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Yang C, Berkalieva A, Mazumdar M, Kwon D. Power calculation for detecting interaction effect in cross-sectional stepped-wedge cluster randomized trials: an important tool for disparity research. BMC Med Res Methodol 2024; 24:57. [PMID: 38431550 DOI: 10.1186/s12874-024-02162-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 01/25/2024] [Indexed: 03/05/2024] Open
Abstract
BACKGROUND The stepped-wedge cluster randomized trial (SW-CRT) design has become popular in healthcare research. It is an appealing alternative to traditional cluster randomized trials (CRTs) since the burden of logistical issues and ethical problems can be reduced. Several approaches for sample size determination for the overall treatment effect in the SW-CRT have been proposed. However, in certain situations we are interested in examining the heterogeneity in treatment effect (HTE) between groups instead. This is equivalent to testing the interaction effect. An important example includes the aim to reduce racial disparities through healthcare delivery interventions, where the focus is the interaction between the intervention and race. Sample size determination and power calculation for detecting an interaction effect between the intervention status variable and a key covariate in the SW-CRT study has not been proposed yet for binary outcomes. METHODS We utilize the generalized estimating equation (GEE) method for detecting the heterogeneity in treatment effect (HTE). The variance of the estimated interaction effect is approximated based on the GEE method for the marginal models. The power is calculated based on the two-sided Wald test. The Kauermann and Carroll (KC) and the Mancl and DeRouen (MD) methods along with GEE (GEE-KC and GEE-MD) are considered as bias-correction methods. RESULTS Among three approaches, GEE has the largest simulated power and GEE-MD has the smallest simulated power. Given cluster size of 120, GEE has over 80% statistical power. When we have a balanced binary covariate (50%), simulated power increases compared to an unbalanced binary covariate (30%). With intermediate effect size of HTE, only cluster sizes of 100 and 120 have more than 80% power using GEE for both correlation structures. With large effect size of HTE, when cluster size is at least 60, all three approaches have more than 80% power. When we compare an increase in cluster size and increase in the number of clusters based on simulated power, the latter has a slight gain in power. When the cluster size changes from 20 to 40 with 20 clusters, power increases from 53.1% to 82.1% for GEE; 50.6% to 79.7% for GEE-KC; and 48.1% to 77.1% for GEE-MD. When the number of clusters changes from 20 to 40 with cluster size of 20, power increases from 53.1% to 82.1% for GEE; 50.6% to 81% for GEE-KC; and 48.1% to 79.8% for GEE-MD. CONCLUSIONS We propose three approaches for cluster size determination given the number of clusters for detecting the interaction effect in SW-CRT. GEE and GEE-KC have reasonable operating characteristics for both intermediate and large effect size of HTE.
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Affiliation(s)
- Chen Yang
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Institute for Healthcare Delivery Science, Mount Sinai Health System, New York, NY, USA
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Asem Berkalieva
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Institute for Healthcare Delivery Science, Mount Sinai Health System, New York, NY, USA
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Madhu Mazumdar
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Institute for Healthcare Delivery Science, Mount Sinai Health System, New York, NY, USA
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Deukwoo Kwon
- Division of Clinical and Translational Sciences, Department of Internal Medicine, University of Texas Health Science Center at Houston, Houston, TX, USA.
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Hense H, Mathiebe J, Helfer S, Glaubitz R, Rüdiger M, Birdir C, Schmitt J, Müller G. Evaluation of the telemedical health care network "SAFE BIRTH" for pregnant women at risk, premature and sick newborns and their families: study protocol of a cluster-randomized controlled stepped-wedge trial. BMC Health Serv Res 2024; 24:200. [PMID: 38355579 PMCID: PMC10865646 DOI: 10.1186/s12913-024-10667-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Accepted: 01/31/2024] [Indexed: 02/16/2024] Open
Abstract
BACKGROUND The Perinatal Center of the University Hospital Carl Gustav Carus Dresden has initiated the telemedical healthcare network "SAFE BIRTH" to coordinate and improve specialized care in non-metropolitan regions for pregnant women and newborns. The network incorporates five intervention bundles (IB): (1) Multi-professional, inter-disciplinary prenatal care plan; (2) Neonatal resuscitation; (3) Neonatal antibiotic stewardship; (4) Inter-facility transfer of premature and sick newborns; (5) Psycho-social support for parents. We evaluate if the network improves care close to home for pregnant women, premature and sick newborns. METHODS To evaluate the complex healthcare intervention "SAFE BIRTH" we will conduct a cluster-randomized controlled stepped-wedge trial in five prenatal medical outpatient offices and eight non-metropolitan hospitals in Saxony, Germany. The offices and hospitals will be randomly allocated to five respectively eight sequential steps over a 30-month period to implement the telemedical IB. We define one specific primary process outcome for each IB (for instance IB#1: "Proportion of patients with inclusion criterion IB#1 who have a prenatal care plan and psychosocial counseling within one week"). We estimated a separate multilevel logistic regression model for each primary process outcome using the intervention status as a regressor (control or intervention group). Across all IB, a total of 1,541 and 1,417 pregnant women or newborns need to be included in the intervention and control group, respectively, for a power above 80% for small to medium intervention effects for all five hypothesis tests. Additionally, we will assess job satisfaction and sense of safety of health professionals caring for newborns (questionnaire survey) and we will assess families' satisfaction, resilience, quality of life and depressive, anxiety and stress symptoms (questionnaire surveys). We will also evaluate the cost-effectiveness of "SAFE BIRTH" (statutory health insurance routine data, process data) and barriers to its implementation (semi-structured interviews). We use multilevel regression models adjusting for relevant confounders (e.g. socioeconomic status, age, place of residence), as well as descriptive analyses and qualitative content analyses. DISCUSSION If the telemedical healthcare network "SAFE BIRTH" proves to be effective and cost-efficient, strategies for its translation into routine care should be developed. TRIAL REGISTRATION German clinical trials register. DRKS-ID DRKS00031482.
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Affiliation(s)
- Helene Hense
- Center for Evidence-Based Healthcare, University Hospital and Faculty of Medicine Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.
| | - Josephine Mathiebe
- Center for Evidence-Based Healthcare, University Hospital and Faculty of Medicine Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Sven Helfer
- Saxony Center for Feto/Neonatal Health, University Hospital and Faculty of Medicine Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Rick Glaubitz
- Center for Evidence-Based Healthcare, University Hospital and Faculty of Medicine Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Mario Rüdiger
- Saxony Center for Feto/Neonatal Health, University Hospital and Faculty of Medicine Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Cahit Birdir
- Saxony Center for Feto/Neonatal Health, University Hospital and Faculty of Medicine Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Jochen Schmitt
- Center for Evidence-Based Healthcare, University Hospital and Faculty of Medicine Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Gabriele Müller
- Center for Evidence-Based Healthcare, University Hospital and Faculty of Medicine Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
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Caille A, Billot L, Kasza J. Practical and methodological challenges when conducting a cluster randomized trial: Examples and recommendations. Journal of Epidemiology and Population Health 2024; 72:202199. [PMID: 38477480 DOI: 10.1016/j.jeph.2024.202199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Revised: 01/19/2024] [Accepted: 01/19/2024] [Indexed: 03/14/2024]
Abstract
The use of cluster randomized trial design to answer research questions is increasing. This design and associated variants such as the cluster randomized crossover and stepped wedge are useful to assess complex interventions in a pragmatic way but when adopting such designs, one may face specific implementation challenges. This article summarizes common challenges faced when conducting cluster randomized trials, cluster randomized crossover trials, and stepped wedge trials, and provides recommendations.
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Affiliation(s)
- Agnès Caille
- Université de Tours, Université de Nantes, INSERM, SPHERE U1246, Tours, France; INSERM CIC 1415, CHRU de Tours, Tours, France.
| | - Laurent Billot
- The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Jessica Kasza
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
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McMahon A, Kaptoge S, Walker M, Mehenny S, Gilchrist PT, Sambrook J, Akhtar N, Sweeting M, Wood AM, Stirrups K, Chung R, Fahle S, Johnson E, Cullen D, Godfrey R, Duthie S, Allen L, Harvey P, Berkson M, Allen E, Watkins NA, Bradley JR, Kingston N, Miflin G, Armitage J, Roberts DJ, Danesh J, Di Angelantonio E. Evaluation of interventions to prevent vasovagal reactions among whole blood donors: rationale and design of a large cluster randomised trial. Trials 2023; 24:512. [PMID: 37563721 PMCID: PMC10413586 DOI: 10.1186/s13063-023-07473-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Accepted: 06/23/2023] [Indexed: 08/12/2023] Open
Abstract
BACKGROUND Vasovagal reactions (VVRs) are the most common acute complications of blood donation. Responsible for substantial morbidity, they also reduce the likelihood of repeated donations and are disruptive and costly for blood services. Although blood establishments worldwide have adopted different strategies to prevent VVRs (including water loading and applied muscle tension [AMT]), robust evidence is limited. The Strategies to Improve Donor Experiences (STRIDES) trial aims to reliably assess the impact of four different interventions to prevent VVRs among blood donors. METHODS STRIDES is a cluster-randomised cross-over/stepped-wedge factorial trial of four interventions to reduce VVRs involving about 1.4 million whole blood donors enrolled from all 73 blood donation sites (mobile teams and donor centres) of National Health Service Blood and Transplant (NHSBT) in England. Each site ("cluster") has been randomly allocated to receive one or more interventions during a 36-month period, using principles of cross-over, stepped-wedge and factorial trial design to assign the sequence of interventions. Each of the four interventions is compared to NHSBT's current practices: (i) 500-ml isotonic drink before donation (vs current 500-ml plain water); (ii) 3-min rest on donation chair after donation (vs current 2 min); (iii) new modified AMT (vs current practice of AMT); and (iv) psychosocial intervention using preparatory materials (vs current practice of nothing). The primary outcome is the number of in-session VVRs with loss of consciousness (i.e. episodes involving loss of consciousness of any duration, with or without additional complications). Secondary outcomes include all in-session VVRs (i.e. with and without loss of consciousness), all delayed VVRs (i.e. those occurring after leaving the venue) and any in-session non-VVR adverse events or reactions. DISCUSSION The STRIDES trial should yield novel information about interventions, singly and in combination, for the prevention of VVRs, with the aim of generating policy-shaping evidence to help inform blood services to improve donor health, donor experience, and service efficiency. TRIAL REGISTRATION ISRCTN: 10412338. Registration date: October 24, 2019.
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Affiliation(s)
- Amy McMahon
- British Heart Foundation Cardiovascular Epidemiology Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK.
- Victor Phillip Dahdaleh Heart and Lung Research Institute, University of Cambridge, Cambridge, UK.
- National Institute for Health and Care Research Blood and Transplant Research Unit in Donor Health and Behaviour, University of Cambridge, Cambridge, UK.
| | - Stephen Kaptoge
- British Heart Foundation Cardiovascular Epidemiology Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
- Victor Phillip Dahdaleh Heart and Lung Research Institute, University of Cambridge, Cambridge, UK
- National Institute for Health and Care Research Blood and Transplant Research Unit in Donor Health and Behaviour, University of Cambridge, Cambridge, UK
- Health Data Research UK Cambridge, Wellcome Genome Campus and University of Cambridge, Cambridge, UK
| | - Matthew Walker
- British Heart Foundation Cardiovascular Epidemiology Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
- Victor Phillip Dahdaleh Heart and Lung Research Institute, University of Cambridge, Cambridge, UK
| | - Susan Mehenny
- NHS Blood & Transplant, Blood Donation, Barnsley, UK
| | - Philippe T Gilchrist
- National Institute for Health and Care Research Blood and Transplant Research Unit in Donor Health and Behaviour, University of Cambridge, Cambridge, UK
- School of Psychological Sciences, Macquarie University, Sydney, NSW, Australia
- Centre for Emotional Health, Macquarie University, Sydney, NSW, Australia
| | - Jennifer Sambrook
- Department of Haematology, University of Cambridge, Cambridge Biomedical Campus, Cambridge, UK
- National Institute for Health and Care Research BioResource, Cambridge University Hospitals NHS Foundation, Cambridge Biomedical Campus, Cambridge, UK
| | | | - Michael Sweeting
- British Heart Foundation Cardiovascular Epidemiology Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
- University of Leicester, Leicester, UK
| | - Angela M Wood
- British Heart Foundation Cardiovascular Epidemiology Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
- Victor Phillip Dahdaleh Heart and Lung Research Institute, University of Cambridge, Cambridge, UK
- National Institute for Health and Care Research Blood and Transplant Research Unit in Donor Health and Behaviour, University of Cambridge, Cambridge, UK
- Health Data Research UK Cambridge, Wellcome Genome Campus and University of Cambridge, Cambridge, UK
- British Heart Foundation Centre of Research Excellence, University of Cambridge, Cambridge, UK
- Cambridge Centre of Artificial Intelligence in Medicine, University of Cambridge, Cambridge, UK
| | - Kathleen Stirrups
- Department of Haematology, University of Cambridge, Cambridge Biomedical Campus, Cambridge, UK
- National Institute for Health and Care Research BioResource, Cambridge University Hospitals NHS Foundation, Cambridge Biomedical Campus, Cambridge, UK
| | - Ryan Chung
- British Heart Foundation Cardiovascular Epidemiology Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
- Victor Phillip Dahdaleh Heart and Lung Research Institute, University of Cambridge, Cambridge, UK
| | - Sarah Fahle
- British Heart Foundation Cardiovascular Epidemiology Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
- Victor Phillip Dahdaleh Heart and Lung Research Institute, University of Cambridge, Cambridge, UK
- National Institute for Health and Care Research Blood and Transplant Research Unit in Donor Health and Behaviour, University of Cambridge, Cambridge, UK
| | - Elisha Johnson
- British Heart Foundation Cardiovascular Epidemiology Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
- Victor Phillip Dahdaleh Heart and Lung Research Institute, University of Cambridge, Cambridge, UK
- National Institute for Health and Care Research Blood and Transplant Research Unit in Donor Health and Behaviour, University of Cambridge, Cambridge, UK
| | - Donna Cullen
- NHS Blood & Transplant, John Radcliffe Hospital, Oxford, UK
| | | | - Shannon Duthie
- British Heart Foundation Cardiovascular Epidemiology Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
- Victor Phillip Dahdaleh Heart and Lung Research Institute, University of Cambridge, Cambridge, UK
- National Institute for Health and Care Research Blood and Transplant Research Unit in Donor Health and Behaviour, University of Cambridge, Cambridge, UK
| | | | - Paul Harvey
- British Heart Foundation Cardiovascular Epidemiology Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
- Victor Phillip Dahdaleh Heart and Lung Research Institute, University of Cambridge, Cambridge, UK
- National Institute for Health and Care Research Blood and Transplant Research Unit in Donor Health and Behaviour, University of Cambridge, Cambridge, UK
| | - Michael Berkson
- British Heart Foundation Cardiovascular Epidemiology Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
- Victor Phillip Dahdaleh Heart and Lung Research Institute, University of Cambridge, Cambridge, UK
- National Institute for Health and Care Research Blood and Transplant Research Unit in Donor Health and Behaviour, University of Cambridge, Cambridge, UK
| | - Elizabeth Allen
- British Heart Foundation Cardiovascular Epidemiology Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
- Victor Phillip Dahdaleh Heart and Lung Research Institute, University of Cambridge, Cambridge, UK
- National Institute for Health and Care Research Blood and Transplant Research Unit in Donor Health and Behaviour, University of Cambridge, Cambridge, UK
| | - Nicholas A Watkins
- Data, Analytics and Surveillance, UK Health Security Agency, Nobel House, London, UK
| | - John R Bradley
- National Institute for Health and Care Research BioResource, Cambridge University Hospitals NHS Foundation, Cambridge Biomedical Campus, Cambridge, UK
| | - Nathalie Kingston
- Department of Haematology, University of Cambridge, Cambridge Biomedical Campus, Cambridge, UK
- National Institute for Health and Care Research BioResource, Cambridge University Hospitals NHS Foundation, Cambridge Biomedical Campus, Cambridge, UK
| | | | - Jane Armitage
- MRC Population Health Research Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - David J Roberts
- National Institute for Health and Care Research Blood and Transplant Research Unit in Donor Health and Behaviour, University of Cambridge, Cambridge, UK
- NHS Blood & Transplant, John Radcliffe Hospital, Oxford, UK
- Radcliffe Dept of Medicine and BRC Haematology Theme, University of Oxford, Oxford, UK
| | - John Danesh
- British Heart Foundation Cardiovascular Epidemiology Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
- Victor Phillip Dahdaleh Heart and Lung Research Institute, University of Cambridge, Cambridge, UK
- National Institute for Health and Care Research Blood and Transplant Research Unit in Donor Health and Behaviour, University of Cambridge, Cambridge, UK
- Health Data Research UK Cambridge, Wellcome Genome Campus and University of Cambridge, Cambridge, UK
- British Heart Foundation Centre of Research Excellence, University of Cambridge, Cambridge, UK
- Department of Human Genetics, Wellcome Sanger Institute, Hinxton, UK
| | - Emanuele Di Angelantonio
- British Heart Foundation Cardiovascular Epidemiology Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
- Victor Phillip Dahdaleh Heart and Lung Research Institute, University of Cambridge, Cambridge, UK
- National Institute for Health and Care Research Blood and Transplant Research Unit in Donor Health and Behaviour, University of Cambridge, Cambridge, UK
- Health Data Research UK Cambridge, Wellcome Genome Campus and University of Cambridge, Cambridge, UK
- British Heart Foundation Centre of Research Excellence, University of Cambridge, Cambridge, UK
- Health Data Science Centre, Human Technopole, Milan, 20157, Italy
- NHS Blood and Transplant, Cambridge, UK
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de Rijk FEM, van Veldhuisen CL, Besselink MG, van Hooft JE, van Santvoort HC, van Geenen EJM, van Werkhoven CH, de Jonge PJF, Bruno MJ, Verdonk RC. Implementation of an evidence-based management algorithm for patients with chronic pancreatitis (COMBO trial): study protocol for a stepped-wedge cluster-randomized controlled trial. Trials 2023; 24:18. [PMID: 36611202 PMCID: PMC9824955 DOI: 10.1186/s13063-022-07044-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Accepted: 12/19/2022] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Chronic pancreatitis (CP) is an inflammatory disease that may be complicated by abdominal pain, pancreatic dysfunction, nutritional deficiencies, and diminished bone density. Importantly, it is also associated with a substantially impaired quality of life and reduced life expectancy. This may partly be explained by suboptimal treatment, in particular the long-term management of this chronic condition, despite several national and international guidelines. Standardization of care through a structured implementation of guideline recommendations may improve the level of care and lower the complication rate of these patients. Therefore, the aim of the present study is to evaluate to what extent patient education and standardization of care, through the implementation of an evidence-based integrated management algorithm, improve quality of life and reduce pain severity in patients with CP. METHODS The COMBO trial is a nationwide stepped-wedge cluster-randomized controlled trial. In a stepwise manner, 26 centers, clustered in 6 health regions, cross-over from current practice to care according to an evidence-based integrated management algorithm. During the current practice phase, study participants are recruited and followed longitudinally through questionnaires. Individual patients contribute data to both study periods. Co-primary study endpoints consist of quality of life (assessed by the PANQOLI score) and level of pain (assessed by the Izbicki questionnaire). Secondary outcomes include process measure outcomes, clinical outcomes (e.g., pancreatic function, nutritional status, bone health, interventions, medication use), utilization of healthcare resources, (in) direct costs, and the level of social participation. Standard follow-up is 35 months from the start of the trial. DISCUSSION This is the first stepped-wedge cluster-randomized controlled trial to investigate whether an evidence-based integrated therapeutic approach improves quality of life and pain severity in patients with CP as compared with current practice. TRIAL REGISTRATION ISRCTN, ISRCTN13042622. Registered on 5 September 2020.
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Affiliation(s)
- Florence E. M. de Rijk
- grid.5645.2000000040459992XDepartment of Gastroenterology and Hepatology, Erasmus University Medical Center, Doctor Molewaterplein 40, 3015 GD Rotterdam, The Netherlands ,grid.415960.f0000 0004 0622 1269Department of Research and Development, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Charlotte L. van Veldhuisen
- grid.415960.f0000 0004 0622 1269Department of Research and Development, St. Antonius Hospital, Nieuwegein, The Netherlands ,grid.509540.d0000 0004 6880 3010Department of Surgery, Amsterdam UMC, Location University of Amsterdam, Amsterdam, The Netherlands ,Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, The Netherlands
| | - Marc G. Besselink
- grid.509540.d0000 0004 6880 3010Department of Surgery, Amsterdam UMC, Location University of Amsterdam, Amsterdam, The Netherlands ,Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, The Netherlands
| | - Jeanin E. van Hooft
- grid.10419.3d0000000089452978Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Hjalmar C. van Santvoort
- grid.415960.f0000 0004 0622 1269Department of Surgery, St. Antonius Hospital, Nieuwegein, The Netherlands ,grid.7692.a0000000090126352Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Erwin J. M. van Geenen
- grid.10417.330000 0004 0444 9382Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Cornelis H. van Werkhoven
- grid.7692.a0000000090126352Julius Center for Health Sciences and Primary Care, Utrecht, The Netherlands
| | - Pieter Jan F. de Jonge
- grid.5645.2000000040459992XDepartment of Gastroenterology and Hepatology, Erasmus University Medical Center, Doctor Molewaterplein 40, 3015 GD Rotterdam, The Netherlands
| | - Marco J. Bruno
- grid.5645.2000000040459992XDepartment of Gastroenterology and Hepatology, Erasmus University Medical Center, Doctor Molewaterplein 40, 3015 GD Rotterdam, The Netherlands
| | - Robert C. Verdonk
- grid.415960.f0000 0004 0622 1269Department of Gastroenterology and Hepatology, St. Antonius Hospital, Nieuwegein, The Netherlands
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Oyamada S, Chiu SW, Yamaguchi T. Comparison of statistical models for estimating intervention effects based on time-to-recurrent-event in stepped wedge cluster randomized trial using open cohort design. BMC Med Res Methodol 2022; 22:123. [PMID: 35473492 PMCID: PMC9040235 DOI: 10.1186/s12874-022-01552-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Accepted: 02/23/2022] [Indexed: 11/20/2022] Open
Abstract
Background There are currently no methodological studies on the performance of the statistical models for estimating intervention effects based on the time-to-recurrent-event (TTRE) in stepped wedge cluster randomised trial (SWCRT) using an open cohort design. This study aims to address this by evaluating the performance of these statistical models using an open cohort design with the Monte Carlo simulation in various settings and their application using an actual example. Methods Using Monte Carlo simulations, we evaluated the performance of the existing extended Cox proportional hazard models, i.e., the Andersen-Gill (AG), Prentice-Williams-Peterson Total-Time (PWP-TT), and Prentice-Williams-Peterson Gap-time (PWP-GT) models, using the settings of several event generation models and true intervention effects, with and without stratification by clusters. Unidirectional switching in SWCRT was represented using time-dependent covariates. Results Using Monte Carlo simulations with the various described settings, in situations where inter-individual variability do not exist, the PWP-GT model with stratification by clusters showed the best performance in most settings and reasonable performance in the others. The only situation in which the performance of the PWP-TT model with stratification by clusters was not inferior to that of the PWP-GT model with stratification by clusters was when there was a certain amount of follow-up period, and the timing of the trial entry was random within the trial period, including the follow-up period. In situations where inter-individual variability existed, the PWP-GT model consistently underperformed compared to the PWP-TT model. The AG model performed well only in a specific setting. By analysing actual examples, it was found that almost all the statistical models suggested that the risk of events during the intervention condition may be somewhat higher than in the control, although the difference was not statistically significant. Conclusions When estimating the TTRE-based intervention effects of SWCRT in various settings using an open cohort design, the PWP-GT model with stratification by clusters performed most reasonably in situations where inter-individual variability was not present. However, if inter-individual variability was present, the PWP-TT model with stratification by clusters performed best. Supplementary Information The online version contains supplementary material available at 10.1186/s12874-022-01552-6.
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Affiliation(s)
- Shunsuke Oyamada
- Division of Biostatistics, Tohoku University Graduate School of Medicine, Sendai, Japan. .,Departments of Biostatistics, JORTC Data Center, Tokyo, Japan.
| | - Shih-Wei Chiu
- Division of Biostatistics, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Takuhiro Yamaguchi
- Division of Biostatistics, Tohoku University Graduate School of Medicine, Sendai, Japan
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Patel K, Say S, Leng D, Prak M, Lo K, Mukaka M, Riedel A, Turner C. Saving babies' lives (SBL) - a programme to reduce neonatal mortality in rural Cambodia: study protocol for a stepped-wedge cluster-randomised trial. BMC Pediatr 2021; 21:390. [PMID: 34493225 PMCID: PMC8421466 DOI: 10.1186/s12887-021-02833-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Accepted: 08/09/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Neonatal mortality remains unacceptably high. Many studies successful at reducing neonatal mortality have failed to realise similar gains at scale. Effective implementation and scale-up of interventions designed to tackle neonatal mortality is a global health priority. Multifaceted programmes targeting the continuum of neonatal care, with sustainability and scalability built into the design, can provide practical insights to solve this challenge. Cambodia has amongst the highest neonatal mortality rates in South-East Asia, with rural areas particularly affected. The primary objective of this study is the design, implementation, and assessment of the Saving Babies' Lives programme, a package of interventions designed to reduce neonatal mortality in rural Cambodia. METHODS This study is a five-year stepped-wedge cluster-randomised trial conducted in a rural Cambodian province with an estimated annual delivery rate of 6615. The study is designed to implement and evaluate the Saving Babies' Lives programme, which is the intervention. The Saving Babies' Lives programme is an iterative package of neonatal interventions spanning the continuum of care and integrating into the existing health system. The Saving Babies' Lives programme comprises two major components: participatory learning and action with community health workers, and capacity building of primary care facilities involving facility-based mentorship. Standard government service continues in control arms. Data collection covering the whole study area includes surveillance of all pregnancies, verbal and social autopsies, and quality of care surveys. Mixed methods data collection supports iteration of the complex intervention, and facilitates impact, outcome, process and economic evaluation. DISCUSSION Our study uses a robust study design to evaluate and develop a holistic, innovative, contextually relevant and sustainable programme that can be scaled-up to reduce neonatal mortality. TRIAL REGISTRATION ClinicalTrials.gov: NCT04663620 . Registered on 11th December 2020, retrospectively registered.
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Affiliation(s)
- Kaajal Patel
- Saving Babies' Lives Programme, Angkor Hospital for Children, Tep Vong (Achamean) Road & Oum Chhay Street, Svay Dangkum, Siem Reap, Cambodia.
- Cambodia Oxford Medical Research Unit, Angkor Hospital for Children, Tep Vong (Achamean) Road & Oum Chhay Street, Svay Dangkum, Siem Reap, Cambodia.
| | - Sopheakneary Say
- Saving Babies' Lives Programme, Angkor Hospital for Children, Tep Vong (Achamean) Road & Oum Chhay Street, Svay Dangkum, Siem Reap, Cambodia
| | - Daly Leng
- Saving Babies' Lives Programme, Angkor Hospital for Children, Tep Vong (Achamean) Road & Oum Chhay Street, Svay Dangkum, Siem Reap, Cambodia
| | - Manila Prak
- Saving Babies' Lives Programme, Angkor Hospital for Children, Tep Vong (Achamean) Road & Oum Chhay Street, Svay Dangkum, Siem Reap, Cambodia
| | - Koung Lo
- Preah Vihear Provincial Health Department, Preah Vihear, Cambodia
| | - Mavuto Mukaka
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, 10400, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, OX3 7FZ, UK
| | - Arthur Riedel
- Saving Babies' Lives Programme, Angkor Hospital for Children, Tep Vong (Achamean) Road & Oum Chhay Street, Svay Dangkum, Siem Reap, Cambodia
| | - Claudia Turner
- Saving Babies' Lives Programme, Angkor Hospital for Children, Tep Vong (Achamean) Road & Oum Chhay Street, Svay Dangkum, Siem Reap, Cambodia
- Cambodia Oxford Medical Research Unit, Angkor Hospital for Children, Tep Vong (Achamean) Road & Oum Chhay Street, Svay Dangkum, Siem Reap, Cambodia
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, OX3 7FZ, UK
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Ouyang Y, Xu L, Karim ME, Gustafson P, Wong H. CRTpowerdist: An R package to calculate attained power and construct the power distribution for cross-sectional stepped-wedge and parallel cluster randomized trials. Comput Methods Programs Biomed 2021; 208:106255. [PMID: 34260969 DOI: 10.1016/j.cmpb.2021.106255] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Accepted: 06/19/2021] [Indexed: 06/13/2023]
Abstract
BACKGROUND The attained power, calculated conditional on the realized allocation, of a clinical trial may differ from the expected power, obtained pre-randomization through averaging over all potential allocations that could be generated by the randomization algorithm (RA). For example, a two-arm trial using a RA that is expected to allocate 20 participants to each arm will attain less than the expected power if by chance it allocates 25 and 15 participants to the arms. Cluster randomized trials with unequal cluster sizes have elevated risk of realizing an allocation that yields an attained power much lower than the expected power when modest numbers of clusters are randomized. METHOD We developed the R package CRTpowerdist, which implements both simulations and approximate analytic formulae to calculate the attained powers associated with different realized allocations and constructs the pre-randomization power distribution associated with the RA to facilitate assessing the risk of obtaining inadequate power. The package covers unequal cluster-size, cross-sectional stepped-wedge and parallel cluster randomized trials, with or without stratification. Allowed outcome types are: continuous (Gaussian), binary (Binomial) and count (Poisson). The analytic formulae-based calculations are also implemented in a Shiny app. RESULTS The functionality of the CRTpowerdist is illustrated for each type of trial design. The examples show how to obtain the attained power, the power distribution, and the risk of low attained power, using both simulation and analytic formulae. CONCLUSION For cluster randomized trials with unequal cluster sizes, the CRTpowerdist package can assist users in identifying an appropriate randomization algorithm by enabling the user to assess the risk that a randomization algorithm will lead to an allocation with inadequate attained power. The Shiny app makes these assessments accessible to researchers who are unable or do not wish to use the CRTpowerdist package.
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Affiliation(s)
- Yongdong Ouyang
- School of Population and Public Health, University of British Columbia, 2206 E Mall, Vancouver, BC Canada V6T 1Z3; Centre for Health Evaluation & Outcome Sciences, 588 - 1081 Burrard Street, St. Paul's Hospital Vancouver, BC Canada V6Z 1Y6.
| | - Liang Xu
- School of Population and Public Health, University of British Columbia, 2206 E Mall, Vancouver, BC Canada V6T 1Z3; Centre for Health Evaluation & Outcome Sciences, 588 - 1081 Burrard Street, St. Paul's Hospital Vancouver, BC Canada V6Z 1Y6
| | - Mohammad Ehsanul Karim
- School of Population and Public Health, University of British Columbia, 2206 E Mall, Vancouver, BC Canada V6T 1Z3; Centre for Health Evaluation & Outcome Sciences, 588 - 1081 Burrard Street, St. Paul's Hospital Vancouver, BC Canada V6Z 1Y6
| | - Paul Gustafson
- Department of Statistics, University of British Columbia, 3182 Earth Sciences Building, 2207 Main Mall Vancouver, BC Canada V6T 1Z4
| | - Hubert Wong
- School of Population and Public Health, University of British Columbia, 2206 E Mall, Vancouver, BC Canada V6T 1Z3; Centre for Health Evaluation & Outcome Sciences, 588 - 1081 Burrard Street, St. Paul's Hospital Vancouver, BC Canada V6Z 1Y6
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Bhattacharya IS, Haviland JS, Turner L, Stobart H, Balasopoulou A, Stones L, Kirby AM, Kirwan CC, Coles CE, Bliss JM. Can patient decision aids reduce decisional conflict in a de-escalation of breast radiotherapy clinical trial? The PRIMETIME Study Within a Trial implemented using a cluster stepped-wedge trial design. Trials 2021; 22:397. [PMID: 34127033 PMCID: PMC8202048 DOI: 10.1186/s13063-021-05345-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Accepted: 05/29/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND For patients with early breast cancer considered at very-low risk of local relapse, risks of radiotherapy may outweigh the benefits. Decisions regarding treatment omission can lead to patient uncertainty (decisional conflict), which may be lessened with patient decision aids (PDA). PRIMETIME (ISRCTN 41579286) is a UK-led biomarker-directed study evaluating omission of adjuvant radiotherapy in breast cancer; an embedded Study Within A Trial (SWAT) investigated whether PDA reduces decisional conflict using a cluster stepped-wedge trial design. METHODS PDA diagrams and a video explaining risks and benefits of radiotherapy were developed in close collaboration between patient advocates and PRIMETIME trialists. The SWAT used a cluster stepped-wedge trial design, where each cluster represented the radiotherapy centre and referring peripheral centres. All clusters began in the standard information group (patient information and diagrams) and were randomised to cross-over to the enhanced information group (standard information plus video) at 2, 4 or 6 months. Primary endpoint was the decisional conflict scale (0-100, higher scores indicating greater conflict) which was assessed on an individual participant level. Multilevel mixed effects models used a random effect for cluster and a fixed effect for each step to adjust for calendar time and clustering. Robust standard errors were also adjusted for the clustering effect. RESULTS Five hundred twenty-one evaluable questionnaires were returned from 809 eligible patients (64%) in 24 clusters between April 2018 and October 2019. Mean decisional conflict scores in the standard group (N = 184) were 10.88 (SD 11.82) and 8.99 (SD 11.82) in the enhanced group (N = 337), with no statistically significant difference [mean difference - 1.78, 95%CI - 3.82-0.25, p = 0.09]. Compliance with patient information and diagrams was high in both groups although in the enhanced group only 121/337 (36%) reported watching the video. CONCLUSION The low levels of decisional conflict in PRIMETIME are reassuring and may reflect the high-quality information provision, such that not everyone required the video. This reinforces the importance of working with patients as partners in clinical trials especially in the development of patient-centred information and decision aids.
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Affiliation(s)
- Indrani S. Bhattacharya
- The Institute of Cancer Research Clinical Trials and Statistics Unit (ICR-CTSU), London, UK
- Oncology & Radiotherapy, Addenbrooke’s Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Joanne S. Haviland
- The Institute of Cancer Research Clinical Trials and Statistics Unit (ICR-CTSU), London, UK
| | | | | | - Ada Balasopoulou
- The Institute of Cancer Research Clinical Trials and Statistics Unit (ICR-CTSU), London, UK
| | - Liba Stones
- The Institute of Cancer Research Clinical Trials and Statistics Unit (ICR-CTSU), London, UK
| | - Anna M. Kirby
- Royal Marsden NHS Foundation Trust, London, UK
- Institute of Cancer Research, London, UK
| | - Cliona C. Kirwan
- Institute of Cancer Sciences, University of Manchester, Manchester University NHS Foundation Trust, Manchester, UK
| | - Charlotte E. Coles
- Oncology & Radiotherapy, Addenbrooke’s Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
- Department of Oncology, University of Cambridge, Cambridge, UK
| | - Judith M. Bliss
- The Institute of Cancer Research Clinical Trials and Statistics Unit (ICR-CTSU), London, UK
| | - on behalf of the PRIMETIME Trialists
- The Institute of Cancer Research Clinical Trials and Statistics Unit (ICR-CTSU), London, UK
- Oncology & Radiotherapy, Addenbrooke’s Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
- Independent Cancer Patients’ Voice, London, UK
- Royal Marsden NHS Foundation Trust, London, UK
- Institute of Cancer Research, London, UK
- Institute of Cancer Sciences, University of Manchester, Manchester University NHS Foundation Trust, Manchester, UK
- Department of Oncology, University of Cambridge, Cambridge, UK
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van der Sluijs R, Fiddelers AAA, Waalwijk JF, Reitsma JB, Dirx MJ, den Hartog D, Evers SMAA, Goslings JC, Hoogeveen WM, Lansink KW, Leenen LPH, van Heijl M, Poeze M. The impact of the Trauma Triage App on pre-hospital trauma triage: design and protocol of the stepped-wedge, cluster-randomized TESLA trial. Diagn Progn Res 2020; 4:10. [PMID: 32566758 PMCID: PMC7302135 DOI: 10.1186/s41512-020-00076-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Accepted: 04/22/2020] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Field triage of trauma patients is crucial to get the right patient to the right hospital within a particular time frame. Minimization of undertriage, overtriage, and interhospital transfer rates could substantially reduce mortality rates, life-long disabilities, and costs. Identification of patients in need of specialized trauma care is predominantly based on the judgment of Emergency Medical Services professionals and a pre-hospital triage protocol. The Trauma Triage App is a smartphone application that includes a prediction model to aid Emergency Medical Services professionals in the identification of patients in need of specialized trauma care. The aim of this trial is to assess the impact of this new digital approach to field triage on the primary endpoint undertriage. METHODS The Trauma triage using Supervised Learning Algorithms (TESLA) trial is a stepped-wedge cluster-randomized controlled trial with eight clusters defined as Emergency Medical Services regions. These clusters are an integral part of five inclusive trauma regions. Injured patients, evaluated on-scene by an Emergency Medical Services professional, suspected of moderate to severe injuries, will be assessed for eligibility. This unidirectional crossover trial will start with a baseline period in which the default pre-hospital triage protocol is used, after which all clusters gradually implement the Trauma Triage App as an add-on to the existing triage protocol. The primary endpoint is undertriage on patient and cluster level and is defined as the transportation of a severely injured patient (Injury Severity Score ≥ 16) to a lower-level trauma center. Secondary endpoints include overtriage, hospital resource use, and a cost-utility analysis. DISCUSSION The TESLA trial will assess the impact of the Trauma Triage App in clinical practice. This novel approach to field triage will give new and previously undiscovered insights into several isolated components of the diagnostic strategy to get the right trauma patient to the right hospital. The stepped-wedge design allows for within and between cluster comparisons. TRIAL REGISTRATION Netherlands Trial Register, NTR7243. Registered 30 May 2018, https://www.trialregister.nl/trial/7038.
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Affiliation(s)
- Rogier van der Sluijs
- Department of Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
- Department of Surgery, Utrecht University Medical Center, Utrecht, The Netherlands
- Network Acute Care Limburg, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Audrey A. A. Fiddelers
- Network Acute Care Limburg, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Job F. Waalwijk
- Department of Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
- Department of Surgery, Utrecht University Medical Center, Utrecht, The Netherlands
- Network Acute Care Limburg, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Johannes B. Reitsma
- Department of Epidemiology, Julius Center, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Miranda J. Dirx
- Network Acute Care Limburg, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Dennis den Hartog
- Department of Surgery, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Silvia M. A. A. Evers
- Care and Public Health Research Institute, Maastricht University, Maastricht, The Netherlands
| | - J. Carel Goslings
- Department of Surgery, Amsterdam University Medical Center, Amsterdam, The Netherlands
- Department of Surgery, Onze Lieve Vrouwe Hospital, Amsterdam, The Netherlands
| | | | - Koen W. Lansink
- Department of Surgery, Elisabeth TweeSteden Hospital, Tilburg, The Netherlands
| | - Luke P. H. Leenen
- Department of Surgery, Utrecht University Medical Center, Utrecht, The Netherlands
| | - Mark van Heijl
- Department of Surgery, Utrecht University Medical Center, Utrecht, The Netherlands
- Department of Surgery, Diakonessenhuis Utrecht/Zeist/Doorn, Utrecht, The Netherlands
| | - Martijn Poeze
- Department of Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
- Network Acute Care Limburg, Maastricht University Medical Center, Maastricht, The Netherlands
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11
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Denoeud-Ndam L, Otieno-Masaba R, Tchounga B, Machekano R, Simo L, Mboya JP, Kose J, Tchendjou P, Bissek ACZK, Okomo GO, Casenghi M, Cohn J, Tiam A. Integrating pediatric TB services into child healthcare services in Africa: study protocol for the INPUT cluster-randomized stepped wedge trial. BMC Public Health 2020; 20:623. [PMID: 32375741 PMCID: PMC7201651 DOI: 10.1186/s12889-020-08741-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Accepted: 04/20/2020] [Indexed: 11/16/2022] Open
Abstract
Background Tuberculosis is among the top-10 causes of mortality in children with more than 1 million children suffering from TB disease annually worldwide. The main challenge in young children is the difficulty in establishing an accurate diagnosis of active TB. The INPUT study is a stepped-wedge cluster-randomized intervention study aiming to assess the effectiveness of integrating TB services into child healthcare services on TB diagnosis capacities in children under 5 years of age. Methods Two strategies will be compared: i) The standard of care, offering pediatric TB services based on national standard of care; ii) The intervention, with pediatric TB services integrated into child healthcare services: it consists of a package of training, supportive supervision, job aids, and logistical support to the integration of TB screening and diagnosis activities into pediatric services. The design is a cluster-randomized stepped-wedge of 12 study clusters in Cameroon and Kenya. The sites start enrolling participants under standard-of-care and will transition to the intervention at randomly assigned time points. We enroll children aged less than 5 years with a presumptive diagnosis of TB after obtaining caregiver written informed consent. The participants are followed through TB diagnosis and treatment, with clinical information prospectively abstracted from their medical records. The primary outcome is the proportion of TB cases diagnosed among children < 5 years old attending the child healthcare services. Secondary outcomes include: number of children screened for presumptive active TB; diagnosed; initiated on TB treatment; and completing treatment. We will also assess the cost-effectiveness of the intervention, its acceptability among health care providers and users, and fidelity of implementation. Discussion Study enrolments started in May 2019, enrolments will be completed in October 2020 and follow up will be completed by June 2021. The study findings will be disseminated to national, regional and international audiences and will inform innovative approaches to integration of TB screening, diagnosis, and treatment initiation into child health care services. Trial resistration NCT03862261, initial release 12 February 2019.
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Affiliation(s)
| | | | | | | | | | | | - Judith Kose
- EGPAF, Nairobi, Kenya.,Erasmus University Medical Centre, Rotterdam, the Netherlands
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12
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Martin JT, Hemming K, Girling A. The impact of varying cluster size in cross-sectional stepped-wedge cluster randomised trials. BMC Med Res Methodol 2019; 19:123. [PMID: 31200640 PMCID: PMC6570871 DOI: 10.1186/s12874-019-0760-6] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Accepted: 05/21/2019] [Indexed: 11/29/2022] Open
Abstract
Background Cluster randomised trials with unequal sized clusters often have lower precision than with clusters of equal size. To allow for this, sample sizes are inflated by a modified version of the design effect for clustering. These inflation factors are valid under the assumption that randomisation is stratified by cluster size. We investigate the impact of unequal cluster size when that constraint is relaxed, with particular focus on the stepped-wedge cluster randomised trial, where this is more difficult to achieve. Methods Assuming a multi-level mixed effect model with exchangeable correlation structure for a cross-sectional design, we use simulation methods to compare the precision for a trial with clusters of unequal size to a trial with clusters of equal size (relative efficiency). For a range of scenarios we illustrate the impact of various design features (the cluster-mean correlation – a function of the intracluster correlation and the cluster size, the number of clusters, number of randomisation sequences) on the average and distribution of the relative efficiency. Results Simulations confirm that the average reduction in precision, due to varying cluster sizes, is smaller in a stepped-wedge trial compared to the parallel trial. However, the variance of the distribution of the relative efficiency is large; and is larger under the stepped-wedge design compared to the parallel design. This can result in large variations in actual power, depending on the allocation of clusters to sequences. Designs with larger variations in cluster sizes, smaller number of clusters and studies with smaller cluster-mean correlations (smaller cluster sizes or smaller intra-cluster correlation) are particularly at risk. Conclusion The actual realised power in a stepped-wedge trial might be substantially higher or lower than that estimated. This is particularly important when there are a small number of clusters or the variability in cluster sizes is large. Constraining the randomisation on cluster size, where feasible, might mitigate this effect. Electronic supplementary material The online version of this article (10.1186/s12874-019-0760-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- James Thomas Martin
- Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Edgbaston, Birmingham, B15 2TT, England.
| | - Karla Hemming
- Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Edgbaston, Birmingham, B15 2TT, England
| | - Alan Girling
- Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Edgbaston, Birmingham, B15 2TT, England
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13
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Reeder RW, Girling A, Wolfe H, Holubkov R, Berg RA, Naim MY, Meert KL, Tilford B, Carcillo JA, Hamilton M, Bochkoris M, Hall M, Maa T, Yates AR, Sapru A, Kelly R, Federman M, Michael Dean J, McQuillen PS, Franzon D, Pollack MM, Siems A, Diddle J, Wessel DL, Mourani PM, Zebuhr C, Bishop R, Friess S, Burns C, Viteri S, Hehir DA, Whitney Coleman R, Jenkins TL, Notterman DA, Tamburro RF, Sutton RM. Improving outcomes after pediatric cardiac arrest - the ICU-Resuscitation Project: study protocol for a randomized controlled trial. Trials 2018; 19:213. [PMID: 29615134 PMCID: PMC5883604 DOI: 10.1186/s13063-018-2590-y] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2017] [Accepted: 03/12/2018] [Indexed: 12/22/2022] Open
Abstract
Background Quality of cardiopulmonary resuscitation (CPR) is associated with survival, but recommended guidelines are often not met, and less than half the children with an in-hospital arrest will survive to discharge. A single-center before-and-after study demonstrated that outcomes may be improved with a novel training program in which all pediatric intensive care unit staff are encouraged to participate in frequent CPR refresher training and regular, structured resuscitation debriefings focused on patient-centric physiology. Methods/design This ongoing trial will assess whether a program of structured debriefings and point-of-care bedside practice that emphasizes physiologic resuscitation targets improves the rate of survival to hospital discharge with favorable neurologic outcome in children receiving CPR in the intensive care unit. This study is designed as a hybrid stepped-wedge trial in which two of ten participating hospitals are randomly assigned to enroll in the intervention group and two are assigned to enroll in the control group for the duration of the trial. The remaining six hospitals enroll initially in the control group but will transition to enrolling in the intervention group at randomly assigned staggered times during the enrollment period. Discussion To our knowledge, this is the first implementation of a hybrid stepped-wedge design. It was chosen over a traditional stepped-wedge design because the resulting improvement in statistical power reduces the required enrollment by 9 months (14%). However, this design comes with additional challenges, including logistics of implementing an intervention prior to the start of enrollment. Nevertheless, if results from the single-center pilot are confirmed in this trial, it will have a profound effect on CPR training and quality improvement initiatives. Trial registration ClinicalTrials.gov, NCT02837497. Registered on July 19, 2016. Electronic supplementary material The online version of this article (10.1186/s13063-018-2590-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Ron W Reeder
- Department of Pediatrics, University of Utah, 295 Chipeta Way, Salt Lake City, UT, 84108, USA.
| | - Alan Girling
- The Learning Centre Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Heather Wolfe
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA
| | - Richard Holubkov
- Department of Pediatrics, University of Utah, 295 Chipeta Way, Salt Lake City, UT, 84108, USA
| | - Robert A Berg
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA
| | - Maryam Y Naim
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA
| | - Kathleen L Meert
- Department of Pediatrics, Children's Hospital of Michigan, Wayne State University, Detroit, MI, USA
| | - Bradley Tilford
- Department of Pediatrics, Children's Hospital of Michigan, Wayne State University, Detroit, MI, USA
| | - Joseph A Carcillo
- Department of Critical Care Medicine, Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA, USA
| | - Melinda Hamilton
- Department of Critical Care Medicine, Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA, USA
| | - Matthew Bochkoris
- Department of Critical Care Medicine, Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA, USA
| | - Mark Hall
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus, OH, USA
| | - Tensing Maa
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus, OH, USA
| | - Andrew R Yates
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus, OH, USA
| | - Anil Sapru
- Department of Pediatrics, UCLA Mattel Children's Hospital, University of California, Los Angeles, Los Angeles, CA, USA
| | - Robert Kelly
- Department of Pediatrics, UCLA Mattel Children's Hospital, University of California, Los Angeles, Los Angeles, CA, USA
| | - Myke Federman
- Department of Pediatrics, UCLA Mattel Children's Hospital, University of California, Los Angeles, Los Angeles, CA, USA
| | - J Michael Dean
- Department of Pediatrics, University of Utah, 295 Chipeta Way, Salt Lake City, UT, 84108, USA
| | - Patrick S McQuillen
- Department of Pediatrics, Benioff Children's Hospital, University of California, San Francisco, San Francisco, CA, USA
| | - Deborah Franzon
- Department of Pediatrics, Benioff Children's Hospital, University of California, San Francisco, San Francisco, CA, USA
| | - Murray M Pollack
- Department of Pediatrics, Children's National Medical Center, George Washington University School of Medicine, Washington, DC, USA
| | - Ashley Siems
- Department of Pediatrics, Children's National Medical Center, George Washington University School of Medicine, Washington, DC, USA
| | - John Diddle
- Department of Pediatrics, Children's National Medical Center, George Washington University School of Medicine, Washington, DC, USA
| | - David L Wessel
- Department of Pediatrics, Children's National Medical Center, Washington, DC, USA
| | - Peter M Mourani
- Department of Pediatrics, Denver Children's Hospital, University of Colorado, Denver, CO, USA
| | - Carleen Zebuhr
- Department of Pediatrics, Denver Children's Hospital, University of Colorado, Denver, CO, USA
| | - Robert Bishop
- Department of Pediatrics, Denver Children's Hospital, University of Colorado, Denver, CO, USA
| | - Stuart Friess
- Department of Pediatrics, Washington University Medical Center, St. Louis, MO, USA
| | - Candice Burns
- Department of Pediatrics, Washington University Medical Center, St. Louis, MO, USA
| | - Shirley Viteri
- Department of Pediatrics, Nemours Alfred I. DuPont Hospital for Children, Wilmington, DE, USA
| | - David A Hehir
- Department of Pediatrics, Nemours Alfred I. DuPont Hospital for Children, Wilmington, DE, USA
| | - R Whitney Coleman
- Department of Pediatrics, University of Utah, 295 Chipeta Way, Salt Lake City, UT, 84108, USA
| | - Tammara L Jenkins
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD, USA
| | - Daniel A Notterman
- Department of Pediatrics, Milton S. Hershey Medical Center, Pennsylvania State University, Hershey, PA, USA
| | - Robert F Tamburro
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD, USA
| | - Robert M Sutton
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA
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Groenen CJM, Faber MJ, Kremer JAM, Vandenbussche FPHA, van Duijnhoven NTL. Improving maternity care using a personal health record: study protocol for a stepped-wedge, randomised, controlled trial. Trials 2016; 17:202. [PMID: 27084751 PMCID: PMC4833906 DOI: 10.1186/s13063-016-1326-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2015] [Accepted: 03/24/2016] [Indexed: 11/10/2022] Open
Abstract
Background A personal health record (PHR) is an online application through which individuals can access, manage, and share their health information in a private, secure, and confidential environment. Personal health records empower patients, facilitate collaboration among healthcare professionals, and improve health outcomes. Given these anticipated positive effects, we want to implement a PHR, named MyPregn@ncy, in a Dutch maternity care setting and to evaluate its effects in routine care. This paper presents the study protocol. Methods/design The effects of implementing a PHR in maternity care on patients and professionals will be identified in a stepped-wedge, cluster-randomised, controlled trial. The study will be performed in the region of Nijmegen, a Dutch area with an average of 4,500 births a year and more than 230 healthcare professionals involved in maternity care. Data analyses will describe the effects of MyPregn@ncy on health outcomes in maternity care, quality of care from the patients’ perspectives, and collaboration among healthcare professionals. Additionally, a process evaluation of the implementation of MyPregn@ncy will be performed. Data will be collected using data from the Dutch perinatal registry, questionnaires, interviews, and log data. Discussion The study is expected to yield new information about the effects, strengths, possibilities, and challenges to the implementation and usage of a PHR in routine maternal care settings. Results may lead to new insights and improvements in the quality of maternal and perinatal care. Trial registration Netherlands Trial Register: NTR4063
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Affiliation(s)
- Carola J M Groenen
- Department of Obstetrics and Gynaecology, Radboud university medical center, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands.
| | - Marjan J Faber
- Scientific Institute for Quality of Healthcare (IQ healthcare), Radboud university medical center, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands
| | - Jan A M Kremer
- Scientific Institute for Quality of Healthcare (IQ healthcare), Radboud university medical center, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands
| | - Frank P H A Vandenbussche
- Department of Obstetrics and Gynaecology, Radboud university medical center, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands
| | - Noortje T L van Duijnhoven
- Department of Obstetrics and Gynaecology, Radboud university medical center, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands
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Nosyk B, Krebs E, Min JE, Ahamad K, Buxton J, Goldsmith C, Hull M, Joe R, Krajden M, Lima VD, Olding M, Wood E, Montaner JSG. The 'Expanded HIV care in opioid substitution treatment' (EHOST) cluster-randomized, stepped-wedge trial: A study protocol. Contemp Clin Trials 2015; 45:201-209. [PMID: 26342295 DOI: 10.1016/j.cct.2015.08.020] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2015] [Revised: 08/28/2015] [Accepted: 08/30/2015] [Indexed: 11/18/2022]
Abstract
The public health response to HIV/AIDS has turned its focus onto optimizing health care system delivery to maximize case identification, access and sustained engagement in antiretroviral treatment (ART). Opioid Agonist Treatment (OAT) provides a critical opportunity for HIV testing and linkage to ART. The EHOST study is a cluster-randomized, stepped-wedge trial to evaluate a prescriber-focused intervention to increase HIV testing rates, and optimize ART engagement and retention outcomes among individuals engaged in OAT. The study will encompass all drug treatment clinics currently admitting patients for the treatment of opioid use disorder across the province of British Columbia, encompassing an estimated 90% of the OAT caseload. The trial will be executed over a 24-month period, with groups of clinics receiving the intervention in 6-month intervals. Evaluation of the proposed intervention's effectiveness will focus on three primary outcomes: (i) the HIV testing rate among those not known to be HIV positive; (ii) the rate of ART initiation among those not on ART; and (iii) the rate of ART continuation among those on ART. A difference-in-differences analytical framework will be applied to estimate the intervention's effect. This approach will assess site-specific changes in primary outcomes across clusters while adjusting for potential residual heterogeneity in patient case mix, volume, and quality of care across clinics. Statistical analysis of outcomes will be conducted entirely with linked population-level administrative health datasets. Facilitated by established collaborations between key stakeholders across the province, the EHOST intervention promises to optimize HIV testing and care within a marginalized and hard-to-reach population.
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Affiliation(s)
- B Nosyk
- BC Centre for Excellence in HIV/AIDS, Canada; Faculty of Health Sciences, Simon Fraser University, Canada.
| | - E Krebs
- BC Centre for Excellence in HIV/AIDS, Canada
| | - J E Min
- BC Centre for Excellence in HIV/AIDS, Canada
| | - K Ahamad
- BC Centre for Excellence in HIV/AIDS, Canada
| | - J Buxton
- BC Centre for Disease Control and Prevention, Canada; School of Population and Public Health, University of British Columbia, Canada
| | - C Goldsmith
- Faculty of Health Sciences, Simon Fraser University, Canada
| | - M Hull
- BC Centre for Excellence in HIV/AIDS, Canada; Vancouver Coastal Health Authority, Canada
| | - R Joe
- Vancouver Coastal Health Authority, Canada
| | - M Krajden
- BC Centre for Disease Control and Prevention, Canada
| | - V D Lima
- BC Centre for Excellence in HIV/AIDS, Canada; Division of AIDS, Faculty of Medicine, University of British Columbia, Canada
| | - M Olding
- BC Centre for Excellence in HIV/AIDS, Canada
| | - E Wood
- BC Centre for Excellence in HIV/AIDS, Canada; Division of AIDS, Faculty of Medicine, University of British Columbia, Canada
| | - J S G Montaner
- BC Centre for Excellence in HIV/AIDS, Canada; Division of AIDS, Faculty of Medicine, University of British Columbia, Canada
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