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Doabler CT, Clarke B, Turtura JE, Sutherland M, Gersib JA, Lesner T, Cook M, Kimmel GL, Smolkowski K, Kosty D. Proficiency With Number Concepts and Operations: Replicating the Efficacy of a First-Grade Mathematics Intervention. JOURNAL OF LEARNING DISABILITIES 2024; 57:224-241. [PMID: 38014809 DOI: 10.1177/00222194231209017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2023]
Abstract
Conceptual replications are part and parcel of education science. Methodologically rigorous conceptual replication studies permit researchers to test and strengthen the generalizability of a study's initial findings. The current conceptual replication sought to replicate the efficacy of a small-group, first-grade mathematics intervention with 240 first-grade students with mathematics difficulties in a new geographical region. Participating students were randomized into one of three conditions: (a) 2:1 mathematics intervention group, (b) 5:1 mathematics intervention group, or (c) business-as-usual instruction. Relative to the original study, findings from the replication varied. When comparing the treatment groups to the control, results suggested positive effects on all outcome measures, including a follow-up assessment administered one year later. However, differences between the two treatment groups based on group size were not found in the mathematics outcome measures. Both groups also received commensurate levels of observed instructional interactions. Implications for unpacking contextual differences between original research and their replications as well as using future research to explore the quantity and quality of instructional interactions as ways to explain variation in findings of group size are discussed.
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Affiliation(s)
| | - Ben Clarke
- University of Oregon, Eugene, Oregon, USA
| | | | | | | | | | | | | | | | - Derek Kosty
- Oregon Research Institute, Eugene, Oregon, USA
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Kearney R, Ellard D, Parsons H, Haque A, Mason J, Nwankwo H, Bradley H, Drew S, Modi C, Bush H, Torgerson D, Underwood M. Advice only versus advice and a physiotherapy programme for acute traumatic anterior shoulder dislocation: the ARTISAN RCT. Health Technol Assess 2024; 28:1-94. [PMID: 38695098 PMCID: PMC11089447 DOI: 10.3310/cmyw9226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/15/2024] Open
Abstract
Background The extra benefit of a programme of physiotherapy in addition to advice alone, following first-time traumatic shoulder dislocation, is uncertain. We compared the clinical and cost-effectiveness of a single session of advice with a single session of advice and a programme of physiotherapy. Objective The primary objective was to quantify and draw inferences about observed differences in the Oxford Shoulder Instability Score between the trial treatment groups 6 months post randomisation, in adults with a first-time traumatic shoulder dislocation. Design A pragmatic, multicentre, superiority, randomised controlled trial with embedded qualitative study. Setting Forty-one hospitals in the UK NHS. Participants Adults with a radiologically confirmed first-time traumatic anterior shoulder dislocation, being managed non-operatively. People with neurovascular complications or bilateral dislocations, and those unable to adhere to trial procedures or unable to attend physiotherapy within 6 weeks of injury, or who had previously been randomised, were excluded. Interventions All participants received the same initial shoulder examination followed by advice to aid self-management, lasting up to 1 hour and administered by a physiotherapist (control). Participants randomised to receive an additional programme of physiotherapy were offered sessions lasting for up to 30 minutes, over a maximum duration of 4 months from the date of randomisation (intervention). Main outcome measures The primary outcome measure was the Oxford Shoulder Instability Score. This is a self-completed outcome measure containing 12 questions (0-4 points each), with possible scores from 0 (worst function) to 48 (best function). Measurements were collected at 6 weeks, 3 months, 6 months and 12 months by postal questionnaire; 6 months was the primary outcome time point. The primary health outcome for economic evaluation was the quality-adjusted life-year, in accordance with National Institute of Health and Care Excellence guidelines. Results Between 14 November 2018 and 14 March 2022, 482 participants were randomised to advice (n = 240) or advice and a programme of physiotherapy (n = 242). Participants were 34% female, with a mean age of 45 years, and treatment arms were balanced at baseline. There was not a statistically significant difference in the primary outcome between advice only and advice plus a programme of physiotherapy at 6 months for the primary intention-to-treat adjusted analysis (favours physiotherapy: 1.5, 95% confidence interval -0.3 to 3.5) or at earlier 3-month and 6-week time points on the Oxford Shoulder Instability Score (0-48; higher scores indicate better function). The probability of physiotherapy being cost-effective at a willingness-to-pay threshold of £30,000 was 0.95. Conclusions We found little difference in the primary outcome or other secondary outcomes. Advice with additional physiotherapy sessions was found likely to be cost-effective. However, small imprecise incremental costs and quality-adjusted life-years raise questions on whether it is the best use of scarce physiotherapy resources given current service demands. Limitations Loss to follow-up was 27%; however, the observed standard deviation was much smaller than anticipated. These changes in parameters reduced the number of participants required to observe the planned target difference of four points. Our post hoc sensitivity analysis, accounting for missing data, gives similar results. Future work Further research should be directed towards optimising self-management strategies. Study registration This study is registered as ISRCTN63184243. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 16/167/56) and is published in full in Health Technology Assessment; Vol. 28, No. 22. See the NIHR Funding and Awards website for further award information.
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Affiliation(s)
| | - David Ellard
- Warwick Medical School, University of Warwick, Coventry, UK
- University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Helen Parsons
- Warwick Medical School, University of Warwick, Coventry, UK
- University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Aminul Haque
- Warwick Medical School, University of Warwick, Coventry, UK
| | - James Mason
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Henry Nwankwo
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Helen Bradley
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Steve Drew
- University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Chetan Modi
- University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Howard Bush
- University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | | | - Martin Underwood
- Warwick Medical School, University of Warwick, Coventry, UK
- University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
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McGregor G, Sandhu H, Bruce J, Sheehan B, McWilliams D, Yeung J, Jones C, Lara B, Alleyne S, Smith J, Lall R, Ji C, Ratna M, Ennis S, Heine P, Patel S, Abraham C, Mason J, Nwankwo H, Nichols V, Seers K, Underwood M. Clinical effectiveness of an online supervised group physical and mental health rehabilitation programme for adults with post-covid-19 condition (REGAIN study): multicentre randomised controlled trial. BMJ 2024; 384:e076506. [PMID: 38325873 PMCID: PMC11134408 DOI: 10.1136/bmj-2023-076506] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/08/2023] [Indexed: 02/09/2024]
Abstract
OBJECTIVE To evaluate whether a structured online supervised group physical and mental health rehabilitation programme can improve health related quality of life compared with usual care in adults with post-covid-19 condition (long covid). DESIGN Pragmatic, multicentre, parallel group, superiority randomised controlled trial. SETTING England and Wales, with home based interventions delivered remotely online from a single trial hub. PARTICIPANTS 585 adults (26-86 years) discharged from NHS hospitals at least three months previously after covid-19 and with ongoing physical and/or mental health sequelae (post-covid-19 condition), randomised (1:1.03) to receive the Rehabilitation Exercise and psycholoGical support After covid-19 InfectioN (REGAIN) intervention (n=298) or usual care (n=287). INTERVENTIONS Best practice usual care was a single online session of advice and support with a trained practitioner. The REGAIN intervention was delivered online over eight weeks and consisted of weekly home based, live, supervised, group exercise and psychological support sessions. MAIN OUTCOME MEASURES The primary outcome was health related quality of life using the patient reported outcomes measurement information system (PROMIS) preference (PROPr) score at three months. Secondary outcomes, measured at three, six, and 12 months, included PROMIS subscores (depression, fatigue, sleep disturbance, pain interference, physical function, social roles/activities, and cognitive function), severity of post-traumatic stress disorder, general health, and adverse events. RESULTS Between January 2021 and July 2022, 39 697 people were invited to take part in the study and 725 were contacted and eligible. 585 participants were randomised. Mean age was 56 (standard deviation (SD) 12) years, 52% were female participants, mean health related quality of life PROMIS-PROPr score was 0.20 (SD 0.17), and mean time from hospital discharge was 323 (SD 144) days. Compared with usual care, the REGAIN intervention led to improvements in health related quality of life (adjusted mean difference in PROPr score 0.03 (95% confidence interval 0.01 to 0.05), P=0.02) at three months, driven predominantly by greater improvements in the PROMIS subscores for depression (1.39 (0.06 to 2.71), P=0.04), fatigue (2.50 (1.19 to 3.81), P<0.001), and pain interference (1.80 (0.50 to 3.11), P=0.01). Effects were sustained at 12 months (0.03 (0.01 to 0.06), P=0.02). Of 21 serious adverse events, only one was possibly related to the REGAIN intervention. In the intervention group, 141 (47%) participants fully adhered to the programme, 117 (39%) partially adhered, and 40 (13%) did not receive the intervention. CONCLUSIONS In adults with post-covid-19 condition, an online, home based, supervised, group physical and mental health rehabilitation programme was clinically effective at improving health related quality of life at three and 12 months compared with usual care. TRIAL REGISTRATION ISRCTN registry ISRCTN11466448.
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Affiliation(s)
- Gordon McGregor
- University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
- Research Institute for Health and Wellbeing, Coventry University, Coventry, UK
| | - Harbinder Sandhu
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
| | - Julie Bruce
- University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
| | | | - David McWilliams
- Centre for Care Excellence, University Hospitals Coventry and Warwickshire NHS Trust and Coventry University, Coventry, UK
| | - Joyce Yeung
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
- Department of Anaesthesia and Critical Care, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | | | - Beatriz Lara
- University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Sharisse Alleyne
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
| | - Jessica Smith
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
| | - Ranjit Lall
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
| | - Chen Ji
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
| | - Mariam Ratna
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
| | - Stuart Ennis
- University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
| | - Peter Heine
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
| | - Shilpa Patel
- University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
| | | | - James Mason
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
| | - Henry Nwankwo
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
| | - Vivien Nichols
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
| | - Kate Seers
- Warwick Research in Nursing, Warwick Medical School, University of Warwick, Coventry, UK
| | - Martin Underwood
- University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
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Wang X, Turner EL, Li F. Designing individually randomized group treatment trials with repeated outcome measurements using generalized estimating equations. Stat Med 2024; 43:358-378. [PMID: 38009329 PMCID: PMC10939061 DOI: 10.1002/sim.9966] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2022] [Revised: 11/04/2023] [Accepted: 11/08/2023] [Indexed: 11/28/2023]
Abstract
Individually randomized group treatment (IRGT) trials, in which the clustering of outcome is induced by group-based treatment delivery, are increasingly popular in public health research. IRGT trials frequently incorporate longitudinal measurements, of which the proper sample size calculations should account for correlation structures reflecting both the treatment-induced clustering and repeated outcome measurements. Given the relatively sparse literature on designing longitudinal IRGT trials, we propose sample size procedures for continuous and binary outcomes based on the generalized estimating equations approach, employing the block exchangeable correlation structures with different correlation parameters for the treatment arm and for the control arm, and surveying five marginal mean models with different assumptions of time effect: no-time constant treatment effect, linear-time constant treatment effect, categorical-time constant treatment effect, linear time by treatment interaction, and categorical time by treatment interaction. Closed-form sample size formulas are derived for continuous outcomes, which depends on the eigenvalues of the correlation matrices; detailed numerical sample size procedures are proposed for binary outcomes. Through simulations, we demonstrate that the empirical power agrees well with the predicted power, for as few as eight groups formed in the treatment arm, when data are analyzed using the matrix-adjusted estimating equations for the correlation parameters with a bias-corrected sandwich variance estimator.
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Affiliation(s)
- Xueqi Wang
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, NC, 27710, USA
- Department of Biostatistics, Yale School of Public Health, New Haven, CT, 06511, USA
| | - Elizabeth L. Turner
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, NC, 27710, USA
- Duke Global Health Institute, Duke University, Durham, NC, 27710, USA
| | - Fan Li
- Department of Biostatistics, Yale School of Public Health, New Haven, CT, 06511, USA
- Center for Methods in Implementation and Prevention Science, Yale University, New Haven, CT, 06511, USA
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Tong G, Tong J, Jiang Y, Esserman D, Harhay MO, Warren JL. Hierarchical Bayesian modeling of heterogeneous outcome variance in cluster randomized trials. Clin Trials 2024:17407745231222018. [PMID: 38197388 PMCID: PMC11233424 DOI: 10.1177/17407745231222018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2024]
Abstract
BACKGROUND Heterogeneous outcome correlations across treatment arms and clusters have been increasingly acknowledged in cluster randomized trials with binary endpoints, where analytical methods have been developed to study such heterogeneity. However, cluster-specific outcome variances and correlations have yet to be studied for cluster randomized trials with continuous outcomes. METHODS This article proposes models fitted in the Bayesian setting with hierarchical variance structure to quantify heterogeneous variances across clusters and explain it with cluster-level covariates when the outcome is continuous. The models can also be extended to analyzing heterogeneous variances in individually randomized group treatment trials, with arm-specific cluster-level covariates, or in partially nested designs. Simulation studies are carried out to validate the performance of the newly introduced models across different settings. RESULTS Simulations showed that overall the newly introduced models have good performance, reporting low bias and approximately 95% coverage for the intraclass correlation coefficients and regression parameters in the variance model. When variances are heterogeneous, our proposed models had improved model fit over models with homogeneous variances. When used to analyze data from the Kerala Diabetes Prevention Program study, our models identified heterogeneous variances and intraclass correlation coefficients across clusters and examined cluster-level characteristics associated with such heterogeneity. CONCLUSION We proposed new hierarchical Bayesian variance models to accommodate cluster-specific variances in cluster randomized trials. The newly developed methods inform the understanding of how an intervention strategy is implemented and disseminated differently across clusters and can help improve future trial design.
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Affiliation(s)
- Guangyu Tong
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
- Department of Biostatistics, Yale School of Public Health, New Haven, Connecticut, USA
- Center for Methods in Implementation and Prevention Science, Yale School of Public Health, New Haven, Connecticut, USA
| | - Jiaqi Tong
- Department of Biostatistics, Yale School of Public Health, New Haven, Connecticut, USA
- Center for Methods in Implementation and Prevention Science, Yale School of Public Health, New Haven, Connecticut, USA
| | - Yi Jiang
- Department of Biostatistics, Penn State College of Medicine, Hershey, Pennsylvania, USA
| | - Denise Esserman
- Department of Biostatistics, Yale School of Public Health, New Haven, Connecticut, USA
- Yale Center for Analytical Science, Yale School of Public Health, New Haven, Connecticut, USA
| | - Michael O Harhay
- Clinical Trials Methods and Outcomes Lab, Palliative and Advanced Illness Research (PAIR) Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Joshua L Warren
- Department of Biostatistics, Yale School of Public Health, New Haven, Connecticut, USA
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Heaven A, Bower P, Day F, Farrin A, Fernadez C, Foster M, Foy R, Hawkins R, Hulme C, Humphrey S, Lawton R, Parker C, Thompson E, West R, Clegg A. PeRsOnaliSed care Planning for oldER people with frailty (PROSPER): protocol for a randomised controlled trial. Trials 2024; 25:8. [PMID: 38167481 PMCID: PMC10759371 DOI: 10.1186/s13063-023-07857-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Accepted: 12/06/2023] [Indexed: 01/05/2024] Open
Abstract
BACKGROUND Frailty is common in older age and is characterised by loss of biological reserves across multiple organ systems. These changes associated with frailty mean older people can be vulnerable to sudden, dramatic changes in health because of relatively small problems. Older people with frailty are at increased risk of adverse outcomes including disability, hospitalisation, and care home admission, with associated reduction in quality of life and increased NHS and social care costs. Personalised Care Planning offers an anticipatory, preventative approach to supporting older adults to live independently for longer, but it has not been robustly evaluated in a population of older adults with frailty. METHODS Following an initial feasibility study, this multi-centre, individually randomised controlled trial aims to establish whether personalised care planning for older people improves health-related quality of life. It will recruit 1337 participants from general practices across Yorkshire and Humber and Mid-Mersey in the North of England. Eligible patients will be aged 65 and over with an electronic frailty index score of 0.21 or above, living in their own homes, without severe cognitive impairment and not in receipt of end-of-life care. Following confirmation of eligibility, informed consent and baseline data collection, participants will be individually randomised to the PeRsOnaliSed care Planning for oldER people with frailty (PROSPER) intervention or usual care in a 2.6:1 allocation ratio. Participants will not be blinded to allocation, but data collection and analysis will be blinded. The intervention will be delivered over 12 weeks by a Personal Independence Co-ordinator worker based within a voluntary sector organisation, Age UK. The primary outcomes are health-related quality of life, measured using both the physical and mental components of the Short-Form 12 Item Health Questionnaire at 12 months after randomisation. Secondary outcomes comprise activities of daily living, self-management capabilities and loneliness, admission to care homes, hospitalisations, and health and social care resource use at 12 months post randomisation. Parallel cost-effectiveness and process evaluations will be conducted alongside the trial. DISCUSSION The PROSPER study will evaluate the effectiveness and cost-effectiveness of a personalised care planning approach for older people with frailty and inform the process of its implementation. TRIAL REGISTRATION ISRCTN16123291 . Registered on 28 August 2020.
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Affiliation(s)
- Anne Heaven
- Academic Unit for Ageing and Stroke Research, University of Leeds, Bradford Institute for Health Research, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, BD9 6RJ, UK.
- Leeds Institute of Health Sciences, School of Medicine, University of Leeds, Leeds, LS2 9JT, UK.
| | - Peter Bower
- NIHR Older People and Frailty Policy Research Unit, Centre for Primary Care and Health Services Research, Manchester Academic Health Science Centre, University of Manchester, M13 9PL, Manchester, UK
| | - Florence Day
- Leeds Institute of Clinical Trials Research (LICTR), Clinical Trials Research Unit, University of Leeds, Leeds, LS2 9JT, UK
| | - Amanda Farrin
- Leeds Institute of Clinical Trials Research (LICTR), Clinical Trials Research Unit, University of Leeds, Leeds, LS2 9JT, UK
| | - Catherine Fernadez
- Leeds Institute of Clinical Trials Research (LICTR), Clinical Trials Research Unit, University of Leeds, Leeds, LS2 9JT, UK
| | - Marilyn Foster
- PPI Representative, c/o Academic Unit for Ageing and Stroke Research, University of Leeds, Bradford Institute for Health Research, Bradford Teaching Hospitals NHS Foundation Trust, Duckworth Lane, Bradford, BD9 6RJ, UK
| | - Robbie Foy
- Leeds Institute of Health Sciences, School of Medicine, University of Leeds, Leeds, LS2 9JT, UK
| | - Rebecca Hawkins
- Academic Unit for Ageing and Stroke Research, University of Leeds, Bradford Institute for Health Research, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, BD9 6RJ, UK
- Leeds Institute of Health Sciences, School of Medicine, University of Leeds, Leeds, LS2 9JT, UK
| | - Claire Hulme
- Health Economics Group, Institute of Health Research, University of Exeter, Exeter, EX1 2LU, UK
| | - Sara Humphrey
- OPMH & Dementia at Yorkshire and Humber Clinical Network, Rotherham, UK
| | - Rebecca Lawton
- School of Psychology, University of Leeds, Leeds, LS2 9JT, UK
| | - Catriona Parker
- Cancer Clinical Trial Centre, Weston Park Cancer Centre, Whitham Road, Sheffield, S10 2SJ, UK
| | - Ellen Thompson
- Leeds Institute of Clinical Trials Research (LICTR), Clinical Trials Research Unit, University of Leeds, Leeds, LS2 9JT, UK
| | - Robert West
- Leeds Institute of Health Sciences, School of Medicine, University of Leeds, Leeds, LS2 9JT, UK
| | - Andrew Clegg
- Academic Unit for Ageing and Stroke Research, University of Leeds, Bradford Institute for Health Research, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, BD9 6RJ, UK
- Leeds Institute of Health Sciences, School of Medicine, University of Leeds, Leeds, LS2 9JT, UK
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7
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Tong G, Tong J, Li F. Designing multicenter individually randomized group treatment trials. Biom J 2024; 66:e2200307. [PMID: 37768850 DOI: 10.1002/bimj.202200307] [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: 11/10/2022] [Revised: 05/29/2023] [Accepted: 07/23/2023] [Indexed: 09/30/2023]
Abstract
In an individually randomized group treatment (IRGT) trial, participant outcomes can be positively correlated due to, for example, shared therapists in treatment delivery. Oftentimes, because of limited treatment resources or participants at one location, an IRGT trial can be carried out across multiple centers. This design can be subject to potential correlations in the participant outcomes between arms within the same center. While the design of a single-center IRGT trial has been studied, little is known about the planning of a multicenter IRGT trial. To address this gap, this paper provides analytical sample size formulas for designing multicenter IRGT trials with a continuous endpoint under the linear mixed model framework. We found that accounting for the additional center-level correlation at the design stage can lead to sample size reduction, and the magnitude of reduction depends on the amount of between-therapist correlation. However, if the variance components of therapist-level random effects are considered as input parameters in the design stage, accounting for the additional center-level variance component has no impact on the sample size estimation. We presented our findings through numeric illustrations and performed simulation studies to validate our sample size procedures under different scenarios. Optimal design configurations under the multicenter IRGT trials have also been discussed, and two real-world trial examples are drawn to illustrate the use of our method.
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Affiliation(s)
- Guangyu Tong
- Department of Biostatistics, Yale University School of Public Health, New Haven, Connecticut, USA
- Center for Methods in Implementation and Prevention Science, Yale University, New Haven, Connecticut, USA
| | - Jiaqi Tong
- Department of Biostatistics, Yale University School of Public Health, New Haven, Connecticut, USA
- Center for Methods in Implementation and Prevention Science, Yale University, New Haven, Connecticut, USA
| | - Fan Li
- Department of Biostatistics, Yale University School of Public Health, New Haven, Connecticut, USA
- Center for Methods in Implementation and Prevention Science, Yale University, New Haven, Connecticut, USA
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8
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Ondruskova T, Royston R, Absoud M, Ambler G, Qu C, Barnes J, Hunter R, Panca M, Kyriakopoulos M, Oulton K, Paliokosta E, Sharma AN, Slonims V, Summerson U, Sutcliffe A, Thomas M, Dhandapani B, Leonard H, Hassiotis A. Clinical and cost-effectiveness of an adapted intervention for preschoolers with moderate to severe intellectual disabilities displaying behaviours that challenge: the EPICC-ID RCT. Health Technol Assess 2024; 28:1-94. [PMID: 38329108 PMCID: PMC11017145 DOI: 10.3310/jkty6144] [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: 02/09/2024] Open
Abstract
Background Stepping Stones Triple P is an adapted intervention for parents of young children with developmental disabilities who display behaviours that challenge, aiming at teaching positive parenting techniques and promoting a positive parent-child relationship. Objective To evaluate the clinical and cost-effectiveness of level 4 Stepping Stones Triple P in reducing behaviours that challenge in children with moderate to severe intellectual disabilities. Design, setting, participants A parallel two-arm pragmatic multisite single-blind randomised controlled trial recruited a total of 261 dyads (parent and child). The children were aged 30-59 months and had moderate to severe intellectual disabilities. Participants were randomised, using a 3 : 2 allocation ratio, into the intervention arm (Stepping Stones Triple P; n = 155) or treatment as usual arm (n = 106). Participants were recruited from four study sites in Blackpool, North and South London and Newcastle. Intervention Level 4 Stepping Stones Triple P consists of six group sessions and three individual phone or face-to-face contacts over 9 weeks. These were changed to remote sessions after 16 March 2020 due to the coronavirus disease 2019 pandemic. Main outcome measure The primary outcome measure was the parent-reported Child Behaviour Checklist, which assesses the severity of behaviours that challenge. Results We found a small non-significant difference in the mean Child Behaviour Checklist scores (-4.23, 95% CI -9.98 to 1.52, p = 0.146) in the intervention arm compared to treatment as usual at 12 months. Per protocol and complier average causal effect sensitivity analyses, which took into consideration the number of sessions attended, showed the Child Behaviour Checklist mean score difference at 12 months was lower in the intervention arm by -10.77 (95% CI -19.12 to -2.42, p = 0.014) and -11.53 (95% CI -26.97 to 3.91, p = 0.143), respectively. The Child Behaviour Checklist mean score difference between participants who were recruited before and after the coronavirus disease 2019 pandemic was estimated as -7.12 (95% CI -13.44 to -0.81) and 7.61 (95% CI -5.43 to 20.64), respectively (p = 0.046), suggesting that any effect pre-pandemic may have reversed during the pandemic. There were no differences in all secondary measures. Stepping Stones Triple P is probably value for money to deliver (-£1057.88; 95% CI -£3218.6 to -£46.67), but decisions to roll this out as an alternative to existing parenting interventions or treatment as usual may be dependent on policymaker willingness to invest in early interventions to reduce behaviours that challenge. Parents reported the intervention boosted their confidence and skills, and the group format enabled them to learn from others and benefit from peer support. There were 20 serious adverse events reported during the study, but none were associated with the intervention. Limitations There were low attendance rates in the Stepping Stones Triple P arm, as well as the coronavirus disease 2019-related challenges with recruitment and delivery of the intervention. Conclusions Level 4 Stepping Stones Triple P did not reduce early onset behaviours that challenge in very young children with moderate to severe intellectual disabilities. However, there was an effect on child behaviours for those who received a sufficient dose of the intervention. There is a high probability of Stepping Stones Triple P being at least cost neutral and therefore worth considering as an early therapeutic option given the long-term consequences of behaviours that challenge on people and their social networks. Future work Further research should investigate the implementation of parenting groups for behaviours that challenge in this population, as well as the optimal mode of delivery to maximise engagement and subsequent outcomes. Study registration This study is registered as NCT03086876 (https://www.clinicaltrials.gov/ct2/show/NCT03086876?term=Hassiotis±Angela&draw=1&rank=1). Funding This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: HTA 15/162/02) and is published in full in Health Technology Assessment; Vol. 28, No. 6. See the NIHR Funding and Awards website for further award information.
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Affiliation(s)
| | - Rachel Royston
- Division of Psychiatry, University College London, London, UK
| | - Michael Absoud
- Evelina Hospital, Guys and St Thomas's NHS Foundation Trust, London, UK
| | - Gareth Ambler
- Department of Statistical Science, University College London, London, UK
| | - Chen Qu
- Department of Statistical Science, University College London, London, UK
| | - Jacqueline Barnes
- Department of Psychological Sciences, Birkbeck University, University of London, London, UK
| | - Rachael Hunter
- Research Department of Primary Care and Population Health, University College London, Royal Free Medical School, London, UK
| | - Monica Panca
- Research Department of Primary Care and Population Health, University College London, Royal Free Medical School, London, UK
| | - Marinos Kyriakopoulos
- South London and Maudsley NHS Foundation Trust, Michael Rutter Centre, Maudsley Hospital, London, UK
- National and Kapodistrian University of Athens, Vyronas-Kessariani Community Mental Health Centre, Athens, Greece
- Department of Child and Adolescent Psychiatry, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | | | - Eleni Paliokosta
- The Tavistock and Portman NHS Foundation Trust, Kentish Town Health Centre, London, UK
| | - Aditya Narain Sharma
- Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust and Newcastle University, Walkergate Park Centre for Neurorehabilitation and Neuropsychiatry, Newcastle upon Tyne, UK
| | - Vicky Slonims
- Evelina Hospital, Guys and St Thomas's NHS Foundation Trust, London, UK
| | | | | | - Megan Thomas
- Blackpool Teaching Hospitals NHS Foundation Trust, Blackpool, UK
| | | | - Helen Leonard
- Great North Children's Hospital, Victoria Wing, Royal Victoria Infirmary, Newcastle upon Tyne, UK
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Murray DM, Heagerty P, Troendle J, Lin FC, Moyer J, Stevens J, Lytle L, Zhang X, Ilias M, Masterson MY, Redmond N, Tonwe V, Clark D, Mensah GA. Implementation Research at NHLBI: Methodological and Design Challenges and Lessons Learned from the DECIPHeR Initiative. Ethn Dis 2023; DECIPHeR:12-17. [PMID: 38846726 PMCID: PMC11099519 DOI: 10.18865/ed.decipher.12] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2024] Open
Abstract
NHLBI funded seven projects as part of the Disparities Elimination through Coordinated Interventions to Prevent and Control Heart and Lung Disease Risk (DECIPHeR) Initiative. They were expected to collaborate with community partners to (1) employ validated theoretical or conceptual implementation research frameworks, (2) include implementation research study designs, (3) include implementation measures as primary outcomes, and (4) inform our understanding of mediators and mechanisms of action of the implementation strategy. Several projects focused on late-stage implementation strategies that optimally and sustainably delivered two or more evidence-based multilevel interventions to reduce or eliminate cardiovascular and/or pulmonary health disparities and to improve population health in high-burden communities. Projects that were successful in the three-year planning phase transitioned to a 4-year execution phase. NHLBI formed a Technical Assistance Workgroup during the planning phase to help awardees refine study aims, strengthen research designs, detail analytic plans, and to use valid sample size methods. This paper highlights methodological and study design challenges encountered during this process. Important lessons learned included (1) the need for greater emphasis on implementation outcomes, (2) the need to clearly distinguish between intervention and implementation strategies in the protocol, (3) the need to address clustering due to randomization of groups or clusters, (4) the need to address the cross-classification that results when intervention agents work across multiple units of randomization in the same arm, (5) the need to accommodate time-varying intervention effects in stepped-wedge designs, and (6) the need for data-based estimates of the parameters required for sample size estimation.
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Affiliation(s)
| | - Patrick Heagerty
- Department of Biostatistics, University of Washington, Seattle, WA
| | - James Troendle
- Office of Biostatistical Research, National Heart, Lung, and Blood Institute, Bethesda, MD
| | - Feng-Chang Lin
- Department of Biostatistics, University of North Carolina, Chapel Hill, NC
| | | | - June Stevens
- Departments of Nutrition and Epidemiology, University of North Carolina, Chapel Hill, NC
| | - Leslie Lytle
- Departments of Health Behavior and Nutrition, University of North Carolina, Chapel Hill, NC
| | - Xinzhi Zhang
- Center for Translation Research and Implementation Science, National Heart, Lung, and Blood Institute, Bethesda, MD
| | - Maliha Ilias
- Center for Translation Research and Implementation Science, National Heart, Lung, and Blood Institute, Bethesda, MD
| | - Mary Y. Masterson
- Center for Translation Research and Implementation Science, National Heart, Lung, and Blood Institute, Bethesda, MD
| | - Nicole Redmond
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, MD
| | - Veronica Tonwe
- Center for Translation Research and Implementation Science, National Heart, Lung, and Blood Institute, Bethesda, MD
| | - Dave Clark
- Center for Translation Research and Implementation Science, National Heart, Lung, and Blood Institute, Bethesda, MD
| | - George A. Mensah
- Center for Translation Research and Implementation Science, National Heart, Lung, and Blood Institute, Bethesda, MD
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10
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Stefanidou T, Ambler G, Bartl G, Barber N, Billings J, Bogatsu T, Carroll R, Chipp B, Conneely M, Downey AM, Evlat G, Hunter R, Le Novere M, Lewis G, Mackay T, Marwaha S, Matin Z, Naughton G, Nekitsing C, O'Sullivan M, Pinfold V, Pan S, Sobers A, Thompson KJ, Vasikaran J, Webber M, Johnson S, Lloyd-Evans B. Randomised controlled trial of the Community Navigator programme to reduce loneliness and depression for adults with treatment-resistant depression in secondary community mental health services: trial protocol. Trials 2023; 24:652. [PMID: 37803385 PMCID: PMC10559405 DOI: 10.1186/s13063-023-07684-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2023] [Accepted: 09/28/2023] [Indexed: 10/08/2023] Open
Abstract
BACKGROUND New treatments are needed for people with treatment-resistant depression (TRD), who do not benefit from anti-depressants and many of whom do not recover fully with psychological treatments. The Community Navigator programme was co-produced with service users and practitioners. It is a novel social intervention which aims to reduce loneliness and thus improve health outcomes for people with TRD. Participants receive up to 10 individual meetings with a Community Navigator, who helps them to map their social world and set and enact goals to enhance their social connections and reduce loneliness. Participants may also access group meet-ups with others in the programme every 2 months, and may be offered modest financial support to enable activities to support social connections. METHODS A researcher-blind, multi-site, 1:1 randomised controlled trial with N = 306 participants will test the effectiveness of the Community Navigator programme for people with TRD in secondary community mental health teams (CMHTs). Our primary hypothesis is that people who are offered the Community Navigator programme as an addition to usual CMHT care will be less depressed, assessed using the PHQ-9 self-report measure, at 8-month, end-of-treatment follow-up, compared to a control group receiving usual CMHT care and a booklet with information about local social groups and activities. We will follow participants up at end-of-treatment and at 14 months, 6 months after end-of-treatment follow-up. Secondary outcomes include the following: loneliness, anxiety, personal recovery, self-efficacy, social network, social identities. We will collect data about health-related quality of life and service use to investigate the cost-effectiveness of the Community Navigator programme. DISCUSSION This trial will provide definitive evidence about the effectiveness and cost-effectiveness of the Community Navigator programme and whether it can be recommended for use in practice. The trial is due to finish in August 2025. TRIAL REGISTRATION Prospectively registered on 8th July 2022 at: ISRCTN13205972.
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Affiliation(s)
- Theodora Stefanidou
- Division of Psychiatry, University College London, Maple House, 149 Tottenham Court Road, London, W1T 7NF, UK
| | - Gareth Ambler
- Department of Statistical Sciences, University College London, London, UK
- Priment Clinical Trials Unit, University College London, London, UK
| | - Gergely Bartl
- Division of Psychiatry, University College London, Maple House, 149 Tottenham Court Road, London, W1T 7NF, UK
| | - Nick Barber
- Division of Psychiatry, University College London, Maple House, 149 Tottenham Court Road, London, W1T 7NF, UK
- The McPin Foundation, London, UK
| | - Jo Billings
- Division of Psychiatry, University College London, Maple House, 149 Tottenham Court Road, London, W1T 7NF, UK
| | - Tumelo Bogatsu
- Institute for Mental Health, University of Birmingham, Birmingham, UK
| | | | - Beverley Chipp
- Division of Psychiatry, University College London, Maple House, 149 Tottenham Court Road, London, W1T 7NF, UK
- The McPin Foundation, London, UK
| | - Maev Conneely
- Division of Psychiatry, University College London, Maple House, 149 Tottenham Court Road, London, W1T 7NF, UK
| | | | - Gamze Evlat
- Division of Psychiatry, University College London, Maple House, 149 Tottenham Court Road, London, W1T 7NF, UK
- Camden and Islington NHS Foundation Trust, London, UK
| | - Rachael Hunter
- Priment Clinical Trials Unit, University College London, London, UK
- Department of Primary Care and Population Health, University College London, London, UK
| | - Marie Le Novere
- Priment Clinical Trials Unit, University College London, London, UK
- Department of Primary Care and Population Health, University College London, London, UK
| | - Glyn Lewis
- Division of Psychiatry, University College London, Maple House, 149 Tottenham Court Road, London, W1T 7NF, UK
- Priment Clinical Trials Unit, University College London, London, UK
- Camden and Islington NHS Foundation Trust, London, UK
| | | | - Steven Marwaha
- Institute for Mental Health, University of Birmingham, Birmingham, UK
| | - Zubair Matin
- Division of Psychiatry, University College London, Maple House, 149 Tottenham Court Road, London, W1T 7NF, UK
| | | | | | - Millie O'Sullivan
- Division of Psychiatry, University College London, Maple House, 149 Tottenham Court Road, London, W1T 7NF, UK
- Camden and Islington NHS Foundation Trust, London, UK
| | | | - Shengning Pan
- Department of Statistical Sciences, University College London, London, UK
- Priment Clinical Trials Unit, University College London, London, UK
| | - Angela Sobers
- Barnet, Enfield and Haringey, NHS Mental Health Trust, London, UK
| | - Keith J Thompson
- The McPin Foundation, London, UK
- Tees, Esk and Wear Valley, NHS Foundation Trust, Durham, UK
| | - Jerusaa Vasikaran
- Division of Psychiatry, University College London, Maple House, 149 Tottenham Court Road, London, W1T 7NF, UK
| | - Martin Webber
- School for Business and Society, University of York, York, UK
| | - Sonia Johnson
- Division of Psychiatry, University College London, Maple House, 149 Tottenham Court Road, London, W1T 7NF, UK
- Camden and Islington NHS Foundation Trust, London, UK
| | - Brynmor Lloyd-Evans
- Division of Psychiatry, University College London, Maple House, 149 Tottenham Court Road, London, W1T 7NF, UK.
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11
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Iso H, Noguchi M, Yokoyama T, Yoshida T, Saito I, Shintani A, Sairenchi T, Nishizawa H, Imano H, Kitamura A, Shimomura I. Effect of a Community-Based Program to Accelerate Referral to Physicians for Individuals at High-Risk of Lifestyle-Related Diseases: A Cluster Randomized Trial. J Atheroscler Thromb 2023; 30:1389-1406. [PMID: 36878606 PMCID: PMC10564631 DOI: 10.5551/jat.64100] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Accepted: 01/23/2023] [Indexed: 03/08/2023] Open
Abstract
AIM A cluster randomized trial was conducted within 43 Japanese municipalities (21 intervention and 22 usual care) to examine whether the standardized health counseling for individuals at high cardiovascular risk screened at community sites accelerates clinic visits to strengthen the primary health care system. METHODS Among high-risk individuals aged 40-74 years screened by health checkups, 8,977 and 6,733 were allocated to the intervention and usual care groups, respectively, who were not under medical treatment but had high levels of blood pressure (systolic/diastolic ≥ 160/100 mmHg), hemoglobin A1c or glucose (≥ 7.0% or corresponding glucose levels), LDL-cholesterol (≥ 180 mg/dL for men), and/or proteinuria of ≥ 2+. The intervention was performed from May 2014 to March 2016 under a standardized health counseling program based on the health belief model primarily by public health nurses. The usual care group was provided with local counseling protocols. RESULTS The cumulative proportions of clinic visits for 12 months after health checkups were 58.1% (95% confidence interval, 57.0%, 59.3%) versus 44.5% (43.2%, 45.8%), with the probability ratio of clinic visits between the groups being 1.46 (1.24, 1.72). The between-group differences between the baseline and 1-year surveys were -1.50 (-2.59, -0.41) mmHg for diastolic blood pressure in the hypertension category, -0.30% (-0.53%, -0.07%) for HbA1c in the diabetes category, -0.37 (-0.48, -0.27) mmol/L for LDL-cholesterol in the dyslipidemia category, and none for proteinuria. CONCLUSION Standardized health counseling for high-risk individuals accelerated clinic visits, with larger reductions in blood pressure, HbA1c, and LDL-cholesterol levels. The nationwide use of counseling after health checkups for high-risk individuals could help in controlling risk factors and in preventing lifestyle-related diseases.
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Affiliation(s)
- Hiroyasu Iso
- Public Health, Department of Social Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
- (Present address) Institute for Global Health Policy Research, Bureau of International Cooperation, National Center for Global Health and Medicine, Tokyo, Japan
| | - Midori Noguchi
- Public Health, Department of Social Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
| | | | - Toshiko Yoshida
- St. Luke’s International University Graduate School of Nursing Science, Tokyo, Japan
| | - Isao Saito
- Department of Public Health and Epidemiology, Faculty of Medicine, Oita University, Oita, Japan
| | - Ayumi Shintani
- Department of Medical Statistics, Graduate School of Medicine, Osaka Metropolitan University, Osaka, Japan
| | - Toshimi Sairenchi
- Medical Science of Nursing, Dokkyo Medical University School of Nursing, Tochigi, Japan
| | - Hitoshi Nishizawa
- Department of Metabolic Medicine, Osaka University Graduate School of Medicine, Graduate School of Medicine Osaka University, Osaka, Japan
| | - Hironori Imano
- Department of Public Health, Kindai University Faculty of Medicine, Osaka, Japan
| | - Akihiko Kitamura
- Health Town Development Science Center, Yao City Public Health Center, Osaka, Japan
| | - Iichiro Shimomura
- Department of Metabolic Medicine, Osaka University Graduate School of Medicine, Graduate School of Medicine Osaka University, Osaka, Japan
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12
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Tong G, Taljaard M, Li F. Sample size considerations for assessing treatment effect heterogeneity in randomized trials with heterogeneous intracluster correlations and variances. Stat Med 2023; 42:3392-3412. [PMID: 37316956 DOI: 10.1002/sim.9811] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2022] [Revised: 02/08/2023] [Accepted: 05/19/2023] [Indexed: 06/16/2023]
Abstract
An important consideration in the design and analysis of randomized trials is the need to account for outcome observations being positively correlated within groups or clusters. Two notable types of designs with this consideration are individually randomized group treatment trials and cluster randomized trials. While sample size methods for testing the average treatment effect are available for both types of designs, methods for detecting treatment effect modification are relatively limited. In this article, we present new sample size formulas for testing treatment effect modification based on either a univariate or multivariate effect modifier in both individually randomized group treatment and cluster randomized trials with a continuous outcome but any types of effect modifier, while accounting for differences across study arms in the outcome variance, outcome intracluster correlation coefficient (ICC) and the cluster size. We consider cases where the effect modifier can be measured at either the individual level or cluster level, and with a univariate effect modifier, our closed-form sample size expressions provide insights into the optimal allocation of groups or clusters to maximize design efficiency. Overall, our results show that the required sample size for testing treatment effect heterogeneity with an individual-level effect modifier can be affected by unequal ICCs and variances between arms, and accounting for such between-arm heterogeneity can lead to more accurate sample size determination. We use simulations to validate our sample size formulas and illustrate their application in the context of two real trials: an individually randomized group treatment trial (the AWARE study) and a cluster randomized trial (the K-DPP study).
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Affiliation(s)
- Guangyu Tong
- Department of Biostatistics, Yale School of Public Health, New Haven, Connecticut, USA
| | - Monica Taljaard
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
- School of Epidemiology and Public Heath, University of Ottawa, Ottawa, Canada
| | - Fan Li
- Department of Biostatistics, Yale School of Public Health, New Haven, Connecticut, USA
- Center for Methods in Implementation and Prevention Science, Yale School of Public Health, New Haven, Connecticut, USA
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13
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Heisler M, Dyer WT, Finertie H, Stoll SC, Wiley D, Turner CD, Sedgwick T, Kullgren J, Richardson CR, Hedderson M, Schmittdiel JA. Using Peer Support to Prevent Diabetes: Results of a Pragmatic RCT. Am J Prev Med 2023; 65:239-250. [PMID: 36898949 PMCID: PMC10810481 DOI: 10.1016/j.amepre.2023.02.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Revised: 02/03/2023] [Accepted: 02/06/2023] [Indexed: 03/10/2023]
Abstract
INTRODUCTION High-contact structured diabetes prevention programs are effective in lowering weight and HbA1cs, yet their intensity level can create barriers to participation. Peer support programs improve clinical outcomes among adults with Type 2 diabetes, but their effectiveness in diabetes prevention is unknown. This study examined whether a low-intensity peer support program improved outcomes more than enhanced usual care in a diverse population with prediabetes. STUDY DESIGN The intervention was tested in a pragmatic 2-arm RCT. SETTING/PARTICIPANTS Participants were adults with prediabetes at three healthcare centers. INTERVENTION Participants randomized to the enhanced usual care arm received educational materials. Participants in the Using Peer Support to Aid in Prevention and Treatment in Prediabetes arm were matched with a peer supporter: another patient who had made healthy lifestyle changes and was trained in autonomy-supportive action planning. Peer supporters were instructed to provide weekly telephone support to their peers on specific action steps toward behavioral goals for 6 months, then monthly support for 6 months. MAIN OUTCOME MEASURES Changes in primary outcomes of weight and HbA1c and secondary outcomes of enrollment in formal diabetes prevention programs, self-reported diet, physical activity, health-specific social support, self-efficacy, motivation, and activation at 6 and 12 months were examined. RESULTS Data collection occurred from October 2018 to March 2022, with analyses completed in September 2022. Among 355 randomized patients, in intention-to-treat analyses, there were no between-group differences in HbA1c or weight changes at 6 and 12 months. Using Peer Support to Aid in Prevention and Treatment in Prediabetes participants were more likely to enroll in structured programs at 6 (AOR=2.45, p=0.009) and 12 (AOR=2.21, p=0.016) months and to report eating whole grains at 6 (4.49, p=0.026) and 12 (4.22, p=0.034) months. They reported greater improvements in perceived social support for diabetes prevention behaviors at 6 (6.39, p<0.001) and 12 (5.48, p<0.001) months, with no differences in other measures. CONCLUSIONS A stand-alone, low-intensity peer support program improved social support and participation in formal diabetes prevention programs but not weight or HbA1c. It will be important to examine whether peer support could effectively complement higher-intensity, structured diabetes prevention programs. TRIAL REGISTRATION This trial is registered at ClinicalTrials.gov, NCT03689530. Full protocol available at https://clinicaltrials.gov/ct2/show/NCT03689530.
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Affiliation(s)
- Michele Heisler
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan; Institute for Healthcare Policy & Innovation, University of Michigan, Ann Arbor, Michigan; Department of Health Behavior and Health Education, School of Public Health, University of Michigan, Ann Arbor, Michigan; VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan.
| | - Wendy T Dyer
- Division of Research, Kaiser Permanente Northern California, Oakland, California
| | - Holly Finertie
- Division of Research, Kaiser Permanente Northern California, Oakland, California
| | - Shelley C Stoll
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan
| | - Deanne Wiley
- Division of Research, Kaiser Permanente Northern California, Oakland, California
| | - Cassie D Turner
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan; VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
| | - Tali Sedgwick
- Division of Research, Kaiser Permanente Northern California, Oakland, California
| | - Jeffrey Kullgren
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan; Institute for Healthcare Policy & Innovation, University of Michigan, Ann Arbor, Michigan; VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
| | - Caroline R Richardson
- Department of Family Medicine, University of Michigan Medical School, Ann Arbor, Michigan
| | - Monique Hedderson
- Division of Research, Kaiser Permanente Northern California, Oakland, California
| | - Julie A Schmittdiel
- Division of Research, Kaiser Permanente Northern California, Oakland, California; Department of Health System Sciences, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California
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14
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Husain N, Kiran T, Chaudhry IB, Williams C, Emsley R, Arshad U, Ansari MA, Bassett P, Bee P, Bhatia MR, Chew-Graham C, Husain MO, Irfan M, Khaliq A, Minhas FA, Naeem F, Naqvi H, Nizami AT, Noureen A, Panagioti M, Rasool G, Saeed S, Bukhari SQ, Tofique S, Zadeh ZF, Zafar SN, Chaudhry N. A culturally adapted manual-assisted problem-solving intervention (CMAP) for adults with a history of self-harm: a multi-centre randomised controlled trial. BMC Med 2023; 21:282. [PMID: 37525207 PMCID: PMC10391745 DOI: 10.1186/s12916-023-02983-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Accepted: 07/18/2023] [Indexed: 08/02/2023] Open
Abstract
BACKGROUND Self-harm is an important predictor of a suicide death. Culturally appropriate strategies for the prevention of self-harm and suicide are needed but the evidence is very limited from low- and middle-income countries (LMICs). This study aims to investigate the effectiveness of a culturally adapted manual-assisted problem-solving intervention (CMAP) for patients presenting after self-harm. METHODS This was a rater-blind, multicenter randomised controlled trial. The study sites were all participating emergency departments, medical wards of general hospitals and primary care centres in Karachi, Lahore, Rawalpindi, Peshawar, and Quetta, Pakistan. Patients presenting after a self-harm episode (n = 901) to participating recruitment sites were assessed and randomised (1:1) to one of the two arms; CMAP with enhanced treatment as usual (E-TAU) or E-TAU. The intervention (CMAP) is a manual-assisted, cognitive behaviour therapy (CBT)-informed problem-focused therapy, comprising six one-to-one sessions delivered over three months. Repetition of self-harm at 12-month post-randomisation was the primary outcome and secondary outcomes included suicidal ideation, hopelessness, depression, health-related quality of life (QoL), coping resources, and level of satisfaction with service received, assessed at baseline, 3-, 6-, 9-, and 12-month post-randomisation. The trial is registered on ClinicalTrials.gov. NCT02742922 (April 2016). RESULTS We screened 3786 patients for eligibility and 901 eligible, consented patients were randomly assigned to the CMAP plus E-TAU arm (n = 440) and E-TAU arm (N = 461). The number of self-harm repetitions for CMAP plus E-TAU was lower (n = 17) compared to the E-TAU arm (n = 23) at 12-month post-randomisation, but the difference was not statistically significant (p = 0.407). There was a statistically and clinically significant reduction in other outcomes including suicidal ideation (- 3.6 (- 4.9, - 2.4)), depression (- 7.1 (- 8.7, - 5.4)), hopelessness (- 2.6 (- 3.4, - 1.8), and improvement in health-related QoL and coping resources after completion of the intervention in the CMAP plus E-TAU arm compared to the E-TAU arm. The effect was sustained at 12-month follow-up for all the outcomes except for suicidal ideation and hopelessness. On suicidal ideation and hopelessness, participants in the intervention arm scored lower compared to the E-TAU arm but the difference was not statistically significant, though the participants in both arms were in low-risk category at 12-month follow-up. The improvement in both arms is explained by the established role of enhanced care in suicide prevention. CONCLUSIONS Suicidal ideation is considered an important target for the prevention of suicide, therefore, CMAP intervention should be considered for inclusion in the self-harm and suicide prevention guidelines. Given the improvement in the E-TAU arm, the potential use of brief interventions such as regular contact requires further exploration.
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Affiliation(s)
- Nusrat Husain
- Division of Psychology and Mental Health, University of Manchester, Oxford Rd, Manchester, M13 9PL, England, UK
- Mersey Care NHS Foundation Trust, Kings Business Park, Trust Offices/V7 Buildings, Prescot, L34 1PJ, England, UK
| | - Tayyeba Kiran
- Pakistan Institute of Living and Learning, Suite No. 201, 2nd Floor, The Plaza, Do-Talwar, Khayaban-E-Iqbal, Clifton, Karachi, Pakistan.
| | - Imran Bashir Chaudhry
- Division of Psychology and Mental Health, University of Manchester, Oxford Rd, Manchester, M13 9PL, England, UK
- Department of Psychiatry, Ziauddin University and Hospital, 4/B Shahrah-E-Ghalib Rd, Block 6 Clifton, Karachi, Pakistan
| | - Christopher Williams
- Institute of Health and Well Being, University of Glasgow, Glasgow, G12 8QQ, Scotland, UK
| | - Richard Emsley
- Medical Statistics & Trials Methodology, Institute of Psychiatry, Kings College London, Strand, London, WC2R 2LS, England, UK
| | - Usman Arshad
- Pakistan Institute of Living and Learning, Suite No. 201, 2nd Floor, The Plaza, Do-Talwar, Khayaban-E-Iqbal, Clifton, Karachi, Pakistan
| | - Moin Ahmed Ansari
- Liaquat University of Medical and Health Sciences, C7PC+337, Hyderabad, Jamshoro, Pakistan
| | - Paul Bassett
- Statistical Consultancy, Hemel Hempstead, England, UK
| | - Penny Bee
- Division of Nursing, Midwifery and Social Work, University of Manchester, Oxford Rd, Manchester, M13 9PL, England, UK
| | - Moti Ram Bhatia
- Peoples University of Medical & Health Science for Women Nawabshah, 6CV3+7HW, Hospital Road, Shaheed Benazirabad, Nawabshah, Pakistan
| | | | - Muhammad Omair Husain
- Department of Psychiatry, University of Toronto, 399 Bathurst St, Toronto, ON, M5T 2S8, Canada
| | - Muhammad Irfan
- Department of Mental Health, Psychiatry and Behavioural Sciences, Peshawar Medical College, Riphah International University, Islamabad, Pakistan
| | - Ayesha Khaliq
- Pakistan Institute of Living and Learning, Suite No. 201, 2nd Floor, The Plaza, Do-Talwar, Khayaban-E-Iqbal, Clifton, Karachi, Pakistan
| | | | - Farooq Naeem
- CAMH, University of Toronto, 399 Bathurst St, Toronto, ON, M5T 2S8, Canada
| | - Haider Naqvi
- Department of Psychiatry, Dow University of Health Sciences, Mission Rd, New Labour Colony Nanakwara, Karachi, Pakistan
| | - Asad Tamizuddin Nizami
- Institute of Psychiatry, Benazir Bhutto Hospital, Near Chandni Chowk, Murree Rd, Chah Sultan, Rawalpindi, Pakistan
| | - Amna Noureen
- Pakistan Institute of Living and Learning, Suite No. 201, 2nd Floor, The Plaza, Do-Talwar, Khayaban-E-Iqbal, Clifton, Karachi, Pakistan
| | - Maria Panagioti
- Division of Population Health, Health Services Research & Primary Care, Institute for Health Policy and Organisation/Alliance Manchester Business School, University of Manchester, Oxford Rd, Manchester, M13 9PL, UK
| | - Ghulam Rasool
- Balochistan Institute of Psychiatry & Behavioural Sciences, Bolan Medical College, 5XRG+VGC, Brewery Rd, Quetta, Pakistan
| | - Sofiya Saeed
- Pakistan Institute of Living and Learning, Suite No. 201, 2nd Floor, The Plaza, Do-Talwar, Khayaban-E-Iqbal, Clifton, Karachi, Pakistan
| | - Sumira Qambar Bukhari
- Department of Psychiatry, Services Institute of Medical Sciences, G8QM+JWR, Jail Rd, Shadman 1 Shadman, Lahore, Pakistan
| | - Sehrish Tofique
- Pakistan Institute of Living and Learning, Suite No. 201, 2nd Floor, The Plaza, Do-Talwar, Khayaban-E-Iqbal, Clifton, Karachi, Pakistan
| | - Zainab F Zadeh
- Pakistan Institute of Living and Learning, Suite No. 201, 2nd Floor, The Plaza, Do-Talwar, Khayaban-E-Iqbal, Clifton, Karachi, Pakistan
| | - Shehla Naeem Zafar
- Institute of Nursing, Iqra University, G-16/1 Allama Rasheed Turabi Rd, Block-B Block B, North Nazimabad Town, Karachi, Pakistan
| | - Nasim Chaudhry
- Pakistan Institute of Living and Learning, Suite No. 201, 2nd Floor, The Plaza, Do-Talwar, Khayaban-E-Iqbal, Clifton, Karachi, Pakistan
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Tallon D, Thomas L, Brabyn S, Ching BCF, Hahn JS, Jude B, X Logan M, Burrage A, Fox F, Gilbody S, Lanham P, Lewis G, Li J, MacNeill SJ, Nazareth I, Parrott S, Peters TJ, Shafran R, Turner K, Williams C, Kessler D, Wiles N. Integrated therapist and online CBT for depression in primary care (INTERACT): study protocol for a multi-centre randomised controlled trial. Trials 2023; 24:421. [PMID: 37340500 DOI: 10.1186/s13063-023-07396-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 05/19/2023] [Indexed: 06/22/2023] Open
Abstract
BACKGROUND Cognitive behavioural therapy (CBT) is an effective treatment for depression. Self-directed online CBT interventions have made CBT more accessible at a lower cost. However, adherence is often poor and, in the absence of therapist support, effects are modest and short-term. Delivering CBT online using instant messaging is clinically and cost-effective; however, most existing platforms are limited to instant messaging sessions, without the support of between-session "homework" activities. The INTERACT intervention integrates online CBT materials and 'high-intensity' therapist-led CBT, delivered remotely in real-time. The INTERACT trial will evaluate this novel integration in terms of clinical and cost-effectiveness, and acceptability to therapists and clients. METHODS Pragmatic, two parallel-group multi-centre individually randomised controlled trial, with 434 patients recruited from primary care practices in Bristol, London and York. Participants with depression will be identified via General Practitioner record searches and direct referrals. INCLUSION CRITERIA aged ≥ 18 years; score ≥ 14 on Beck Depression Inventory (BDI-II); meeting International Classification of Diseases (ICD-10) criteria for depression. EXCLUSION CRITERIA alcohol or substance dependency in the past year; bipolar disorder; schizophrenia; psychosis; dementia; currently under psychiatric care for depression (including those referred but not yet seen); cannot complete questionnaires unaided or requires an interpreter; currently receiving CBT/other psychotherapy; received high-intensity CBT in the past four years; participating in another intervention trial; unwilling/unable to receive CBT via computer/laptop/smartphone. Eligible participants will be randomised to integrated CBT or usual care. Integrated CBT utilises the standard Beckian intervention for depression and comprises nine live therapist-led sessions, with (up to) a further three if clinically appropriate. The first session is 60-90 min via videocall, with subsequent 50-min sessions delivered online, using instant messaging. Participants allocated integrated CBT can access integrated online CBT resources (worksheets/information sheets/videos) within and between sessions. Outcome assessments at 3-, 6-, 9- and 12-month post-randomisation. The primary outcome is the Beck Depression Inventory (BDI-II) score at 6 months (as a continuous variable). A nested qualitative study and health economic evaluation will be conducted. DISCUSSION If clinically and cost-effective, this model of integrated CBT could be introduced into existing psychological services, increasing access to, and equity of, CBT provision. TRIAL REGISTRATION ISRCTN, ISRCTN13112900. Registered on 11/11/2020. Currently recruiting participants. Trial registration data are presented in Table 1.
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Affiliation(s)
- Debbie Tallon
- Bristol Medical School, Centre for Academic Mental Health, Population Health Sciences, University of Bristol, Oakfield House, Oakfield Grove, Bristol, BS8 2BN, UK.
| | - Laura Thomas
- Bristol Medical School, Centre for Academic Mental Health, Population Health Sciences, University of Bristol, Oakfield House, Oakfield Grove, Bristol, BS8 2BN, UK
| | - Sally Brabyn
- ARRC 208, Department of Health Sciences, University of York, York, YO10 5DF, UK
| | - Brian Chi Fung Ching
- UCL Division of Psychiatry, Maple House, 149 Tottenham Court Road, London, WIT 7BN, UK
| | - Jane Sungmin Hahn
- UCL Division of Psychiatry, Maple House, 149 Tottenham Court Road, London, WIT 7BN, UK
| | - Berry Jude
- UCL Division of Psychiatry, Maple House, 149 Tottenham Court Road, London, WIT 7BN, UK
| | - Mekeda X Logan
- UCL Division of Psychiatry, Maple House, 149 Tottenham Court Road, London, WIT 7BN, UK
| | - Alex Burrage
- Bristol Medical School, Centre for Academic Mental Health, Population Health Sciences, University of Bristol, Oakfield House, Oakfield Grove, Bristol, BS8 2BN, UK
| | - Fiona Fox
- Bristol Medical School, Centre for Academic Mental Health, Population Health Sciences, University of Bristol, Oakfield House, Oakfield Grove, Bristol, BS8 2BN, UK
| | - Simon Gilbody
- Mental Health & Addiction Research Group, University of York & Hull York Medical School, York, UK
| | - Paul Lanham
- Public and Patient Involvement Representative, London, UK
| | - Glyn Lewis
- UCL Division of Psychiatry, Maple House, 149 Tottenham Court Road, London, WIT 7BN, UK
| | - Jinshuo Li
- Department of Health Sciences, Seebohm Rowntree Building, University of York, Heslington, York, YO10 5DD, UK
| | - Stephanie J MacNeill
- Bristol Medical School, Population Health Sciences, University of Bristol, Bristol, UK
| | - Irwin Nazareth
- Department of Primary Care & Population Health, University College London, Royal Free Site, Rowland Hill Street, London, NW3, UK
| | - Steve Parrott
- Department of Health Sciences, Seebohm Rowntree Building, University of York, Heslington, York, YO10 5DD, UK
| | - Tim J Peters
- Bristol Dental School, University of Bristol, Lower Maudlin Street, Bristol, BS21 2LY, UK
| | - Roz Shafran
- Great Ormond Street Institute of Child Health London, University College London, London, WC1N 1EH, UK
| | - Katrina Turner
- Centre for Academic Primary Care, Bristol Medical School, Population Health Sciences, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK
| | - Chris Williams
- Clarice Pears Building, University of Glasgow, 90 Byres Road, Glasgow, G12 8TA, UK
- Five Areas Ltd, 1 Aurora Avenue, Clydebank, G81 1BF, UK
| | - David Kessler
- Bristol Medical School, Centre for Academic Mental Health, Population Health Sciences, University of Bristol, Oakfield House, Oakfield Grove, Bristol, BS8 2BN, UK
| | - Nicola Wiles
- Bristol Medical School, Centre for Academic Mental Health, Population Health Sciences, University of Bristol, Oakfield House, Oakfield Grove, Bristol, BS8 2BN, UK
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COVID-19 and the Physio4FMD trial: Impact, mitigating strategies and analysis plans. Contemp Clin Trials Commun 2023; 33:101124. [PMID: 37008795 PMCID: PMC10038674 DOI: 10.1016/j.conctc.2023.101124] [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: 10/06/2022] [Revised: 01/10/2023] [Accepted: 03/23/2023] [Indexed: 03/29/2023] Open
Abstract
Introduction Functional motor disorder (FMD) is a common cause of disabling neurological symptoms such as weakness and tremor. Physio4FMD is a pragmatic, multicentre single blind randomised controlled trial to evaluate effectiveness and cost effectiveness of specialist physiotherapy for FMD. Like many other studies this trial was affected by the COVID-19 pandemic. Methods The planned statistical and health economics analyses for this trial are described, as well as the sensitivity analyses designed to assess the disruption caused by COVID-19. The trial treatment of at least 89 participants (33%) was disrupted due to the pandemic. To account for this, we have extended the trial to increase the sample size. We have identified four groups based on how participants’ involvement in Physio4FMD was affected; A: 25 were unaffected; B: 134 received their trial treatment before the start of the COVID-19 pandemic and were followed up during the pandemic; C: 89 were recruited in early 2020 and had not received any randomised treatment before clinical services closed because of COVID-19; D: 88 participants were recruited after the trial was restarted in July 2021. The primary analysis will involve groups A, B and D. Regression analysis will be used to assess treatment effectiveness. We will conduct descriptive analyses for each of the groups identified and sensitivity regression analyses with participants from all groups, including group C, separately. Discussion The COVID-19 mitigation strategy and analysis plans are designed to maintain the integrity of the trial while providing meaningful results. Trial registration ISRCTN56136713.
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17
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Ding R, Zhao M, Wang Y, Wang M, Guo D, Liu X, Wang L, Wei W, Zhang W, He P. Community-based rehabilitation interventions on quality of care for people with schizophrenia in China (CRISC): study protocol for a cluster-randomized controlled trial. BMC Psychiatry 2023; 23:339. [PMID: 37173691 PMCID: PMC10176931 DOI: 10.1186/s12888-023-04774-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2023] [Accepted: 04/12/2023] [Indexed: 05/15/2023] Open
Abstract
BACKGROUND International consensus shows that community-based rehabilitation (CBR) service is an effective way to improve functioning and negative symptoms and address the treatment gap for schizophrenia. Rigorous trials are needed in China to demonstrate effective and scalable CBR interventions to significantly improve outcomes for people with schizophrenia and to provide evidence of the economic benefits. The objectives of this trial are to examine the effectiveness of CBR as an adjunct to test the usual facility-cased care (FBC) in comparison to FBC alone in improving a range of outcomes in people with schizophrenia and their caregivers. METHODS This trial is a cluster randomized controlled trial design in China. The trial will be conducted at three districts of Weifang city, Shandong province. Eligible participants will be identified from the psychiatric management system where community-dwelling patients with schizophrenia have been registered. Participants will be recruited after providing informed consent. 18 sub-districts will be randomly allocated in a 1:1 ratio to facility-based care (FBC) plus CBR (intervention arm) or FBC alone (control arm). The structured CBR intervention will be delivered by trained psychiatric nurses or community health workers. We aim to recruit 264 participants. The primary outcomes include symptoms of schizophrenia, personal and social function, quality of life, family burden of caring, etc. The study will be conducted according to good ethical practice, data analysis and reporting guidelines. DISCUSSION If the hypothesized clinical benefit and cost-effectiveness of CBR intervention are confirmed, this trial will provide significant implications for policy makers and practitioners to scale up rehabilitation services, as well as for people with schizophrenia and their family to promote recovery and social inclusion, and to alleviate the burden of care. TRIAL REGISTRATION Chinese Clinical Trial Registry (ChiCTR2200066945). Registered December 22, 2022.
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Affiliation(s)
- Ruoxi Ding
- China Center for Health and Development Studies, Peking University, Beijing, China
- School of Public Health, Peking University, Beijing, China
| | - Miaomiao Zhao
- Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Center for Mental Health Management, China Hospital Development Institute, Shanghai Jiao Tong University, Shanghai, China
- Mental Health Branch, China Hospital Development Institute, Shanghai Jiao Tong University, Shanghai, China
| | - Yanshang Wang
- School of Public Health, Peking University, Beijing, China
| | - Ming Wang
- School of Public Health, Peking University, Beijing, China
| | - Dan Guo
- China Center for Health and Development Studies, Peking University, Beijing, China
- School of Public Health, Peking University, Beijing, China
| | - Xiao Liu
- School of Management, Weifang Medical University, Weifang, Shandong province, China
| | - Lei Wang
- Weifang Kuiwen District Medical care and Health Industry Development Center, Weifang, Shandong province, China
| | - Wentao Wei
- Weifang City Hanting District Gudi street Pozi hospital, Weifang, Shandong province, China
| | - Wei Zhang
- Weicheng District health comprehensive law enforcement brigade, Weifang, Shandong province, China
| | - Ping He
- China Center for Health and Development Studies, Peking University, Beijing, China.
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18
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Azuara-Blanco A, Carlisle A, O'Donnell M, Jayaram H, Gazzard G, Larkin DFP, Wickham L, Lois N. Design and Conduct of Randomized Clinical Trials Evaluating Surgical Innovations in Ophthalmology: A Systematic Review. Am J Ophthalmol 2023; 248:164-175. [PMID: 36565904 DOI: 10.1016/j.ajo.2022.12.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2022] [Revised: 12/07/2022] [Accepted: 12/07/2022] [Indexed: 12/24/2022]
Abstract
PURPOSE Surgical innovations are necessary to improve patient care. After an initial exploratory phase, novel surgical technique should be compared with alternative options or standard care in randomized controlled trials (RCTs). However, surgical RCTs have unique methodological challenges. Our study sought to investigate key aspects of the design, conduct, and reporting of RCTs of novel surgeries. DESIGN Systematic review. METHODS The protocol was prospectively registered in PROSPERO (CRD42021253297). RCTs evaluating novel surgeries for cataract, vitreoretinal, glaucoma, and corneal diseases were included. Medline, EMBASE, Cochrane Library, and Clinicaltrials.gov were searched. The search period was January 1, 2016, to June 16, 2021. RESULTS A total of 52 ophthalmic surgery RCTs were identified in the fields of glaucoma (n = 12), vitreoretinal surgery (n = 5), cataract (n = 19), and cornea (n = 16). A description defining the surgeon's experience or level of expertise was reported in 30 RCTs (57%) and was presented in both control and intervention groups in 11 (21%). Specification of the number of cases performed in the particular surgical innovation being assessed prior to the trial was reported in 10 RCTs (19%) and an evaluation of quality of the surgical intervention in 7 (13%). Prospective trial registration was recorded in 12 RCTs (23%) and retrospective registration in 13 (25%); and there was no registration record in the remaining 28 (53%) studies. CONCLUSIONS Important aspects of the study design such as the surgical learning curve, surgeon's previous experience, quality assurance, and trial registration details were often missing in novel ophthalmic surgical procedures. The Idea, Development, Exploration, Assessment, Long-term follow-up (IDEAL) framework aims to improve the quality of study design.
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Affiliation(s)
| | - Aaron Carlisle
- From the Centre for Public Health (A.A.-B., A.C., M.O.D.), Belfast, UK; Belfast Health and Social Care Trust (A.C.), Belfast, UK
| | - Matthew O'Donnell
- From the Centre for Public Health (A.A.-B., A.C., M.O.D.), Belfast, UK
| | - Hari Jayaram
- NIHR Biomedical Research Centre & Glaucoma Service at Moorfields Eye Hospital NHS Foundation Trust (H.J., G.G.), London, UK; Institute of Ophthalmology (H.J., G.G.), University College London, UK
| | - Gus Gazzard
- NIHR Biomedical Research Centre & Glaucoma Service at Moorfields Eye Hospital NHS Foundation Trust (H.J., G.G.), London, UK; Institute of Ophthalmology (H.J., G.G.), University College London, UK
| | - Daniel F P Larkin
- Cornea & External Diseases Service (D.F.P.L.), Moorfields Eye Hospital, London, UK
| | - Louisa Wickham
- Vitreo-retinal Service (L.W.), Moorfields Eye Hospital, London, UK
| | - Noemi Lois
- Wellcome-Wolfson Institute for Experimental Medicine (N.L.), Queen's University, Belfast, UK
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19
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Lange KM, Kasza J, Sullivan TR, Yelland LN. Partially clustered designs for clinical trials: Unifying existing designs using consistent terminology. Clin Trials 2023; 20:99-110. [PMID: 36628406 PMCID: PMC10021130 DOI: 10.1177/17407745221146987] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
INTRODUCTION Clinical trial designs based on the assumption of independent observations are well established. Clustered clinical trial designs, where all observational units belong to a cluster and outcomes within clusters are expected to be correlated, have also received considerable attention. However, many clinical trials involve partially clustered data, where only some observational units belong to a cluster. Examples of such trials occur in neonatology, where participants include infants from both singleton and multiple births, and ophthalmology, where one or two eyes per participant may need treatment. Partial clustering can also arise in trials of group-based treatments (e.g. group education or counselling sessions) or treatments administered individually by a discrete number of health care professionals (e.g. surgeons or physical therapists), when this is compared to an unclustered control arm. Trials involving partially clustered data have received limited attention in the literature and the current lack of standardised terminology may be hampering the development and dissemination of methods for designing and analysing these trials. METHODS AND EXAMPLES In this article, we present an overarching definition of partially clustered trials, bringing together several existing trial designs including those for group-based treatments, clustering due to facilitator effects and the re-randomisation design. We define and describe four types of partially clustered trial designs, characterised by whether the clustering occurs pre-randomisation or post-randomisation and, in the case of pre-randomisation clustering, by the method of randomisation that is used for the clustered observations (individual randomisation, cluster randomisation or balanced randomisation within clusters). Real life examples are provided to highlight the occurrence of partially clustered trials across a variety of fields. To assess how partially clustered trials are currently reported, we review published reports of partially clustered trials. DISCUSSION Our findings demonstrate that the description of these trials is often incomplete and the terminology used to describe the trial designs is inconsistent, restricting the ability to identify these trials in the literature. By adopting the definitions and terminology presented in this article, the reporting of partially clustered trials can be substantially improved, and we present several recommendations for reporting these trial designs in practice. Greater awareness of partially clustered trials will facilitate more methodological research into their design and analysis, ultimately improving the quality of these trials.
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Affiliation(s)
- Kylie M Lange
- School of Public Health, The University of Adelaide, Adelaide, SA, Australia.,Women and Kids Theme, South Australian Health and Medical Research Institute, Adelaide, SA, Australia
| | - Jessica Kasza
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Thomas R Sullivan
- School of Public Health, The University of Adelaide, Adelaide, SA, Australia.,Women and Kids Theme, South Australian Health and Medical Research Institute, Adelaide, SA, Australia
| | - Lisa N Yelland
- School of Public Health, The University of Adelaide, Adelaide, SA, Australia.,Women and Kids Theme, South Australian Health and Medical Research Institute, Adelaide, SA, Australia
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20
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Comparison of Prior Setting Methods for Multilevel Model Effect Estimation Based on Small Sample Imbalanced Nested Data in Bayesian Framework. COMPUTATIONAL INTELLIGENCE AND NEUROSCIENCE 2022; 2022:2726602. [DOI: 10.1155/2022/2726602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Revised: 09/08/2022] [Accepted: 09/17/2022] [Indexed: 11/16/2022]
Abstract
In the fields of education and psychology, nested data with small samples and imbalances are very common. Bauer et al. (2008) first proposed adjusting the traditional multilevel model to analyze the small sample imbalanced nested data (SSIND). In terms of parameter estimation, the Bayesian method shows the possibility of providing unbiased estimation when the sample size is small. This study proposes that the Bayesian method should be used to analyze the SSIND. This study explores the performance of different treatment effects and nesting effects estimation methods in the multilevel model based on the Bayesian method that performs well in the case of small samples, to provide an appropriate and scientific method reference for the subsequent analysis of the model. Two prior setting methods are compared for multilevel model effect estimation based on a small sample of imbalanced nested data in the Bayesian framework. Two prior setting methods are gamma prior setting method and uniform prior setting method. The research results show that when the treatment condition ICC is small (0.05), the bias and RMSE values of the parameter estimation by the gamma prior setting method are larger and the performance is unstable, while the bias and RMSE values of the parameter estimation by the uniform prior setting method are smaller and the performance is relatively stable, so the uniform prior setting method is recommended; when the treatment condition ICC is large (0.15), the bias and RMSE values of the parameter estimation by the uniform prior setting method are larger and the performance is unstable, while the bias and RMSE values of the parameter estimation by the gamma prior setting method are smaller and the performance is relatively stable, so the gamma prior setting method is recommended; when the treatment condition ICC is between 0.05 and 0.15, both prior setting methods have similar effects. Furthermore, when the number of treatment groups is small (8), the gamma prior setting method is recommended; when the number of treatment groups is large (16), the uniform prior setting method is recommended; when the number of treatment groups is between 8 and 16, both prior setting methods have similar effects. Summarily, when we choose which prior setting method to use for the SSIND, we must consider the interaction between the ICC and the number of treatment groups.
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21
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Brown CH, Hedeker D, Gibbons RD, Duan N, Almirall D, Gallo C, Burnett-Zeigler I, Prado G, Young SD, Valido A, Wyman PA. Accounting for Context in Randomized Trials after Assignment. PREVENTION SCIENCE : THE OFFICIAL JOURNAL OF THE SOCIETY FOR PREVENTION RESEARCH 2022; 23:1321-1332. [PMID: 36083435 PMCID: PMC9461380 DOI: 10.1007/s11121-022-01426-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/05/2022] [Indexed: 10/25/2022]
Abstract
Many preventive trials randomize individuals to intervention condition which is then delivered in a group setting. Other trials randomize higher levels, say organizations, and then use learning collaboratives comprised of multiple organizations to support improved implementation or sustainment. Other trials randomize or expand existing social networks and use key opinion leaders to deliver interventions through these networks. We use the term contextually driven to refer generally to such trials (traditionally referred to as clustering, where groups are formed either pre-randomization or post-randomization - i.e., a cluster-randomized trial), as these groupings or networks provide fixed or time-varying contexts that matter both theoretically and practically in the delivery of interventions. While such contextually driven trials can provide efficient and effective ways to deliver and evaluate prevention programs, they all require analytical procedures that take appropriate account of non-independence, something not always appreciated. Published analyses of many prevention trials have failed to take this into account. We discuss different types of contextually driven designs and then show that even small amounts of non-independence can inflate actual Type I error rates. This inflation leads to rejecting the null hypotheses too often, and erroneously leading us to conclude that there are significant differences between interventions when they do not exist. We describe a procedure to account for non-independence in the important case of a two-arm trial that randomizes units of individuals or organizations in both arms and then provides the active treatment in one arm through groups formed after assignment. We provide sample code in multiple programming languages to guide the analyst, distinguish diverse contextually driven designs, and summarize implications for multiple audiences.
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Affiliation(s)
- C Hendricks Brown
- Department of Psychiatry and Behavioral Sciences, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA.
| | - Donald Hedeker
- Center for Health Statistics, The University of Chicago, Chicago, IL, USA
| | - Robert D Gibbons
- Center for Health Statistics, The University of Chicago, Chicago, IL, USA
| | - Naihua Duan
- Department of Psychiatry, Columbia University Medical Center, New York, NY, USA
| | - Daniel Almirall
- Institute for Social Research and Department of Statistics, University of Michigan, Ann Arbor, MI, USA
| | - Carlos Gallo
- Department of Psychiatry and Behavioral Sciences, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Inger Burnett-Zeigler
- Department of Psychiatry and Behavioral Sciences, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | | | - Sean D Young
- Department of Emergency Medicine, School of Medicine, Department of Informatics, Bren School of Information and Computer Sciences, University of California, Irvine, CA, USA
| | - Alberto Valido
- School of Education, University of North Carolina at Chapel Hill, Chapel Hill, Orange, NC, USA
| | - Peter A Wyman
- Department of Psychiatry, University of Rochester School of Medicine, Rochester, NY, USA
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22
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Giraudeau B, Caille A, Eldridge SM, Weijer C, Zwarenstein M, Taljaard M. Heterogeneity in pragmatic randomised trials: sources and management. BMC Med 2022; 20:372. [PMID: 36303153 PMCID: PMC9615398 DOI: 10.1186/s12916-022-02569-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Accepted: 09/14/2022] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Pragmatic trials aim to generate evidence to directly inform patient, caregiver and health-system manager policies and decisions. Heterogeneity in patient characteristics contributes to heterogeneity in their response to the intervention. However, there are many other sources of heterogeneity in outcomes. Based on the expertise and judgements of the authors, we identify different sources of clinical and methodological heterogeneity, which translate into heterogeneity in patient responses-some we consider as desirable and some as undesirable. For each of them, we discuss and, using real-world trial examples, illustrate how heterogeneity should be managed over the whole course of the trial. MAIN TEXT Heterogeneity in centres and patients should be welcomed rather than limited. Interventions can be flexible or tailored and control interventions are expected to reflect usual care, avoiding use of a placebo. Co-interventions should be allowed; adherence should not be enforced. All these elements introduce heterogeneity in interventions (experimental or control), which has to be welcomed because it mimics reality. Outcomes should be objective and possibly routinely collected; standardised assessment, blinding and adjudication should be avoided as much as possible because this is not how assessment would be done outside a trial setting. The statistical analysis strategy must be guided by the objective to inform decision-making, thus favouring the intention-to-treat principle. Pragmatic trials should consider including process analyses to inform an understanding of the trial results. Needed data to conduct these analyses should be collected unobtrusively. Finally, ethical principles must be respected, even though this may seem to conflict with goals of pragmatism; consent procedures could be incorporated in the flow of care.
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Affiliation(s)
- Bruno Giraudeau
- Université de Tours, Université de Nantes, INSERM, SPHERE U1246, 2 Bd Tonnellé, 37044, Tours cedex 9, France.
- INSERM CIC1415, CHRU de Tours, Tours, France.
| | - Agnès Caille
- Université de Tours, Université de Nantes, INSERM, SPHERE U1246, 2 Bd Tonnellé, 37044, Tours cedex 9, France
- INSERM CIC1415, CHRU de Tours, Tours, France
| | - Sandra M Eldridge
- Centre for Primary Care and Public Health, Queen Mary University of London, 58 Turner Street, London, E1 2AB, UK
| | - Charles Weijer
- Departments of Medicine and Philosophy, Western University, Stevenson Hall 4130, 1151 Richmond Street, London, ON, N6A 5B7, Canada
| | - Merrick Zwarenstein
- Centre for Studies in Family Medicine, Department of Family Medicine Schulich School of Medicine & Dentistry Western University, 1151 Richmond Street, London, ON, N6A 3K7, Canada
| | - Monica Taljaard
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, The Ottawa Hospital, Civic Campus, 1053 Carling Avenue, Ottawa, Ontario, K1Y 4E9, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
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23
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Filderman MJ, Toste JR. Effects of Varying Levels of Data Use to Intensify a Multisyllabic Word Reading Intervention for Upper Elementary Students With or at Risk for Reading Disabilities. JOURNAL OF LEARNING DISABILITIES 2022; 55:393-407. [PMID: 34796757 DOI: 10.1177/00222194211048405] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
For students who show inadequate response to research-based intervention, intensification of intervention using data-based decision making (DBDM) is recommended. There is a paucity of research on upper elementary students related to the efficacy of (a) word reading interventions and (b) DBDM procedures. This randomized controlled trial examined the differential effects of data use at two timepoints to intensify a multisyllabic word reading intervention for Grades 4 and 5 students with or at risk for reading disabilities (RD). Eighty-eight students were randomly assigned to one of three conditions: initial customization of the intervention (IC-only), initial customization with DBDM (IC + DBDM), or a business-as-usual comparison condition. Results indicated that (a) students in both treatment conditions outperformed the comparison condition on multisyllabic word reading and (b) students in the IC + DBDM condition also outperformed comparison students on decoding. Implications, including the use of DBDM in addition to IC-only as well as methods for decision-making within a small-group context, are discussed.
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24
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Leadbitter K, Smallman R, James K, Shields G, Ellis C, Langhorne S, Harrison L, Hackett L, Dunkerley A, Kroll L, Davies L, Emsley R, Bee P, Green J. REACH-ASD: a UK randomised controlled trial of a new post-diagnostic psycho-education and acceptance and commitment therapy programme against treatment-as-usual for improving the mental health and adjustment of caregivers of children recently diagnosed with autism spectrum disorder. Trials 2022; 23:585. [PMID: 35869533 PMCID: PMC9306249 DOI: 10.1186/s13063-022-06524-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Accepted: 07/06/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Autism is a neurodevelopmental disability affecting over 1% of UK children. The period following a child's autism diagnosis can present real challenges in adaptation for families. Twenty to 50% of caregivers show clinically significant levels of mental health need within the post-diagnostic period and on an ongoing basis. Best practice guidelines recommend timely post-diagnostic family support. Current provision is patchy, largely unevidenced, and a source of dissatisfaction for both families and professionals. There is a pressing need for an evidenced programme of post-diagnostic support focusing on caregiver mental health and adjustment, alongside autism psycho-education. This trial tests the clinical and cost-effectiveness of a new brief manualised psychosocial intervention designed to address this gap. METHODS This is a multi-centre two-parallel-group single (researcher)-blinded randomised controlled trial of the Empower-Autism programme plus treatment-as-usual versus usual local post-diagnostic offer plus treatment-as-usual. Caregivers of children aged 2-15 years with a recent autism diagnosis will be recruited from North West England NHS or local authority centres. Randomisation is individually by child, with one "index" caregiver per child, stratified by centre, using 2:1 randomisation ratio to assist recruitment and timely intervention. Empower-Autism is a group-based, manualised, post-diagnostic programme that combines autism psycho-education and psychotherapeutic components based on Acceptance and Commitment Therapy to support caregiver mental health, stress management and adjustment to their child's diagnosis. The comparator is any usual local group-based post-diagnostic psycho-education offer. Receipt of services will be specified through health economic data. PRIMARY OUTCOME caregiver mental health (General Health Questionnaire-30) at 52-week follow-up. SECONDARY OUTCOMES key caregiver measures (wellbeing, self-efficacy, adjustment, autism knowledge) at 12-, 26- and 52-week follow-up and family and child outcomes (wellbeing and functioning) at 52-week endpoint. SAMPLE N=380 (approximately 253 intervention/127 treatment-as-usual). Primary analysis will follow intention-to-treat principles using linear mixed models with random intercepts for group membership and repeated measures. Cost-effectiveness acceptability analyses will be over 52 weeks, with decision modelling to extrapolate to longer time periods. DISCUSSION If effective, this new approach will fill a key gap in the provision of evidence-based care pathways for autistic children and their families. TRIAL REGISTRATION ISRCTN 45412843 . Prospectively registered on 11 September 2019.
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Affiliation(s)
- Kathy Leadbitter
- Division of Neuroscience and Experimental Psychology, University of Manchester, Manchester, UK.
| | - Richard Smallman
- Division of Neuroscience and Experimental Psychology, University of Manchester, Manchester, UK
| | - Kirsty James
- Department of Biostatistics and Health Informatics, Institute of Psychiatry, Psychology and Neuroscience, Kings College London, London, UK
| | - Gemma Shields
- Division of Neuroscience and Experimental Psychology, University of Manchester, Manchester, UK
| | - Ceri Ellis
- Division of Neuroscience and Experimental Psychology, University of Manchester, Manchester, UK
| | - Sophie Langhorne
- Division of Neuroscience and Experimental Psychology, University of Manchester, Manchester, UK
| | - Louisa Harrison
- Division of Neuroscience and Experimental Psychology, University of Manchester, Manchester, UK
| | - Latha Hackett
- Manchester University NHS Foundation Trust, Manchester, UK
| | | | - Leo Kroll
- Pennine Care NHS Foundation Trust, Ashton-under-Lyne, UK
| | - Linda Davies
- Division of Neuroscience and Experimental Psychology, University of Manchester, Manchester, UK
| | - Richard Emsley
- Department of Biostatistics and Health Informatics, Institute of Psychiatry, Psychology and Neuroscience, Kings College London, London, UK
| | - Penny Bee
- Division of Neuroscience and Experimental Psychology, University of Manchester, Manchester, UK
| | - Jonathan Green
- Division of Neuroscience and Experimental Psychology, University of Manchester, Manchester, UK
- Manchester University NHS Foundation Trust, Manchester, UK
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Bui MV, McInnes E, Ennis G, Foster K. Protocol for a mixed methods process evaluation of the Promoting Resilience in Nurses (PRiN) trial. Int J Ment Health Nurs 2022; 31:687-696. [PMID: 35279934 PMCID: PMC9314145 DOI: 10.1111/inm.12989] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Revised: 01/31/2022] [Accepted: 02/28/2022] [Indexed: 11/30/2022]
Abstract
Mental health nurses are exposed frequently to occupational stress and can experience a range of negative impacts on their well-being and intention to stay in the nursing workforce. Promoting Resilience in Nurses (PRiN) is a strength-based resilience education programme that incorporates evidence-based cognitive behavioural and interpersonal approaches with post-traumatic growth theory. A partially clustered randomized controlled trial at a large public mental health service will be used to examine the effects of PRiN on mental health nurses' coping self-efficacy, resilience, well-being, mental health, emotional regulation, post-traumatic growth, workplace belonging, and turnover intention as compared to controls. Process evaluations are increasingly used to help understand and interpret trial results for complex interventions. This paper describes the protocol for an embedded mixed methods process evaluation that aims to evaluate the PRiN programme implementation and identify factors that may explain variation in participant outcomes in the trial. Data collection includes a programme participant satisfaction survey; a follow-up semi-structured interview with selected programme participants; a unit/team manager survey on barriers and facilitators to staff recruitment and programme participation; and a fidelity checklist completed by programme facilitators. Normalisation Process Theory will be used to inform data analysis and integration. The findings will provide insights into factors that affect programme implementation, particularly in the context of the COVID-19 pandemic and may help explain differences in participant outcomes. Findings will also inform post-trial programme sustainability as well as potential future upscale and adaptation for implementation across healthcare settings.
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Affiliation(s)
- Minh Viet Bui
- School of Nursing, Midwifery and Paramedicine, Australian Catholic University, Fitzroy, Victoria, Australia.,NorthWestern Mental Health, Melbourne Health, Parkville, Victoria, Australia
| | - Elizabeth McInnes
- School of Nursing, Midwifery and Paramedicine, Australian Catholic University, Fitzroy, Victoria, Australia.,Nursing Research Institute - St Vincent's Health Network Sydney, St Vincent's Hospital Melbourne and Australian Catholic University, Parkville, Victoria, Australia
| | - Gary Ennis
- NorthWestern Mental Health, Melbourne Health, Parkville, Victoria, Australia
| | - Kim Foster
- School of Nursing, Midwifery and Paramedicine, Australian Catholic University, Fitzroy, Victoria, Australia.,NorthWestern Mental Health, Melbourne Health, Parkville, Victoria, Australia
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Federico CA, Heagerty PJ, Lantos J, O'Rourke P, Rahimzadeh V, Sugarman J, Weinfurt K, Wendler D, Wilfond BS, Magnus D. Ethical and epistemic issues in the design and conduct of pragmatic stepped-wedge cluster randomized clinical trials. Contemp Clin Trials 2022; 115:106703. [PMID: 35176501 PMCID: PMC9272561 DOI: 10.1016/j.cct.2022.106703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Revised: 01/27/2022] [Accepted: 02/02/2022] [Indexed: 11/27/2022]
Abstract
Stepped-wedge cluster randomized trial (SW-CRT) designs are increasingly employed in pragmatic research; they differ from traditional parallel cluster randomized trials in which an intervention is delivered to a subset of clusters, but not to all. In a SW-CRT, all clusters receive the intervention under investigation by the end of the study. This approach is thought to avoid ethical concerns about the denial of a desired intervention to participants in control groups. Such concerns have been cited in the literature as a primary motivation for choosing SW-CRT design, however SW-CRTs raise additional ethical concerns related to the delayed implementation of an intervention and consent. Yet, PCT investigators may choose SW-CRT designs simply because they are concerned that other study designs are infeasible. In this paper, we examine justifications for the use of SW-CRT study design, over other designs, by drawing on the experience of the National Institutes of Health's Health Care Systems Research Collaboratory (NIH Collaboratory) with five pragmatic SW-CRTs. We found that decisions to use SW-CRT design were justified by practical and epistemic reasons rather than ethical ones. These include concerns about feasibility, the heterogeneity of cluster characteristics, and the desire for simultaneous clinical evaluation and implementation. In this paper we compare the potential benefits of SW-CRTs against the ethical and epistemic challenges brought forth by the design and suggest that the choice of SW-CRT design must balance epistemic, feasibility and ethical justifications. Moreover, given their complexity, such studies need rigorous and informed ethical oversight.
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Affiliation(s)
- Carole A Federico
- Stanford Center for Biomedical Ethics, Stanford University, Stanford, CA 94305, USA
| | - Patrick J Heagerty
- Department of Biostatistics, University of Washington, Seattle, WA 98185, USA
| | - John Lantos
- Children's Mercy Hospital Bioethics Center, University of Missouri-Kansas City, Kansas City, MO 64108, USA
| | | | - Vasiliki Rahimzadeh
- Stanford Center for Biomedical Ethics, Stanford University, Stanford, CA 94305, USA
| | - Jeremy Sugarman
- Berman Institute of Bioethics, Johns Hopkins University, Baltimore, MD 21218, USA
| | - Kevin Weinfurt
- Center for Health Measurement, Duke University, Durham, NC 27701, USA
| | - David Wendler
- Department of Bioethics, NIH Clinical Center, Bethesda, MD 20892, USA
| | - Benjamin S Wilfond
- Treuman Katz Center for Pediatric Bioethics, Seattle Children's Research Institute, Seattle, WA 98185, USA
| | - David Magnus
- Stanford Center for Biomedical Ethics, Stanford University, Stanford, CA 94305, USA.
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27
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Caron B, D'Amico F, Danese S, Peyrin-Biroulet L. Cluster Randomized Trials: Lessons for Inflammatory Bowel Disease Trials. J Crohns Colitis 2022; 16:312-318. [PMID: 34389850 DOI: 10.1093/ecco-jcc/jjab149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Randomized clinical trials are the gold standard for the development of new drugs. Clinical trials have become increasingly complex, in particular in the field of inflammatory bowel diseases. For this reason, a new study design called 'cluster randomized trial' has been introduced. Cluster randomized trials randomly assign groups of individuals within a population of interest, such as people in a particular research site, clinic or hospital, and measure the effects of an intervention at the individual level. In contrast to individual randomization, cluster randomization permits the evaluation of a cluster-level intervention, may be logistically simpler and less expensive than a conventional randomized trial, and can help reduce the effect of treatment contamination. An important aspect requiring particular attention in cluster randomized trials is the risk for imbalance of covariates at baseline which decreases the statistical power and precision of the results, and reduces face validity and credibility of the trial results. A variety of restricted randomization methods have been proposed to minimize risk of imbalance. Our aim here is to clarify the advantages and drawbacks of cluster randomized trials in order to properly interpret study results and to identify their role in upcoming inflammatory bowel disease trials.
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Affiliation(s)
- Bénédicte Caron
- Department of Gastroenterology and Inserm NGERE U1256, Nancy University Hospital, University of Lorraine, Vandoeuvre-lès-Nancy, France
| | - Ferdinando D'Amico
- Gastroenterology and Endoscopy, IRCCS Ospedale San Raffaele and University Vita-Salute San Raffaele, Milano, Italy.,Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Silvio Danese
- Gastroenterology and Endoscopy, IRCCS Ospedale San Raffaele and University Vita-Salute San Raffaele, Milano, Italy
| | - Laurent Peyrin-Biroulet
- Department of Gastroenterology and Inserm NGERE U1256, Nancy University Hospital, University of Lorraine, Vandoeuvre-lès-Nancy, France
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Abstract
BACKGROUND This article identifies the most influential methods reports for group-randomized trials and related designs published through 2020. Many interventions are delivered to participants in real or virtual groups or in groups defined by a shared interventionist so that there is an expectation for positive correlation among observations taken on participants in the same group. These interventions are typically evaluated using a group- or cluster-randomized trial, an individually randomized group treatment trial, or a stepped wedge group- or cluster-randomized trial. These trials face methodological issues beyond those encountered in the more familiar individually randomized controlled trial. METHODS PubMed was searched to identify candidate methods reports; that search was supplemented by reports known to the author. Candidate reports were reviewed by the author to include only those focused on the designs of interest. Citation counts and the relative citation ratio, a new bibliometric tool developed at the National Institutes of Health, were used to identify influential reports. The relative citation ratio measures influence at the article level by comparing the citation rate of the reference article to the citation rates of the articles cited by other articles that also cite the reference article. RESULTS In total, 1043 reports were identified that were published through 2020. However, 55 were deemed to be the most influential based on their relative citation ratio or their citation count using criteria specific to each of the three designs, with 32 group-randomized trial reports, 7 individually randomized group treatment trial reports, and 16 stepped wedge group-randomized trial reports. Many of the influential reports were early publications that drew attention to the issues that distinguish these designs from the more familiar individually randomized controlled trial. Others were textbooks that covered a wide range of issues for these designs. Others were "first reports" on analytic methods appropriate for a specific type of data (e.g. binary data, ordinal data), for features commonly encountered in these studies (e.g. unequal cluster size, attrition), or for important variations in study design (e.g. repeated measures, cohort versus cross-section). Many presented methods for sample size calculations. Others described how these designs could be applied to a new area (e.g. dissemination and implementation research). Among the reports with the highest relative citation ratios were the CONSORT statements for each design. CONCLUSIONS Collectively, the influential reports address topics of great interest to investigators who might consider using one of these designs and need guidance on selecting the most appropriate design for their research question and on the best methods for design, analysis, and sample size.
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Affiliation(s)
- David M Murray
- Office of Disease Prevention, National Institutes of Health, North Bethesda, MD, USA
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29
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Forestier R, Fioravanti A, Bender T, Santos I, Erol Forestier FB, Muela Garcia A, Françon A. Crenobalneotherapy for low back pain: systematic review of clinical trials. INTERNATIONAL JOURNAL OF BIOMETEOROLOGY 2022; 66:13-23. [PMID: 34625843 DOI: 10.1007/s00484-021-02188-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Revised: 07/25/2021] [Accepted: 08/30/2021] [Indexed: 06/13/2023]
Abstract
Crenobalneotherapy is a treatment commonly used in Europe and Middle East. It uses mineral water sometimes combined with different hydrotherapy techniques. Most patients treated in spa centers suffer from low back pain. The purpose of this work is to identify clinical trials on crenobalneotherapy for low back pain. Publication research was performed on Medline, Cochrane, and PEDRO databases. Clinical trials were analyzed for internal validity, external validity, quality of statistical analysis, and quality of collection of adverse events. We present the best level of evidence. Bibliographic research identified 21 clinical trials and the coauthors added 5 references. The 26 trials represent 2695 patients. Some have good methodological quality and allow considering crenobalneotherapy as a potential treatment for low back pain, even if the role of mineral water remains uncertain. The methodological quality of therapeutic trials should be improved. These trials should be analyzed in the future guidelines on low back pain.
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Affiliation(s)
- R Forestier
- Centre de Recherche Rhumatologique Et Thermal, 15, Av Charles de Gaulle, 73100, Aix Les Bains, France.
| | - A Fioravanti
- Rheumatology Unit, Department of Medicine, Surgery and Neurosciences, Azienda Ospedaliera Universitaria Senese, Siena, Italy
| | - T Bender
- Polyclinic, Hospital of the Hospitaller, Brothers of St. John of God, Budapest, Hungary
| | | | - F B Erol Forestier
- Centre de Recherche Rhumatologique Et Thermal, 15, Av Charles de Gaulle, 73100, Aix Les Bains, France
| | - A Muela Garcia
- Centre de Recherche Rhumatologique Et Thermal, 15, Av Charles de Gaulle, 73100, Aix Les Bains, France
| | - A Françon
- Centre de Recherche Rhumatologique Et Thermal, 15, Av Charles de Gaulle, 73100, Aix Les Bains, France
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30
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Multicentre randomised controlled trial of a group psychological intervention for postnatal depression in British mothers of South Asian origin (ROSHNI-2): study protocol. BJPsych Open 2021. [PMCID: PMC8693900 DOI: 10.1192/bjo.2021.1032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BackgroundIn the UK, postnatal depression is more common in British South Asian women than White Caucasion women. Cognitive–behavioural therapy (CBT) is recommended as a first-line treatment, but there is little evidence for the adaptation of CBT for postnatal depression to ensure its applicability to different ethnic groups.AimsTo evaluate the clinical and cost-effectiveness of a CBT-based positive health programme group intervention in British South Asian women with postnatal depression.MethodWe have designed a multicentre, two-arm, partially nested, randomised controlled trial with 4- and 12-month follow-up, comparing a 12-session group CBT-based intervention (positive health programme) plus treatment as usual with treatment as usual alone, for British South Asian women with postnatal depression. Participants will be recruited from primary care and appropriate community venues in areas of high South Asian density across the UK. It has been estimated that randomising 720 participants (360 into each group) will be sufficient to detect a clinically important difference between a 55% recovery rate in the intervention group and a 40% recovery rate in the treatment-as-usual group. An economic analysis will estimate the cost-effectiveness of the positive health programme. A qualitative process evaluation will explore barriers and enablers to study participation and examine the acceptability and impact of the programme from the perspective of British South Asian women and other key stakeholders.
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31
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Nordlund J, Henry RS, Kwakkenbos L, Carrier ME, Levis B, Nielson WR, Bartlett SJ, Dyas L, Tao L, Fedoruk C, Nielsen K, Hudson M, Pope J, Frech T, Gholizadeh S, Johnson SR, Piotrowski P, Jewett LR, Gordon J, Chung L, Bilsker D, Levis AW, Turner KA, Cumin J, Welling J, Fortuné C, Leite C, Gottesman K, Sauve M, Rodríguez-Reyna TS, Larche M, van Breda W, Suarez-Almazor ME, Wurz A, Culos-Reed N, Malcarne VL, Mayes MD, Boutron I, Mouthon L, Benedetti A, Thombs BD. The Scleroderma Patient-centered Intervention Network Self-Management (SPIN-SELF) Program: protocol for a two-arm parallel partially nested randomized controlled feasibility trial with progression to full-scale trial. Trials 2021; 22:856. [PMID: 34838105 PMCID: PMC8626736 DOI: 10.1186/s13063-021-05827-z] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2021] [Accepted: 11/13/2021] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Systemic sclerosis (scleroderma; SSc) is a rare autoimmune connective tissue disease. We completed an initial feasibility trial of an online self-administered version of the Scleroderma Patient-centered Intervention Network Self-Management (SPIN-SELF) Program using the cohort multiple randomized controlled trial (RCT) design. Due to low intervention offer uptake, we will conduct a new feasibility trial with progression to full-scale trial, using a two-arm parallel, partially nested RCT design. The SPIN-SELF Program has also been revised to include facilitator-led videoconference group sessions in addition to online material. We will test the group-based intervention delivery format, then evaluate the effect of the SPIN-SELF Program on disease management self-efficacy (primary) and patient activation, social appearance anxiety, and functional health outcomes (secondary). METHODS This study is a feasibility trial with progression to full-scale RCT, pending meeting pre-defined criteria, of the SPIN-SELF Program. Participants will be recruited from the ongoing SPIN Cohort ( http://www.spinsclero.com/en/cohort ) and via social media and partner patient organizations. Eligible participants must have SSc and low to moderate disease management self-efficacy (Self-Efficacy for Managing Chronic Disease (SEMCD) Scale score ≤ 7.0). Participants will be randomized (1:1 allocation) to the group-based SPIN-SELF Program or usual care for 3 months. The primary outcome in the full-scale trial will be disease management self-efficacy based on SEMCD Scale scores at 3 months post-randomization. Secondary outcomes include SEMCD scores 6 months post-randomization plus patient activation, social appearance anxiety, and functional health outcomes at 3 and 6 months post-randomization. We will include 40 participants to assess feasibility. At the end of the feasibility portion, stoppage criteria will be used to determine if the trial procedures or SPIN-SELF Program need important modifications, thereby requiring a re-set for the full-scale trial. Otherwise, the full-scale RCT will proceed, and outcome data from the feasibility portion will be utilized in the full-scale trial. In the full-scale RCT, 524 participants will be recruited. DISCUSSION The SPIN-SELF Program may improve disease management self-efficacy, patient activation, social appearance anxiety, and functional health outcomes in people with SSc. SPIN works with partner patient organizations around the world to disseminate its programs free-of-charge. TRIAL REGISTRATION ClinicalTrials.gov NCT04246528 . Registered on 27 January 2020.
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Affiliation(s)
- Julia Nordlund
- Lady Davis Institute of the Jewish General Hospital, 3755 Côte-Sainte-Catherine Road, Montreal, Quebec, H3T 1E2 Canada
| | - Richard S. Henry
- Lady Davis Institute of the Jewish General Hospital, 3755 Côte-Sainte-Catherine Road, Montreal, Quebec, H3T 1E2 Canada
- Department of Psychiatry, McGill University, Montreal, Quebec Canada
| | - Linda Kwakkenbos
- Department of Clinical Psychology, Radboud University, Nijmegen, The Netherlands
- Department of Medical Psychology, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Marie-Eve Carrier
- Lady Davis Institute of the Jewish General Hospital, 3755 Côte-Sainte-Catherine Road, Montreal, Quebec, H3T 1E2 Canada
| | - Brooke Levis
- Centre for Prognosis Research, School of Medicine, Keele University, Keele, Staffordshire UK
| | | | - Susan J. Bartlett
- Department of Medicine, McGill University, Montreal, Quebec Canada
- Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, Quebec Canada
| | - Laura Dyas
- Scleroderma Foundation, Michigan Chapter, Southfield, MI USA
| | - Lydia Tao
- Lady Davis Institute of the Jewish General Hospital, 3755 Côte-Sainte-Catherine Road, Montreal, Quebec, H3T 1E2 Canada
| | - Claire Fedoruk
- Lady Davis Institute of the Jewish General Hospital, 3755 Côte-Sainte-Catherine Road, Montreal, Quebec, H3T 1E2 Canada
| | - Karen Nielsen
- Scleroderma Society of Ontario, Hamilton, Ontario Canada
| | - Marie Hudson
- Lady Davis Institute of the Jewish General Hospital, 3755 Côte-Sainte-Catherine Road, Montreal, Quebec, H3T 1E2 Canada
- Department of Medicine, McGill University, Montreal, Quebec Canada
| | - Janet Pope
- Department of Medicine, University of Western Ontario, London, Ontario Canada
| | - Tracy Frech
- Department of Internal Medicine, University of Utah, Salt Lake City, UT USA
| | - Shadi Gholizadeh
- California School of Professional Psychology/Alliant, Los Angeles, CA USA
| | - Sindhu R. Johnson
- Toronto Scleroderma Program, Mount Sinai Hospital & Toronto Western Hospital, Toronto, Ontario Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario Canada
| | | | - Lisa R. Jewett
- Department of Psychology, Jewish General Hospital, Montreal, Quebec Canada
| | - Jessica Gordon
- Department of Medicine, Hospital for Special Surgery, New York City, NY USA
| | - Lorinda Chung
- Department of Medicine, Stanford University, Palo Alto, CA USA
- Department of Medicine, Palo Alto VA Health Care System, Palo Alto, CA USA
| | - Dan Bilsker
- Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia Canada
- Department of Psychiatry, University of British Columbia, Vancouver, British Columbia Canada
| | - Alexander W. Levis
- Department of Biostatistics, Harvard T. H. Chan School of Public Health, Boston, MA USA
| | - Kimberly A. Turner
- Lady Davis Institute of the Jewish General Hospital, 3755 Côte-Sainte-Catherine Road, Montreal, Quebec, H3T 1E2 Canada
| | - Julie Cumin
- Lady Davis Institute of the Jewish General Hospital, 3755 Côte-Sainte-Catherine Road, Montreal, Quebec, H3T 1E2 Canada
| | - Joep Welling
- NVLE Dutch patient organization for systemic autoimmune diseases, Utrecht, The Netherlands
| | | | | | | | - Maureen Sauve
- Scleroderma Society of Ontario, Hamilton, Ontario Canada
- Scleroderma Canada, Hamilton, Ontario Canada
| | | | - Maggie Larche
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario Canada
| | - Ward van Breda
- Faculty of Behavioural and Movement Sciences, VU University, Amsterdam, The Netherlands
| | - Maria E. Suarez-Almazor
- Department of General Internal Medicine, University of Texas MD Anderson Cancer Center, Houston, TX USA
| | - Amanda Wurz
- School of Kinesiology, University of the Fraser Valley, Chilliwack, British Columbia Canada
| | - Nicole Culos-Reed
- Faculty of Kinesiology, University of Calgary, Calgary, Alberta Canada
- Department of Oncology, Cumming School of Medicine, Calgary, Canada
- Department of Psychosocial Resources, Tom Baker Cancer Centre, Alberta Health Services, Calgary, Alberta Canada
| | - Vanessa L. Malcarne
- Department of Psychology, San Diego State University, San Diego, CA USA
- Joint Doctoral Program in Clinical Psychology, San Diego State University/University of California San Diego, San Diego, CA USA
| | - Maureen D. Mayes
- Department of Internal Medicine, University of Texas McGovern School of Medicine, Houston, TX USA
| | - Isabelle Boutron
- Université de Paris, Centre of Research Epidemiology and Statistics (CRESS), Inserm, INRA, Paris, France
- Centre d’Épidémiologie Clinique, Assistance Publique–Hôpitaux de Paris (AP-HP), Hôpital Hôtel Dieu, Paris, France
| | - Luc Mouthon
- Service de Médecine Interne, Centre de Référence Maladies Autoimmunes Systémiques Rares d’Ile de France, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
- APHP-CUP, Hôpital Cochin, Université de Paris, F-75014 Paris, France
| | - Andrea Benedetti
- Department of Medicine, McGill University, Montreal, Quebec Canada
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Quebec Canada
- Respiratory Epidemiology and Clinical Research Unit, McGill University Health Centre, Montreal, Quebec Canada
| | - Brett D. Thombs
- Lady Davis Institute of the Jewish General Hospital, 3755 Côte-Sainte-Catherine Road, Montreal, Quebec, H3T 1E2 Canada
- Department of Psychiatry, McGill University, Montreal, Quebec Canada
- Department of Medicine, McGill University, Montreal, Quebec Canada
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Quebec Canada
- Respiratory Epidemiology and Clinical Research Unit, McGill University Health Centre, Montreal, Quebec Canada
- Department of Psychology, McGill University, Montreal, Quebec Canada
- Department of Educational and Counselling Psychology, McGill University, Montreal, Quebec Canada
- Biomedical Ethics Unit, McGill University, Montreal, Quebec Canada
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Prescott M, Lilley-Kelly A, Cundill B, Clarke D, Drake S, Farrin AJ, Forster A, Goodwin M, Goodwin VA, Hall AJ, Hartley S, Holland M, Hulme C, Nikolova S, Parker C, Wright P, Ziegler F, Clegg A. Home-based Extended Rehabilitation for Older people (HERO): study protocol for an individually randomised controlled multi-centre trial to determine the clinical and cost-effectiveness of a home-based exercise intervention for older people with frailty as extended rehabilitation following acute illness or injury, including embedded process evaluation. Trials 2021; 22:783. [PMID: 34749783 PMCID: PMC8576988 DOI: 10.1186/s13063-021-05778-5] [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: 03/30/2021] [Accepted: 10/29/2021] [Indexed: 11/25/2022] Open
Abstract
Background The majority of older people (> 65 years) in hospital have frailty and are at increased risk of readmission or death following discharge home. In the UK, following acute hospitalisation, around one third of older people with frailty are referred on for rehabilitation, termed ‘intermediate care’ services. Although this rehabilitation can reduce early readmission to hospital (< 30 days), recipients often do not feel ready to leave the service on discharge, suggesting possible incomplete recovery. Limited evidence suggests extended rehabilitation is of benefit in several conditions and there is preliminary evidence that progressive physical exercise can improve mobility and function for older people with frailty, and slow progression to disability. Our aim is to evaluate the effectiveness of the Home-based Older People’s Exercise (HOPE) programme as extended rehabilitation for older people with frailty discharged home from hospital or intermediate care services after acute illness or injury. Methods A multi-centre individually randomised controlled trial, to evaluate the clinical and cost-effectiveness of the HOPE programme. This individualised, graded and progressive 24-week exercise programme is delivered by NHS physiotherapy teams to people aged 65 and older with frailty, identified using the Clinical Frailty Scale, following discharge from acute hospitalisation and linked intermediate care rehabilitation pathways. The primary outcome is physical health-related quality of life, measured using the physical component summary score of the modified Short Form 36- item health questionnaire (SF36) at 12 months. Secondary outcomes include self-reported physical and mental health, functional independence, death, hospitalisations, care home admissions. Plans include health economic analyses and an embedded process evaluation. Discussion This trial seeks to determine if extended rehabilitation, via the HOPE programme, can improve physical health-related quality of life for older people with frailty following acute hospitalisation. Results will improve awareness of the rehabilitation needs of older people with frailty, and provide evidence on the clinical and cost-effectiveness of the targeted exercise intervention. There is potential for considerable benefit for health and social care services through widespread implementation of trial findings if clinical and cost-effectiveness is demonstrated. Trial registration ISRCTN 13927531. Registered on April 19, 2017. Supplementary Information The online version contains supplementary material available at 10.1186/s13063-021-05778-5.
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Affiliation(s)
- Matthew Prescott
- Academic Unit for Ageing and Stroke Research, Bradford Institute for Health Research, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, BD9 6RJ, UK.
| | - Amanda Lilley-Kelly
- Clinical Trials Research Unit (CTRU), Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, LS2 9JT, UK
| | - Bonnie Cundill
- Clinical Trials Research Unit (CTRU), Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, LS2 9JT, UK
| | - David Clarke
- Academic Unit for Ageing and Stroke Research, Leeds Institute of Health Science, University of Leeds, based at: Bradford Institute for Health Research, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, BD9 6RJ, UK
| | - Sian Drake
- Clinical Trials Research Unit (CTRU), Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, LS2 9JT, UK
| | - Amanda J Farrin
- Clinical Trials Research Unit (CTRU), Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, LS2 9JT, UK
| | - Anne Forster
- Academic Unit for Ageing and Stroke Research, Leeds Institute of Health Science, University of Leeds, based at: Bradford Institute for Health Research, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, BD9 6RJ, UK
| | - Madeline Goodwin
- Clinical Trials Research Unit (CTRU), Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, LS2 9JT, UK
| | - Victoria A Goodwin
- College of Medicine and Health, University of Exeter, Exeter, EX1 2LU, UK
| | - Abi J Hall
- College of Medicine and Health, University of Exeter, Exeter, EX1 2LU, UK
| | - Suzanne Hartley
- Clinical Trials Research Unit (CTRU), Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, LS2 9JT, UK
| | - Mike Holland
- Clinical Trials Research Unit (CTRU), Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, LS2 9JT, UK
| | - Claire Hulme
- College of Medicine and Health, University of Exeter, Exeter, EX1 2LU, UK
| | - Silviya Nikolova
- Academic Unit of Health Economics, University of Leeds, Leeds, LS2 9JT, UK
| | - Catriona Parker
- Clinical Trials Research Unit (CTRU), Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, LS2 9JT, UK
| | - Phil Wright
- Physiotherapy Department, Bradford Teaching Hospitals NHS Foundation Trust, Bradford Royal Infirmary, Bradford, BD9 6RJ, UK
| | - Friederike Ziegler
- Academic Unit for Ageing and Stroke Research, Bradford Institute for Health Research, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, BD9 6RJ, UK
| | - Andrew Clegg
- Academic Unit for Ageing and Stroke Research, Leeds Institute of Health Science, University of Leeds, based at: Bradford Institute for Health Research, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, BD9 6RJ, UK
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33
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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.
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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
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34
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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.
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Affiliation(s)
| | - Math J. J. M. Candel
- Department of Methodology and StatisticsMaastricht UniversityMaastrichtThe Netherlands
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35
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Morciano A, Moerbeek M. Optimal allocation to treatments in a sequential multiple assignment randomized trial. Stat Methods Med Res 2021; 30:2471-2484. [PMID: 34554015 PMCID: PMC8649474 DOI: 10.1177/09622802211037066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
One of the main questions in the design of a trial is how many subjects should be
assigned to each treatment condition. Previous research has shown that equal
randomization is not necessarily the best choice. We study the optimal
allocation for a novel trial design, the sequential multiple assignment
randomized trial, where subjects receive a sequence of treatments across various
stages. A subject's randomization probabilities to treatments in the next stage
depend on whether he or she responded to treatment in the current stage. We
consider a prototypical sequential multiple assignment randomized trial design
with two stages. Within such a design, many pairwise comparisons of treatment
sequences can be made, and a multiple-objective optimal design strategy is
proposed to consider all such comparisons simultaneously. The optimal design is
sought under either a fixed total sample size or a fixed budget. A Shiny App is
made available to find the optimal allocations and to evaluate the efficiency of
competing designs. As the optimal design depends on the response rates to
first-stage treatments, maximin optimal design methodology is used to find
robust optimal designs. The proposed methodology is illustrated using a
sequential multiple assignment randomized trial example on weight loss
management.
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Affiliation(s)
| | - Mirjam Moerbeek
- Department of Methodology and Statistics, Utrecht University, the Netherlands
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36
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Zhan D, Xu L, Ouyang Y, Sawatzky R, Wong H. Methods for dealing with unequal cluster sizes in cluster randomized trials: A scoping review. PLoS One 2021; 16:e0255389. [PMID: 34324593 PMCID: PMC8320970 DOI: 10.1371/journal.pone.0255389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Accepted: 07/15/2021] [Indexed: 11/18/2022] Open
Abstract
In a cluster-randomized trial (CRT), the number of participants enrolled often varies across clusters. This variation should be considered during both trial design and data analysis to ensure statistical performance goals are achieved. Most methodological literature on the CRT design has assumed equal cluster sizes. This scoping review focuses on methodology for unequal cluster size CRTs. EMBASE, Medline, Google Scholar, MathSciNet and Web of Science databases were searched to identify English-language articles reporting on methodology for unequal cluster size CRTs published until March 2021. We extracted data on the focus of the paper (power calculation, Type I error etc.), the type of CRT, the type and the range of parameter values investigated (number of clusters, mean cluster size, cluster size coefficient of variation, intra-cluster correlation coefficient, etc.), and the main conclusions. Seventy-nine of 5032 identified papers met the inclusion criteria. Papers primarily focused on the parallel-arm CRT (p-CRT, n = 60, 76%) and the stepped-wedge CRT (n = 14, 18%). Roughly 75% of the papers addressed trial design issues (sample size/power calculation) while 25% focused on analysis considerations (Type I error, bias, etc.). The ranges of parameter values explored varied substantially across different studies. Methods for accounting for unequal cluster sizes in the p-CRT have been investigated extensively for Gaussian and binary outcomes. Synthesizing the findings of these works is difficult as the magnitude of impact of the unequal cluster sizes varies substantially across the combinations and ranges of input parameters. Limited investigations have been done for other combinations of a CRT design by outcome type, particularly methodology involving binary outcomes-the most commonly used type of primary outcome in trials. The paucity of methodological papers outside of the p-CRT with Gaussian or binary outcomes highlights the need for further methodological development to fill the gaps.
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Affiliation(s)
- Denghuang Zhan
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
- Centre for Health Evaluation and Outcomes Sciences, University of British Columbia, Vancouver, British Columbia, Canada
| | - Liang Xu
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
- Centre for Health Evaluation and Outcomes Sciences, University of British Columbia, Vancouver, British Columbia, Canada
| | - Yongdong Ouyang
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
- Centre for Health Evaluation and Outcomes Sciences, University of British Columbia, Vancouver, British Columbia, Canada
| | - Richard Sawatzky
- Centre for Health Evaluation and Outcomes Sciences, University of British Columbia, Vancouver, British Columbia, Canada
- School of Nursing, Trinity Western University, Langley City, British Columbia, Canada
| | - Hubert Wong
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
- Centre for Health Evaluation and Outcomes Sciences, University of British Columbia, Vancouver, British Columbia, Canada
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37
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Copas AJ, Hooper R. Optimal design of cluster randomized trials allowing unequal allocation of clusters and unequal cluster size between arms. Stat Med 2021; 40:5474-5486. [PMID: 34312902 DOI: 10.1002/sim.9135] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Revised: 06/25/2021] [Accepted: 06/28/2021] [Indexed: 11/06/2022]
Abstract
There are sometimes cost, scientific, or logistical reasons to allocate individuals unequally in an individually randomized trial. In cluster randomized trials we can allocate clusters unequally and/or allow different cluster size between trial arms. We consider parallel group designs with a continuous outcome, and optimal designs that require the smallest number of individuals to be measured given the number of clusters. Previous authors have derived the optimal allocation ratio for clusters under different variance and/or intracluster correlations (ICCs) between arms, allowing different but prespecified cluster sizes by arm. We derive closed-form expressions to identify the optimal proportions of clusters and of individuals measured for each arm, thereby defining optimal cluster sizes, when cluster size can be chosen freely. When ICCs differ between arms but the variance is equal, the optimal design allocates more than half the clusters to the arm with the higher ICC, but (typically only slightly) less than half the individuals and hence a smaller cluster size. We also describe optimal design under constraints on the number of clusters or cluster size in one or both arms. This methodology allows trialists to consider a range for the number of clusters in the trial and for each to identify the optimal design. Except if there is clear prior evidence for the ICC and variance by arm, a range of values will need to be considered. Researchers should choose a design with adequate power across the range, while also keeping enough clusters in each arm to permit the intended analysis method.
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Affiliation(s)
- Andrew J Copas
- MRC Clinical Trials Unit, University College London, London, UK
| | - Richard Hooper
- Centre for Primary Care and Public Health, Queen Mary University of London, London, UK
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38
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Ntani G, Inskip H, Osmond C, Coggon D. Consequences of ignoring clustering in linear regression. BMC Med Res Methodol 2021; 21:139. [PMID: 34233609 PMCID: PMC8265092 DOI: 10.1186/s12874-021-01333-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Accepted: 06/15/2021] [Indexed: 11/25/2022] Open
Abstract
Background Clustering of observations is a common phenomenon in epidemiological and clinical research. Previous studies have highlighted the importance of using multilevel analysis to account for such clustering, but in practice, methods ignoring clustering are often employed. We used simulated data to explore the circumstances in which failure to account for clustering in linear regression could lead to importantly erroneous conclusions. Methods We simulated data following the random-intercept model specification under different scenarios of clustering of a continuous outcome and a single continuous or binary explanatory variable. We fitted random-intercept (RI) and ordinary least squares (OLS) models and compared effect estimates with the “true” value that had been used in simulation. We also assessed the relative precision of effect estimates, and explored the extent to which coverage by 95% confidence intervals and Type I error rates were appropriate. Results We found that effect estimates from both types of regression model were on average unbiased. However, deviations from the “true” value were greater when the outcome variable was more clustered. For a continuous explanatory variable, they tended also to be greater for the OLS than the RI model, and when the explanatory variable was less clustered. The precision of effect estimates from the OLS model was overestimated when the explanatory variable varied more between than within clusters, and was somewhat underestimated when the explanatory variable was less clustered. The cluster-unadjusted model gave poor coverage rates by 95% confidence intervals and high Type I error rates when the explanatory variable was continuous. With a binary explanatory variable, coverage rates by 95% confidence intervals and Type I error rates deviated from nominal values when the outcome variable was more clustered, but the direction of the deviation varied according to the overall prevalence of the explanatory variable, and the extent to which it was clustered. Conclusions In this study we identified circumstances in which application of an OLS regression model to clustered data is more likely to mislead statistical inference. The potential for error is greatest when the explanatory variable is continuous, and the outcome variable more clustered (intraclass correlation coefficient is ≥ 0.01). Supplementary Information The online version contains supplementary material available at 10.1186/s12874-021-01333-7.
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Affiliation(s)
- Georgia Ntani
- Medical Research Council Lifecourse Epidemiology Unit, University of Southampton, Southampton, UK. .,Medical Research Council Versus Arthritis Centre for Musculoskeletal Health and Work, Medical Research Council Lifecourse Epidemiology Unit, University of Southampton, Southampton, UK.
| | - Hazel Inskip
- Medical Research Council Lifecourse Epidemiology Unit, University of Southampton, Southampton, UK.,NIHR Southampton Biomedical Research Centre, University of Southampton and University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Clive Osmond
- Medical Research Council Lifecourse Epidemiology Unit, University of Southampton, Southampton, UK
| | - David Coggon
- Medical Research Council Lifecourse Epidemiology Unit, University of Southampton, Southampton, UK.,Medical Research Council Versus Arthritis Centre for Musculoskeletal Health and Work, Medical Research Council Lifecourse Epidemiology Unit, University of Southampton, Southampton, UK
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39
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Lincoln NB, Bradshaw LE, Constantinescu CS, Day F, Drummond AE, Fitzsimmons D, Harris S, Montgomery AA, das Nair R. Group cognitive rehabilitation to reduce the psychological impact of multiple sclerosis on quality of life: the CRAMMS RCT. Health Technol Assess 2021; 24:1-182. [PMID: 31934845 DOI: 10.3310/hta24040] [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] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND People with multiple sclerosis have problems with memory and attention. The effectiveness of cognitive rehabilitation has not been established. OBJECTIVES The objectives were to assess the clinical effectiveness and cost-effectiveness of a cognitive rehabilitation programme for people with multiple sclerosis. DESIGN This was a multicentre, randomised controlled trial in which participants were randomised in a ratio of 6 : 5 to receive cognitive rehabilitation plus usual care or usual care alone. Participants were assessed at 6 and 12 months after randomisation. SETTING The trial was set in hospital neurology clinics and community services. PARTICIPANTS Participants were people with multiple sclerosis who had cognitive problems, were aged 18-69 years, could travel to attend group sessions and gave informed consent. INTERVENTION The intervention was a group cognitive rehabilitation programme delivered weekly by an assistant psychologist to between four and six participants for 10 weeks. MAIN OUTCOME MEASURES The primary outcome was the Multiple Sclerosis Impact Scale - Psychological subscale at 12 months. Secondary outcomes included results from the Everyday Memory Questionnaire, the 30-Item General Health Questionnaire, the EuroQol-5 Dimensions, five-level version and a service use questionnaire from participants, and the Everyday Memory Questionnaire - relative version and the Modified Carer Strain Index from a relative or friend of the participant. RESULTS Of the 449 participants randomised, 245 were allocated to cognitive rehabilitation (intervention group) and 204 were allocated to usual care (control group). Of these, 214 in the intervention group and 173 in the control group were included in the primary analysis. There was no clinically important difference in the Multiple Sclerosis Impact Scale - Psychological subscale score between the two groups at the 12-month follow-up (adjusted difference in means -0.6, 95% confidence interval -1.5 to 0.3; p = 0.20). There were no important differences between the groups in relation to cognitive abilities, fatigue, employment, or carer strain at follow-up. However, there were differences, although small, between the groups in the Multiple Sclerosis Impact Scale - Psychological subscale score at 6 months (adjusted difference in means -0.9, 95% confidence interval -1.7 to -0.1; p = 0.03) and in everyday memory on the Everyday Memory Questionnaire as reported by participants at 6 (adjusted difference in means -5.3, 95% confidence interval -8.7 to -1.9) and 12 months (adjusted difference in means -4.4, 95% confidence interval -7.8 to -0.9) and by relatives at 6 (adjusted difference in means -5.4, 95% confidence interval -9.1 to -1.7) and 12 months (adjusted difference in means -5.5, 95% confidence interval -9.6 to -1.5) in favour of the cognitive rehabilitation group. There were also differences in mood on the 30-Item General Health Questionnaire at 6 (adjusted difference in means -3.4, 95% confidence interval -5.9 to -0.8) and 12 months (adjusted difference in means -3.4, 95% confidence interval -6.2 to -0.6) in favour of the cognitive rehabilitation group. A qualitative analysis indicated perceived benefits of the intervention. There was no evidence of a difference in costs (adjusted difference in means -£574.93, 95% confidence interval -£1878.93 to £729.07) or quality-adjusted life-year gain (adjusted difference in means 0.00, 95% confidence interval -0.02 to 0.02). No safety concerns were raised and no deaths were reported. LIMITATIONS The trial included a sample of participants who had relatively severe cognitive problems in daily life. The trial was not powered to perform subgroup analyses. Participants could not be blinded to treatment allocation. CONCLUSIONS This cognitive rehabilitation programme had no long-term benefits on quality of life for people with multiple sclerosis. FUTURE WORK Future research should evaluate the selection of those who may benefit from cognitive rehabilitation. TRIAL REGISTRATION Current Controlled Trials ISRCTN09697576. FUNDING This project was funded by the National Institute for Health Research Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 4. See the National Institute for Health Research Journals Library website for further project information.
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Affiliation(s)
- Nadina B Lincoln
- Division of Rehabilitation and Ageing, University of Nottingham, Nottingham, UK
| | - Lucy E Bradshaw
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | | | - Florence Day
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | | | | | - Shaun Harris
- Swansea Centre for Health Economics, Swansea University, Swansea, UK
| | - Alan A Montgomery
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
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40
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Optimal allocations for two treatment comparisons within the proportional odds cumulative logits model. PLoS One 2021; 16:e0250119. [PMID: 33882086 PMCID: PMC8059828 DOI: 10.1371/journal.pone.0250119] [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: 10/27/2020] [Accepted: 03/30/2021] [Indexed: 12/02/2022] Open
Abstract
This paper studies optimal treatment allocations for two treatment comparisons when the outcome is ordinal and analyzed by a proportional odds cumulative logits model. The variance of the treatment effect estimator is used as optimality criterion. The optimal design is sought so that this variance is minimal for a given total sample size or a given budget, meaning that the power for the test on treatment effect is maximal, or it is sought so that a required power level is achieved at a minimal total sample size or budget. Results are presented for three, five and seven ordered response categories, three treatment effect sizes and a skewed, bell-shaped or polarized distribution of the response probabilities. The optimal proportion subjects in the intervention condition decreases with the number of response categories and the costs for the intervention relative to those for the control. The relation between the optimal proportion and effect size depends on the distribution of the response probabilities. The widely used balanced design is not always the most efficient; its efficiency as compared to the optimal design decreases with increasing cost ratio. The optimal design is highly robust to misspecification of the response probabilities and treatment effect size. The optimal design methodology is illustrated using two pharmaceutical examples. A Shiny app is available to find the optimal treatment allocation, to evaluate the efficiency of the balanced design and to study the relation between budget or sample size and power.
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41
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Gunn H, Stevens KN, Creanor S, Andrade J, Paul L, Miller L, Green C, Ewings P, Barton A, Berrow M, Vickery J, Marshall B, Zajicek J, Freeman JA. Balance Right in Multiple Sclerosis (BRiMS): a feasibility randomised controlled trial of a falls prevention programme. Pilot Feasibility Stud 2021; 7:2. [PMID: 33390184 PMCID: PMC7780657 DOI: 10.1186/s40814-020-00732-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Accepted: 11/23/2020] [Indexed: 11/24/2022] Open
Abstract
Background Balance, mobility impairments and falls are problematic for people with multiple sclerosis (MS). The “Balance Right in MS (BRiMS)” intervention, a 13-week home and group-based exercise and education programme, aims to improve balance and minimise falls. This study aimed to evaluate the feasibility of undertaking a multi-centre randomised controlled trial and to collect the necessary data to design a definitive trial. Methods This randomised controlled feasibility study recruited from four United Kingdom NHS clinical neurology services. Patients ≥ 18 years with secondary progressive MS (Expanded Disability Status Scale 4 to 7) reporting more than two falls in the preceding 6 months were recruited. Participants were block-randomised to either a manualised 13-week education and exercise programme (BRiMS) plus usual care, or usual care alone. Feasibility assessment evaluated recruitment and retention rates, adherence to group assignment and data completeness. Proposed outcomes for the definitive trial (including impact of MS, mobility, quality of life and falls) and economic data were collected at baseline, 13 and 27 weeks, and participants completed daily paper falls diaries. Results Fifty-six participants (mean age 59.7 years, 66% female, median EDSS 6.0) were recruited in 5 months; 30 randomised to the intervention group. Ten (18%) participants withdrew, 7 from the intervention group. Two additional participants were lost to follow up at the final assessment point. Completion rates were > 98% for all outcomes apart from the falls diary (return rate 62%). After adjusting for baseline score, mean intervention—usual care between-group differences for the potential primary outcomes at week 27 were MS Walking Scale-12v2: − 7.7 (95% confidence interval [CI] − 17.2 to 1.8) and MS Impact Scale-29v2: physical 0.6 (CI − 7.8 to 9), psychological − 0.4 (CI − 9.9 to 9). In total, 715 falls were reported, rate ratio (intervention:usual care) for falls 0.81 (0.41 to 2.26) and injurious falls 0.44 (0.41 to 2.23). Conclusions Procedures were practical, and retention, programme engagement and outcome completion rates satisfied a priori progression criteria. Challenges were experienced in completion and return of daily falls diaries. Refinement of methods for reporting falls is therefore required, but we consider a full trial to be feasible. Trial registration ISRCTN13587999 Date of registration: 29 September 2016
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Affiliation(s)
- H Gunn
- Faculty of Health, School of Health Professions, Peninsula Allied Health Centre, University of Plymouth, Derriford Road, Plymouth, PL6 8BH, England.
| | - K N Stevens
- Faculty of Health, Medical Statistics Group, Room N15, Plymouth Science Park, Plymouth, PL6 8BX, England.,Peninsula Clinical Trials Unit, University of Plymouth, Room N16, Plymouth Science Park, Plymouth, PL6 8BX, England
| | - S Creanor
- Faculty of Health, Medical Statistics Group, Room N15, Plymouth Science Park, Plymouth, PL6 8BX, England.,University of Exeter Medical School, College of Medicine & Health, University of Exeter, Exeter, England
| | - J Andrade
- Faculty of Health, School of Psychology, University of Plymouth, Portland Square Building, Drake Circus Campus, Plymouth, PL4 8AA, England
| | - L Paul
- School of Health & Life Sciences, Glasgow Caledonian University, Cowcaddens Road, Glasgow, G4 0BA, Scotland
| | - L Miller
- Douglas Grant Rehabilitation Unit, Ayrshire Central Hospital, Kilwinning Road, Irvine, KA12 8SS, Scotland
| | - C Green
- University of Exeter Medical School, Health Economics Group, University of Exeter, St. Luke's Campus, Exeter, EX1 2LU, England
| | - P Ewings
- NIHR Research Design Service (South West), Musgrove Park Hospital, Taunton, TA1 5DA, England
| | - A Barton
- Faculty of Medicine and Dentistry, NIHR Research Design Service South West, ITTC Building, Plymouth Science Park, Plymouth, PL6 8BX, England
| | - M Berrow
- Faculty of Health, Medical Statistics Group, Room N15, Plymouth Science Park, Plymouth, PL6 8BX, England
| | - J Vickery
- Faculty of Health, Medical Statistics Group, Room N15, Plymouth Science Park, Plymouth, PL6 8BX, England
| | - B Marshall
- Faculty of Health, School of Health Professions, Peninsula Allied Health Centre, University of Plymouth, Derriford Road, Plymouth, PL6 8BH, England
| | - J Zajicek
- School of Medicine, Medical and Biological Sciences, University of St. Andrews, North Haugh, St. Andrews, KY16 9TF, Scotland
| | - J A Freeman
- Faculty of Health, School of Health Professions, Peninsula Allied Health Centre, University of Plymouth, Derriford Road, Plymouth, PL6 8BH, England
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Herrmann-Lingen C, Albus C, de Zwaan M, Geiser F, Heinemann K, Hellmich M, Michal M, Sadlonova M, Tostmann R, Wachter R, Herbeck Belnap B. Efficacy of team-based collaborative care for distressed patients in secondary prevention of chronic coronary heart disease (TEACH): study protocol of a multicenter randomized controlled trial. BMC Cardiovasc Disord 2020; 20:520. [PMID: 33302871 PMCID: PMC7731481 DOI: 10.1186/s12872-020-01810-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Accepted: 12/02/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Coronary heart disease (CHD) is the leading cause of death and years of life lost worldwide. While effective treatments are available for both acute and chronic disease stages there are unmet needs for effective interventions to support patients in health behaviors required for secondary prevention. Psychosocial distress is a common comorbidity in patients with CHD and associated with substantially reduced health-related quality of life (HRQoL), poor health behavior, and low treatment adherence. METHODS In a confirmatory, randomized, controlled, two-arm parallel group, multicenter behavioral intervention trial we will randomize 440 distressed CHD patients with at least one insufficiently controlled cardiac risk factor to either their physicians' usual care (UC) or UC plus 12-months of blended collaborative care (TeamCare = TC). Trained nurse care managers (NCM) will proactively support patients to identify individual sources of distress and risk behaviors, establish a stepwise treatment plan to improve self-help and healthy behavior, and actively monitor adherence and progress. Additional e-health resources are available to patients and their families. Intervention fidelity is ensured by a treatment manual, an electronic patient registry, and a specialist team regularly supervising NCM via videoconferences and recommending protocol and guideline-compliant treatment adjustments as indicated. Recommendations will be shared with patients and their physicians who remain in charge of patients' care. Since HRQoL is a recommended outcome by both, several guidelines and patient preference we chose a ≥ 50% improvement over baseline on the HeartQoL questionnaire at 12 months as primary outcome. Our primary hypothesis is that significantly more patients receiving TC will meet the primary outcome criterion compared to the UC group. Secondary hypotheses will evaluate improvements in risk factors, psychosocial variables, health care utilization, and durability of intervention effects over 18-30 months of follow-up. DISCUSSION TEACH is the first study of a blended collaborative care intervention simultaneously addressing distress and medical CHD risk factors conducted in cardiac patients in a European health care setting. If proven effective, its results can improve long-term chronic care of this vulnerable patient group and may be adapted for patients with other chronic conditions. TRIAL REGISTRATION German Clinical Trials Register, DRKS00020824, registered on 4 June, 2020; https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00020824.
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Affiliation(s)
- Christoph Herrmann-Lingen
- Department of Psychosomatic Medicine and Psychotherapy, University of Göttingen Medical Center, Von-Siebold-Str. 5, 37075, Göttingen, Germany. .,German Center for Cardiovascular Research (DZHK), Partner Site Göttingen, Göttingen, Germany.
| | - Christian Albus
- Department of Psychosomatics and Psychotherapy, University of Cologne, Cologne, Germany
| | - Martina de Zwaan
- Department of Psychosomatic Medicine and Psychotherapy, Hannover Medical School, Hannover, Germany
| | - Franziska Geiser
- Department of Psychosomatic Medicine and Psychotherapy, University of Bonn Medical Center, Bonn, Germany
| | - Katrin Heinemann
- Department of Psychosomatic Medicine and Psychotherapy, University of Göttingen Medical Center, Von-Siebold-Str. 5, 37075, Göttingen, Germany
| | - Martin Hellmich
- Institute of Medical Statistics and Computational Biology, Faculty of Medicine, University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Matthias Michal
- Department of Psychosomatic Medicine and Psychotherapy, University Medical Center Mainz, Mainz, Germany.,German Center for Cardiovascular Research (DZHK), Partner Site Rhine-Main, Mainz, Germany
| | - Monika Sadlonova
- Department of Psychosomatic Medicine and Psychotherapy, University of Göttingen Medical Center, Von-Siebold-Str. 5, 37075, Göttingen, Germany.,German Center for Cardiovascular Research (DZHK), Partner Site Göttingen, Göttingen, Germany.,Department of Thoracic and Cardiovascular Surgery, University of Göttingen Medical Center, Göttingen, Germany
| | - Ralf Tostmann
- Clinical Trials Unit, University of Göttingen Medical Center, Göttingen, Germany
| | - Rolf Wachter
- Clinic and Policlinic for Cardiology, University Hospital of Leipzig, Leipzig, Germany
| | - Birgit Herbeck Belnap
- Department of Psychosomatic Medicine and Psychotherapy, University of Göttingen Medical Center, Von-Siebold-Str. 5, 37075, Göttingen, Germany.,Center for Behavioral Health, Media, and Technology, University of Pittsburgh School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
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43
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Fonagy P, Yakeley J, Gardner T, Simes E, McMurran M, Moran P, Crawford M, Frater A, Barrett B, Cameron A, Wason J, Pilling S, Butler S, Bateman A. Mentalization for Offending Adult Males (MOAM): study protocol for a randomized controlled trial to evaluate mentalization-based treatment for antisocial personality disorder in male offenders on community probation. Trials 2020; 21:1001. [PMID: 33287865 PMCID: PMC7720544 DOI: 10.1186/s13063-020-04896-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Accepted: 11/12/2020] [Indexed: 11/10/2022] Open
Abstract
Background Antisocial personality disorder (ASPD), although associated with very significant health and social burden, is an under-researched mental disorder for which clinically effective and cost-effective treatment methods are urgently needed. No intervention has been established for prevention or as the treatment of choice for this disorder. Mentalization-based treatment (MBT) is a psychotherapeutic treatment that has shown some promising preliminary results for reducing personality disorder symptomatology by specifically targeting the ability to recognize and understand the mental states of oneself and others, an ability that is compromised in people with ASPD. This paper describes the protocol of a multi-site RCT designed to test the effectiveness and cost-effectiveness of MBT for reducing aggression and alleviating the wider symptoms of ASPD in male offenders subject to probation supervision who fulfil diagnostic criteria for ASPD. Methods Three hundred and two participants recruited from a pool of offenders subject to statutory supervision by the National Probation Service at 13 sites across the UK will be randomized on a 1:1 basis to 12 months of probation plus MBT or standard probation as usual, with follow-up to 24 months post-randomization. The primary outcome is frequency of aggressive antisocial behaviour as assessed by the Overt Aggression Scale – Modified. Secondary outcomes include violence, offending rates, alcohol use, drug use, mental health status, quality of life, and total service use costs. Data will be gathered from police and criminal justice databases, NHS record linkage, and interviews and self-report measures administered to participants. Primary analysis will be on an intent-to-treat basis; per-protocol analysis will be undertaken as secondary analysis. The primary outcome will be analysed using hierarchical mixed-effects linear regression. Secondary outcomes will be analysed using mixed-effects linear regression, mixed-effects logistic regression, and mixed-effects Poisson models for secondary outcomes depending on whether the outcome is continuous, binary, or count data. A cost-effectiveness and cost-utility analysis will be undertaken. Discussion This definitive, national, multi-site trial is of sufficient size to evaluate MBT to inform policymakers, service commissioners, clinicians, and service users about its potential to treat offenders with ASPD and the likely impact on the population at risk. Trial registration ISRCTN 32309003. Registered on 8 April 2016.
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Affiliation(s)
- Peter Fonagy
- Research Department of Clinical, Educational and Health Psychology, University College London, London, UK. .,Anna Freud National Centre for Children and Families, London, UK.
| | - Jessica Yakeley
- Portman Clinic, Tavistock and Portman NHS Foundation Trust, London, UK
| | - Tessa Gardner
- Anna Freud National Centre for Children and Families, London, UK
| | - Elizabeth Simes
- Research Department of Clinical, Educational and Health Psychology, University College London, London, UK.,Anna Freud National Centre for Children and Families, London, UK
| | - Mary McMurran
- Institute of Mental Health, University of Nottingham, Nottingham, UK
| | - Paul Moran
- Centre for Academic Mental Health, Population Health Sciences Department, Bristol Medical School, University of Bristol, Bristol, UK
| | - Mike Crawford
- Centre for Mental Health, Imperial College, London, UK
| | - Alison Frater
- School of Law, Royal Holloway, University of London, London, UK
| | - Barbara Barrett
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Angus Cameron
- National Probation Service London Division, London, UK
| | - James Wason
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK.,MRC Biostatistics Unit, University of Cambridge, Cambridge, UK
| | - Stephen Pilling
- Research Department of Clinical, Educational and Health Psychology, University College London, London, UK
| | - Stephen Butler
- Psychology Department, University of Prince Edward Island, Charlottetown, Canada
| | - Anthony Bateman
- Research Department of Clinical, Educational and Health Psychology, University College London, London, UK.,Anna Freud National Centre for Children and Families, London, UK
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Puka K, Bax K, Andrade A, Devries-Rizzo M, Gangam H, Levin S, Nouri MN, Prasad AN, Secco M, Zou G, Speechley KN. A live-online mindfulness-based intervention for children living with epilepsy and their families: protocol for a randomized controlled trial of Making Mindfulness Matter©. Trials 2020; 21:922. [PMID: 33176853 PMCID: PMC7657360 DOI: 10.1186/s13063-020-04792-3] [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: 06/30/2020] [Accepted: 10/05/2020] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Epilepsy extends far beyond seizures; up to 80% of children with epilepsy (CWE) may have comorbid cognitive or mental health problems, and up to 50% of parents of CWE are at risk for major depression. Past research has also shown that family environment has a greater influence on children's and parents' health-related quality of life (HRQOL) and mental health than epilepsy-related factors. There is a pressing need for low-cost, innovative interventions to improve HRQOL and mental health for CWE and their parents. The aim of this randomized controlled trial (RCT) is to evaluate whether an interactive online mindfulness-based intervention program, Making Mindfulness Matter (M3), can be feasibly implemented and whether it positively affects CWE's and parents' HRQOL and mental health (specifically, stress, behavioral, depressive, and anxiety symptoms). METHODS This parallel RCT was planned to recruit 100 child-parent dyads to be randomized 1:1 to the 8-week intervention or waitlist control and followed over 20 weeks. The intervention, M3, will be delivered online and separately to parents and children (ages 4-10 years) in groups of 4-8 by non-clinician staff of a local community epilepsy agency. The intervention incorporates mindful awareness, social-emotional learning skills, and positive psychology. It is modeled after the validated school-based MindUP program and adapted for provision online and to include a parent component. DISCUSSION This RCT will determine whether this online mindfulness-based intervention is feasible and effective for CWE and their parents. The proposed intervention may be an ideal vector to significantly improve HRQOL and mental health for CWE and their parents given its low cost and implementation by community epilepsy agencies. TRIAL REGISTRATION ClinicalTrials.gov NCT04020484 . Registered on July 16, 2019.
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Affiliation(s)
- Klajdi Puka
- Department of Epidemiology & Biostatistics, Western University, Kresge Building, Room K201, 1151 Richmond Street, London, ON, N6A 5C1, Canada. .,Children's Health Research Institute, Lawson Health Research Institute, London, Ontario, Canada.
| | - Karen Bax
- Children's Health Research Institute, Lawson Health Research Institute, London, Ontario, Canada.,The Mary J. Wright Research and Education Centre, Western University, London, Ontario, Canada
| | - Andrea Andrade
- Children's Health Research Institute, Lawson Health Research Institute, London, Ontario, Canada.,Paediatrics, Western University, London, Ontario, Canada.,Children's Hospital at London Health Sciences Centre, London, Ontario, Canada
| | - Margo Devries-Rizzo
- Children's Hospital at London Health Sciences Centre, London, Ontario, Canada.,Health Sciences, Western University, London, Ontario, Canada
| | - Hema Gangam
- Paediatrics, Western University, London, Ontario, Canada
| | - Simon Levin
- Children's Health Research Institute, Lawson Health Research Institute, London, Ontario, Canada.,Paediatrics, Western University, London, Ontario, Canada.,Children's Hospital at London Health Sciences Centre, London, Ontario, Canada
| | - Maryam N Nouri
- Children's Health Research Institute, Lawson Health Research Institute, London, Ontario, Canada.,Paediatrics, Western University, London, Ontario, Canada.,Children's Hospital at London Health Sciences Centre, London, Ontario, Canada
| | - Asuri N Prasad
- Children's Health Research Institute, Lawson Health Research Institute, London, Ontario, Canada.,Paediatrics, Western University, London, Ontario, Canada.,Children's Hospital at London Health Sciences Centre, London, Ontario, Canada
| | - Mary Secco
- Epilepsy Southwestern Ontario, London, Ontario, Canada
| | - Guangyong Zou
- Department of Epidemiology & Biostatistics, Western University, Kresge Building, Room K201, 1151 Richmond Street, London, ON, N6A 5C1, Canada.,Robarts Research Institute, London, Ontario, Canada
| | - Kathy N Speechley
- Department of Epidemiology & Biostatistics, Western University, Kresge Building, Room K201, 1151 Richmond Street, London, ON, N6A 5C1, Canada.,Children's Health Research Institute, Lawson Health Research Institute, London, Ontario, Canada.,Paediatrics, Western University, London, Ontario, Canada
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45
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Roberts C. The implications of noncompliance for randomized trials with partial nesting due to group treatment. Stat Med 2020; 40:349-368. [PMID: 33118193 PMCID: PMC7821326 DOI: 10.1002/sim.8778] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Revised: 09/23/2020] [Accepted: 09/29/2020] [Indexed: 01/09/2023]
Abstract
Analyses of trials of group administered treatments require an identifier for therapy group to account for clustering by group. All patients randomized to receive the group administered treatment could be assigned an intended group identifier following randomization. Alternatively, an actual group could be based on those patients that comply with group therapy. We investigate the implications for intention‐to‐treat (ITT) analyses of using either the intended or actual group to adjust for the clustering effect. We also consider causal models using the actual group. A simulation study showed that ITT estimates based on random effects models or GEE with an exchangeable correlation matrix performed much better when using the intended group than the actual group. OLS with robust standard errors performed well with both. Most compliance average causal effect (CACE) models performed well. While practical constraints of the clinical setting may determine the choice between an intended or actual group analyses, it is desirable to record both. An ITT analysis using mixed models can then be fitted using the intended group with data generation assumptions checked by a causal model using the actual group. Where an ITT analysis is based on the actual group, worse outcome for never‐takers than compliers may allow one to infer that some estimators are biased toward no treatment effect. The work here is motivated and illustrated by a trial of a group therapy, but also has relevance to trials with treatment related clustering due to therapist examples of which include physical and talking therapies or surgery.
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Affiliation(s)
- Chris Roberts
- Centre for Biostatistics, Division of Population Health, School of Health Sciences, University of Manchester, Manchester, UK
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46
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Taylor PJ, Playle R, Robling M, Bezeczky Z, John-Evans H, Dimitropoulou P, McNamara R, Moriarty Y, Summers Z, Bagshaw R. A randomized controlled trial of a Group psychological intervention to increase locus of control for alcohol consumption among Alcohol-Misusing Short-term (male) Prisoners (GASP). Addiction 2020; 115:1844-1854. [PMID: 32045077 DOI: 10.1111/add.15006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Revised: 05/30/2019] [Accepted: 02/03/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND AIM Reducing alcohol misuse by male prisoners is an important global issue. Control of drinking behaviour could be a useful target for intervention in this population, and locus of control could be a causal factor in this. We aimed to assess the effect of a clinical psychologist-facilitated group intervention on male prisoners' locus of control of drinking behaviour. DESIGN A two-arm, single-site, open, randomized controlled trial. SETTING A category B local training prison in South Wales, housing about 770 mainly sentenced men. PARTICIPANTS Prisoners serving less than 2 years who met inclusion criteria for pre-imprisonment alcohol misuse, alone or with drug misuse. A total of 119 were allocated to the intervention arm and 119 to the control arm; 104 and 87, respectively, completed the post-randomization baseline interview and 68 and 60 completed a second interview approximately 4 weeks later, respectively, after intervention or treatment as usual (TAU) alone. INTERVENTION Nine clinical psychologist-facilitated groups in the prison over 3 weeks. Range of participants per session was one to seven, with three to five most usual. MEASURES The primary outcome was locus of control of behaviour (LCB); secondary outcomes included mental state generally (comprehensive psychiatric rating scale/CPRS) and specifically (Beck Depression Inventory/BDI). An integral process evaluation was conducted. FINDINGS LCB scores decreased during the study, but without significant intervention effect [-1.7, 95% confidence interval (CI) = -5.1 to 1.6, P = 0.329]. Change among completers in the control group was from a mean score of 37.4 [standard deviation (SD) = 10.0] to 33.7[SD = 11.7] and in the intervention group from 37.4 (SD = 11.6) to 31.9 (SD = 11.8). Secondary outcomes, including change in mental state, did not differ between arms, but 686 (64%) sessions were lost, most because of 'prison issues'. CONCLUSIONS A clinical psychologist-facilitated group intervention did not have a statistically significant effect on sense of control of drinking behaviour among men with pre-imprisonment alcohol misuse serving less than 2 years in a South Wales prison. The study proved coterminous, however, with 40% prison staff cuts which seem likely to have contributed to the high loss of group sessions and possibly overwhelmed any treatment effect. Intervention completion failures, previously cited as harmful, had no effect here, so the trial should be repeated when the prison climate improves.
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Affiliation(s)
- Pamela J Taylor
- Division of Psychological Medicine and Clinical Neurosciences, School of Medicine, Cardiff University, Cardiff, UK
| | - Rebecca Playle
- Centre for Trials Research, Cardiff University, Cardiff, UK
| | | | - Zoe Bezeczky
- Division of Psychological Medicine and Clinical Neurosciences, School of Medicine, Cardiff University, Cardiff, UK
| | - Hannah John-Evans
- Division of Psychological Medicine and Clinical Neurosciences, School of Medicine, Cardiff University, Cardiff, UK
| | | | | | | | - Zelda Summers
- Abertawe Bro Morgannwg University Health Board, Port Talbot, UK
| | - Ruth Bagshaw
- Abertawe Bro Morgannwg University Health Board, Port Talbot, UK
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Rodgers H, Bosomworth H, Krebs HI, van Wijck F, Howel D, Wilson N, Finch T, Alvarado N, Ternent L, Fernandez-Garcia C, Aird L, Andole S, Cohen DL, Dawson J, Ford GA, Francis R, Hogg S, Hughes N, Price CI, Turner DL, Vale L, Wilkes S, Shaw L. Robot-assisted training compared with an enhanced upper limb therapy programme and with usual care for upper limb functional limitation after stroke: the RATULS three-group RCT. Health Technol Assess 2020; 24:1-232. [PMID: 33140719 PMCID: PMC7682262 DOI: 10.3310/hta24540] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Loss of arm function is common after stroke. Robot-assisted training may improve arm outcomes. OBJECTIVE The objectives were to determine the clinical effectiveness and cost-effectiveness of robot-assisted training, compared with an enhanced upper limb therapy programme and with usual care. DESIGN This was a pragmatic, observer-blind, multicentre randomised controlled trial with embedded health economic and process evaluations. SETTING The trial was set in four NHS trial centres. PARTICIPANTS Patients with moderate or severe upper limb functional limitation, between 1 week and 5 years following first stroke, were recruited. INTERVENTIONS Robot-assisted training using the Massachusetts Institute of Technology-Manus robotic gym system (InMotion commercial version, Interactive Motion Technologies, Inc., Watertown, MA, USA), an enhanced upper limb therapy programme comprising repetitive functional task practice, and usual care. MAIN OUTCOME MEASURES The primary outcome was upper limb functional recovery 'success' (assessed using the Action Research Arm Test) at 3 months. Secondary outcomes at 3 and 6 months were the Action Research Arm Test results, upper limb impairment (measured using the Fugl-Meyer Assessment), activities of daily living (measured using the Barthel Activities of Daily Living Index), quality of life (measured using the Stroke Impact Scale), resource use costs and quality-adjusted life-years. RESULTS A total of 770 participants were randomised (robot-assisted training, n = 257; enhanced upper limb therapy, n = 259; usual care, n = 254). Upper limb functional recovery 'success' was achieved in the robot-assisted training [103/232 (44%)], enhanced upper limb therapy [118/234 (50%)] and usual care groups [85/203 (42%)]. These differences were not statistically significant; the adjusted odds ratios were as follows: robot-assisted training versus usual care, 1.2 (98.33% confidence interval 0.7 to 2.0); enhanced upper limb therapy versus usual care, 1.5 (98.33% confidence interval 0.9 to 2.5); and robot-assisted training versus enhanced upper limb therapy, 0.8 (98.33% confidence interval 0.5 to 1.3). The robot-assisted training group had less upper limb impairment (as measured by the Fugl-Meyer Assessment motor subscale) than the usual care group at 3 and 6 months. The enhanced upper limb therapy group had less upper limb impairment (as measured by the Fugl-Meyer Assessment motor subscale), better mobility (as measured by the Stroke Impact Scale mobility domain) and better performance in activities of daily living (as measured by the Stroke Impact Scale activities of daily living domain) than the usual care group, at 3 months. The robot-assisted training group performed less well in activities of daily living (as measured by the Stroke Impact Scale activities of daily living domain) than the enhanced upper limb therapy group at 3 months. No other differences were clinically important and statistically significant. Participants found the robot-assisted training and the enhanced upper limb therapy group programmes acceptable. Neither intervention, as provided in this trial, was cost-effective at current National Institute for Health and Care Excellence willingness-to-pay thresholds for a quality-adjusted life-year. CONCLUSIONS Robot-assisted training did not improve upper limb function compared with usual care. Although robot-assisted training improved upper limb impairment, this did not translate into improvements in other outcomes. Enhanced upper limb therapy resulted in potentially important improvements on upper limb impairment, in performance of activities of daily living, and in mobility. Neither intervention was cost-effective. FUTURE WORK Further research is needed to find ways to translate the improvements in upper limb impairment seen with robot-assisted training into improvements in upper limb function and activities of daily living. Innovations to make rehabilitation programmes more cost-effective are required. LIMITATIONS Pragmatic inclusion criteria led to the recruitment of some participants with little prospect of recovery. The attrition rate was higher in the usual care group than in the robot-assisted training or enhanced upper limb therapy groups, and differential attrition is a potential source of bias. Obtaining accurate information about the usual care that participants were receiving was a challenge. TRIAL REGISTRATION Current Controlled Trials ISRCTN69371850. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 54. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Helen Rodgers
- Stroke Research Group, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
- Stroke Northumbria, Northumbria Healthcare NHS Foundation Trust, North Tyneside, UK
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Helen Bosomworth
- Stroke Research Group, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Hermano I Krebs
- Mechanical Engineering Department, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Frederike van Wijck
- School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, UK
| | - Denise Howel
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Nina Wilson
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Tracy Finch
- Nursing, Midwifery and Health, Northumbria University, Newcastle upon Tyne, UK
| | | | - Laura Ternent
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | | | - Lydia Aird
- Stroke Northumbria, Northumbria Healthcare NHS Foundation Trust, North Tyneside, UK
| | - Sreeman Andole
- Barking, Havering and Redbridge University Hospitals NHS Trust, Romford, UK
| | - David L Cohen
- London North West University Healthcare NHS Trust, London, UK
| | - Jesse Dawson
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Gary A Ford
- Stroke Research Group, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
- Medical Sciences Division, University of Oxford, Oxford, UK
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Richard Francis
- Stroke Research Group, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Steven Hogg
- Lay investigator (contact Stroke Research Group, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK)
| | | | - Christopher I Price
- Stroke Research Group, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
- Stroke Northumbria, Northumbria Healthcare NHS Foundation Trust, North Tyneside, UK
| | - Duncan L Turner
- School of Health, Sport and Bioscience, University of East London, London, UK
| | - Luke Vale
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Scott Wilkes
- School of Medicine, University of Sunderland, Sunderland, UK
| | - Lisa Shaw
- Stroke Research Group, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
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Gunn H, Andrade J, Paul L, Miller L, Creanor S, Stevens K, Green C, Ewings P, Barton A, Berrow M, Vickery J, Marshall B, Zajicek J, Freeman J. A self-management programme to reduce falls and improve safe mobility in people with secondary progressive MS: the BRiMS feasibility RCT. Health Technol Assess 2020; 23:1-166. [PMID: 31217069 DOI: 10.3310/hta23270] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Balance, mobility impairments and falls are common problems for people with multiple sclerosis (MS). Our ongoing research has led to the development of Balance Right in MS (BRiMS), a 13-week home- and group-based exercise and education programme intended to improve balance and encourage safer mobility. OBJECTIVE This feasibility trial aimed to obtain the necessary data and operational experience to finalise the planning of a future definitive multicentre randomised controlled trial. DESIGN Randomised controlled feasibility trial. Participants were block randomised 1 : 1. Researcher-blinded assessments were scheduled at baseline and at 15 and 27 weeks post randomisation. As is appropriate in a feasibility trial, statistical analyses were descriptive rather than involving formal/inferential comparisons. The qualitative elements utilised template analysis as the chosen analytical framework. SETTING Four sites across the UK. PARTICIPANTS Eligibility criteria included having a diagnosis of secondary progressive MS, an Expanded Disability Status Scale (EDSS) score of between ≥ 4.0 and ≤ 7.0 points and a self-report of two or more falls in the preceding 6 months. INTERVENTIONS Intervention - manualised 13-week education and exercise programme (BRiMS) plus usual care. Comparator - usual care alone. MAIN OUTCOME MEASURES Trial feasibility, proposed outcomes for the definitive trial (including impact of MS, mobility, quality of life and falls), feasibility of the BRiMS programme (via process evaluation) and economic data. RESULTS A total of 56 participants (mean age 59.7 years, standard deviation 9.7 years; 66% female; median EDSS score of 6.0 points, interquartile range 6.0-6.5 points) were recruited in 5 months; 30 were block randomised to the intervention group. The demographic and clinical data were broadly comparable at baseline; however, the intervention group scored worse on the majority of baseline outcome measures. Eleven participants (19.6%) withdrew or were lost to follow-up. Worsening of MS-related symptoms unrelated to the trial was the most common reason (n = 5) for withdrawal. Potential primary and secondary outcomes and economic data had completion rates of > 98% for all those assessed. However, the overall return rate for the patient-reported falls diary was 62%. After adjusting for baseline score, the differences between the groups (intervention compared with usual care) at week 27 for the potential primary outcomes were MS Walking Scale (12-item) version 2 -7.7 [95% confidence interval (CI) -17.2 to 1.8], MS Impact Scale (29-item) version 2 (MSIS-29vs2) physical 0.6 (95% CI -7.8 to 9) and MSIS-29vs2 psychological -0.4 (95% CI -9.9 to 9) (negative score indicates improvement). After the removal of one outlier, a total of 715 falls were self-reported over the 27-week trial period, with substantial variation between individuals (range 0-93 falls). Of these 715 falls, 101 (14%) were reported as injurious. Qualitative feedback indicated that trial processes and participant burden were acceptable, and participants highlighted physical and behavioural changes that they perceived to result from undertaking BRiMS. Engagement varied, influenced by a range of condition- and context-related factors. Suggestions to improve the utility and accessibility of BRiMS were highlighted. CONCLUSIONS The results suggest that the trial procedures are feasible and acceptable, and retention, programme engagement and outcome completion rates were sufficient to satisfy the a priori progression criteria. Challenges were experienced in some areas of data collection, such as completion of daily diaries. FUTURE WORK Further development of BRiMS is required to address logistical issues and enhance user-satisfaction and adherence. Following this, a definitive trial to assess the clinical effectiveness and cost-effectiveness of the BRiMS intervention is warranted. TRIAL REGISTRATION Current Controlled Trials ISRCTN13587999. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 23, No. 27. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Hilary Gunn
- School of Health Professions, Faculty of Health and Human Sciences, Peninsula Allied Health Centre, University of Plymouth, Plymouth, UK
| | - Jackie Andrade
- School of Psychology, Faculty of Health and Human Sciences, University of Plymouth, Plymouth, UK
| | - Lorna Paul
- School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, UK
| | - Linda Miller
- Douglas Grant Rehabilitation Unit, Ayrshire Central Hospital, Irvine, UK
| | - Siobhan Creanor
- Peninsula Clinical Trials Unit at Plymouth University (PenCTU), Faculty of Medicine and Dentistry, University of Plymouth, Plymouth, UK.,Medical Statistics Group, Faculty of Medicine and Dentistry, University of Plymouth, Plymouth, UK
| | - Kara Stevens
- Medical Statistics Group, Faculty of Medicine and Dentistry, University of Plymouth, Plymouth, UK
| | - Colin Green
- University of Exeter Medical School, Health Economics Group, University of Exeter, Exeter, UK
| | - Paul Ewings
- National Institute for Health Research (NIHR) Research Design Service (South West), Musgrove Park Hospital, Taunton, UK
| | - Andrew Barton
- National Institute for Health Research (NIHR) Research Design Service, Faculty of Medicine and Dentistry, University of Plymouth, Plymouth, UK
| | - Margie Berrow
- Peninsula Clinical Trials Unit at Plymouth University (PenCTU), Faculty of Medicine and Dentistry, University of Plymouth, Plymouth, UK
| | - Jane Vickery
- Peninsula Clinical Trials Unit at Plymouth University (PenCTU), Faculty of Medicine and Dentistry, University of Plymouth, Plymouth, UK
| | | | - John Zajicek
- School of Medicine, University of St Andrews, St Andrews, UK
| | - Jennifer Freeman
- School of Health Professions, Faculty of Health and Human Sciences, Peninsula Allied Health Centre, University of Plymouth, Plymouth, UK
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das Nair R, Bradshaw LE, Carpenter H, Clarke S, Day F, Drummond A, Fitzsimmons D, Harris S, Montgomery AA, Newby G, Sackley C, Lincoln NB. A group memory rehabilitation programme for people with traumatic brain injuries: the ReMemBrIn RCT. Health Technol Assess 2020; 23:1-194. [PMID: 31032782 DOI: 10.3310/hta23160] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND People with traumatic brain injuries (TBIs) commonly report memory impairments. These are persistent, debilitating and reduce quality of life, but patients do not routinely receive memory rehabilitation after discharge from hospital. OBJECTIVE To assess the clinical effectiveness and cost-effectiveness of a group memory rehabilitation programme for people with TBI. DESIGN Multicentre, pragmatic, cluster randomised controlled trial. Qualitative and health economic evaluations were also undertaken. SETTING Community settings in nine sites in England. PARTICIPANTS Participants were aged 18-69 years, had undergone a TBI > 3 months prior to recruitment, reported memory problems, were able to travel to a site to attend group sessions, could communicate in English and gave informed consent. RANDOMISATION AND BLINDING Clusters of four to six participants were randomised to the memory rehabilitation arm or the usual-care arm on a 1 : 1 ratio. Randomisation was based on a computer-generated pseudo-random code using random permuted blocks of randomly varying size, stratified by study site. Participants and therapists were aware of the treatment allocation whereas outcome assessors were blinded. INTERVENTIONS In the memory rehabilitation arm 10 weekly sessions of a manualised memory rehabilitation programme were provided in addition to usual care. Participants were taught restitution strategies to retrain impaired memory functions and compensation strategies to enable them to cope with memory problems. The usual-care arm received usual care only. MAIN OUTCOME MEASURES Outcomes were assessed at 6 and 12 months after randomisation. Primary outcome: patient-completed Everyday Memory Questionnaire - patient version (EMQ-p) at 6 months' follow-up. Secondary outcomes: Rivermead Behavioural Memory Test - third edition (RBMT-3), General Health Questionnaire 30-item version, European Brain Injury Questionnaire, Everyday Memory Questionnaire - relative version and individual goal attainment. Costs (based on a UK NHS and Personal Social Services perspective) were collected using a service use questionnaire, with the EuroQol-5 Dimensions, five-level version, used to derive quality-adjusted life-years (QALYs). A Markov model was developed to explore cost-effectiveness at 5 and 10 years, with a 3.5% discount applied. RESULTS We randomised 328 participants (memory rehabilitation, n = 171; usual care, n = 157), with 129 in the memory rehabilitation arm and 122 in the usual-care arm included in the primary analysis. We found no clinically important difference on the EMQ-p between the two arms at 6 months' follow-up (adjusted difference in mean scores -2.1, 95% confidence interval -6.7 to 2.5; p = 0.37). For secondary outcomes, differences favouring the memory rehabilitation arm were observed at 6 months' follow-up for the RBMT-3 and goal attainment, but remained only for goal attainment at 12 months' follow-up. There were no differences between arms in mood or quality of life. The qualitative results suggested positive experiences of participating in the trial and of attending the groups. Participants reported that memory rehabilitation was not routinely accessible in usual care. The primary health economics outcome at 12 months found memory rehabilitation to be £26.89 cheaper than usual care but less effective, with an incremental QALY loss of 0.007. Differences in costs and effects were not statistically significant and non-parametric bootstrapping demonstrated considerable uncertainty in these findings. No safety concerns were raised and no deaths were reported. LIMITATIONS As a pragmatic trial, we had broad inclusion criteria and, therefore, there was considerable heterogeneity within the sample. The study was not powered to perform further subgroup analyses. Participants and therapists could not be blinded to treatment allocation. CONCLUSIONS The group memory rehabilitation delivered in this trial is very unlikely to lead to clinical benefits or to be a cost-effective treatment for people with TBI in the community. Future studies should examine the selection of participants who may benefit most from memory rehabilitation. TRIAL REGISTRATION Current Controlled Trials ISRCTN65792154. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 23, No. 16. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Roshan das Nair
- Division of Psychiatry and Applied Psychology, University of Nottingham, Nottingham, UK.,Institute of Mental Health, Nottingham, UK.,Department of Clinical Psychology and Neuropsychology, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Lucy E Bradshaw
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - Hannah Carpenter
- Division of Rehabilitation and Ageing, University of Nottingham, Nottingham, UK
| | - Sara Clarke
- Division of Rehabilitation and Ageing, University of Nottingham, Nottingham, UK
| | - Florence Day
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - Avril Drummond
- School of Health Sciences, University of Nottingham, Nottingham, UK
| | | | - Shaun Harris
- Swansea Centre for Health Economics, Swansea University, Swansea, UK
| | - Alan A Montgomery
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - Gavin Newby
- Newby Psychological Services Ltd, Northwich, UK
| | - Catherine Sackley
- Division of Health and Social Care, King's College London, London, UK
| | - Nadina B Lincoln
- Division of Rehabilitation and Ageing, University of Nottingham, Nottingham, UK
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50
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Li D, Zhang S, Cao J. Incorporating pragmatic features into power analysis for cluster randomized trials with a count outcome. Stat Med 2020; 39:4037-4050. [PMID: 33165949 DOI: 10.1002/sim.8707] [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: 06/06/2019] [Revised: 04/17/2020] [Accepted: 07/03/2020] [Indexed: 11/09/2022]
Abstract
Cluster randomized designs are frequently employed in pragmatic clinical trials which test interventions in the full spectrum of everyday clinical settings in order to maximize applicability and generalizability. In this study, we propose to directly incorporate pragmatic features into power analysis for cluster randomized trials with count outcomes. The pragmatic features considered include arbitrary randomization ratio, overdispersion, random variability in cluster size, and unequal lengths of follow-up over which the count outcome is measured. The proposed method is developed based on generalized estimating equation (GEE) and it is advantageous in that the sample size formula retains a closed form, facilitating its implementation in pragmatic trials. We theoretically explore the impact of various pragmatic features on sample size requirements. An efficient Jackknife algorithm is presented to address the problem of underestimated variance by the GEE sandwich estimator when the number of clusters is small. We assess the performance of the proposed sample size method through extensive simulation and an application example to a real clinical trial is presented.
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Affiliation(s)
- Dateng Li
- Early clinical development, Biostatistics, Regeneron Pharmaceuticals Inc., Tarrytown, New York, USA
| | - Song Zhang
- Department of Population and Data Sciences, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Jing Cao
- Department of Statistical Science, Southern Methodist University, Dallas, Texas, USA
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