKGROUND This article identifies the most influential methods reports for group-randomized trials and related designs published through 2020. Many interventions are delivered to participants in real or virtual groups or in groups defined by a shared interventionist so that there is an expectation for positive correlation among observations taken on participants in the same group. These interventions are typically evaluated using a group- or cluster-randomized trial, an individually randomized group treatment trial, or a stepped wedge group- or cluster-randomized trial. These trials face methodological issues beyond those encountered in the more familiar individually randomized controlled trial. METHODS PubMed was searched to identify candidate methods reports; that search was supplemented by reports known to the author. Candidate reports were reviewed by the author to include only those focused on the designs of interest. Citation counts and the relative citation ratio, a new bibliometric tool developed at the National Institutes of Health, were used to identify influential reports. The relative citation ratio measures influence at the article level by comparing the citation rate of the reference article to the citation rates of the articles cited by other articles that also cite the reference article. RESULTS In total, 1043 reports were identified that were published through 2020. However, 55 were deemed to be the most influential based on their relative citation ratio or their citation count using criteria specific to each of the three designs, with 32 group-randomized trial reports, 7 individually randomized group treatment trial reports, and 16 stepped wedge group-randomized trial reports. Many of the influential reports were early publications that drew attention to the issues that distinguish these designs from the more familiar individually randomized controlled trial. Others were textbooks that covered a wide range of issues for these designs. Others were "first reports" on analytic methods appropriate for a specific type of data (e.g. binary data, ordinal data), for features commonly encountered in these studies (e.g. unequal cluster size, attrition), or for important variations in study design (e.g. repeated measures, cohort versus cross-section). Many presented methods for sample size calculations. Others described how these designs could be applied to a new area (e.g. dissemination and implementation research). Among the reports with the highest relative citation ratios were the CONSORT statements for each design. CONCLUSIONS Collectively, the influential reports address topics of great interest to investigators who might consider using one of these designs and need guidance on selecting the most appropriate design for their research question and on the best methods for design, analysis, and sample size.
Collapse
Affiliation(s)
- David M Murray
- Office of Disease Prevention, National Institutes of Health, North Bethesda, MD, USA
| |
Collapse
|
11
|
Palin V, Van Staa TP, Steels S, Troxel AB, Groenwold RHH, MacDonald TM, Torgerson D, Faries D, Mancini P, Ouwens M, Frith LJ, Tsirtsonis K, MacLennan G, Nordon C. A first step towards best practice recommendations for the design and statistical analyses of pragmatic clinical trials: a modified Delphi approach. Br J Clin Pharmacol 2022; 88:5183-5201. [PMID: 35701368 DOI: 10.1111/bcp.15441] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Revised: 04/29/2022] [Accepted: 05/22/2022] [Indexed: 11/30/2022] Open
Abstract
AIM Pragmatic clinical trials (PCTs) are randomised trials implemented through routine clinical practice, where design parameters of traditional randomised controlled trials are modified to increase generalizability. However, this may introduce statistical challenges. We aimed to identify these challenges and discuss possible solutions leading to best practice recommendations for the design and analysis of PCTs. METHODS A modified Delphi method was used to reach consensus among a panel of 11 experts in clinical trials and statistics. Statistical issues were identified in a focused literature review and aggregated with insights and possible solutions from expert collected through a series of survey iterations. Issues were ranked according to their importance. RESULTS 27 articles were included and combined with experts' insight to generate a list of issues categorized into: participants; recruiting sites; randomisation, blinding and intervention; outcome (selection and measurement); and data analysis. Consensus was reached about the most important issues: risk of participants' attrition; heterogeneity of "usual care" across sites; absence of blinding; use of a subjective endpoint; and data analysis aligned with the trial estimand. Potential issues should be anticipated and preferably be addressed in the trial protocol. The experts provided solutions regarding data collection and data analysis, which were considered of equal importance. DISCUSSION A set of important statistical issues in PCTs was identified and approaches were suggested to anticipate and/or minimize these through data analysis. Any impact of choosing a pragmatic design feature should be gauged in the light of the trial estimand.
Collapse
Affiliation(s)
- Victoria Palin
- Division of Informatics, Imaging & Data Sciences, Manchester Environmental Research Institute, University of Manchester, United Kingdom
| | - Tjeerd P Van Staa
- Division of Informatics, Imaging & Data Sciences, Manchester Environmental Research Institute, University of Manchester, United Kingdom
| | - Stephanie Steels
- Department of Social Care and Social Work, Manchester Metropolitan University, Manchester, United Kingdom
| | - Andrea B Troxel
- Division of Biostatistics, Department of Population Health, NYU Grossman School of Medicine, NYU, USA
| | - Rolf H H Groenwold
- Department of Clinical Epidemiology, Leiden University Medical Centre, The Netherlands
| | - Tom M MacDonald
- MEMO Research, University of Dundee, Ninewells Hospital & Medical School, Dundee, United Kingdom
| | - David Torgerson
- Department of Health Sciences, University of York, United Kingdom
| | - Douglas Faries
- Global Statistical Sciences, Eli Lilly & Co., Indianapolis, IN, USA
| | | | | | | | | | - Graham MacLennan
- The Centre for Healthcare Randomised Trials, University of Aberdeen, United Kingdom
| | - Clementine Nordon
- formally LASER Research, Paris, France; currently AstraZeneca, Cambridge, United Kingdom
| | | |
Collapse
|
12
|
Smit DJM, van Oostrom SH, Engels JA, van der Beek AJ, Proper KI. A study protocol of the adaptation and evaluation by means of a cluster-RCT of an integrated workplace health promotion program based on a European good practice. BMC Public Health 2022; 22:1028. [PMID: 35597983 PMCID: PMC9123680 DOI: 10.1186/s12889-022-13352-0] [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: 04/29/2022] [Accepted: 05/03/2022] [Indexed: 11/10/2022] Open
Abstract
Background An integrated workplace health promotion program (WHPP) which targets multiple lifestyle factors at different levels (individual and organizational) is potentially more effective than a single component WHPP. The aim of this study is to describe the protocol of a study to tailor a European good practice of such an integral approach to the Dutch context and to evaluate its effectiveness and implementation. Methods This study consists of two components. First, the five steps of the Map of Adaptation Process (MAP) will be followed to tailor the Lombardy WHP to the Dutch context. Both the employers and employees will be actively involved in this process. Second, the effectiveness of the integrated Dutch WHPP will be evaluated in a clustered randomized controlled trial (C-RCT) with measurements at baseline, 6 months and 12 months. Clusters will be composed based on working locations or units - dependent on the organization’s structure and randomization within each organization takes place after baseline measurements. Primary outcome will be a combined lifestyle score. Secondary outcomes will be the separate lifestyle behaviors targeted, stress, work-life balance, need for recovery, general health, and well-being. Simultaneously, a process evaluation will be conducted. The study population will consist of employees from multiple organizations in different industry sectors. Organizations in the intervention condition will receive the integrated Dutch WHPP during 12 months, consisting of an implementation plan and a catalogue with activities for multiple lifestyle themes on various domains: 1) screening and support; 2) information and education; 3) adjustments in the social, digital or physical environment; and 4) policy. Discussion The MAP approach provides an appropriate framework to systematically adapt an existing WHPP to the Dutch context, involving both employers and employees and retaining the core elements, i.e. the catalogue with evidence-based activities on multiple lifestyle themes and domains enabling an integrated approach. The following process and effect evaluation will contribute to further insight in the actual implementation and effectiveness of the integrated WHP approach. Trial registration NTR (trialregister.nl), NL9526. Registered on 3 June 2021. Supplementary Information The online version contains supplementary material available at 10.1186/s12889-022-13352-0.
Collapse
Affiliation(s)
- Denise J M Smit
- Center for Nutrition, Prevention and Health Services, National Institute for Public Health and the Environment, Bilthoven, 3721 MA, The Netherlands. .,Department of Public and Occupational Health, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Public Health Research Institute, Amsterdam, 1081 BT, The Netherlands.
| | - Sandra H van Oostrom
- Center for Nutrition, Prevention and Health Services, National Institute for Public Health and the Environment, Bilthoven, 3721 MA, The Netherlands
| | - Josephine A Engels
- Occupation & Health Research Group, HAN University of Applied Sciences, Nijmegen, 6525 EN, the Netherlands
| | - Allard J van der Beek
- Department of Public and Occupational Health, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Public Health Research Institute, Amsterdam, 1081 BT, The Netherlands
| | - Karin I Proper
- Center for Nutrition, Prevention and Health Services, National Institute for Public Health and the Environment, Bilthoven, 3721 MA, The Netherlands.,Department of Public and Occupational Health, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Public Health Research Institute, Amsterdam, 1081 BT, The Netherlands
| |
Collapse
|
13
|
Ficek J, Chen H, Lu Y, Huang Y, Mayer JM. Assessing the impacts of cluster effects and covariate imbalance in cluster randomized equivalence trials. Stat Biopharm Res 2022. [DOI: 10.1080/19466315.2022.2071981] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Joseph Ficek
- College of Public Health, University of South Florida (USF), Tampa, FL 33612, USA
| | - Henian Chen
- College of Public Health, University of South Florida (USF), Tampa, FL 33612, USA
| | - Yuanyuan Lu
- College of Public Health, University of South Florida (USF), Tampa, FL 33612, USA
| | - Yangxin Huang
- College of Public Health, University of South Florida (USF), Tampa, FL 33612, USA
| | | |
Collapse
|
14
|
Turmaine K, Dumas A, Chevreul K. Conditions for the Successful Integration of an eHealth Tool "StopBlues" Into Community-Based Interventions in France: Results From a Multiple Correspondence Analysis. J Med Internet Res 2022; 24:e30218. [PMID: 35451977 PMCID: PMC9077507 DOI: 10.2196/30218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Revised: 09/23/2021] [Accepted: 10/29/2021] [Indexed: 11/30/2022] Open
Abstract
Background For over a decade, digital health has held promise for enabling broader access to health information, education, and services for the general population at a lower cost. However, recent studies have shown mixed results leading to a certain disappointment regarding the benefits of eHealth technologies. In this context, community-based health promotion represents an interesting and efficient conceptual framework that could help increase the adoption of digital health solutions and facilitate their evaluation. Objective To understand how the local implementation of the promotion of an eHealth tool, StopBlues (SB), aimed at preventing psychological distress and suicide, varied according to local contexts and if the implementation was related to the use of the tool. Methods The study was nested within a cluster-randomized controlled trial that was conducted to evaluate the effectiveness of the promotion, with before and after observation (NCT03565562). Data from questionnaires, observations, and institutional sources were collected in 27 localities where SB was implemented. A multiple correspondence analysis was performed to assess the relations between context, type of implementation and promotion, and use of the tool. Results Three distinct promotion patterns emerged according to the profiles of the localities that were associated with specific SB utilization rates. From highest to lowest utilization rates, they are listed as follows: the privileged urban localities, investing in health that implemented a high-intensity and digital promotion, demonstrating a greater capacity to take ownership of the project; the urban, but less privileged localities that, in spite of having relatively little experience in health policy implementation, managed to implement a traditional and high-intensity promotion; and the rural localities, with little experience in addressing health issues, that implemented low-intensity promotion but could not overcome the challenges associated with their local context. Conclusions These findings indicate the substantial influence of local context on the reception of digital tools. The urban and socioeconomic status profiles of the localities, along with their investment and pre-existing experience in health, appear to be critical for shaping the promotion and implementation of eHealth tools in terms of intensity and use of digital communication. The more digital channels used, the higher the utilization rates, ultimately leading to the overall success of the intervention. International Registered Report Identifier (IRRID) RR2-10.1186/s13063-020-04464-2
Collapse
Affiliation(s)
| | - Agnès Dumas
- Université Paris Cité, ECEVE, UMR 1123, Inserm, Paris, France
| | - Karine Chevreul
- Université Paris Cité, ECEVE, UMR 1123, Inserm, Paris, France.,Assistance Publique-Hôpitaux de Paris, URC Eco Ile-de-France, Paris, France, Paris, France.,Assistance Publique-Hôpitaux de Paris, Hôpital Robert Debré, Unité d'épidémiologie clinique, Paris, France
| | -
- See Authors' Contributions,
| |
Collapse
|
15
|
Hadisoemarto PF, Lestari BW, Sharples K, Afifah N, Chaidir L, Huang CC, McAllister S, van Crevel R, Murray M, Alisjahbana B, Hill PC. A public health intervention package for increasing tuberculosis notifications from private practitioners in Bandung, Indonesia (INSTEP2): A cluster-randomised controlled trial protocol. F1000Res 2022; 10:327. [PMID: 35528962 PMCID: PMC9039369 DOI: 10.12688/f1000research.52089.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/23/2022] [Indexed: 11/20/2022] Open
Abstract
Background. A significant proportion of tuberculosis (TB) patients globally make their initial visit for medical care to either an informal provider or a private practitioner, and many are not formally notified. Involvement of private practitioners (PPs) in a public–private mix for TB (TB-PPM) provides an opportunity for improving TB control. However, context-specific interventions beyond public–private agreements and mandatory notification are needed. In this study we will evaluate whether a tailored intervention package can increase TB notifications from PPs in Indonesia. Methods. This is a cluster-randomized trial of a multi-component public health intervention. 36 community health centre (CHC) areas will be selected as study locations and randomly allocated to intervention and control arms (1:1). PPs in the intervention areas will be identified using a mapping exercise and recruited into the study if they are eligible and consent. They will receive a tailored intervention package including in-person education about TB management along with bimonthly electronic refreshers, context-specific selection of referral pathways, and access to a TB-reporting app developed in collaboration with the National TB programme. The primary hypothesis is that the intervention package will increase the TB notification rate. The primary outcome will be measured by collecting notification data from the CHCs in intervention and control arms at the end of a 1-year observation period and comparing with the 1-year pre-intervention. The primary analysis will be intention-to-treat at the cluster level, using a generalised mixed model with repeated measures of TB notifications for 1 year pre- and 1 year post-intervention. Discussion. The results from this study will provide evidence on whether a tailored intervention package is effective in increasing the number of TB notifications, and whether the PPs refer presumptive TB cases correctly. The study results will guide policy in the development of TB-PPM in Indonesia and similar settings.
Collapse
Affiliation(s)
- Panji Fortuna Hadisoemarto
- Tuberculosis Working Group, Infectious Disease Research Centre, Faculty of Medicine Universitas Padjadjaran, Bandung, West Java, 40161, Indonesia
- Department of Public Health, Faculty of Medicine Universitas Padjadjaran, Bandung, West Java, 40161, Indonesia
- Department of Preventive and Social Medicine, Centre for International Health, University of Otago, Dunedin, 9016, New Zealand
| | - Bony Wiem Lestari
- Tuberculosis Working Group, Infectious Disease Research Centre, Faculty of Medicine Universitas Padjadjaran, Bandung, West Java, 40161, Indonesia
- Department of Public Health, Faculty of Medicine Universitas Padjadjaran, Bandung, West Java, 40161, Indonesia
- Department of Internal Medicine, Radboud Institute for Health Sciences, Radboud University Medical Centre, Nijmegen, 6525 GA, The Netherlands
| | - Katrina Sharples
- Department of Mathematics and Statistics, University of Otago, Dunedin, 9016, New Zealand
| | - Nur Afifah
- Tuberculosis Working Group, Infectious Disease Research Centre, Faculty of Medicine Universitas Padjadjaran, Bandung, West Java, 40161, Indonesia
| | - Lidya Chaidir
- Tuberculosis Working Group, Infectious Disease Research Centre, Faculty of Medicine Universitas Padjadjaran, Bandung, West Java, 40161, Indonesia
- Department of Microbiology, Faculty of Medicine Universitas Padjadjaran, Bandung, West Java, 40161, Indonesia
| | - Chuan-Chin Huang
- Division of Global Health Equity, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, 02115, USA
| | - Susan McAllister
- Department of Preventive and Social Medicine, Centre for International Health, University of Otago, Dunedin, 9016, New Zealand
| | - Reinout van Crevel
- Department of Internal Medicine, Radboud Institute for Health Sciences, Radboud University Medical Centre, Nijmegen, 6525 GA, The Netherlands
| | - Megan Murray
- Division of Global Health Equity, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, 02115, USA
| | - Bachti Alisjahbana
- Tuberculosis Working Group, Infectious Disease Research Centre, Faculty of Medicine Universitas Padjadjaran, Bandung, West Java, 40161, Indonesia
- Department of Internal Medicine, Dr Hasan Sadikin General Hospital, Bandung, West Java, 40161, Indonesia
| | - Philip C Hill
- Department of Preventive and Social Medicine, Centre for International Health, University of Otago, Dunedin, 9016, New Zealand
| |
Collapse
|
16
|
Melendez-Torres GJ, Warren E, Ukoumunne OC, Viner R, Bonell C. Locating and testing the healthy context paradox: examples from the INCLUSIVE trial. BMC Med Res Methodol 2022; 22:57. [PMID: 35220938 PMCID: PMC8883633 DOI: 10.1186/s12874-022-01537-5] [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: 06/02/2021] [Accepted: 01/17/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
The healthy context paradox, originally described with respect to school-level bullying interventions, refers to the generation of differences in mental wellbeing amongst those who continue to experience bullying even after interventions successfully reduce victimisation. Using data from the INCLUSIVE trial of restorative practice in schools, we relate this paradox to the need to theorise potential harms when developing interventions; formulate the healthy context paradox in a more general form defined by mediational relationships and cluster-level interventions; and propose two statistical models for testing the healthy context paradox informed by multilevel mediation methods, with relevance to structural and individual explanations for this paradox.
Methods
We estimated two multilevel mediation models with bullying victimisation as the mediator and mental wellbeing as the outcome: one with a school-level interaction between intervention assignment and the mediator; and one with a random slope component for the student-level mediator-outcome relationship predicted by school-level assignment. We relate each of these models to contextual or individual-level explanations for the healthy context paradox.
Results
Neither model suggested that the INCLUSIVE trial represented an example of the healthy context paradox. However, each model has different interpretations which relate to a multilevel understanding of the healthy context paradox.
Conclusions
Greater exploration of intervention harms, especially when those accrue to population subgroups, is an essential step in better understanding how interventions work and for whom. Our proposed tests for the presence of a healthy context paradox provide the analytic tools to better understand how to support development and implementation of interventions that work for all groups in a population.
Trial registration
Current Controlled Trials, ISRCTN10751359.
Collapse
|
17
|
Wibbelink CJM, Arntz A, Grasman RPPP, Sinnaeve R, Boog M, Bremer OMC, Dek ECP, Alkan SG, James C, Koppeschaar AM, Kramer L, Ploegmakers M, Schaling A, Smits FI, Kamphuis JH. Towards optimal treatment selection for borderline personality disorder patients (BOOTS): a study protocol for a multicenter randomized clinical trial comparing schema therapy and dialectical behavior therapy. BMC Psychiatry 2022; 22:89. [PMID: 35123450 PMCID: PMC8817780 DOI: 10.1186/s12888-021-03670-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Accepted: 12/21/2021] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Specialized evidence-based treatments have been developed and evaluated for borderline personality disorder (BPD), including Dialectical Behavior Therapy (DBT) and Schema Therapy (ST). Individual differences in treatment response to both ST and DBT have been observed across studies, but the factors driving these differences are largely unknown. Understanding which treatment works best for whom and why remain central issues in psychotherapy research. The aim of the present study is to improve treatment response of DBT and ST for BPD patients by a) identifying patient characteristics that predict (differential) treatment response (i.e., treatment selection) and b) understanding how both treatments lead to change (i.e., mechanisms of change). Moreover, the clinical effectiveness and cost-effectiveness of DBT and ST will be evaluated. METHODS The BOOTS trial is a multicenter randomized clinical trial conducted in a routine clinical setting in several outpatient clinics in the Netherlands. We aim to recruit 200 participants, to be randomized to DBT or ST. Patients receive a combined program of individual and group sessions for a maximum duration of 25 months. Data are collected at baseline until three-year follow-up. Candidate predictors of (differential) treatment response have been selected based on the literature, a patient representative of the Borderline Foundation of the Netherlands, and semi-structured interviews among 18 expert clinicians. In addition, BPD-treatment-specific (ST: beliefs and schema modes; DBT: emotion regulation and skills use), BPD-treatment-generic (therapeutic environment characterized by genuineness, safety, and equality), and non-specific (attachment and therapeutic alliance) mechanisms of change are assessed. The primary outcome measure is change in BPD manifestations. Secondary outcome measures include functioning, additional self-reported symptoms, and well-being. DISCUSSION The current study contributes to the optimization of treatments for BPD patients by extending our knowledge on "Which treatment - DBT or ST - works the best for which BPD patient, and why?", which is likely to yield important benefits for both BPD patients (e.g., prevention of overtreatment and potential harm of treatments) and society (e.g., increased economic productivity of patients and efficient use of treatments). TRIAL REGISTRATION Netherlands Trial Register, NL7699 , registered 25/04/2019 - retrospectively registered.
Collapse
Affiliation(s)
- Carlijn J. M. Wibbelink
- Department of Clinical Psychology, University of Amsterdam, Nieuwe Achtergracht 129-B, Amsterdam, 1018 WS the Netherlands
| | - Arnoud Arntz
- Department of Clinical Psychology, University of Amsterdam, Nieuwe Achtergracht 129-B, Amsterdam, 1018 WS the Netherlands
| | - Raoul P. P. P. Grasman
- Department of Clinical Psychology, University of Amsterdam, Nieuwe Achtergracht 129-B, Amsterdam, 1018 WS the Netherlands
| | - Roland Sinnaeve
- Department of Neurosciences, Mind Body Research, KU Leuven, Herestraat 49, 3000 Leuven, Belgium
| | - Michiel Boog
- Department of Addiction and Personality, Antes Mental Health Care, Max Euwelaan 1, Rotterdam, 3062 MA the Netherlands
- Institute of Psychology, Erasmus University Rotterdam, P.O. Box 1738, Rotterdam, 3000 DR the Netherlands
| | - Odile M. C. Bremer
- Arkin Mental Health, NPI Institute for Personality Disorders, Domselaerstraat 128, Amsterdam, 1093 MB the Netherlands
| | - Eliane C. P. Dek
- PsyQ Personality Disorders Rotterdam-Kralingen, Max Euwelaan 70, Rotterdam, 3062 MA the Netherlands
| | | | - Chrissy James
- Department of Personality Disorders, Outpatient Clinic De Nieuwe Valerius, GGZ inGeest, Amstelveenseweg 589, Amsterdam, 1082 JC the Netherlands
| | | | - Linda Kramer
- GGZ Noord-Holland-Noord, Stationsplein 138, 1703 WC Heerhugowaard, the Netherlands
| | | | - Arita Schaling
- Pro Persona, Willy Brandtlaan 20, Ede, 6716 RR the Netherlands
| | - Faye I. Smits
- GGZ Rivierduinen, Sandifortdreef 19, Leiden, 2333 ZZ the Netherlands
| | - Jan H. Kamphuis
- Department of Clinical Psychology, University of Amsterdam, Nieuwe Achtergracht 129-B, Amsterdam, 1018 WS the Netherlands
| |
Collapse
|
18
|
Tong G, Esserman D, Li F. Accounting for unequal cluster sizes in designing cluster randomized trials to detect treatment effect heterogeneity. Stat Med 2021; 41:1376-1396. [PMID: 34923655 DOI: 10.1002/sim.9283] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Revised: 11/14/2021] [Accepted: 11/24/2021] [Indexed: 12/26/2022]
Abstract
Unequal cluster sizes are common in cluster randomized trials (CRTs). While there are a number of previous investigations studying the impact of unequal cluster sizes on the power for testing the average treatment effect in CRTs, little is known about the impact of unequal cluster sizes on the power for testing the heterogeneous treatment effect (HTE) in CRTs. In this work, we expand the sample size procedures for studying HTE in CRTs to accommodate cluster size variation under the linear mixed model framework. Through analytical derivation and graphical exploration, we show that the sample size for the HTE with an individual-level effect modifier is less affected by unequal cluster sizes than with a cluster-level effect modifier. The impact of cluster size variability jointly depends on the mean and coefficient of variation of cluster sizes, covariate intraclass correlation coefficient (ICC) and the conditional outcome ICC. In addition, we demonstrate that the HTE-motivated analysis of covariance framework can be used for analyzing the average treatment effect, and offer a more efficient sample size procedure for studying the average treatment effect adjusting for the effect modifier. We use simulations to confirm the accuracy of the proposed sample size procedures for both the average treatment effect and HTE in CRTs. Extensions to multivariate effect modifiers are provided and our procedure is illustrated in the context of the Strategies to Reduce Injuries and Develop Confidence in Elders trial.
Collapse
Affiliation(s)
- Guangyu Tong
- Department of Biostatistics, Yale School of Public Health, New Haven, Connecticut, USA.,Yale Center for Analytical Sciences, Yale School of Public Health, New Haven, Connecticut, USA
| | - Denise Esserman
- Department of Biostatistics, Yale School of Public Health, New Haven, Connecticut, USA.,Yale Center for Analytical Sciences, Yale School of Public Health, New Haven, Connecticut, USA
| | - Fan Li
- Department of Biostatistics, Yale School of Public Health, New Haven, Connecticut, USA.,Yale Center for Analytical Sciences, Yale School of Public Health, New Haven, Connecticut, USA.,Center for Methods in Implementation and Prevention Science, Yale School of Public Health, New Haven, Connecticut, USA
| |
Collapse
|
19
|
Ip A, Muller I, Geraghty AWA, Rumsby K, Stuart B, Little P, Santer M. Supporting Self-management Among Young People With Acne Vulgaris Through a Web-Based Behavioral Intervention: Development and Feasibility Randomized Controlled Trial. JMIR DERMATOLOGY 2021; 4:e25918. [PMID: 37632804 PMCID: PMC10334953 DOI: 10.2196/25918] [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: 11/20/2020] [Revised: 02/05/2021] [Accepted: 08/05/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Acne is a common skin condition that is most prevalent in young people. It can have a substantial impact on the quality of life, which can be minimized with the appropriate use of topical treatments. Nonadherence to topical treatments for acne is common and often leads to treatment failure. OBJECTIVE The aim of this study is to develop a web-based behavioral intervention to support the self-management of acne and to assess the feasibility of recruitment, retention, and engagement of users with the intervention. METHODS The intervention was developed iteratively using the LifeGuide software and following the person-based approach for intervention development. The target behavior was appropriate use of topical treatments. Barriers and facilitators identified from the qualitative research and evidence from the wider literature were used to identify techniques to improve and promote their use. Young people with acne aged 14-25 years who had received treatment for acne in the past 6 months were invited to participate through mail-out from primary care practices in the South of England in a parallel, unblinded randomized trial. Participants were automatically randomized using a computer-generated algorithm to usual care or to usual care plus access to the web-based intervention. Usage data was collected, and a series of questionnaires, including the primary outcome measure for skin-specific quality of life (Skindex-16), were collected at baseline and at the 4- and 6-week follow-ups. RESULTS A total of 1193 participants were invited, and 53 young people with acne were randomized to usual care (27/53, 51%) or usual care plus intervention (26/53, 49%). The response rate for the primary outcome measure (Skindex-16) was 87% at 4 weeks, 6 weeks, and at both time points. The estimate of mean scores between groups (with 95% CI) using linear regression showed a trend in the direction of benefit for the web-based intervention group in the primary outcome measure (Skindex-16) and secondary measures (Patient Health Questionnaire-4 and the Problematic Experiences of Therapy Scale). Intervention usage data showed high uptake of the core module in the usual care plus web-based intervention group, with 88% (23/26) of participants completing the module. Uptake of the optional modules was low, with less than half visiting each (myth-busting quiz: 27%; living with spots or acne: 42%; oral antibiotics: 19%; what are spots or acne: 27%; other treatments: 27%; talking to your general practitioner: 12%). CONCLUSIONS This study demonstrated the feasibility of delivering a trial of a web-based intervention to support self-management in young people with acne. Additional work is needed before a full definitive trial, including enhancing engagement with the intervention, recruitment, and follow-up rates. TRIAL REGISTRATION ISRCTN 78626638; https://tinyurl.com/n4wackrw.
Collapse
Affiliation(s)
- Athena Ip
- Primary Care, Population Sciences and Medical Education, University of Southampton, Southampton, United Kingdom
- School of Health Sciences, University of Surrey, Guildford, United Kingdom
| | - Ingrid Muller
- Primary Care, Population Sciences and Medical Education, University of Southampton, Southampton, United Kingdom
| | - Adam W A Geraghty
- Primary Care, Population Sciences and Medical Education, University of Southampton, Southampton, United Kingdom
| | - Kate Rumsby
- Primary Care, Population Sciences and Medical Education, University of Southampton, Southampton, United Kingdom
| | - Beth Stuart
- Primary Care, Population Sciences and Medical Education, University of Southampton, Southampton, United Kingdom
| | - Paul Little
- Primary Care, Population Sciences and Medical Education, University of Southampton, Southampton, United Kingdom
| | - Miriam Santer
- Primary Care, Population Sciences and Medical Education, University of Southampton, Southampton, United Kingdom
| |
Collapse
|
20
|
Tong G, Seal KH, Becker WC, Li F, Dziura JD, Peduzzi PN, Esserman DA. Impact of complex, partially nested clustering in a three-arm individually randomized group treatment trial: A case study with the wHOPE trial. Clin Trials 2021; 19:3-13. [PMID: 34693748 DOI: 10.1177/17407745211051288] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND/AIMS When participants in individually randomized group treatment trials are treated by multiple clinicians or in multiple group treatment sessions throughout the trial, this induces partially nested clusters which can affect the power of a trial. We investigate this issue in the Whole Health Options and Pain Education trial, a three-arm pragmatic, individually randomized clinical trial. We evaluate whether partial clusters due to multiple visits delivered by different clinicians in the Whole Health Team arm and dynamic participant groups due to changing group leaders and/or participants across treatment sessions during treatment delivery in the Primary Care Group Education arm may impact the power of the trial. We also present a Bayesian approach to estimate the intraclass correlation coefficients. METHODS We present statistical models for each treatment arm of Whole Health Options and Pain Education trial in which power is estimated under different intraclass correlation coefficients and mapping matrices between participants and clinicians or treatment sessions. Power calculations are based on pairwise comparisons. In practice, sample size calculations depend on estimates of the intraclass correlation coefficients at the treatment sessions and clinician levels. To accommodate such complexities, we present a Bayesian framework for the estimation of intraclass correlation coefficients under different participant-to-session and participant-to-clinician mapping scenarios. We simulated continuous outcome data based on various clinical scenarios in Whole Health Options and Pain Education trial using a range of intraclass correlation coefficients and mapping matrices and used Gibbs samplers with conjugate priors to obtain posteriors of the intraclass correlation coefficients under those different scenarios. Posterior means and medians and their biases are calculated for the intraclass correlation coefficients to evaluate the operating characteristics of the Bayesian intraclass correlation coefficient estimators. RESULTS Power for Whole Health Team versus Primary Care Group Education is sensitive to the intraclass correlation coefficient in the Whole Health Team arm. In these two arms, an increased number of clinicians, more evenly distributed workload of clinicians, or more homogeneous treatment group sizes leads to increased power. Our simulation study for the intraclass correlation coefficient estimation indicates that the posterior mean intraclass correlation coefficient estimator has less bias when the true intraclass correlation coefficients are large (i.e. 0.10), but when the intraclass correlation coefficient is small (i.e. 0.01), the posterior median intraclass correlation coefficient estimator is less biased. CONCLUSION Knowledge of intraclass correlation coefficients and the structure of clustering are critical to the design of individually randomized group treatment trials with partially nested clusters. We demonstrate that the intraclass correlation coefficient of the Whole Health Team arm can affect power in the Whole Health Options and Pain Education trial. A Bayesian approach provides a flexible procedure for estimating the intraclass correlation coefficients under complex scenarios. More work is needed to educate the research community about the individually randomized group treatment design and encourage publication of intraclass correlation coefficients to help inform future trial designs.
Collapse
Affiliation(s)
- Guangyu Tong
- Department of Biostatistics, Yale School of Public Health, New Haven, CT, USA.,Yale Center for Analytical Sciences, Yale School of Public Health, New Haven, CT, USA
| | - Karen H Seal
- San Francisco VA Health Care System, Integrative Health Service, San Francisco, CA, USA.,Department of Medicine and Psychiatry, University of California-San Francisco, San Francisco, CA, USA
| | - William C Becker
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA.,VA Connecticut Healthcare System, Pain Research, Informatics, Multimorbidities and Education Center of Innovation, West Haven, CT, USA
| | - Fan Li
- Department of Biostatistics, Yale School of Public Health, New Haven, CT, USA
| | - James D Dziura
- Department of Biostatistics, Yale School of Public Health, New Haven, CT, USA.,Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Peter N Peduzzi
- Department of Biostatistics, Yale School of Public Health, New Haven, CT, USA
| | - Denise A Esserman
- Department of Biostatistics, Yale School of Public Health, New Haven, CT, USA
| |
Collapse
|
21
|
van Breukelen GJP, Candel MJJM. Maximin design of cluster randomized trials with heterogeneous costs and variances. Biom J 2021; 63:1444-1463. [PMID: 34247406 PMCID: PMC8519108 DOI: 10.1002/bimj.202100019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Revised: 05/07/2021] [Accepted: 05/22/2021] [Indexed: 11/29/2022]
Abstract
Cluster randomized trials evaluate the effect of a treatment on persons nested within clusters, with clusters being randomly assigned to treatment. The optimal sample size at the cluster and person level depends on the study cost per cluster and per person, and the outcome variance at the cluster and the person level. The variances are unknown in the design stage and can differ between treatment arms. As a solution, this paper presents a Maximin design that maximizes the minimum relative efficiency (relative to the optimal design) over the variance parameter space, for trials with two treatment arms and a quantitative outcome. This maximin relative efficiency design (MMRED) is compared with a published Maximin design which maximizes the minimum efficiency (MMED). Both designs are also compared with the optimal designs for homogeneous costs and variances (balanced design) and heterogeneous costs and homogeneous variances (cost-conscious design), for a range of variances based upon three published trials. Whereas the MMED is balanced under high uncertainty about the treatment-to-control variance ratio, the MMRED then tends towards a balanced budget allocation between arms, leading to an unbalanced sample size allocation if costs are heterogeneous, similar to the cost-conscious design. Further, the MMRED corresponds to an optimal design for an intraclass correlation (ICC) in the lower half of the assumed ICC range (optimistic), whereas the MMED is the optimal design for the maximum ICC within the ICC range (pessimistic). Attention is given to the effect of the Welch-Satterthwaite degrees of freedom for treatment effect testing on the design efficiencies.
Collapse
Affiliation(s)
| | - Math J. J. M. Candel
- Department of Methodology and StatisticsMaastricht UniversityMaastrichtThe Netherlands
| |
Collapse
|
22
|
Sex/gender considerations in school-based interventions to promote children’s and adolescents’ physical activity. GERMAN JOURNAL OF EXERCISE AND SPORT RESEARCH 2021. [DOI: 10.1007/s12662-021-00724-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
AbstractPhysical inactivity is an increasing problem worldwide, but especially among girls. This difference by gender increases with age. Schools serve virtually all young people in most parts of the world and can thus play an important role in promoting physical activity. In this systematic review, we qualitatively and comprehensively assessed the treatment of sex/gender considerations (from study design to discussion of results) in 56 school-based intervention studies aiming to promote physical activity in children and adolescents. In all 56 studies, the factor of sex/gender was only rudimentarily considered, regardless of the effectiveness of the intervention. The meta-analysis revealed that the interventions had significant but relatively small effects with both girls and boys, along with high heterogeneity. To obtain better information about effective strategies that promote physical activity for both girls and boys equally, researchers conducting future intervention studies should pay attention to sex/gender differences and report on how they take this factor into account.
Collapse
|
23
|
Chondros P, Ukoumunne OC, Gunn JM, Carlin JB. When should matching be used in the design of cluster randomized trials? Stat Med 2021; 40:5765-5778. [PMID: 34390264 DOI: 10.1002/sim.9152] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 05/25/2021] [Accepted: 07/18/2021] [Indexed: 01/10/2023]
Abstract
For cluster randomized trials (CRTs) with a small number of clusters, the matched-pair (MP) design, where clusters are paired before randomizing one to each trial arm, is often recommended to minimize imbalance on known prognostic factors, add face-validity to the study, and increase efficiency, provided the analysis recognizes the matching. Little evidence exists to guide decisions on when to use matching. We used simulation to compare the efficiency of the MP design with the stratified and simple designs, based on the mean confidence interval width of the estimated intervention effect. Matched and unmatched analyses were used for the MP design; a stratified analysis was used for the stratified design; and analyses without and with post-stratification adjustment for factors that would otherwise have been used for restricted allocation were used for the simple design. Results showed the MP design was generally the most efficient for CRTs with 10 or more pairs when the correlation between cluster-level outcomes within pairs (matching correlation) was moderate to strong (0.3-0.5). There was little gain in efficiency for the MP or stratified designs compared to simple randomization when the matching correlation was weak (0.05-0.1). For trials with four pairs of clusters, the simple and stratified designs were more efficient than the MP design because greater degrees of freedom were available for the analysis, although an unmatched analysis of the MP design recovered precision for weak matching correlations. Practical guidance on choosing between the MP, stratified, and simple designs is provided.
Collapse
Affiliation(s)
- Patty Chondros
- Department of General Practice, Melbourne Medical School, The University of Melbourne, Melbourne, Victoria, Australia
| | - Obioha C Ukoumunne
- NIHR Applied Research Collaboration South West Peninsula (PenARC), University of Exeter, Exeter, UK
| | - Jane M Gunn
- Department of General Practice, Melbourne Medical School, The University of Melbourne, Melbourne, Victoria, Australia
| | - John B Carlin
- Clinical Epidemiology and Biostatistics Unit, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Paediatrics, The University of Melbourne, Melbourne, Victoria, Australia
| |
Collapse
|
24
|
Ciolino JD, Spino C, Ambrosius WT, Khalatbari S, Cayetano SM, Lapidus JA, Nietert PJ, Oster RA, Perkins SM, Pollock BH, Pomann GM, Price LL, Rice TW, Tosteson TD, Lindsell CJ, Spratt H. Guidance for biostatisticians on their essential contributions to clinical and translational research protocol review. J Clin Transl Sci 2021; 5:e161. [PMID: 34527300 PMCID: PMC8427547 DOI: 10.1017/cts.2021.814] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Revised: 06/30/2021] [Accepted: 07/02/2021] [Indexed: 12/23/2022] Open
Abstract
Rigorous scientific review of research protocols is critical to making funding decisions, and to the protection of both human and non-human research participants. Given the increasing complexity of research designs and data analysis methods, quantitative experts, such as biostatisticians, play an essential role in evaluating the rigor and reproducibility of proposed methods. However, there is a common misconception that a statistician's input is relevant only to sample size/power and statistical analysis sections of a protocol. The comprehensive nature of a biostatistical review coupled with limited guidance on key components of protocol review motived this work. Members of the Biostatistics, Epidemiology, and Research Design Special Interest Group of the Association for Clinical and Translational Science used a consensus approach to identify the elements of research protocols that a biostatistician should consider in a review, and provide specific guidance on how each element should be reviewed. We present the resulting review framework as an educational tool and guideline for biostatisticians navigating review boards and panels. We briefly describe the approach to developing the framework, and we provide a comprehensive checklist and guidance on review of each protocol element. We posit that the biostatistical reviewer, through their breadth of engagement across multiple disciplines and experience with a range of research designs, can and should contribute significantly beyond review of the statistical analysis plan and sample size justification. Through careful scientific review, we hope to prevent excess resource expenditure and risk to humans and animals on poorly planned studies.
Collapse
Affiliation(s)
- Jody D. Ciolino
- Department of Preventive Medicine, Division of Biostatistics, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Cathie Spino
- Department of Biostatistics, University of Michigan, Washington Heights, Ann Arbor, MI, USA
| | - Walter T. Ambrosius
- Department of Biostatistics and Data Science, Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Shokoufeh Khalatbari
- Michigan Institute for Clinical & Health Research (MICHR), University of Michigan, Ann Arbor, MI, USA
| | | | - Jodi A. Lapidus
- School of Public Health, Oregon Health & Sciences University, Portland, OR, USA
| | - Paul J Nietert
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC, USA
| | - Robert A. Oster
- Department of Medicine, Division of Preventive Medicine, University of Alabama at Birmingham, Birmingham, AL, UK
| | - Susan M. Perkins
- Department of Biostatistics, Indiana University, Indianapolis, IN, USA
| | - Brad H. Pollock
- Department of Public Health Sciences, UC Davis School of Medicine, Davis, CA, USA
| | - Gina-Maria Pomann
- Duke Biostatistics, Epidemiology and Research Design (BERD) Methods Core, Duke University, Durham, NC, USA
| | - Lori Lyn Price
- Tufts Clinical and Translational Science Institute, Tufts University, Boston, MA, USA
- Institute of Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA, USA
| | - Todd W. Rice
- Department of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine, Medical Director, Vanderbilt Human Research Protections Program, Vice-President for Clinical Trials Innovation and Operations, Nashville, TN, USA
| | - Tor D. Tosteson
- Department of Biomedical Data Science, Division of Biostatistics, Geisel School of Medicine at Dartmouth, Hanover, NH, USA
| | | | - Heidi Spratt
- Department of Preventive Medicine and Population Health, University of Texas Medical Branch, Galveston, TX, USA
| |
Collapse
|
25
|
Schulze C, Bucksch J, Demetriou Y, Emmerling S, Linder S, Reimers AK. Considering sex/gender in interventions to promote children’s and adolescents’ leisure-time physical activity: a systematic review and meta-analysis. J Public Health (Oxf) 2021. [DOI: 10.1007/s10389-021-01625-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Abstract
Aim
The main objectives of this systematic review were to evaluate the effects of interventions on leisure-time PA of boys and girls and to appraise the extent to which studies have taken sex/gender into account.
Subject and methods
PRISMA guidelines were followed. Two researchers independently screened studies for eligibility and assessed the risk of bias. Descriptive analyses were conducted to evaluate intervention effects in relation to the consideration of sex/gender in the studies based on a newly developed checklist. Additionally, meta-analyses were performed to determine the effect of interventions on girls’ and boys’ leisure-time PA.
Results
Overall 31 unique studies reported 44 outcomes on leisure-time PA and 20,088 participants were included in the current study. Consideration of sex/gender aspects in studies is low. PA outcomes with statistically significant same/similar effects in boys and girls showed higher quality of reporting sex/gender aspects of theoretical and/or conceptual linkages with sex/gender, measurement instruments, intervention delivery, location and interventionists and participant flow than PA outcomes without significant effects in both boys and girls or effects only in boys or girls. Interventions had a small but significant effect on girls (number of included studies (k) = 9, g = 0.220, p = .003) and boys (k = 7, g = 0.193, p = .020) leisure-time PA.
Conclusion
Higher reporting of sex/gender aspects may improve leisure-time PA of boys and girls. Nevertheless, there remains a need to address sufficient consideration of sex/gender aspects in interventions in the context of PA.
Collapse
|
26
|
Gaynes BN, Akiba CF, Hosseinipour MC, Kulisewa K, Amberbir A, Udedi M, Zimba CC, Masiye JK, Crampin M, Amarreh I, Pence BW. The Sub-Saharan Africa Regional Partnership (SHARP) for Mental Health Capacity-Building Scale-Up Trial: Study Design and Protocol. Psychiatr Serv 2021; 72:812-821. [PMID: 33291973 PMCID: PMC8187465 DOI: 10.1176/appi.ps.202000003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND Depression is a leading cause of death and disability worldwide, including in low- and middle-income countries (LMICs). Depression often coexists with chronic medical conditions and is associated with worse clinical outcomes. This confluence has led to calls to integrate mental health treatment with chronic disease care systems in LMICs. This article describes the rationale and protocol for a trial comparing the clinical effectiveness and cost-effectiveness of two different intervention packages to implement evidence-based antidepressant management and psychotherapy into chronic noncommunicable disease (NCD) clinics in Malawi. METHODS Using constrained randomization, the Sub-Saharan Africa Regional Partnership (SHARP) for mental health capacity building will assign five Malawian NCD clinics to a basic implementation strategy via an internal coordinator, a provider within the chronic care clinic who champions depression services by providing training, supervision, operations, and reporting. Another five clinics will be assigned to depression services implementation via an internal coordinator along with an external quality assurance committee, which will provide a quarterly audit of intervention component delivery with feedback to providers and the health management team. RESULTS The authors will compare key implementation outcomes (fidelity to intervention), clinical effectiveness outcomes (patient health), and cost-effectiveness and will assess characteristics of clinics that may influence uptake and fidelity. NEXT STEPS This trial will provide key information to guide the Malawi Ministry of Health in scaling up depression management in existing NCD settings. The SHARP trial is anticipated to substantially contribute to enhancing both mental health treatment and implementation science research capacity in Malawi and the wider region.
Collapse
Affiliation(s)
- Bradley N Gaynes
- Department of Psychiatry (Gaynes) and Department of Medicine (Hosseinipour), School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill; Department of Health Behavior (Akiba) and Department of Epidemiology (Pence), Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill; Department of Mental Health and Psychiatry, University of Malawi College of Medicine, Blantyre, Malawi (Kulisewa); Partners in Hope, Lilongwe, Malawi (Amberbir); Malawi Ministry of Health, Lilongwe, Malawi (Udedi, Masiye); University of North Carolina Project-Malawi, Lilongwe, Malawi (Zimba); Malawi Epidemiology and Intervention Research Unit, Lilongwe, Malawi (Crampin); National Institute of Mental Health, Bethesda, Maryland (Amarreh)
| | - Christopher F Akiba
- Department of Psychiatry (Gaynes) and Department of Medicine (Hosseinipour), School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill; Department of Health Behavior (Akiba) and Department of Epidemiology (Pence), Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill; Department of Mental Health and Psychiatry, University of Malawi College of Medicine, Blantyre, Malawi (Kulisewa); Partners in Hope, Lilongwe, Malawi (Amberbir); Malawi Ministry of Health, Lilongwe, Malawi (Udedi, Masiye); University of North Carolina Project-Malawi, Lilongwe, Malawi (Zimba); Malawi Epidemiology and Intervention Research Unit, Lilongwe, Malawi (Crampin); National Institute of Mental Health, Bethesda, Maryland (Amarreh)
| | - Mina C Hosseinipour
- Department of Psychiatry (Gaynes) and Department of Medicine (Hosseinipour), School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill; Department of Health Behavior (Akiba) and Department of Epidemiology (Pence), Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill; Department of Mental Health and Psychiatry, University of Malawi College of Medicine, Blantyre, Malawi (Kulisewa); Partners in Hope, Lilongwe, Malawi (Amberbir); Malawi Ministry of Health, Lilongwe, Malawi (Udedi, Masiye); University of North Carolina Project-Malawi, Lilongwe, Malawi (Zimba); Malawi Epidemiology and Intervention Research Unit, Lilongwe, Malawi (Crampin); National Institute of Mental Health, Bethesda, Maryland (Amarreh)
| | - Kazione Kulisewa
- Department of Psychiatry (Gaynes) and Department of Medicine (Hosseinipour), School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill; Department of Health Behavior (Akiba) and Department of Epidemiology (Pence), Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill; Department of Mental Health and Psychiatry, University of Malawi College of Medicine, Blantyre, Malawi (Kulisewa); Partners in Hope, Lilongwe, Malawi (Amberbir); Malawi Ministry of Health, Lilongwe, Malawi (Udedi, Masiye); University of North Carolina Project-Malawi, Lilongwe, Malawi (Zimba); Malawi Epidemiology and Intervention Research Unit, Lilongwe, Malawi (Crampin); National Institute of Mental Health, Bethesda, Maryland (Amarreh)
| | - Alemayehu Amberbir
- Department of Psychiatry (Gaynes) and Department of Medicine (Hosseinipour), School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill; Department of Health Behavior (Akiba) and Department of Epidemiology (Pence), Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill; Department of Mental Health and Psychiatry, University of Malawi College of Medicine, Blantyre, Malawi (Kulisewa); Partners in Hope, Lilongwe, Malawi (Amberbir); Malawi Ministry of Health, Lilongwe, Malawi (Udedi, Masiye); University of North Carolina Project-Malawi, Lilongwe, Malawi (Zimba); Malawi Epidemiology and Intervention Research Unit, Lilongwe, Malawi (Crampin); National Institute of Mental Health, Bethesda, Maryland (Amarreh)
| | - Michael Udedi
- Department of Psychiatry (Gaynes) and Department of Medicine (Hosseinipour), School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill; Department of Health Behavior (Akiba) and Department of Epidemiology (Pence), Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill; Department of Mental Health and Psychiatry, University of Malawi College of Medicine, Blantyre, Malawi (Kulisewa); Partners in Hope, Lilongwe, Malawi (Amberbir); Malawi Ministry of Health, Lilongwe, Malawi (Udedi, Masiye); University of North Carolina Project-Malawi, Lilongwe, Malawi (Zimba); Malawi Epidemiology and Intervention Research Unit, Lilongwe, Malawi (Crampin); National Institute of Mental Health, Bethesda, Maryland (Amarreh)
| | - Chifundo C Zimba
- Department of Psychiatry (Gaynes) and Department of Medicine (Hosseinipour), School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill; Department of Health Behavior (Akiba) and Department of Epidemiology (Pence), Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill; Department of Mental Health and Psychiatry, University of Malawi College of Medicine, Blantyre, Malawi (Kulisewa); Partners in Hope, Lilongwe, Malawi (Amberbir); Malawi Ministry of Health, Lilongwe, Malawi (Udedi, Masiye); University of North Carolina Project-Malawi, Lilongwe, Malawi (Zimba); Malawi Epidemiology and Intervention Research Unit, Lilongwe, Malawi (Crampin); National Institute of Mental Health, Bethesda, Maryland (Amarreh)
| | - Jones K Masiye
- Department of Psychiatry (Gaynes) and Department of Medicine (Hosseinipour), School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill; Department of Health Behavior (Akiba) and Department of Epidemiology (Pence), Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill; Department of Mental Health and Psychiatry, University of Malawi College of Medicine, Blantyre, Malawi (Kulisewa); Partners in Hope, Lilongwe, Malawi (Amberbir); Malawi Ministry of Health, Lilongwe, Malawi (Udedi, Masiye); University of North Carolina Project-Malawi, Lilongwe, Malawi (Zimba); Malawi Epidemiology and Intervention Research Unit, Lilongwe, Malawi (Crampin); National Institute of Mental Health, Bethesda, Maryland (Amarreh)
| | - Mia Crampin
- Department of Psychiatry (Gaynes) and Department of Medicine (Hosseinipour), School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill; Department of Health Behavior (Akiba) and Department of Epidemiology (Pence), Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill; Department of Mental Health and Psychiatry, University of Malawi College of Medicine, Blantyre, Malawi (Kulisewa); Partners in Hope, Lilongwe, Malawi (Amberbir); Malawi Ministry of Health, Lilongwe, Malawi (Udedi, Masiye); University of North Carolina Project-Malawi, Lilongwe, Malawi (Zimba); Malawi Epidemiology and Intervention Research Unit, Lilongwe, Malawi (Crampin); National Institute of Mental Health, Bethesda, Maryland (Amarreh)
| | - Ishmael Amarreh
- Department of Psychiatry (Gaynes) and Department of Medicine (Hosseinipour), School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill; Department of Health Behavior (Akiba) and Department of Epidemiology (Pence), Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill; Department of Mental Health and Psychiatry, University of Malawi College of Medicine, Blantyre, Malawi (Kulisewa); Partners in Hope, Lilongwe, Malawi (Amberbir); Malawi Ministry of Health, Lilongwe, Malawi (Udedi, Masiye); University of North Carolina Project-Malawi, Lilongwe, Malawi (Zimba); Malawi Epidemiology and Intervention Research Unit, Lilongwe, Malawi (Crampin); National Institute of Mental Health, Bethesda, Maryland (Amarreh)
| | - Brian W Pence
- Department of Psychiatry (Gaynes) and Department of Medicine (Hosseinipour), School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill; Department of Health Behavior (Akiba) and Department of Epidemiology (Pence), Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill; Department of Mental Health and Psychiatry, University of Malawi College of Medicine, Blantyre, Malawi (Kulisewa); Partners in Hope, Lilongwe, Malawi (Amberbir); Malawi Ministry of Health, Lilongwe, Malawi (Udedi, Masiye); University of North Carolina Project-Malawi, Lilongwe, Malawi (Zimba); Malawi Epidemiology and Intervention Research Unit, Lilongwe, Malawi (Crampin); National Institute of Mental Health, Bethesda, Maryland (Amarreh)
| |
Collapse
|
27
|
Imputing intracluster correlation coefficients from a posterior predictive distribution is a feasible method of dealing with unit of analysis errors in a meta-analysis of cluster RCTs. J Clin Epidemiol 2021; 139:307-318. [PMID: 34171503 DOI: 10.1016/j.jclinepi.2021.06.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Revised: 05/14/2021] [Accepted: 06/16/2021] [Indexed: 11/23/2022]
Abstract
BACKGROUND Incorporating cluster randomized trials (CRTs) into meta-analyses is challenging because appropriate standard errors of study estimates accounting for clustering are not always reported. Systematic reviews of CRTs often use a single constant external estimate of the intraclass correlation coefficient (ICC) to adjust study estimate standard errors and facilitate meta-analyses; an approach that fails to account for possible variation of ICCs among studies and the imprecision with which they are estimated. Using a large systematic review of the effects of diabetes quality improvement interventions, we investigated whether we could better account for ICC variation and uncertainty in meta-analyzed effect estimates by imputing missing ICCs from a posterior predictive distribution constructed from a database of relevant ICCs. METHODS We constructed a dataset of ICC estimates from applicable studies. For outcomes with two or more available ICC estimates, we constructed posterior predictive ICC distributions in a Bayesian framework. For a selected continuous outcome, glycosylated hemoglobin (HbA1c), we compared the impact of incorporating a single constant ICC versus imputing ICCs drawn from the posterior predictive distribution when estimating the effect of intervention components on post treatment mean in a case study of diabetes quality improvement trials. RESULTS Using internal and external ICC estimates, we were able to construct a database of 59 ICCs for 12 of the 13 review outcomes (range 1-10 per outcome) and estimate the posterior predictive ICC distribution for 11 review outcomes. Synthesized results were not markedly changed by our approach for HbA1c. CONCLUSION Building posterior predictive distributions to impute missing ICCs is a feasible approach to facilitate principled meta-analyses of cluster randomized trials using prior data. Further work is needed to establish whether the application of these methods leads to improved review inferences for different reviews based on different factors (e.g., proportion of CRTs and CRTs with missing ICCs, different outcomes, variation and precision of ICCs).
Collapse
|
28
|
Foraker RE, Davidson EC, Dressler EV, Wells BJ, Lee SC, Klepin HD, Winkfield KM, Hundley WG, Payne PRO, Lai AM, Lesser GJ, Weaver KE. Addressing cancer survivors' cardiovascular health using the automated heart health assessment (AH-HA) EHR tool: Initial protocol and modifications to address COVID-19 challenges. Contemp Clin Trials Commun 2021; 22:100808. [PMID: 34189339 PMCID: PMC8220316 DOI: 10.1016/j.conctc.2021.100808] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Revised: 05/14/2021] [Accepted: 06/13/2021] [Indexed: 11/26/2022] Open
Abstract
Background The purpose of this paper is to describe the Automated Heart-Health Assessment (AH-HA) study protocol, which demonstrates an agile approach to cancer care delivery research. This study aims to assess the effect of a clinical decision support tool for cancer survivors on cardiovascular health (CVH) discussions, referrals, completed visits with primary care providers and cardiologists, and control of modifiable CVH factors and behaviors. The COVID-19 pandemic has caused widespread disruption to clinical trial accrual and operations. Studies conducted with potentially vulnerable populations, including cancer survivors, must shift towards virtual consent, data collection, and study visits to reduce risk for participants and study staff. Studies examining cancer care delivery innovations may also need to accommodate the increased use of virtual visits. Methods/design This group-randomized, mixed methods study will recruit 600 cancer survivors from 12 National Cancer Institute Community Oncology Research Program (NCORP) practices. Survivors at intervention sites will use the AH-HA tool with their oncology provider; survivors at usual care sites will complete routine survivorship visits. Outcomes will be measured immediately after the study visit, with follow-up at 6 and 12 months. The study was amended during the COVID-19 pandemic to allow for virtual consent, data collection, and intervention options, with the goal of minimizing participant-staff in-person contact and accommodating virtual survivorship visits. Conclusions Changes to the study protocol and procedures allow important cancer care delivery research to continue safely during the COVID-19 pandemic and give sites and survivors flexibility to conduct study activities in-person or remotely. We present a protocol to examine the effectiveness of an electronic health record (EHR)-embedded CVH assessment tool for cancer survivors. The protocol was adapted to include virtual data collection and study visits to continue in the COVID-19 era. Flexibility to conduct study activities in-person or remotely supports accrual during the COVID-19 pandemic and beyond.
Collapse
Affiliation(s)
- Randi E Foraker
- Washington University School of Medicine, Institute for Informatics, 600 S. Taylor Avenue, St. Louis, MO, 63110, USA
| | - Eleanor C Davidson
- Wake Forest School of Medicine, Department of Social Sciences and Health Policy, 1 Medical Center Boulevard, Winston-Salem, NC, 27157, USA
| | - Emily V Dressler
- Wake Forest School of Medicine, Department of Biostatistics and Data Science, 1 Medical Center Boulevard, Winston-Salem, NC, 27157, USA
| | - Brian J Wells
- Wake Forest School of Medicine, Department of Biostatistics and Data Science & Department of Family Medicine, 1 Medical Center Boulevard, Winston-Salem, NC, 27157, USA
| | - Simon Craddock Lee
- University of Texas Southwestern Medical Center, Department of Population & Data Sciences, 5323 Harry Hines Boulevard, Dallas, TX, 75390, USA
| | - Heidi D Klepin
- Wake Forest School of Medicine, Department of Internal Medicine, Section on Hematology-Oncology, 1 Medical Center Boulevard, Winston-Salem, NC, 27157, USA
| | - Karen M Winkfield
- Wake Forest School of Medicine, Department of Radiation Oncology, 1 Medical Center Boulevard, Winston-Salem, NC, 27157, USA
| | - W Gregory Hundley
- Wake Forest School of Medicine, Department of Internal Medicine, Section on Cardiology, 1 Medical Center Boulevard, Winston-Salem, NC, 27157, USA
| | - Philip R O Payne
- Washington University in St. Louis, Computer Science and Engineering, Institute for Informatics, 4444 Forest Park Avenue, St. Louis, MO, 63110, USA
| | - Albert M Lai
- Washington University in St. Louis, General Medical Sciences, Institute for Informatics, 4444 Forest Park Avenue, St. Louis, MO, 63110, USA
| | - Glenn J Lesser
- Wake Forest School of Medicine, Department of Internal Medicine, Section on Hematology-Oncology, 1 Medical Center Boulevard, Winston-Salem, NC, 27157, USA
| | - Kathryn E Weaver
- Wake Forest School of Medicine, Department of Social Sciences and Health Policy & Department of Implementation Science, 1 Medical Center Boulevard, Winston-Salem, NC, 27157, USA
| |
Collapse
|
29
|
Picariello F, Moss-Morris R, Norton S, Macdougall IC, Da Silva-Gane M, Farrington K, Clayton H, Chilcot J. Feasibility Trial of Cognitive Behavioral Therapy for Fatigue in Hemodialysis (BReF Intervention). J Pain Symptom Manage 2021; 61:1234-1246.e5. [PMID: 33068707 DOI: 10.1016/j.jpainsymman.2020.10.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Revised: 10/06/2020] [Accepted: 10/08/2020] [Indexed: 02/08/2023]
Abstract
CONTEXT Fatigue affects at least half of patients who are on hemodialysis (HD) with considerable repercussions on their functioning, quality of life, and clinical outcomes. OBJECTIVES This study assessed the feasibility, acceptability, and potential benefits of a cognitive behavioral therapy intervention for renal fatigue (BReF intervention). METHODS This was a feasibility randomized controlled trial of the BReF intervention vs. waiting-list control. Outcomes included recruitment, retention, and adherence rates. Exploratory estimates of treatment effect were computed. The statistician was blinded to allocation. RESULTS Twenty-four prevalent HD patients experiencing clinical levels of fatigue were individually randomized (1:1) to BReF (N = 12) or waiting-list control arms (N = 12). Fifty-three (16.6%; 95% CI = 12.7-21.1) of 320 patients approached consented and completed the screening questionnaire. It was necessary to approach 13 patients for screening for every one patient randomized. The rate of retention at follow-up was 75% (95% CI = 53.29-90.23). Moderate to large treatment effects were observed in favor of BReF on fatigue severity, fatigue-related functional impairment, depression, and anxiety (standardized mean difference [SMD]g = 0.81; SMDg = 0.93; SMDg = 0.38; SMDg = 0.42, respectively) but not sleep quality (SMDg = -0.31). No trial adverse events occurred. CONCLUSION There was promising evidence in support of the need and benefits of a cognitive behavioral therapy-based intervention for fatigue in HD. However, uptake was low, possibly as a result of an already high treatment burden in this setting. Considerations on the context of delivery are necessary before pursuing a definitive trial.
Collapse
Affiliation(s)
- Federica Picariello
- Health Psychology Section, Psychology Department, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK.
| | - Rona Moss-Morris
- Health Psychology Section, Psychology Department, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Sam Norton
- Health Psychology Section, Psychology Department, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | | | - Maria Da Silva-Gane
- Department of Renal Medicine, Lister Hospital, Stevenage, UK; University of Hertfordshire, Hertfordshire, UK
| | - Ken Farrington
- Department of Renal Medicine, Lister Hospital, Stevenage, UK; University of Hertfordshire, Hertfordshire, UK
| | - Hope Clayton
- Department of Renal Medicine, Lister Hospital, Stevenage, UK
| | - Joseph Chilcot
- Health Psychology Section, Psychology Department, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| |
Collapse
|
30
|
Salz T, Ostroff JS, Nightingale CL, Atkinson TM, Davidson EC, Jinna SR, Kriplani A, Lesser GJ, Lynch KA, Mayer DK, Oeffinger KC, Patil S, Salner AL, Weaver KE. The Head and Neck Survivorship Tool (HN-STAR) Trial (WF-1805CD): A protocol for a cluster-randomized, hybrid effectiveness-implementation, pragmatic trial to improve the follow-up care of head and neck cancer survivors. Contemp Clin Trials 2021; 107:106448. [PMID: 34023515 DOI: 10.1016/j.cct.2021.106448] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Revised: 04/26/2021] [Accepted: 05/17/2021] [Indexed: 11/25/2022]
Abstract
Survivors of head and neck cancer (HNC) can have multiple health concerns. To facilitate their care, we developed and pilot-tested a clinical informatics intervention, HN-STAR. HN-STAR elicits concerns online from HNC survivors prior to a routine oncology clinic visit. HN-STAR then presents tailored evidence-based clinical recommendations as a clinical decision support tool to be used during the visit where the oncology clinician and survivor select symptom management strategies and other actions. This generates a survivorship care plan (SCP). Online elicitation of health concerns occurs 3, 6, and 9 months after the clinic visit, generating an updated SCP each time. HN-STAR encompasses important methods of improving survivorship care (e.g., needs assessment, tailored interventions, dissemination of guidelines) and will be evaluated in a pragmatic trial to maximize external validity. This hybrid type 1 implementation-effectiveness trial tests HN-STAR effectiveness while studying barriers and facilitators to implementation in community oncology practices within the National Cancer Institute Community Oncology Research Program. Effectiveness will be measured as differences in key survivorship outcomes between HNC participants who do and do not use HN-STAR over one year after the clinic visit. The primary endpoint is HNC-specific quality of life; other outcomes include patient-centered measures and receipt of guideline-concordant care. Implementation outcomes will be assessed of survivors, providers, and clinic stakeholders. The hybrid design will provide insight into a dose-response relationship between the extent of implementation fidelity and effectiveness outcomes, as well as how to incorporate HN-STAR into standard practice outside the research setting.
Collapse
Affiliation(s)
- Talya Salz
- Memorial Sloan Kettering Cancer Center, 1275 York Street, New York, NY 10065, USA.
| | - Jamie S Ostroff
- Memorial Sloan Kettering Cancer Center, 1275 York Street, New York, NY 10065, USA
| | - Chandylen L Nightingale
- Wake Forest School of Medicine, Department of Social Sciences & Health Policy, Medical Center Boulevard, Winston-Salem, NC 27157, USA
| | - Thomas M Atkinson
- Memorial Sloan Kettering Cancer Center, 1275 York Street, New York, NY 10065, USA
| | - Eleanor C Davidson
- Wake Forest School of Medicine, Department of Social Sciences & Health Policy, Medical Center Boulevard, Winston-Salem, NC 27157, USA
| | - Sankeerth R Jinna
- Memorial Sloan Kettering Cancer Center, 1275 York Street, New York, NY 10065, USA
| | - Anuja Kriplani
- Memorial Sloan Kettering Cancer Center, 1275 York Street, New York, NY 10065, USA
| | - Glenn J Lesser
- Wake Forest School of Medicine, Department of Social Sciences & Health Policy, Medical Center Boulevard, Winston-Salem, NC 27157, USA
| | - Kathleen A Lynch
- Memorial Sloan Kettering Cancer Center, 1275 York Street, New York, NY 10065, USA
| | - Deborah K Mayer
- University of North Carolina Lineberger Comprehensive Cancer Center, 450 West Dr, Chapel Hill, NC 27599, USA
| | - Kevin C Oeffinger
- Duke Cancer Institute, 2424 Erwin Dr, Suite 601, Durham, NC 27705, USA
| | - Sujata Patil
- The Cleveland Clinic Foundation, 9500 Euclid Avenue, CA6-160, Cleveland, OH 44195, USA
| | - Andrew L Salner
- Hartford HealthCare Cancer Institute at Hartford Hospital, 79 Retreat Ave, Hartford, CT 06106, USA
| | - Kathryn E Weaver
- Wake Forest School of Medicine, Department of Social Sciences & Health Policy, Medical Center Boulevard, Winston-Salem, NC 27157, USA
| |
Collapse
|
31
|
Hadisoemarto PF, Lestari BW, Sharples K, Afifah N, Chaidir L, Huang CC, McAllister S, van Crevel R, Murray M, Alisjahbana B, Hill PC. A public health intervention package for increasing tuberculosis notifications from private practitioners in Bandung, Indonesia (INSTEP2): A cluster-randomised controlled trial protocol. F1000Res 2021; 10:327. [PMID: 35528962 PMCID: PMC9039369 DOI: 10.12688/f1000research.52089.1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/23/2022] [Indexed: 02/13/2024] Open
Abstract
Background. A significant proportion of tuberculosis (TB) patients globally make their initial visit for medical care to either an informal provider or a private practitioner, and many are not formally notified. Involvement of private practitioners (PPs) in a public-private mix for TB (TB-PPM) provides an opportunity for improving TB control. However, context-specific interventions beyond public-private agreements and mandatory notification are needed. In this study we will evaluate whether a tailored intervention package can increase TB notifications from PPs in Indonesia. Methods. This is a cluster-randomized trial of a multi-component public health intervention. 36 community health centre (CHC) areas will be selected as study locations and randomly allocated to intervention and control arms (1:1). PPs in the intervention areas will be identified using a mapping exercise and recruited into the study if they are eligible and consent. They will receive a tailored intervention package including in-person education about TB management along with bimonthly electronic refreshers, context-specific selection of referral pathways, and access to a TB-reporting app developed in collaboration with the National TB programme. The primary hypothesis is that the intervention package will increase the TB notification rate. The primary outcome will be measured by collecting notification data from the CHCs in intervention and control arms at the end of a 1-year observation period and comparing with the 1-year pre-intervention. The primary analysis will be intention-to-treat at the cluster level, using a generalised mixed model with repeated measures of TB notifications for 1 year pre- and 1 year post-intervention. Discussion. The results from this study will provide evidence on whether a tailored intervention package is effective in increasing the number of TB notifications, and whether the PPs refer presumptive TB cases correctly. The study results will guide policy in the development of TB-PPM in Indonesia and similar settings.
Collapse
Affiliation(s)
- Panji Fortuna Hadisoemarto
- Tuberculosis Working Group, Infectious Disease Research Centre, Faculty of Medicine Universitas Padjadjaran, Bandung, West Java, 40161, Indonesia
- Department of Public Health, Faculty of Medicine Universitas Padjadjaran, Bandung, West Java, 40161, Indonesia
- Department of Preventive and Social Medicine, Centre for International Health, University of Otago, Dunedin, 9016, New Zealand
| | - Bony Wiem Lestari
- Tuberculosis Working Group, Infectious Disease Research Centre, Faculty of Medicine Universitas Padjadjaran, Bandung, West Java, 40161, Indonesia
- Department of Public Health, Faculty of Medicine Universitas Padjadjaran, Bandung, West Java, 40161, Indonesia
- Department of Internal Medicine, Radboud Institute for Health Sciences, Radboud University Medical Centre, Nijmegen, 6525 GA, The Netherlands
| | - Katrina Sharples
- Department of Mathematics and Statistics, University of Otago, Dunedin, 9016, New Zealand
| | - Nur Afifah
- Tuberculosis Working Group, Infectious Disease Research Centre, Faculty of Medicine Universitas Padjadjaran, Bandung, West Java, 40161, Indonesia
| | - Lidya Chaidir
- Tuberculosis Working Group, Infectious Disease Research Centre, Faculty of Medicine Universitas Padjadjaran, Bandung, West Java, 40161, Indonesia
- Department of Microbiology, Faculty of Medicine Universitas Padjadjaran, Bandung, West Java, 40161, Indonesia
| | - Chuan-Chin Huang
- Division of Global Health Equity, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, 02115, USA
| | - Susan McAllister
- Department of Preventive and Social Medicine, Centre for International Health, University of Otago, Dunedin, 9016, New Zealand
| | - Reinout van Crevel
- Department of Internal Medicine, Radboud Institute for Health Sciences, Radboud University Medical Centre, Nijmegen, 6525 GA, The Netherlands
| | - Megan Murray
- Division of Global Health Equity, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, 02115, USA
| | - Bachti Alisjahbana
- Tuberculosis Working Group, Infectious Disease Research Centre, Faculty of Medicine Universitas Padjadjaran, Bandung, West Java, 40161, Indonesia
- Department of Internal Medicine, Dr Hasan Sadikin General Hospital, Bandung, West Java, 40161, Indonesia
| | - Philip C Hill
- Department of Preventive and Social Medicine, Centre for International Health, University of Otago, Dunedin, 9016, New Zealand
| |
Collapse
|
32
|
Parker K, Nunns MP, Xiao Z, Ford T, Ukoumunne OC. Characteristics and practices of school-based cluster randomised controlled trials for improving health outcomes in pupils in the UK: a systematic review protocol. BMJ Open 2021; 11:e044143. [PMID: 33589463 PMCID: PMC7887361 DOI: 10.1136/bmjopen-2020-044143] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
INTRODUCTION Cluster randomised trials (CRTs) are studies in which groups (clusters) of participants rather than the individuals themselves are randomised to trial arms. CRTs are becoming increasingly relevant for evaluating interventions delivered in school settings for improving the health of children. Schools are a convenient setting for health interventions targeted at children and the CRT design respects the clustered structure in schools (ie, pupils within classrooms/teachers within schools). Some of the methodological challenges of CRTs, such as ethical considerations for enrolment of children into trials and how best to handle the analysis of data from participants (pupils) that change clusters (schools), may be more salient for the school setting. A better understanding of the characteristics and methodological considerations of school-based CRTs of health interventions would inform the design of future similar studies. To our knowledge, this is the only systematic review to focus specifically on the characteristics and methodological practices of CRTs delivered in schools to evaluate interventions for improving health outcomes in pupils in the UK. METHODS AND ANALYSIS We will search for CRTs published from inception to 30 June 2020 inclusively indexed in MEDLINE (Ovid). We will identify relevant articles through title and abstract screening, and subsequent full-text screening for eligibility against predefined inclusion criteria. Disagreements will be resolved through discussion. Two independent reviewers will extract data for each study using a prepiloted data extraction form. Findings will be summarised using descriptive statistics and graphs. ETHICS AND DISSEMINATION This methodological systematic review does not require ethical approval as only secondary data extracted from papers will be analysed and the data are not linked to individual participants. After completion of the systematic review, the data will be analysed, and the findings disseminated through peer-reviewed publications and scientific meetings. PROSPERO REGISTRATION NUMBER CRD42020201792.
Collapse
Affiliation(s)
- Kitty Parker
- NIHR ARC South West Peninsula (PenARC), University of Exeter, Exeter, Devon, UK
| | - Michael P Nunns
- College of Medicine and Health, University of Exeter, Exeter, UK
| | - ZhiMin Xiao
- Graduate School of Education, University of Exeter, Exeter, Devon, UK
| | - Tamsin Ford
- Department of Psychiatry, University of Cambridge, Cambridge, UK
| | - Obioha C Ukoumunne
- NIHR ARC South West Peninsula (PenARC), University of Exeter, Exeter, Devon, UK
| |
Collapse
|
33
|
Rationale, Methodological Quality, and Reporting of Cluster-Randomized Controlled Trials in Critical Care Medicine: A Systematic Review. Crit Care Med 2021; 49:977-987. [PMID: 33591020 DOI: 10.1097/ccm.0000000000004885] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVE Compared with individual-patient randomized controlled trials, cluster randomized controlled trials have unique methodological and ethical considerations. We evaluated the rationale, methodological quality, and reporting of cluster randomized controlled trials in critical care studies. DATA SOURCES Systematic searches of Medline, Embase, and Cochrane Central Register were performed. STUDY SELECTION We included all cluster randomized controlled trials conducted in adult, pediatric, or neonatal critical care units from January 2005 to September 2019. DATA EXTRACTION Two reviewers independently screened citations, reviewed full texts, protocols, and supplements of potentially eligible studies, abstracted data, and assessed methodology of included studies. DATA SYNTHESIS From 1,902 citations, 59 cluster randomized controlled trials met criteria. Most focused on quality improvement (24, 41%), antimicrobial therapy (9, 15%), or infection control (9, 15%) interventions. Designs included parallel-group (25, 42%), crossover (21, 36%), and stepped-wedge (13, 22%). Concealment of allocation was reported in 21 studies (36%). Thirteen studies (22%) reported at least one method of blinding. The median total sample size was 1,660 patients (interquartile range, 813-4,295); the median number of clusters was 12 (interquartile range, 5-24); and the median patients per cluster was 141 (interquartile range, 54-452). Sample size calculations were reported in 90% of trials, but only 54% met Consolidated Standards of Reporting Trials guidance for sample size reporting. Twenty-seven of the studies (46%) identified a fixed number of available clusters prior to trial commencement, and only nine (15%) prespecified both the number of clusters and patients required to detect the expected effect size. Overall, 36 trials (68%) achieved the total prespecified sample size. When analyzing data, 44 studies (75%) appropriately adjusted for clustering when analyzing the primary outcome. Only 12 (20%) reported an intracluster coefficient (median 0.047 [interquartile range, 0.01-0.13]). CONCLUSIONS Cluster randomized controlled trials in critical care typically involve a small and fixed number of relatively large clusters. The reporting of key methodological aspects of these trials is often inadequate.
Collapse
|
34
|
Adane MM, Alene GD, Mereta ST. Biomass-fuelled improved cookstove intervention to prevent household air pollution in Northwest Ethiopia: a cluster randomized controlled trial. Environ Health Prev Med 2021; 26:1. [PMID: 33397282 PMCID: PMC7783973 DOI: 10.1186/s12199-020-00923-z] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Accepted: 12/06/2020] [Indexed: 12/15/2022] Open
Abstract
Background Household air pollution from biomass fuels burning in traditional cookstoves currently appeared as one of the most serious threats to public health with a recent burden estimate of 2.6 million premature deaths every year worldwide, ranking highest among environmental risk factors and one of the major risk factors of any type globally. Improved cookstove interventions have been widely practiced as potential solutions. However, studies on the effect of improved cookstove interventions are limited and heterogeneous which suggested the need for further research. Methods A cluster randomized controlled trial study was conducted to assess the effect of biomass-fuelled improved cookstove intervention on the concentration of household air pollution compared with the continuation of an open burning traditional cookstove. A total of 36 clusters were randomly allocated to both arms at a 1:1 ratio, and improved cookstove intervention was delivered to all households allocated into the treatment arm. All households in the included clusters were biomass fuel users and relatively homogenous in terms of basic socio-demographic and cooking-related characteristics. Household air pollution was determined by measuring the concentration of indoor fine particulate, and the effect of the intervention was estimated using the Generalized Estimating Equation. Results A total of 2031 household was enrolled in the study across 36 randomly selected clusters in both arms, among which data were obtained from a total of 1977 households for at least one follow-up visit which establishes the intention-to-treat population dataset for analysis. The improved cookstove intervention significantly reduces the concentration of household air pollution by about 343 μg/m3 (Ḃ = − 343, 95% CI − 350, − 336) compared to the traditional cookstove method. The overall reduction was found to be about 46% from the baseline value of 859 (95% CI 837–881) to 465 (95% CI 458–472) in the intervention arm compared to only about 5% reduction from 850 (95% CI 828–872) to 805 (95% CI 794–817) in the control arm. Conclusions The biomass-fuelled improved cookstove intervention significantly reduces the concentration of household air pollution compared to the traditional method. This suggests that the implementation of these cookstove technologies may be necessary to achieve household air pollution exposure reductions. Trial registration The trial project was retrospectively registered on August 2, 2018, at the clinical trials.gov registry database (https://clinicaltrials.gov/) with the NCT03612362 registration identifier number. Supplementary Information The online version contains supplementary material available at 10.1186/s12199-020-00923-z.
Collapse
Affiliation(s)
- Mesafint Molla Adane
- Department of Environmental Health, College of Medicine & Health Sciences, School of Public Health, Bahir Dar University, Bahir Dar, Ethiopia.
| | - Getu Degu Alene
- Department of Epidemiology and Biostatistics, College of Medicine & Health Sciences, School of Public Health, Bahir Dar University, Bahir Dar, Ethiopia
| | - Seid Tiku Mereta
- Department of Environmental Health Sciences and Technology, Jimma University, Jimma, Ethiopia
| |
Collapse
|
35
|
Yang S, Li F, Starks MA, Hernandez AF, Mentz RJ, Choudhury KR. Sample size requirements for detecting treatment effect heterogeneity in cluster randomized trials. Stat Med 2020; 39:4218-4237. [PMID: 32823372 PMCID: PMC7948251 DOI: 10.1002/sim.8721] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Revised: 07/13/2020] [Accepted: 07/16/2020] [Indexed: 12/14/2022]
Abstract
Cluster randomized trials (CRTs) refer to experiments with randomization carried out at the cluster or the group level. While numerous statistical methods have been developed for the design and analysis of CRTs, most of the existing methods focused on testing the overall treatment effect across the population characteristics, with few discussions on the differential treatment effect among subpopulations. In addition, the sample size and power requirements for detecting differential treatment effect in CRTs remain unclear, but are helpful for studies planned with such an objective. In this article, we develop a new sample size formula for detecting treatment effect heterogeneity in two-level CRTs for continuous outcomes, continuous or binary covariates measured at cluster or individual level. We also investigate the roles of two intraclass correlation coefficients (ICCs): the adjusted ICC for the outcome of interest and the marginal ICC for the covariate of interest. We further derive a closed-form design effect formula to facilitate the application of the proposed method, and provide extensions to accommodate multiple covariates. Extensive simulations are carried out to validate the proposed formula in finite samples. We find that the empirical power agrees well with the prediction across a range of parameter constellations, when data are analyzed by a linear mixed effects model with a treatment-by-covariate interaction. Finally, we use data from the HF-ACTION study to illustrate the proposed sample size procedure for detecting heterogeneous treatment effects.
Collapse
Affiliation(s)
- Siyun Yang
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina
| | - Fan Li
- Department of Biostatistics, Yale School of Public Health, New Haven, Connecticut
- Center for Methods in Implementation and Prevention Science, Yale School of Public Health, New Haven, Connecticut
| | - Monique A. Starks
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Adrian F. Hernandez
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Robert J. Mentz
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Kingshuk R. Choudhury
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina
| |
Collapse
|
36
|
Curth NK, Brinck-Claussen UØ, Hjorthøj C, Davidsen AS, Mikkelsen JH, Lau ME, Lundsteen M, Csillag C, Christensen KS, Jakobsen M, Bojesen AB, Nordentoft M, Eplov LF. Collaborative care for depression and anxiety disorders: results and lessons learned from the Danish cluster-randomized Collabri trials. BMC FAMILY PRACTICE 2020; 21:234. [PMID: 33203365 PMCID: PMC7673096 DOI: 10.1186/s12875-020-01299-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Accepted: 10/26/2020] [Indexed: 11/10/2022]
Abstract
BACKGROUND Meta-analyses suggest that collaborative care (CC) improves symptoms of depression and anxiety. In CC, a care manager collaborates with a general practitioner (GP) to provide evidence-based care. Most CC research is from the US, focusing on depression. As research results may not transfer to other settings, we developed and tested a Danish CC-model (the Collabri-model) for depression, panic disorder, generalized anxiety disorder, and social anxiety disorder in general practice. METHODS Four cluster-randomized superiority trials evaluated the effects of CC. The overall aim was to explore if CC significantly improved depression and anxiety symptoms compared to treatment-as-usual at 6-months' follow-up. The Collabri-model was founded on a multi-professional collaboration between a team of mental-health specialists (psychiatrists and care managers) and GPs. In collaboration with GPs, care managers provided treatment according to a structured plan, including regular reassessments and follow-up. Treatment modalities (cognitive behavioral therapy, psychoeducation, and medication) were offered based on stepped care algorithms. Face-to-face meetings between GPs and care managers took place regularly, and a psychiatrist provided supervision. The control group received treatment-as-usual. Primary outcomes were symptoms of depression (BDI-II) and anxiety (BAI) at 6-months' follow-up. The incremental cost-effectiveness ratio (ICER) was estimated based on 6-months' follow-up. RESULTS Despite various attempts to improve inclusion rates, the necessary number of participants was not recruited. Seven hundred thirty-one participants were included: 325 in the depression trial and 406 in the anxiety trials. The Collabri-model was implemented, demonstrating good fidelity to core model elements. In favor of CC, we found a statistically significant difference between depression scores at 6-months' follow-up in the depression trial. The difference was not significant at 15-months' follow-up. The anxiety trials were pooled for data analysis due to inadequate sample sizes. At 6- and 15-months' follow-up, there was a difference in anxiety symptoms favoring CC. These differences were not statistically significant. The ICER was 58,280 Euro per QALY. CONCLUSIONS At 6 months, a significant difference between groups was found in the depression trial, but not in the pooled anxiety trial. However, these results should be cautiously interpreted as there is a risk of selection bias and lacking statistical power. TRIAL REGISTRATION ClinicalTrials.gov, ID: NCT02678624 and NCT02678845 . Retrospectively registered on 7 February 2016.
Collapse
Affiliation(s)
- Nadja Kehler Curth
- Copenhagen Research Center for Mental Health - CORE, Mental Health Center Copenhagen, Mental Health Services, Gentofte Hospitalsvej 15, 2900, Hellerup, Denmark.
| | - Ursula Ødum Brinck-Claussen
- Copenhagen Research Center for Mental Health - CORE, Mental Health Center Copenhagen, Mental Health Services, Gentofte Hospitalsvej 15, 2900, Hellerup, Denmark
| | - Carsten Hjorthøj
- Copenhagen Research Center for Mental Health - CORE, Mental Health Center Copenhagen, Mental Health Services, Gentofte Hospitalsvej 15, 2900, Hellerup, Denmark
- Department of Public Health, Section of Epidemiology, University of Copenhagen, Copenhagen, Denmark
| | - Annette Sofie Davidsen
- The Research Unit for General Practice and Section of General Practice, University of Copenhagen, Øster Farimagsgade 5, Postbox 2099, 1014, Copenhagen K, Denmark
| | - John Hagel Mikkelsen
- Mental Health Center Frederiksberg, Mental Health Services, Nordre Fasanvej 57-59, 2000, Frederiksberg, Denmark
| | - Marianne Engelbrecht Lau
- Stolpegård Psychotherapy Center, Mental Health Services, Stolpegårdsvej 20, 2820, Gentofte, Denmark
| | | | - Claudio Csillag
- Mental Health Center North Zealand, Mental Health Services, Dyrehavevej 48, 3400, Hillerød, Denmark
| | - Kaj Sparle Christensen
- Department of Public Health, Aarhus University, Aarhus, Denmark
- Research Unit for General Practice, Institute of Public Health, Aarhus University, Bartholins Allé 2, 8000, Aarhus C, Denmark
| | - Marie Jakobsen
- VIVE - The Danish Center for Social Science Research, Herluf Trolles Gade 11, 1052, Copenhagen K, Denmark
| | - Anders Bo Bojesen
- VIVE - The Danish Center for Social Science Research, Herluf Trolles Gade 11, 1052, Copenhagen K, Denmark
| | - Merete Nordentoft
- Copenhagen Research Center for Mental Health - CORE, Mental Health Center Copenhagen, Mental Health Services, Gentofte Hospitalsvej 15, 2900, Hellerup, Denmark
- Institute for Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Lene Falgaard Eplov
- Copenhagen Research Center for Mental Health - CORE, Mental Health Center Copenhagen, Mental Health Services, Gentofte Hospitalsvej 15, 2900, Hellerup, Denmark
| |
Collapse
|
37
|
Borhan S, Papaioannou A, Ma J, Adachi J, Thabane L. Analysis and reporting of stratified cluster randomized trials-a systematic survey. Trials 2020; 21:930. [PMID: 33203468 PMCID: PMC7672868 DOI: 10.1186/s13063-020-04850-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Accepted: 10/29/2020] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND In order to correctly assess the effect of intervention from stratified cluster randomized trials (CRTs), it is necessary to adjust for both clustering and stratification, as failure to do so leads to misleading conclusions about the intervention effect. We have conducted a systematic survey to examine the current practices about analysis and reporting of stratified CRTs. METHOD We used the search terms to identify the stratified CRTs from MEDLINE since the inception to July 2019. In phase 1, we screened the title and abstract for English-only studies and selected, including the main results paper of the identified protocols, for the next phase. In phase 2, we screened the full text and selected studies for data abstraction. The data abstraction form was piloted and developed using the REDCap. We abstracted data on multiple design and methodological aspects of the study including whether the primary method adjusted for both clustering and stratification, reporting of sample size, randomization, and results. RESULTS We screened 2686 studies in the phase 1 and selected 286 studies for phase 2-among them 185 studies were selected for data abstraction. Most of the selected studies were two-arm 140/185 (76%) and parallel-group 165/185 (89%) trials. Among these 185 studies, 27 (15%) of them did not provide any sample size or power calculation, while 105 (57%) studies did not mention any method used for randomization within each stratum. Further, 43 (23%) and 150 (81%) of 185 studies did not provide the definition of all the strata, while more than 60% of the studies did not include all the stratification variable(s) in the flow chart or baseline characteristics table. More than half 114/185 (62%) of the studies did not adjust the primary method for both clustering and stratification. CONCLUSION Stratification helps to achieve the balance among intervention groups. However, to correctly assess the intervention effect from stratified CRTs, it is important to adjust the primary analysis for both stratification and clustering. There are significant deficiencies in the reporting of methodological aspects of stratified CRTs, which require substantial improvements in several areas including definition of strata, inclusion of stratification variable(s) in the flow chart or baseline characteristics table, and reporting the stratum-specific number of clusters and individuals in the intervention groups.
Collapse
Affiliation(s)
- Sayem Borhan
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
- Biostatistics Unit, Research Institute of St Joseph's Healthcare, Hamilton, ON, Canada
- GERAS Centre, Hamilton Health Sciences, Hamilton, ON, Canada
| | - Alexandra Papaioannou
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
- GERAS Centre, Hamilton Health Sciences, Hamilton, ON, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Jinhui Ma
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Jonathan Adachi
- GERAS Centre, Hamilton Health Sciences, Hamilton, ON, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Lehana Thabane
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada.
- Biostatistics Unit, Research Institute of St Joseph's Healthcare, Hamilton, ON, Canada.
- GERAS Centre, Hamilton Health Sciences, Hamilton, ON, Canada.
- Departments of Pediatrics and Anesthesia, McMaster University, Hamilton, ON, Canada.
| |
Collapse
|
38
|
Innocenti F, Candel MJ, Tan FE, van Breukelen GJ. Optimal two-stage sampling for mean estimation in multilevel populations when cluster size is informative. Stat Methods Med Res 2020; 30:357-375. [PMID: 32940135 PMCID: PMC8172256 DOI: 10.1177/0962280220952833] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
To estimate the mean of a quantitative variable in a hierarchical population, it is logistically convenient to sample in two stages (two-stage sampling), i.e. selecting first clusters, and then individuals from the sampled clusters. Allowing cluster size to vary in the population and to be related to the mean of the outcome variable of interest (informative cluster size), the following competing sampling designs are considered: sampling clusters with probability proportional to cluster size, and then the same number of individuals per cluster; drawing clusters with equal probability, and then the same percentage of individuals per cluster; and selecting clusters with equal probability, and then the same number of individuals per cluster. For each design, optimal sample sizes are derived under a budget constraint. The three optimal two-stage sampling designs are compared, in terms of efficiency, with each other and with simple random sampling of individuals. Sampling clusters with probability proportional to size is recommended. To overcome the dependency of the optimal design on unknown nuisance parameters, maximin designs are derived. The results are illustrated, assuming probability proportional to size sampling of clusters, with the planning of a hypothetical survey to compare adolescent alcohol consumption between France and Italy.
Collapse
Affiliation(s)
- Francesco Innocenti
- Department of Methodology and Statistics, Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, the Netherlands
| | - Math Jjm Candel
- Department of Methodology and Statistics, Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, the Netherlands
| | - Frans Es Tan
- Department of Methodology and Statistics, Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, the Netherlands
| | - Gerard Jp van Breukelen
- Department of Methodology and Statistics, Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, the Netherlands.,Department of Methodology and Statistics, Graduate School of Psychology and Neuroscience, Maastricht University, Maastricht, the Netherlands
| |
Collapse
|
39
|
Nguyen MXB, Chu AV, Powell BJ, Tran HV, Nguyen LH, Dao ATM, Pham MD, Vo SH, Bui NH, Dowdy DW, Latkin CA, Lancaster KE, Pence BW, Sripaipan T, Hoffman I, Miller WC, Go VF. Comparing a standard and tailored approach to scaling up an evidence-based intervention for antiretroviral therapy for people who inject drugs in Vietnam: study protocol for a cluster randomized hybrid type III trial. Implement Sci 2020; 15:64. [PMID: 32771017 PMCID: PMC7414564 DOI: 10.1186/s13012-020-01020-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Accepted: 07/08/2020] [Indexed: 12/03/2022] Open
Abstract
Background People who inject drugs (PWID) bear a disproportionate burden of HIV infection and experience poor outcomes. A randomized trial demonstrated the efficacy of an integrated System Navigation and Psychosocial Counseling (SNaP) intervention in improving HIV outcomes, including antiretroviral therapy (ART) and medications for opioid use disorder (MOUD) uptake, viral suppression, and mortality. There is limited evidence about how to effectively scale such intervention. This protocol presents a hybrid type III effectiveness-implementation trial comparing two approaches for scaling-up SNaP. We will evaluate the effectiveness of SNaP implementation approaches as well as cost and the characteristics of HIV testing sites achieving successful or unsuccessful implementation of SNaP in Vietnam. Methods Design: In this cluster randomized controlled trial, two approaches to scaling-up SNaP for PWID in Vietnam will be compared. HIV testing sites (n = 42) were randomized 1:1 to the standard approach or the tailored approach. Intervention mapping was used to develop implementation strategies for both arms. The standard arm will receive a uniform package of these strategies, while implementation strategies for the tailored arm will be designed to address site-specific needs. Participants: HIV-positive PWID participants (n = 6200) will be recruited for medical record assessment at baseline; of those, 1500 will be enrolled for detailed assessments at baseline, 12, and 24 months. Site directors and staff at each of the 42 HIV testing sites will complete surveys at baseline, 12, and 24 months. Outcomes: Implementation outcomes (fidelity, penetration, acceptability) and effectiveness outcomes (ART, MOUD uptake, viral suppression) will be compared between the arms. To measure incremental costs, we will conduct an empirical costing study of each arm and the actual process of implementation from a societal perspective. Qualitative and quantitative site-level data will be used to explore key characteristics of HIV testing sites that successfully or unsuccessfully implement the intervention for each arm. Discussion Scaling up evidence-based interventions poses substantial challenges. The proposed trial contributes to the field of implementation science by applying a systematic approach to designing and tailoring implementation strategies, conducting a rigorous comparison of two promising implementation approaches, and assessing their incremental costs. Our study will provide critical guidance to Ministries of Health worldwide regarding the most effective, cost-efficient approach to SNaP implementation. Trial registration NCT03952520 on Clinialtrials.gov. Registered 16 May 2019.
Collapse
Affiliation(s)
- Minh X B Nguyen
- Department of Health Behavior, Gillings School of Global Public Health, 135 Dauer Dr, Chapel Hill, NC, 27599, USA. .,Department of Epidemiology, Institute of Preventive Medicine and Public Health, 1 Ton That Tung St., Dong Da, Hanoi, Vietnam.
| | - Anh V Chu
- University of North Carolina Project Vietnam, Lot E2 Duong Dinh Nghe St., Cau Giay, Hanoi, Vietnam
| | - Byron J Powell
- Brown School, Washington University in St. Louis, One Brookings Drive, St. Louis, MO, 63130, USA
| | - Ha V Tran
- Department of Health Behavior, Gillings School of Global Public Health, 135 Dauer Dr, Chapel Hill, NC, 27599, USA.,University of North Carolina Project Vietnam, Lot E2 Duong Dinh Nghe St., Cau Giay, Hanoi, Vietnam
| | - Long H Nguyen
- Vietnam Authority of HIV/AIDS Control, Land 8 That Thuyet St., Ba Dinh, Hanoi, Vietnam
| | - An T M Dao
- Department of Epidemiology, Institute of Preventive Medicine and Public Health, 1 Ton That Tung St., Dong Da, Hanoi, Vietnam
| | - Manh D Pham
- Vietnam Authority of HIV/AIDS Control, Land 8 That Thuyet St., Ba Dinh, Hanoi, Vietnam
| | - Son H Vo
- Vietnam Authority of HIV/AIDS Control, Land 8 That Thuyet St., Ba Dinh, Hanoi, Vietnam
| | - Ngoc H Bui
- Department of Epidemiology, Institute of Preventive Medicine and Public Health, 1 Ton That Tung St., Dong Da, Hanoi, Vietnam
| | - David W Dowdy
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe St, Baltimore, MD, 21205, USA
| | - Carl A Latkin
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe St, Baltimore, MD, 21205, USA
| | - Kathryn E Lancaster
- Department of Epidemiology, College of Public Health, Ohio State University, 250 Cunz Hall, 1841 Neil Ave, Columbus, OH, 43210, USA
| | - Brian W Pence
- Department of Epidemiology, Gillings School of Global Public Health, 135 Dauer Dr, Chapel Hill, NC, 27599, USA
| | - Teerada Sripaipan
- Department of Health Behavior, Gillings School of Global Public Health, 135 Dauer Dr, Chapel Hill, NC, 27599, USA
| | - Irving Hoffman
- Division of Infectious Diseases, UNC School of Medicine, 321 S Columbia St, Chapel Hill, NC, 27516, USA
| | - William C Miller
- Department of Epidemiology, College of Public Health, Ohio State University, 250 Cunz Hall, 1841 Neil Ave, Columbus, OH, 43210, USA
| | - Vivian F Go
- Department of Health Behavior, Gillings School of Global Public Health, 135 Dauer Dr, Chapel Hill, NC, 27599, USA.
| |
Collapse
|
40
|
Intra-cluster correlation coefficients in primary care patients with type 2 diabetes and hypertension. Trials 2020; 21:530. [PMID: 32546189 PMCID: PMC7298818 DOI: 10.1186/s13063-020-04349-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Accepted: 04/25/2020] [Indexed: 11/21/2022] Open
Abstract
Introduction There are few sources of published data on intra-cluster correlation coefficients (ICCs) amongst patients with type 2 diabetes (T2D) and/or hypertension in primary care, particularly in low- and middle-income countries. ICC values are necessary for determining the sample sizes of cluster randomized trials. Hence, we aim to report the ICC values for a range of measures from a cluster-based interventional study conducted in Malaysia. Method Baseline data from a large study entitled Evaluation of Enhanced Primary Health Care interventions in public health clinics (EnPHC-EVA: Facility) were used in this analysis. Data from 40 public primary care clinics were collected through retrospective chart reviews and a patient exit survey. We calculated the ICCs for processes of care, clinical outcomes and patient experiences in patients with T2D and/or hypertension using the analysis of variance approach. Results Patient experience had the highest ICC values compared to processes of care and clinical outcomes. The ICC values ranged from 0.01 to 0.48 for processes of care. Generally, the ICC values for processes of care for patients with hypertension only are higher than those for T2D patients, with or without hypertension. However, both groups of patients have similar ICCs for antihypertensive medications use. In addition, similar ICC values were observed for clinical outcomes, ranging from 0.01 to 0.09. For patient experience, the ICCs were between 0.03 (proportion of patients who are willing to recommend the clinic to their friends and family) and 0.25 (for Patient Assessment of Chronic Illness Care item 9, Given a copy of my treatment plan). Conclusion The reported ICCs and their respective 95% confidence intervals for T2D and hypertension will be useful for estimating sample sizes and improving efficiency of cluster trials conducted in the primary care setting, particularly for low- and middle-income countries.
Collapse
|
41
|
Anger HA, Dabash R, Hassanein N, Darwish E, Ramadan MC, Nawar M, Charles D, Breebaart M, Winikoff B. A cluster-randomized, non-inferiority trial comparing use of misoprostol for universal prophylaxis vs. secondary prevention of postpartum hemorrhage among community level births in Egypt. BMC Pregnancy Childbirth 2020; 20:317. [PMID: 32448257 PMCID: PMC7245883 DOI: 10.1186/s12884-020-03008-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Accepted: 05/11/2020] [Indexed: 11/10/2022] Open
Abstract
Background Previous community-based research shows that secondary prevention of postpartum hemorrhage (PPH) with misoprostol only given to women with above-average measured blood loss produces similar clinical outcomes compared to routine administration of misoprostol for prevention of PPH. Given the difficulty of routinely measuring blood loss for all deliveries, more operational models of secondary prevention are needed. Methods This cluster-randomized, non-inferiority trial included women giving birth with nurse-midwives at home or in Primary Health Units (PHUs) in rural Egypt. Two PPH management approaches were compared: 1) 600mcg oral misoprostol given to all women after delivery (i.e. primary prevention, current standard of care); 2) 800mcg sublingual misoprostol given only to women with 350-500 ml postpartum blood loss estimated using an underpad (i.e. secondary prevention). The primary outcome was mean change in pre- and post-delivery hemoglobin. Secondary outcomes included hemoglobin ≥2 g/dL and other PPH interventions. Results Misoprostol was administered after delivery to 100% (1555/1555) and 10.7% (117/1099) of women in primary and secondary prevention clusters, respectively. The mean drop in pre- to post-delivery hemoglobin was 0.37 (SD: 0.91) and 0.45 (SD: 0.76) among women in primary and secondary prevention clusters, respectively (difference adjusted for clustering = 0.01, one-sided 95% CI: < 0.27, p = 0.535). There were no statistically significant differences in secondary outcomes, including hemoglobin drop ≥2 g/dL, PPH diagnosis, transfer to higher level, or other interventions. Conclusions Misoprostol for secondary prevention of PPH is comparable to universal prophylaxis and can be implemented using local materials, such as underpads. Trial registration Clinicaltrials.gov NCT02226588, date of registration 27 August 2014.
Collapse
Affiliation(s)
- Holly A Anger
- Gynuity Health Projects, 220 E 42nd St, Suite 710, New York, NY, USA.
| | - Rasha Dabash
- Gynuity Health Projects, 220 E 42nd St, Suite 710, New York, NY, USA
| | | | - Emad Darwish
- Faculty of Medicine, Alexandria University, 17 Champollion St, El Messalah, Alexandria, Egypt
| | | | - Medhat Nawar
- El Beheira Governorate, Ministry of Health and Population, Damanhour, Egypt
| | - Dyanna Charles
- Gynuity Health Projects, 220 E 42nd St, Suite 710, New York, NY, USA
| | | | - Beverly Winikoff
- Gynuity Health Projects, 220 E 42nd St, Suite 710, New York, NY, USA
| |
Collapse
|
42
|
Martin MA, Zimmerman LJ, Rosales GF, Lee HH, Songthangtham N, Pugach O, Sandoval AS, Avenetti D, Alvarez G, Gansky SA. Design and sample characteristics of COordinated Oral health Promotion (CO-OP) Chicago: A cluster-randomized controlled trial. Contemp Clin Trials 2020; 92:105919. [PMID: 31899372 PMCID: PMC7309222 DOI: 10.1016/j.cct.2019.105919] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Revised: 12/20/2019] [Accepted: 12/23/2019] [Indexed: 12/01/2022]
Abstract
COordinated Oral health Promotion (CO-OP) Chicago is a two-arm cluster-randomized trial with a wait-list control. The primary aim is to evaluate the efficacy of an oral health community health worker (CHW) intervention to improve oral health behaviors in low-income, urban children under the age of three years. Exploratory aims will determine cost-effectiveness, and if any CHW intervention impact on child tooth brushing behaviors varies when CHWs are based out of a medical clinic compared to a community setting. This paper describes progress toward achieving these aims. Participating families were recruited from community social service centers and pediatric primary care medical clinics in Cook County, Illinois. Sites were cluster-randomized to CHW intervention or usual services (a wait-list control). The intervention is oral health support from CHWs delivered in four visits to individual families over one year. The trial sample consists of 420 child/caregiver dyads enrolled at the 20 participating sites over 11 months. Participant demographics varied across the sites, but primary outcomes values at baseline did not. Data on brushing frequency, plaque, and other oral health behaviors are collected at three timepoints: baseline, 6-, and 12-months. The primary analysis will assess differences in caregiver-reported child brushing frequency and observed plaque score between the two arms at 12-months. The trial is currently in the active intervention phase. The trial's cluster-randomized controlled design takes a real-world approach by integrating into existing health and social service agencies and collecting data in participant homes. Results will address an important child health disparity. ClinicalTrials.gov identifier: NCT03397589. CLINICAL TRIAL REGISTRATION: University of Illinois at Chicago Protocol Record 2017-1090. National Institutes of Dental & Craniofacial Research of the National Institutes of Health (NIDCR) Protocol Number: 17-074-E. NCT03397589.
Collapse
Affiliation(s)
- Molly A Martin
- University of Illinois at Chicago, College of Medicine, 1853 W Polk St, Chicago, IL 60612, United States; University of Illinois at Chicago, Institute for Health Research and Policy, 1747 W Roosevelt Road, Chicago, IL 60608, United States.
| | - Lacey J Zimmerman
- University of Illinois at Chicago, College of Medicine, 1853 W Polk St, Chicago, IL 60612, United States
| | - Genesis F Rosales
- University of Illinois at Chicago, Institute for Health Research and Policy, 1747 W Roosevelt Road, Chicago, IL 60608, United States
| | - Helen H Lee
- University of Illinois at Chicago, College of Medicine, 1853 W Polk St, Chicago, IL 60612, United States; University of Illinois at Chicago, Institute for Health Research and Policy, 1747 W Roosevelt Road, Chicago, IL 60608, United States
| | - Nattanit Songthangtham
- University of Illinois at Chicago, Institute for Health Research and Policy, 1747 W Roosevelt Road, Chicago, IL 60608, United States
| | - Oksana Pugach
- University of Illinois at Chicago, Institute for Health Research and Policy, 1747 W Roosevelt Road, Chicago, IL 60608, United States
| | - Anna S Sandoval
- University of Illinois at Chicago, Institute for Health Research and Policy, 1747 W Roosevelt Road, Chicago, IL 60608, United States
| | - David Avenetti
- University of Illinois at Chicago, College of Dentistry, 801 S Paulina St, Chicago, IL 60612, United States
| | - Gizelle Alvarez
- University of Illinois at Chicago, Institute for Health Research and Policy, 1747 W Roosevelt Road, Chicago, IL 60608, United States
| | - Stuart A Gansky
- University of California, Box# 1361, San Francisco, CA 94143, United States
| |
Collapse
|
43
|
White RO, Chakkalakal RJ, Wallston KA, Wolff K, Gregory B, Davis D, Schlundt D, Trochez KM, Barto S, Harris LA, Bian A, Schildcrout JS, Kripalani S, Rothman RL. The Partnership to Improve Diabetes Education Trial: a Cluster Randomized Trial Addressing Health Communication in Diabetes Care. J Gen Intern Med 2020; 35:1052-1059. [PMID: 31919724 PMCID: PMC7174470 DOI: 10.1007/s11606-019-05617-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Accepted: 12/12/2019] [Indexed: 11/29/2022]
Abstract
BACKGROUND Effective type 2 diabetes care remains a challenge for patients including those receiving primary care in safety net settings. OBJECTIVE The Partnership to Improve Diabetes Education (PRIDE) trial team and leaders from a regional department of health evaluated approaches to improve care for vulnerable patients. DESIGN Cluster randomized controlled trial. PATIENTS Adults with uncontrolled type 2 diabetes seeking care across 10 unblinded, randomly assigned safety net clinics in Middle TN. INTERVENTIONS A literacy-sensitive, provider-focused, health communication intervention (PRIDE; 5 clinics) vs. standard diabetes education (5 clinics). MAIN MEASURES Participant-level primary outcome was glycemic control [A1c] at 12 months. Secondary outcomes included select health behaviors and psychosocial aspects of care at 12 and 24 months. Adjusted mixed effects regression models were used to examine the comparative effectiveness of each approach to care. KEY RESULTS Of 410 patients enrolled, 364 (89%) were included in analyses. Median age was 51 years; Black and Hispanic patients represented 18% and 25%; 96% were uninsured, and 82% had low annual income level (< $20,000); adequate health literacy was seen in 83%, but numeracy deficits were common. At 12 months, significant within-group treatment effects occurred from baseline for both PRIDE and control sites: adjusted A1c (- 0.76 [95% CI, - 1.08 to - 0.44]; P < .001 vs - 0.54 [95% CI, - 0.86 to - 0.21]; P = .001), odds of poor eating (0.53 [95% CI, 0.33-0.83]; P = .01 vs 0.42 [95% CI, 0.26-0.68]; P < .001), treatment satisfaction (3.93 [95% CI, 2.48-6.21]; P < .001 vs 3.04 [95% CI, 1.93-4.77]; P < .001), and self-efficacy (2.97 [95% CI, 1.89-4.67]; P < .001 vs 1.81 [95% CI, 1.1-2.84]; P = .01). No significant difference was observed between study arms in adjusted analyses. CONCLUSIONS Both interventions improved the participant's A1c and behavioral outcomes. PRIDE was not more effective than standard education. Further research may elucidate the added value of a focused health communication program in this setting.
Collapse
Affiliation(s)
- Richard O White
- Division of Community Internal Medicine, Mayo Clinic, Jacksonville, FL, USA.
| | - Rosette James Chakkalakal
- Department of General Internal Medicine and Public Health, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Kenneth A Wallston
- Center for Health Services Research, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Kathleen Wolff
- School of Nursing, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Becky Gregory
- Vanderbilt Diabetes Research and Training Center, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Dianne Davis
- Vanderbilt Diabetes Research and Training Center, Vanderbilt University Medical Center, Nashville, TN, USA
| | - David Schlundt
- Department of Psychology, Vanderbilt University, Nashville, TN, USA
| | - Karen M Trochez
- Center for Health Services Research, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Shari Barto
- Center for Health Services Research, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Laura A Harris
- Mid-Cumberland Regional Office, Tennessee Department of Health , Nashville, TN, USA
| | - Aihua Bian
- Department of Biostatistics, Vanderbilt University, Nashville, TN, USA
| | | | - Sunil Kripalani
- Department of General Internal Medicine and Public Health, Vanderbilt University Medical Center, Nashville, TN, USA.,Center for Health Services Research, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Russell L Rothman
- Department of General Internal Medicine and Public Health, Vanderbilt University Medical Center, Nashville, TN, USA.,Center for Health Services Research, Vanderbilt University Medical Center, Nashville, TN, USA
| |
Collapse
|
44
|
Staniford LJ, Schmidtke KA. A systematic review of hand-hygiene and environmental-disinfection interventions in settings with children. BMC Public Health 2020; 20:195. [PMID: 32028932 PMCID: PMC7006391 DOI: 10.1186/s12889-020-8301-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2019] [Accepted: 01/29/2020] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Helping adults and children develop better hygiene habits is an important public health focus. As infection causing bacteria can live on one's body and in the surrounding environment, more effective interventions should simultaneously encourage personal-hygiene (e.g. hand-hygiene) and environmental-disinfecting (e.g. cleaning surfaces). To inform the development of a future multi-faceted intervention to improve public health, a systematic literature review was conducted on behavior change interventions designed to increase hand-hygiene and environmental-disinfecting in settings likely to include children. METHODS The search was conducted over two comprehensive data-bases, Ebsco Medline and Web of Science, to locate intervention studies that aimed to increase hand-hygiene or environmental-disinfecting behavior in settings likely to include children. Located article titles and abstracts were independently assessed, and the full-texts of agreed articles were collaboratively assessed for inclusion. Of the 2893 titles assessed, 29 met the eligibility criteria. The extracted data describe the Behavior Change Techniques (version 1) that the interventions employed and the interventions' effectiveness. The techniques were then linked to their associated theoretical domains and to their capability-opportunity-motivation (i.e., COM-B model) components, as described in the Behavior Change Wheel. Due to the heterogeneity of the studies' methods and measures, a meta-analysis was not conducted. RESULTS A total of 29 studies met the inclusion criteria. The majority of interventions were designed to increase hand-hygiene alone (N = 27), and the remaining two interventions were designed to increase both hand-hygiene and environmental-disinfecting. The most used techniques involved shaping knowledge (N = 22) and antecedents (N = 21). Interventions that included techniques targeting four or more theoretical domains and all the capability-opportunity-motivation components were descriptively more effective. CONCLUSIONS In alignment with previous findings, the current review encourages future interventions to target multiple theoretical domains, across all capability-opportunity-motivation components. The discussion urges interventionists to consider the appropriateness of interventions in their development, feasibility/pilot, evaluation, and implementation stages. REGISTRATION Prospero ID - CRD42019133735.
Collapse
Affiliation(s)
- Leanne J Staniford
- Department of Psychology, Manchester Metropolitan University, Brooks Building, 53 Bonsall Street, Manchester, M15 6GX, England
| | - Kelly A Schmidtke
- Department of Psychology, Manchester Metropolitan University, Brooks Building, 53 Bonsall Street, Manchester, M15 6GX, England.
| |
Collapse
|
45
|
Yang S, Starks MA, Hernandez AF, Turner EL, Califf RM, O'Connor CM, Mentz RJ, Roy Choudhury K. Impact of baseline covariate imbalance on bias in treatment effect estimation in cluster randomized trials: Race as an example. Contemp Clin Trials 2020; 88:105775. [PMID: 31228563 PMCID: PMC8337048 DOI: 10.1016/j.cct.2019.04.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Revised: 04/21/2019] [Accepted: 04/25/2019] [Indexed: 12/31/2022]
Abstract
Individual-level baseline covariate imbalance could happen more frequently in cluster randomized trials, and may influence the observed treatment effect. Using computer and real-data simulations, this paper quantifies the extent and impact of covariate imbalance on the estimated treatment effect for both continuous and binary outcomes, and relates it to the degree of imbalance for different numbers of clusters, cluster sizes, and covariate intraclass correlation coefficients. We focused on the impact of race as a covariate, given the emphasis of regulatory and funding bodies on understanding the influence of demographic characteristics on treatment effectiveness. We found that bias in the treatment effect is proportional to both the degree of baseline covariate imbalance and the covariate effect size. Larger numbers of clusters result in lower covariate imbalance, and increasing cluster size is less effective in reducing imbalance compared to increasing the number of clusters. Models adjusted for important baseline confounders are superior to unadjusted models for minimizing bias in both model-based simulations and an innovative simulation based on real clinical trial data. Higher outcome intraclass correlation coefficients did not affect bias but resulted in greater variance in treatment estimates.
Collapse
Affiliation(s)
- Siyun Yang
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, NC, United States of America
| | - Monique Anderson Starks
- Department of Medicine, Duke University School of Medicine, Durham, NC, United States of America; Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, United States of America.
| | - Adrian F Hernandez
- Department of Medicine, Duke University School of Medicine, Durham, NC, United States of America; Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, United States of America
| | - Elizabeth L Turner
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, NC, United States of America; Duke Global Health Institute, Duke University, Durham, NC, United States of America
| | - Robert M Califf
- Department of Medicine, Duke University School of Medicine, Durham, NC, United States of America; Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, United States of America
| | | | - Robert J Mentz
- Department of Medicine, Duke University School of Medicine, Durham, NC, United States of America; Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, United States of America
| | - Kingshuk Roy Choudhury
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, NC, United States of America
| |
Collapse
|
46
|
Ginsburg GS, Pella JE, Piselli K, Chan G. Teacher Anxiety Program for Elementary Students (TAPES): intervention development and proposed randomized controlled trial. Trials 2019; 20:792. [PMID: 31888726 PMCID: PMC6937798 DOI: 10.1186/s13063-019-3863-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2019] [Accepted: 10/29/2019] [Indexed: 11/10/2022] Open
Abstract
Background Excessive student anxiety is a common problem that severely impairs short- and long-term academic functioning and increases teacher burden. Reducing student anxiety has been associated with improvement in educational functioning. Because anxiety manifests daily in the classroom, teachers are in an ideal position to identify and help students manage their anxiety. Unfortunately, teachers lack the knowledge and skills to support the learning of students with excessive anxiety. The Teacher Anxiety Program for Elementary Students (TAPES), a novel teacher-administered school-home collaborative intervention, was designed to address this gap. Methods This manuscript describes the protocol for developing and evaluating TAPES. Specifically, we present a description of: (1) the intervention and theoretical model; and (2) methods for the proposed randomized controlled trial comparing TAPES to a standard professional development seminar focused on reducing student anxiety. Discussion Primary aims examine the impact of the TAPES training on teacher knowledge and skill. Secondary aims examine the impact of TAPES on student outcomes. Exploratory aims will examine mediators based on our proposed theory of change. If effective, TAPES has the potential to directly benefit teachers (improving skills) and students (reducing anxiety and improving functioning). Trial registration ClinicalTrials.gov, NCT03899948. Registered on 28 March 2019.
Collapse
Affiliation(s)
- Golda S Ginsburg
- University of Connecticut School of Medicine, 65 Kane Street Room 2033, West Hartford, CT, 06119, USA.
| | - Jeffrey E Pella
- University of Connecticut School of Medicine, 65 Kane Street Room 2033, West Hartford, CT, 06119, USA
| | - Kate Piselli
- University of Connecticut School of Medicine, 65 Kane Street Room 2033, West Hartford, CT, 06119, USA
| | - Grace Chan
- University of Connecticut School of Medicine, 65 Kane Street Room 2033, West Hartford, CT, 06119, USA.,University of Connecticut School of Medicine Department of Psychiatry, 263 Farmington Avenue, Farmington, CT, 06030-2103, USA
| |
Collapse
|
47
|
Murray DM, Taljaard M, Turner EL, George SM. Essential Ingredients and Innovations in the Design and Analysis of Group-Randomized Trials. Annu Rev Public Health 2019; 41:1-19. [PMID: 31869281 DOI: 10.1146/annurev-publhealth-040119-094027] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
This article reviews the essential ingredients and innovations in the design and analysis of group-randomized trials. The methods literature for these trials has grown steadily since they were introduced to the biomedical research community in the late 1970s, and we summarize those developments. We review, in addition to the group-randomized trial, methods for two closely related designs, the individually randomized group treatment trial and the stepped-wedge group-randomized trial. After describing the essential ingredients for these designs, we review the most important developments in the evolution of their methods using a new bibliometric tool developed at the National Institutes of Health. We then discuss the questions to be considered when selecting from among these designs or selecting the traditional randomized controlled trial. We close with a review of current methods for the analysis of data from these designs, a case study to illustrate each design, and a brief summary.
Collapse
Affiliation(s)
- David M Murray
- Office of Disease Prevention, National Institutes of Health, North Bethesda, Maryland 20892, USA; ,
| | - Monica Taljaard
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, The Ottawa Hospital, Civic Campus, Ottawa, Ontario K1Y 4E9, Canada; .,School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario K1Y 4E9, Canada
| | - Elizabeth L Turner
- Department of Biostatistics and Bioinformatics, and Duke Global Health Institute, Duke University, Durham, North Carolina 27710, USA;
| | - Stephanie M George
- Office of Disease Prevention, National Institutes of Health, North Bethesda, Maryland 20892, USA; ,
| |
Collapse
|
48
|
Branson Z, Dasgupta T. Sampling‐based Randomised Designs for Causal Inference under the Potential Outcomes Framework. Int Stat Rev 2019. [DOI: 10.1111/insr.12339] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
|
49
|
Starks MA, Sanders GD, Coeytaux RR, Riley IL, Jackson LR, Brooks AM, Thomas KL, Choudhury KR, Califf RM, Hernandez AF. Assessing heterogeneity of treatment effect analyses in health-related cluster randomized trials: A systematic review. PLoS One 2019; 14:e0219894. [PMID: 31404063 PMCID: PMC6690528 DOI: 10.1371/journal.pone.0219894] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2018] [Accepted: 07/04/2019] [Indexed: 01/28/2023] Open
Abstract
Background Cluster-randomized trials (CRTs) are being increasingly used to test a range of interventions, including medical interventions commonly used in clinical practice. Policies created by the NIH and the Food and Drug Administration (FDA) require the reporting of demographics and the examination of demographic heterogeneity of treatment effect (HTE) for individually randomized trials. Little is known about how frequent demographics are reported and HTE analyses are conducted in CRTs. Objectives We sought to understand the prevalence of HTE analyses and the statistical methods used to conduct them in CRTs focused on treating cardiovascular disease, cancer, and chronic lower respiratory diseases. Additionally, we also report on the proportion of CRTs that reported on baseline demographics of its populations and conducted demographic HTE analyses. Data sources We searched PubMed and Embase for CRTs published between 1/1/2010 and 3/29/2016 that focused on treating the top 3 Center for Disease Control causes of death (cardiovascular disease, chronic lower respiratory disease, and cancer). Evidence Screening And Review: Of 1,682 unique titles, 117 abstracts were screened. After excluding 53 articles, we included 64 CRT publications and abstracted information on study characteristics and demographic information, statistical analysis, HTE analysis, and study quality. Results Age and sex were reported in greater than 95.3% of CRTs, while race and ethnicity were reported in only 20.3% of CRTs. HTE analyses were conducted in 28.1% (n = 18) of included CRTs and 77.8% (n = 12) were prespecified analyses. Four CRTs conducted a demographic subgroup analysis. Only 6/18 CRTs used interaction testing to determine whether HTE existed. Conclusions Baseline demographic reporting was high for age and sex in CRTs, but was uncommon for race and ethnicity. HTE analyses were uncommon and was rare for demographic subgroups, which limits the ability to examine the extent of benefits or risks for treatments tested with CRT designs.
Collapse
Affiliation(s)
- Monique Anderson Starks
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC, United States of America
- Division of Cardiology, Department of Medicine, Duke University School of Medicine, Durham, NC, United States of America
- * E-mail:
| | - Gillian D. Sanders
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC, United States of America
- Division of Cardiology, Department of Medicine, Duke University School of Medicine, Durham, NC, United States of America
| | - Remy Rene Coeytaux
- Department of Family and Community Medicine, Wake Forest School of Medicine; Winston-Salem, NC, United States of America
| | - Isaretta L. Riley
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, Duke University School of Medicine, Durham, NC, United States of America
| | - Larry R. Jackson
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC, United States of America
- Division of Cardiology, Department of Medicine, Duke University School of Medicine, Durham, NC, United States of America
| | - Amanda McBroom Brooks
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC, United States of America
| | - Kevin L. Thomas
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC, United States of America
- Division of Cardiology, Department of Medicine, Duke University School of Medicine, Durham, NC, United States of America
| | - Kingshuk Roy Choudhury
- Department of Biostatistics and Bioinformatics, Duke University, Durham, NC, United States of America
| | - Robert M. Califf
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC, United States of America
- Division of Cardiology, Department of Medicine, Duke University School of Medicine, Durham, NC, United States of America
| | - Adrian F. Hernandez
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC, United States of America
- Division of Cardiology, Department of Medicine, Duke University School of Medicine, Durham, NC, United States of America
| |
Collapse
|
50
|
Lyndon H, Latour JM, Marsden J, Campbell S, Stevens K, Kent B. The holistic assessment and care planning in partnership intervention study (HAPPI): A protocol for a feasibility, cluster randomized controlled trial. J Adv Nurs 2019; 75:3078-3087. [PMID: 31222778 DOI: 10.1111/jan.14106] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Revised: 03/25/2019] [Accepted: 05/21/2019] [Indexed: 11/29/2022]
Abstract
AIM During an initial phase of this research, an e-Delphi survey was conducted to gain consensus among stakeholders on the components of a nurse-led assessment and care planning intervention for older people who live with frailty in primary care. This feasibility randomized controlled trial (fRCT) will test the proposed intervention and its implementation and determine methods for the design of a conclusive randomized controlled trial. METHODS The fRCT, with embedded qualitative study, aims to recruit 60 participants. Moderately and severely frail older people will be identified using the electronic frailty index (eFI) and the intervention will be delivered by senior community nurses. The control participants will receive usual primary care for frailty. The study is funded by the National Institute of Health Research (NIHR; funding granted in May 2016, ref: ICA-CDRF-2016-02-018) and received NHS and University Research Ethics Committee approval in 2018. DISCUSSION There is evidence that the delivery of complex interventions for community-dwelling older people can reduce care home and hospital admissions and falls, there is less evidence for the benefit of any specific type or intensity of intervention or the additional benefits of targeting the frail population. This trial will determine feasibility of the intervention, define recruitment and retention parameters and trial logistics, and decide outcome measures. IMPACT This study aims to address the limitations of current research by using a systematic method of frailty diagnosis and participant identification, trialling implementation of a person-centred intervention, and testing of feasibility parameters. TRIAL REGISTRATION NUMBER ISRCTN: 74345449.
Collapse
Affiliation(s)
| | - Jos M Latour
- University of Plymouth, Plymouth, UK.,Curtin University, Perth, WA, Australia
| | | | - Sarah Campbell
- Peninsula Clinical Trials Unit, University of Plymouth, Plymouth, UK
| | - Kara Stevens
- Peninsula Clinical Trials Unit, University of Plymouth, Plymouth, UK
| | - Bridie Kent
- Faculty of Health and Human Sciences, University of Plymouth, Plymouth, UK
| |
Collapse
|