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Chen Y, Shah A, Jani Y, Higgins D, Saleem N, Chafer K, Sydes MR, Asselbergs FW, Lumbers RT. Rationale and design of the THIRST Alert feasibility study: a pragmatic, single-centre, parallel-group randomised controlled trial of an interruptive alert for oral fluid restriction in patients treated with intravenous furosemide. BMJ Open 2024; 14:e080410. [PMID: 38216198 PMCID: PMC10806795 DOI: 10.1136/bmjopen-2023-080410] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Accepted: 12/11/2023] [Indexed: 01/14/2024] Open
Abstract
INTRODUCTION Acute heart failure (HF) is a major cause of unplanned hospitalisation characterised by excess body water. A restriction in oral fluid intake is commonly imposed on patients as an adjunct to pharmacological therapy with loop diuretics, but there is a lack of evidence from traditional randomised controlled trials (RCTs) to support the safety and effectiveness of this intervention in the acute setting.This study aims to explore the feasibility of using computer alerts within the electronic health record (EHR) system to invite clinical care teams to enrol patients into a pragmatic RCT at the time of clinical decision-making. It will additionally assess the effectiveness of using an alert to help address the clinical research question of whether oral fluid restriction is a safe and effective adjunct to pharmacological therapy for patients admitted with fluid overload. METHODS AND ANALYSIS THIRST (Randomised Controlled Trial within the electronic Health record of an Interruptive alert displaying a fluid Restriction Suggestion in patients with the treatable Trait of congestion) Alert is a single-centre, parallel-group, open-label pragmatic RCT embedded in the EHR system that will be conducted as a feasibility study at an National Health Service (NHS) hospital in London. The clinical care team will be invited to enrol suitable patients in the study using a point-of-care alert with a target sample size of 50 patients. Enrolled patients will then be randomised to either restricted or unrestricted oral fluid intake. Two primary outcomes will be explored (1) the proportion of eligible patients enrolled in the study and (2) the mean difference in oral fluid intake between randomised groups. A series of secondary outcomes are specified to evaluate the effectiveness of the alert, adherence to the randomised treatment allocation and the quality of data generated from routine care, relevant to the outcomes of interest. ETHICS AND DISSEMINATION This study was approved by Riverside Research Ethics Committee (Ref: 22/LO/0889) and will be published on completion. TRIAL REGISTRATION NUMBER NCT05869656.
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Affiliation(s)
- Yang Chen
- Institute of Health Informatics, University College London, London, UK
- Clinical and Research Informatics Unit, NIHR UCLH Biomedical Research Centre, University College London Hospitals NHS Foundation Trust, London, UK
| | - Anoop Shah
- Institute of Health Informatics, University College London, London, UK
- Clinical and Research Informatics Unit, NIHR UCLH Biomedical Research Centre, University College London Hospitals NHS Foundation Trust, London, UK
| | - Yogini Jani
- Centre for Medicines Optimisation Research & Education - CMORE, University College London Hospitals NHS Foundation Trust, London, UK
| | - Daniel Higgins
- Clinical and Research Informatics Unit, NIHR UCLH Biomedical Research Centre, University College London Hospitals NHS Foundation Trust, London, UK
| | - Nausheen Saleem
- Clinical and Research Informatics Unit, NIHR UCLH Biomedical Research Centre, University College London Hospitals NHS Foundation Trust, London, UK
| | - Kris Chafer
- Clinical and Research Informatics Unit, NIHR UCLH Biomedical Research Centre, University College London Hospitals NHS Foundation Trust, London, UK
| | - Matthew Robert Sydes
- Institute of Clinical Trials and Methodology, Medical Research Council Clinical Trials Unit at University College London, London, UK
- Health Data Research UK, London, UK
| | - Folkert W Asselbergs
- Institute of Health Informatics, University College London, London, UK
- Department of Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam University Medical Centre, University of Amsterdam, Amsterdam, Netherlands
| | - R Thomas Lumbers
- Institute of Health Informatics, University College London, London, UK
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Vanderhout S, Fergusson DA, Cook JA, Taljaard M. Patient-reported outcomes and target effect sizes in pragmatic randomized trials in ClinicalTrials.gov: A cross-sectional analysis. PLoS Med 2022; 19:e1003896. [PMID: 35134080 PMCID: PMC8824332 DOI: 10.1371/journal.pmed.1003896] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Accepted: 12/21/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Use of patient-reported outcomes (PROs) and patient and public engagement are critical ingredients of pragmatic trials, which are intended to be patient centered. Engagement of patients and members of the public in selecting the primary trial outcome and determining the target difference can better ensure that the trial is designed to inform the decisions of those who ultimately stand to benefit. However, to the best of our knowledge, the use and reporting of PROs and patient and public engagement in pragmatic trials have not been described. The objectives of this study were to review a sample of pragmatic trials to describe (1) the prevalence of reporting patient and public engagement; (2) the prevalence and types of PROs used; (3) how its use varies across trial characteristics; and (4) how sample sizes and target differences are determined for trials with primary PROs. METHODS AND FINDINGS This was a methodological review of primary reports of pragmatic trials. We used a published electronic search filter in MEDLINE to identify pragmatic trials, published in English between January 1, 2014 and April 3, 2019; we identified the subset that were registered in ClinicalTrials.gov and explicitly labeled as pragmatic. Trial descriptors were downloaded from ClinicalTrials.gov; information about PROs and sample size calculations were extracted from the manuscript. Chi-squared, Cochran-Armitage, and Wilcoxon rank sum tests were used to examine associations between trial characteristics and use of PROs. Among 4,337 identified primary trial reports, 1,988 were registered in CT.gov, of which 415 were explicitly labeled as pragmatic. Use of patient and public engagement was identified in 39 (9.4%). PROs were measured in 235 (56.6%): 144 (34.7%) used PROs as primary outcomes and 91 (21.9%) as only secondary outcomes. Primary PROs were symptoms (64; 44%), health behaviors (36; 25.0%), quality of life (17; 11.8%), functional status (16; 11.1%), and patient experience (10; 6.9%). Trial characteristics with lower prevalence of use of PROs included being conducted exclusively in children or adults over age 65 years, cluster randomization, recruitment in low- and middle-income countries, and primary purpose of prevention; trials conducted in Europe had the highest prevalence of PROs. For the 144 trials with a primary PRO, 117 (81.3%) reported a sample size calculation for that outcome; of these, 71 (60.7%) justified the choice of target difference, most commonly, using estimates from pilot studies (31; 26.5%), standardized effect sizes (20; 17.1%), or evidence reviews (16; 13.7%); patient or stakeholder opinions were used to justify the target difference in 8 (6.8%). Limitations of this study are the need for trials to be registered in ClinicalTrials.gov, which may have reduced generalizability, and extracting information only from the primary trial report. CONCLUSIONS In this study, we observed that pragmatic trials rarely report patient and public engagement and do not commonly use PROs as primary outcomes. When provided, target differences are often not justified and rarely informed by patients and stakeholders. Research funders, scientific journals, and institutions should support trialists to incorporate patient engagement to fulfill the mandate of pragmatic trials to be patient centered.
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Affiliation(s)
- Shelley Vanderhout
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Dean A. Fergusson
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Jonathan A. Cook
- Centre for Statistics in Medicine & Oxford Clinical Trials Research Unit, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom
| | - Monica Taljaard
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
- * E-mail:
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Wallach JD, Zhang AD, Skydel JJ, Bartlett VL, Dhruva SS, Shah ND, Ross JS. Feasibility of Using Real-world Data to Emulate Postapproval Confirmatory Clinical Trials of Therapeutic Agents Granted US Food and Drug Administration Accelerated Approval. JAMA Netw Open 2021; 4:e2133667. [PMID: 34751763 PMCID: PMC8579227 DOI: 10.1001/jamanetworkopen.2021.33667] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
This cross-sectional study examines the feasibility of using real-world data, such as billing, claims, and electronic health records, to emulate US Food and Drug Administration–required confirmatory clinical trials for the 50 new therapeutic agents that received accelerated approval between 2009 and 2018.
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Affiliation(s)
- Joshua D. Wallach
- Department of Environmental Health Sciences, Yale School of Public Health, New Haven, Connecticut
| | | | | | | | - Sanket S. Dhruva
- Section of Cardiology, San Francisco Veterans Affairs Health Care System, San Francisco, California
- Department of Medicine, School of Medicine, University of California, San Francisco
| | - Nilay D. Shah
- Division of Health Care Policy and Research, Mayo Clinic, Rochester, Minnesota
| | - Joseph S. Ross
- Section of General Internal Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
- National Clinician Scholars Program, Yale School of Medicine, Department of Internal Medicine, New Haven, Connecticut
- Department of Health Policy and Management, Yale School of Public Health, New Haven, Connecticut
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Kow CS, Hasan SS. Real-world effectiveness of BNT162b2 mRNA vaccine: a meta-analysis of large observational studies. Inflammopharmacology 2021; 29:1075-1090. [PMID: 34241782 PMCID: PMC8266992 DOI: 10.1007/s10787-021-00839-2] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Accepted: 06/16/2021] [Indexed: 11/18/2022]
Abstract
This paper aims to summarize through meta-analyses the overall vaccine effectiveness of the BNT162b2 mRNA vaccine from observational studies. A systematic literature search with no language restriction was performed in electronic databases to identify eligible observational studies which reported the adjusted effectiveness of the BNT162b2 mRNA vaccine to prevent RT-PCR confirmed COVID-19. Meta-analyses with the random-effects model were used to calculate the pooled hazard ratio (HR) and pooled incidence rate ratio (IRR) at 95% confidence intervals, and the vaccine effectiveness was indicated as (pooled HR - 1)/HR or (pooled IRR - 1)/IRR. Nineteen studies were included for this meta-analysis. The meta-analysis revealed significant protective effect against RT-PCR confirmed COVID-19 ≥ 14 days after the first dose, with vaccine effectiveness of 53% (95% confidence interval 32-68%), and ≥ 7 days after the second dose, with vaccine effectiveness of 95% (95% confidence interval: 96-97%). Despite its effectiveness, reporting vaccine safety data by relevant stakeholders should be encouraged as BNT162b2 mRNA is a new vaccine that has not gained full approval. There have been limited data about vaccine effectiveness among immunocompromised patients; thus, the vaccine should be used cautiously in this patient population.
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Affiliation(s)
- Chia Siang Kow
- School of Postgraduate Studies, International Medical University, Kuala Lumpur, Malaysia.
- School of Pharmacy, Monash University Malaysia, Bandar Sunway, Petaling Jaya, Selangor, Malaysia.
| | - Syed Shahzad Hasan
- School of Applied Sciences, University of Huddersfield, Huddersfield, United Kingdom
- School of Biomedical Sciences and Pharmacy, University of Newcastle, Callaghan, Australia
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Franklin JM, Patorno E, Desai RJ, Glynn RJ, Martin D, Quinto K, Pawar A, Bessette LG, Lee H, Garry EM, Gautam N, Schneeweiss S. Emulating Randomized Clinical Trials With Nonrandomized Real-World Evidence Studies: First Results From the RCT DUPLICATE Initiative. Circulation 2020; 143:1002-1013. [PMID: 33327727 DOI: 10.1161/circulationaha.120.051718] [Citation(s) in RCA: 146] [Impact Index Per Article: 36.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Regulators are evaluating the use of noninterventional real-world evidence (RWE) studies to assess the effectiveness of medical products. The RCT DUPLICATE initiative (Randomized, Controlled Trials Duplicated Using Prospective Longitudinal Insurance Claims: Applying Techniques of Epidemiology) uses a structured process to design RWE studies emulating randomized, controlled trials (RCTs) and compare results. We report findings of the first 10 trial emulations, evaluating cardiovascular outcomes of antidiabetic or antiplatelet medications. METHODS We selected 3 active-controlled and 7 placebo-controlled RCTs for replication. Using patient-level claims data from US commercial and Medicare payers, we implemented inclusion and exclusion criteria, selected primary end points, and comparator populations to emulate those of each corresponding RCT. Within the trial-mimicking populations, we conducted propensity score matching to control for >120 preexposure confounders. All study measures were prospectively defined and protocols registered before hazard ratios and 95% CIs were computed. Success criteria for the primary analysis were prespecified for each replication. RESULTS Despite attempts to emulate RCT design as closely as possible, differences between the RCT and corresponding RWE study populations remained. The regulatory conclusions were equivalent in 6 of 10. The RWE emulations achieved a hazard ratio estimate that was within the 95% CI from the corresponding RCT in 8 of 10 studies. In 9 of 10, either the regulatory or estimate agreement success criteria were fulfilled. The largest differences in effect estimates were found for RCTs where second-generation sulfonylureas were used as a proxy for placebo regarding cardiovascular effects. Nine of 10 replications had a standardized difference between effect estimates of <2, which suggests differences within expected random variation. CONCLUSIONS Agreement between RCT and RWE findings varies depending on which agreement metric is used. Interim findings indicate that selection of active comparator therapies with similar indications and use patterns enhances the validity of RWE. Even in the context of active comparators, concordance between RCT and RWE findings is not guaranteed, partially because trials are not emulated exactly. More trial emulations are needed to understand how often and in what contexts RWE findings match RCTs. Registration: URL: https://www.clinicaltrials.gov; Unique identifiers: NCT03936049, NCT04215523, NCT04215536, NCT03936010, NCT03936036, NCT03936062, NCT03936023, NCT03648424, NCT04237935, NCT04237922.
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Affiliation(s)
- Jessica M Franklin
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (J.M.F., E.P., R.J.D., R.J.G., A.P., L.G.B., H.L., N.G., S.S.)
| | - Elisabetta Patorno
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (J.M.F., E.P., R.J.D., R.J.G., A.P., L.G.B., H.L., N.G., S.S.)
| | - Rishi J Desai
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (J.M.F., E.P., R.J.D., R.J.G., A.P., L.G.B., H.L., N.G., S.S.)
| | - Robert J Glynn
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (J.M.F., E.P., R.J.D., R.J.G., A.P., L.G.B., H.L., N.G., S.S.)
| | - David Martin
- Office of Medical Policy, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, MD (D.M., K.Q.)
| | - Kenneth Quinto
- Office of Medical Policy, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, MD (D.M., K.Q.)
| | - Ajinkya Pawar
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (J.M.F., E.P., R.J.D., R.J.G., A.P., L.G.B., H.L., N.G., S.S.)
| | - Lily G Bessette
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (J.M.F., E.P., R.J.D., R.J.G., A.P., L.G.B., H.L., N.G., S.S.)
| | - Hemin Lee
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (J.M.F., E.P., R.J.D., R.J.G., A.P., L.G.B., H.L., N.G., S.S.)
| | | | - Nileesa Gautam
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (J.M.F., E.P., R.J.D., R.J.G., A.P., L.G.B., H.L., N.G., S.S.)
| | - Sebastian Schneeweiss
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (J.M.F., E.P., R.J.D., R.J.G., A.P., L.G.B., H.L., N.G., S.S.)
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Hussain S, Baxi H, Chand Jamali M, Nisar N, Hussain MS. Burden of diabetes mellitus and its impact on COVID-19 patients: A meta-analysis of real-world evidence. Diabetes Metab Syndr 2020; 14:1595-1602. [PMID: 32862098 PMCID: PMC7439970 DOI: 10.1016/j.dsx.2020.08.014] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Revised: 08/08/2020] [Accepted: 08/13/2020] [Indexed: 12/16/2022]
Abstract
BACKGROUND & AIMS Coronavirus disease 2019 (COVID-19) spreads rapidly and within no time, it has been declared a pandemic by the World Health Organization. Evidence suggests diabetes to be a risk factor for the progression and poor prognosis of COVID-19. Therefore, we aimed to understand the pooled prevalence of diabetes in patients infected with COVID-19. We also aimed to compute the risk of mortality and ICU admissions in COVID-19 patients with and without diabetes. METHODS A comprehensive literature search was performed in PubMed to identify the articles reporting the diabetes prevalence and risk of mortality or ICU admission in COVID-19 patients. The primary outcome was to compute the pooled prevalence of diabetes in COVID-19 patients. Secondary outcomes included risk of mortality and ICU admissions in COVID-19 patients with diabetes compared to patients without diabetes. RESULTS This meta-analysis was based on a total of 23007 patients from 43 studies. The pooled prevalence of diabetes in patients infected with COVID-19 was found to be 15% (95% CI: 12%-18%), p = <0.0001. Mortality risk was found to be significantly higher in COVID-19 patients with diabetes as compared to COVID-19 patients without diabetes with a pooled risk ratio of 1.61 (95% CI: 1.16-2.25%), p = 0.005. Likewise, risk of ICU admission rate was significantly higher in COVID-19 patients with diabetes as compared to COVID-19 patients without diabetes with a pooled risk ratio of 1.88 (1.20%-2.93%), p = 0.006. CONCLUSION This meta-analysis found a high prevalence of diabetes and higher mortality and ICU admission risk in COVID-19 patients with diabetes.
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Affiliation(s)
- Salman Hussain
- Department of Pharmaceutical Medicine (Division of Pharmacology), School of Pharmaceutical Education and Research, Jamia Hamdard, New Delhi, India
| | | | - Mohammad Chand Jamali
- Department of Health and Medical Sciences, Al-Khawarizmi International College, Abu Dhabi, United Arab Emirates.
| | - Nazima Nisar
- Department of Clinical Laboratory Sciences, College of Applied Medical Sciences, King Khalid University, Abha, Kingdom of Saudi Arabia
| | - Md Sarfaraj Hussain
- Department of Pharmacognosy & Phytochemistry, R.V. Northland Institute of Pharmacy, U.P, India
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Norris DC, Sen S, Groisberg R, Subbiah V. Patient-Centered, Physician-Investigator Friendly Pragmatic Phase Trial Designs-The 4P Model. Mayo Clin Proc 2020; 95:2566-2568. [PMID: 33153645 DOI: 10.1016/j.mayocp.2020.09.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Accepted: 09/08/2020] [Indexed: 11/18/2022]
Affiliation(s)
| | - Shiraj Sen
- Sarah Cannon Research Institute at HealthONE, Denver, CO
| | | | - Vivek Subbiah
- The University of Texas MD, Anderson Cancer Center, Houston, TX
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Affiliation(s)
- Diamond Hale
- The PATIENTS Program, Department of Pharmaceutical Health Services Research, School of Pharmacy, University of Maryland, Baltimore, Maryland
| | - Debra Marvel
- The PATIENTS Program, Department of Pharmaceutical Health Services Research, School of Pharmacy, University of Maryland, Baltimore, Maryland
| | - Jeffrey Wells
- The PATIENTS Program, Department of Pharmaceutical Health Services Research, School of Pharmacy, University of Maryland, Baltimore, Maryland
- Patient Trauma Survivors Network, Falls Church, Virginia
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Feinberg BA, Gajra A, Zettler ME, Phillips TD, Phillips EG, Kish JK. Use of Real-World Evidence to Support FDA Approval of Oncology Drugs. Value Health 2020; 23:1358-1365. [PMID: 33032780 DOI: 10.1016/j.jval.2020.06.006] [Citation(s) in RCA: 52] [Impact Index Per Article: 13.0] [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: 04/09/2020] [Revised: 06/11/2020] [Accepted: 06/19/2020] [Indexed: 05/02/2023]
Abstract
OBJECTIVES Real-world evidence (RWE) has gained increased attention in recent years as a complement to traditional clinical trials. The use of RWE to establish the efficacy of oncology drugs for Food and Drug Administration (FDA) approval has not been described. In this paper, we review 5 recent examples where RWE was submitted in support of the FDA approvals of original or supplementary indications for oncology drugs. METHODS To identify cases where RWE was used, we reviewed drug approval packages available at Drugs@FDA for oncology drugs approved between 2017 and 2019. Five cases were selected to present a broad overview of different types of RWE, different circumstances under which RWE has been used for regulatory approvals, and how FDA evaluated the data in each case. The type of RWE submitted, the indication, limitations identified by FDA reviewers, and the outcome of the submission are discussed. RESULTS RWE, particularly historical controls for rare or orphan indications, has been used to support both original and supplementary oncology drug approvals. Types of RWE included data from electronic health records, claims, post-marketing safety reports, retrospective medical record reviews, and expanded access studies. Small sample sizes, data quality, and methodological issues were among concerns cited by FDA reviewers. CONCLUSION By bridging the gap between the constraints of the trial setting and the realities of clinical practice, RWE can add value to a regulatory submission. These early examples provide insight into how regulators evaluated RWE submitted as evidence of efficacy for oncology drugs.
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Affiliation(s)
- Bruce A Feinberg
- Cardinal Health Specialty Solutions, Cardinal Health, Dublin, OH, USA.
| | - Ajeet Gajra
- Cardinal Health Specialty Solutions, Cardinal Health, Dublin, OH, USA
| | | | - Todd D Phillips
- Cardinal Health Specialty Solutions, Cardinal Health, Dublin, OH, USA
| | - Eli G Phillips
- Cardinal Health Specialty Solutions, Cardinal Health, Dublin, OH, USA
| | - Jonathan K Kish
- Cardinal Health Specialty Solutions, Cardinal Health, Dublin, OH, USA
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Forrest CB, McTigue KM, Hernandez AF, Cohen LW, Cruz H, Haynes K, Kaushal R, Kho AN, Marsolo KA, Nair VP, Platt R, Puro JE, Rothman RL, Shenkman EA, Waitman LR, Williams NA, Carton TW. PCORnet® 2020: current state, accomplishments, and future directions. J Clin Epidemiol 2020; 129:60-67. [PMID: 33002635 PMCID: PMC7521354 DOI: 10.1016/j.jclinepi.2020.09.036] [Citation(s) in RCA: 84] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 09/01/2020] [Accepted: 09/22/2020] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To describe PCORnet, a clinical research network developed for patient-centered outcomes research on a national scale. STUDY DESIGN AND SETTING Descriptive study of the current state and future directions for PCORnet. We conducted cross-sectional analyses of the health systems and patient populations of the 9 Clinical Research Networks and 2 Health Plan Research Networks that are part of PCORnet. RESULTS Within the Clinical Research Networks, electronic health data are currently collected from 337 hospitals, 169,695 physicians, 3,564 primary care practices, 338 emergency departments, and 1,024 community clinics. Patients can be recruited for prospective studies from any of these clinical sites. The Clinical Research Networks have accumulated data from 80 million patients with at least one visit from 2009 to 2018. The PCORnet Health Plan Research Network population of individuals with a valid enrollment segment from 2009 to 2019 exceeds 60 million individuals, who on average have 2.63 years of follow-up. CONCLUSION PCORnet's infrastructure comprises clinical data from a diverse cohort of patients and has the capacity to rapidly access these patient populations for pragmatic clinical trials, epidemiological research, and patient-centered research on rare diseases.
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Affiliation(s)
- Christopher B Forrest
- Applied Clinical Research Center, Children's Hospital of Philadelphia, 2716 South St., Suite 11-473, Philadelphia, PA 19146, USA.
| | - Kathleen M McTigue
- Department of Medicine, University of Pittsburgh, 230 McKee Place, Suite 600, Pittsburgh, PA 15213 USA
| | - Adrian F Hernandez
- Duke Clinical Research Institute, Duke University School of Medicine, 200 Trent Drive, Durham, NC 27710, USA
| | - Lauren W Cohen
- Duke Clinical Research Institute, Duke University School of Medicine, 200 Trent Drive, Durham, NC 27710, USA
| | - Henry Cruz
- Weill Cornell Medicine and New York-Presbyterian Hospital, 515 E 71st St, New York, NY 10021, USA
| | - Kevin Haynes
- Scientific Affairs, HealthCore Inc., 123 Justison St, Wilmington, DE 19801, USA
| | - Rainu Kaushal
- Weill Cornell Medicine and New York-Presbyterian Hospital, 515 E 71st St, New York, NY 10021, USA
| | - Abel N Kho
- Center for Health Information Partnerships, Feinberg School of Medicine, 625 N. Michigan Ave, Chicago, IL 60611, USA
| | - Keith A Marsolo
- Duke Clinical Research Institute, Duke University School of Medicine, 200 Trent Drive, Durham, NC 27710, USA
| | - Vinit P Nair
- PRACnet, 15 South Main Street, Sharon, MA 02067, USA
| | - Richard Platt
- Harvard Medical School Department of Population Medicine, Harvard Pilgrim Health Care Institute, 401 Park Drive, Boston, MA 02215, USA
| | - Jon E Puro
- OCHIN, Inc., 1881 SW Naito Pkwy, Portland, OR 97201, USA
| | - Russell L Rothman
- Institute for Medicine and Public Health, Vanderbilt University Medical Center, 1161 21st Ave S, Nashville, TN 37232, USA
| | - Elizabeth A Shenkman
- Department of Health Outcomes and Biomedical Informatics, College of Medicine, University of Florida, 1600 SW Archer Rd, Gainesville, FL 32610, USA
| | - Lemuel Russell Waitman
- Department of Internal Medicine, Division of Medical Informatics, University of Kansas Medical Center, 3901 Rainbow Blvd, Kansas City, KS 66160, USA
| | - Neely A Williams
- Institute for Medicine and Public Health, Vanderbilt University Medical Center, 1161 21st Ave S, Nashville, TN 37232, USA
| | - Thomas W Carton
- Louisiana Public Health Institute, 1515 Poydras St, New Orleans, LA 70112, USA
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Hernández Rojas Z, Dalmau Llorca MR, Aguilar Martín C, Gonçalves AQ, Casajuana M, Fernández-Sáez J, Rodríguez Cumplido D, Forcadell Drago E, Carrasco-Querol N, Pepió Vilaubí JM, Alegret JM. Cost-effectiveness of direct oral anticoagulants versus vitamin K antagonist in atrial fibrillation: A study protocol using Real-World Data from Catalonia (FantasTIC Study). Medicine (Baltimore) 2020; 99:e22054. [PMID: 32899067 PMCID: PMC7478774 DOI: 10.1097/md.0000000000022054] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 07/22/2020] [Accepted: 08/02/2020] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND Anticoagulant therapy is used for stroke prevention and proved to be effective and safe in the long term. The study aims to analyse the cost-effectiveness relationship of using of direct-acting oral anticoagulants vs vitamin K antagonists to prevent ischaemic stroke in patients with nonvalvular atrial fibrillation, including all the active ingredients marketed in Spain, prescribed for 2 years in the Primary Care service of the Institut Català de la Salut. METHODS Population-based cohort study, in which the cost of the 2 treatment groups will be evaluated. Direct costs (pharmacy, primary care, emergency and hospitalization) and indirect costs (lost productivity) will be included from a social perspective. Effectiveness (assessed as the occurrence of a health event, the 1 of primary interest being stroke) will be determined, with a 2-year time horizon and a 3% discount rate. The average cost of the 2 groups of drugs will be compared using a regression model to determine the factors with the greatest influence on determining costs. We will carry out a univariate ('one-way') deterministic sensitivity analysis. DISCUSSION We hope to provide relevant information about direct and indirect costs of oral anticoagulants, which, together with aspects of effectiveness and safety, could help shape the consensual decision-making of evaluating bodies.
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Affiliation(s)
- Zojaina Hernández Rojas
- Equip d’Atenció Primària Tortosa Est, Institut Català de la Salut, Tortosa, Tarragona, Spain
- Unitat de Suport a la Recerca Terres de l’Ebre, Fundació Institut Universitari per a la Recerca a l’Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol), Tortosa, Tarragona, Spain
- Universitat Rovira i Virgili, Tarragona, Spain
- GAVINA Research Grup
| | - Maria Rosa Dalmau Llorca
- Equip d’Atenció Primària Tortosa Est, Institut Català de la Salut, Tortosa, Tarragona, Spain
- Unitat de Suport a la Recerca Terres de l’Ebre, Fundació Institut Universitari per a la Recerca a l’Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol), Tortosa, Tarragona, Spain
- Universitat Rovira i Virgili, Tarragona, Spain
- GAVINA Research Grup
| | - Carina Aguilar Martín
- Unitat de Suport a la Recerca Terres de l’Ebre, Fundació Institut Universitari per a la Recerca a l’Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol), Tortosa, Tarragona, Spain
- GAVINA Research Grup
- Unitat d’Avaluació, Direcció d’Atenció Primària Terres de l’Ebre, Institut Català de la Salut, Tortosa, Tarragona, Spain
| | - Alessandra Queiroga Gonçalves
- Unitat de Suport a la Recerca Terres de l’Ebre, Fundació Institut Universitari per a la Recerca a l’Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol), Tortosa, Tarragona, Spain
- GAVINA Research Grup
- Unitat Docent de Medicina de Familia i Comunitària, Tortosa-Terres de l’Ebre, Institut Català de la Salut, Tortosa, Tarragona, Spain
| | - Marc Casajuana
- Fundació Institut Universitari per a la recerca a l’Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol), Barcelona, Spain
- Universitat Autònoma de Barcelona, Bellaterra (Cerdanyola del Vallès), Spain
| | - José Fernández-Sáez
- Unitat de Suport a la Recerca Terres de l’Ebre, Fundació Institut Universitari per a la Recerca a l’Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol), Tortosa, Tarragona, Spain
- GAVINA Research Grup
- Unitat de Recerca, Gerència Territorial Terres de l’Ebre, Institut Català de la Salut, Tortosa, Tarragona, Spain
- Facultat d’Enfermeria, Campus Terres de l’Ebre, Universitat Rovira i Virgili, Tortosa, Tarragona, Spain
| | | | - Emma Forcadell Drago
- GAVINA Research Grup
- Equip d’Atenció Primària Tortosa Oest, Institut Català de la Salut, Tortosa, Tarragona, Spain
| | - Noèlia Carrasco-Querol
- Unitat de Suport a la Recerca Terres de l’Ebre, Fundació Institut Universitari per a la Recerca a l’Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol), Tortosa, Tarragona, Spain
| | - Josep Maria Pepió Vilaubí
- GAVINA Research Grup
- Equip d’Atenció Primària Tortosa Oest, Institut Català de la Salut, Tortosa, Tarragona, Spain
| | - Josep M. Alegret
- Grup de Recerca Cardiovascular, Departament de Cardiologia, Hospital Universitari de Sant Joan, Institut de Investigació Sanitaria Pere Virgili (IISPV), Reus, Spain
- Departament de Medicina i Cirurgia, Universitat Rovira i Virgili, Reus, Spain
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Abstract
Background Almost half of all patients with non-small-cell lung cancer (nsclc) present with stage iv disease. The objective of the present study was to characterize treatment patterns and survival outcomes in patients with advanced nsclc. Methods We conducted a longitudinal population-level study in patients diagnosed with stage iv nsclc in Ontario between 1 April 2010 and 31 March 2015, with follow-up to 31 March 2017 for overall survival and treatment sequence. Patients were stratified as nonsquamous or squamous histology. A sub-analysis was conducted for patients with nonsquamous histology who received targeted therapies, on the assumption that their tumours were EGFR mutation-positive (EGFRm+). Treatment patterns were determined, and survival was calculated from date of diagnosis to death or censoring. Results Of 24,729 nsclc cases identified, stage iv disease was diagnosed in 49.2%, histology was nonsquamous in 10,103, and EGFRm+ was assumed in 508. Median patient age ranged from 69 to 72 years for the three cohorts. For patients with nonsquamous histology, palliative radiotherapy was the most frequently used first-line treatment (44.4%), followed by no treatment (26.7%) and chemotherapy (14.9%). In the EGFRm+ cohort, 75.6% received gefitinib as first- or second-line therapy, and almost half (47.4%) the 473 patients with squamous histology treated with first-line chemotherapy received cisplatin or carboplatin with gemcitabine. Median overall survival in the nonsquamous and squamous cohorts was 4.9 and 4.6 months respectively; it was 17.6 months for patients who were EGFRm+. Conclusions Survival of patients with stage iv nsclc remains poor, with the exception of patients who are EGFRm+. Only 14.9% of patients received first-line chemotherapy; the mainstay of treatment was palliative radiotherapy.
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Affiliation(s)
- S J Seung
- hope Research Centre, Sunnybrook Research Institute, Toronto, ON
| | - M Hurry
- AstraZeneca Canada Inc., Mississauga, ON
| | - R N Walton
- AstraZeneca Canada Inc., Mississauga, ON
| | - W K Evans
- McMaster University, Department of Oncology, Division of Medical Oncology, Hamilton, ON
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Babcock A, Ali AA, Balkrishnan R, Montero A, Diaby V. Real-World Clinical and Economic Outcomes Associated with Palbociclib for HR-Positive/HER2 Negative Metastatic Breast Cancer: A Commentary. J Manag Care Spec Pharm 2020; 26:826-831. [PMID: 32584682 PMCID: PMC10391228 DOI: 10.18553/jmcp.2020.26.7.826] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Despite the achieved advancement in pharmacological cancer treatments, the majority of postmenopausal women with hormone receptor-positive metastatic breast cancer (mBC) will experience disease progression. Research into alternative therapies with improved efficacy and reduced side effects has led to the development of a new class of oral anticancer medications, the cyclin-dependent kinase (CDK) 4/6 inhibitors, which include palbociclib, ribociclib, and abemaciclib. Nonetheless, there is growing evidence that the effectiveness of oral anticancer medications is sub-optimal, being influenced by low adherence, sociodemographic factors, and adverse effect profiles. In addition, there is a disconnect between the high price tags of CDK 4/6 inhibitors and their observed effectiveness, raising questions about their value. Currently, the existing knowledge base on the effectiveness and cost-effectiveness of newer oral anticancer medications in understudied populations with possible health disparities is scant. This commentary discusses what is known about palbociclib's clinical effectiveness, safety, and adherence and suggests the need for further studies of real-world effectiveness and cost-effectiveness to help establish the value of newer oncologic drugs, such as palbociclib. DISCLOSURES: No funding supported the writing of this article. The authors have nothing to disclose.
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Affiliation(s)
- Aram Babcock
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville
| | - Askal Ayalew Ali
- Economic, Social & Administrative Pharmacy, College of Pharmacy and Pharmaceutical Sciences, Florida A&M University, Tallahassee
| | - Rajesh Balkrishnan
- School of Medicine and School of Nursing, University of Virginia, Charlottesville
| | - Alberto Montero
- Department of Hematology/Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | - Vakaramoko Diaby
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville
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Cardinale F, Ciprandi G, Barberi S, Bernardini R, Caffarelli C, Calvani M, Cavagni G, Galli E, Minasi D, Del Giudice MM, Moschese V, Novembre E, Paravati F, Peroni DG, Tosca MA, Traina G, Tripodi S, Marseglia GL. Consensus statement of the Italian society of pediatric allergy and immunology for the pragmatic management of children and adolescents with allergic or immunological diseases during the COVID-19 pandemic. Ital J Pediatr 2020; 46:84. [PMID: 32546234 PMCID: PMC7296524 DOI: 10.1186/s13052-020-00843-2] [Citation(s) in RCA: 52] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Accepted: 05/27/2020] [Indexed: 01/08/2023] Open
Abstract
The COVID-19 pandemic has surprised the entire population. The world has had to face an unprecedented pandemic. Only, Spanish flu had similar disastrous consequences. As a result, drastic measures (lockdown) have been adopted worldwide. Healthcare service has been overwhelmed by the extraordinary influx of patients, often requiring high intensity of care. Mortality has been associated with severe comorbidities, including chronic diseases. Patients with frailty were, therefore, the victim of the SARS-COV-2 infection. Allergy and asthma are the most prevalent chronic disorders in children and adolescents, so they need careful attention and, if necessary, an adaptation of their regular treatment plans. Fortunately, at present, young people are less suffering from COVID-19, both as incidence and severity. However, any age, including infancy, could be affected by the pandemic.Based on this background, the Italian Society of Pediatric Allergy and Immunology has felt it necessary to provide a Consensus Statement. This expert panel consensus document offers a rationale to help guide decision-making in the management of children and adolescents with allergic or immunologic diseases.
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Affiliation(s)
- Fabio Cardinale
- Pediatric Unit, Azienda Ospedaliero-Universitaria "Policlinico- Giovanni XXIII, Bari, Italy
| | | | | | | | - Carlo Caffarelli
- Pediatric Clinic, Mother-child Department, University of Parma, Parma, Italy
| | - Mauro Calvani
- Operative Unit of Pediatrics, S. Camillo-Forlanini Hospital, Rome, Italy
| | - Giovanni Cavagni
- Coordinator European Allergology Center - European Diagnostic Center Dalla Rosa Prati, Parma, Italy
| | - Elena Galli
- Pediatric Allergology Unit, Department of Pediatric Medicine, S. Pietro Hospital Fatebenefratelli, Rome, Italy
| | - Domenico Minasi
- Pediatric Unit, Grande Ospedale Metropolitano, Reggio Calabria, Italy
| | - Michele Miraglia Del Giudice
- Department of Woman and Child and General and Specialized Surgery, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Viviana Moschese
- Pediatric Allergology and Immunology Unit, University of Rome Tor Vergata, Policlinico Tor Vergata, Rome, Italy
| | - Elio Novembre
- Allergy Unit, Department of Science Health, Meyer Children's Hospital, University of Florence, Florence, Italy
| | | | | | | | | | | | - Gian Luigi Marseglia
- Pediatric Clinic, Pediatrics Department, Policlinico San Matteo, University of Pavia, Pavia, Italy
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Eichler H, Koenig F, Arlett P, Enzmann H, Humphreys A, Pétavy F, Schwarzer‐Daum B, Sepodes B, Vamvakas S, Rasi G. Are Novel, Nonrandomized Analytic Methods Fit for Decision Making? The Need for Prospective, Controlled, and Transparent Validation. Clin Pharmacol Ther 2020; 107:773-779. [PMID: 31574163 PMCID: PMC7158212 DOI: 10.1002/cpt.1638] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Accepted: 09/02/2019] [Indexed: 12/11/2022]
Abstract
Real-world data and patient-level data from completed randomized controlled trials are becoming available for secondary analysis on an unprecedented scale. A range of novel methodologies and study designs have been proposed for their analysis or combination. However, to make novel analytical methods acceptable for regulators and other decision makers will require their testing and validation in broadly the same way one would evaluate a new drug: prospectively, well-controlled, and according to a pre-agreed plan. From a European regulators' perspective, the established methods qualification advice procedure with active participation of patient groups and other decision makers is an efficient and transparent platform for the development and validation of novel study designs.
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Affiliation(s)
- Hans‐Georg Eichler
- European Medicines Agency (EMA)AmsterdamThe Netherlands
- Medical University of ViennaViennaAustria
| | | | - Peter Arlett
- European Medicines Agency (EMA)AmsterdamThe Netherlands
| | - Harald Enzmann
- Federal Institute for Drugs and Medical Devices (BfArM)BonnGermany
- EMA's Committee for Medicinal Products for Human Use (CHMP)AmsterdamThe Netherlands
| | | | - Frank Pétavy
- European Medicines Agency (EMA)AmsterdamThe Netherlands
| | - Brigitte Schwarzer‐Daum
- Medical University of ViennaViennaAustria
- EMA's Committee for Orphan Medicinal Products (COMP)AmsterdamThe Netherlands
| | - Bruno Sepodes
- EMA's Committee for Medicinal Products for Human Use (CHMP)AmsterdamThe Netherlands
- EMA's Committee for Orphan Medicinal Products (COMP)AmsterdamThe Netherlands
- Universidade de LisboaLisbonPortugal
| | | | - Guido Rasi
- European Medicines Agency (EMA)AmsterdamThe Netherlands
- University Tor VergataRomeItaly
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16
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Abstract
Health-related information is increasingly being collected and stored digitally. These data, either structured or unstructured, are becoming the ubiquitous assets that might enable us to comprehensively map out a patient's health journey from an asymptomatic state of wellness to disease onset and its trajectory. These new data could provide rich real-world evidence for better clinical care and research, if they can be accessed, linked and analyzed-all of which are possible. In this review, these opportunities will be explored through a case vignette of a patient with OA, followed by discussion on how this digitalized real-world evidence could best be utilized, as well as the challenges of data access, quality and maintaining public trust.
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Affiliation(s)
- Huai Leng Pisaniello
- Arthritis Research UK Centre for Epidemiology, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
- Department of Medicine, University of Adelaide, Adelaide, South Australia, Australia
| | - William Gregory Dixon
- Arthritis Research UK Centre for Epidemiology, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
- Correspondence to: William Gregory Dixon, Arthritis Research UK Centre for Epidemiology, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Oxford Road, Manchester M13 9PT, UK. E-mail:
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Samuel S, Dimitropoulos G, Schraeder K, Klarenbach S, Nettel-Aguirre A, Guilcher G, Pacaud D, Pinzon J, Lang E, Andrew G, Zwaigenbaum L, Scott S, McBrien K, Hamiwka L, Mackie A. Pragmatic trial evaluating the effectiveness of a patient navigator to decrease emergency room utilisation in transition age youth with chronic conditions: the Transition Navigator Trial protocol. BMJ Open 2019; 9:e034309. [PMID: 31826899 PMCID: PMC6924868 DOI: 10.1136/bmjopen-2019-034309] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [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] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Transition to adult care is a challenging and complex process for youth with special healthcare needs. We aim to compare effectiveness of a patient navigator service in reducing emergency room (ER) use among adolescents with chronic health conditions transitioning to adult care. METHODS AND ANALYSIS Pragmatic randomised controlled trial parallel group design comparing ER visit rates between patients with access to a personalised navigator intervention compared with usual care. Unit of randomisation is the patient. Treatment assignment will not be blinded. Embedded qualitative study to understand navigator's role and cost analysis attributable to the intervention will be performed. Patients aged 16-21 years, followed within a chronic disease clinic, expected to be transferred to adult care within 12 months and residing in Alberta during study period will be recruited from three tertiary care paediatric hospitals. Sample size will be 300 in each arm. Navigator intervention over 24 months is designed to assist participants in four domains: transition preparation, health system brokering, socioeconomic determinants of health and self-management. Primary outcome is ER visit rate during observation period. Secondary outcomes are ambulatory and inpatient care utilisation measures, as well as Transition Readiness Assessment Questionnaire score, and Short-Form Health Survey 12 (SF-12) score at 6 and 18 months post-randomisation. Poisson regression will compare rates of ER/urgent care visits between navigator and control participants, using intention to treat principle. Cost analysis of the intervention will be conducted. Thematic analysis will be used to identify perceptions of stakeholders regarding the role of navigators. ETHICS AND DISSEMINATION Ethics approval was obtained from the University of Calgary Conjoint Health Research Ethics Board (REB #162561) and the University of Alberta Health Research Ethics Board (Pro00077325). Our team is composed of diverse stakeholders who are committed to improving transition of care who will assist with dissemination of results. TRIAL REGISTRATION NUMBER NCT03342495.
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Affiliation(s)
- Susan Samuel
- Section of Nephrology, Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada
| | | | - Kyleigh Schraeder
- Alberta Children's Hospital Research Institute, Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada
| | - Scott Klarenbach
- Division of Nephrology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | | | - Greg Guilcher
- Section of Pediatric Oncology and Blood and Marrow Transplant, Alberta Children's Hospital, University of Calgary, Calgary, Alberta, Canada
| | - Daniele Pacaud
- Section of Endocrinology, Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada
| | - Jorge Pinzon
- Section of Adolescent Medicine, Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada
| | - Eddy Lang
- Department of Emergency Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Gail Andrew
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Lonnie Zwaigenbaum
- Department of Pediatrics, Autism Research Centre, University of Alberta, Edmonton, Alberta, Canada
| | - Shannon Scott
- Faculty of Nursing, University of Alberta, Edmonton, Alberta, Canada
| | - Kerry McBrien
- Department of Family Medicine, Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Lorraine Hamiwka
- Section of Nephrology, Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada
| | - Andrew Mackie
- Division of Cardiology, Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
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Giulio Formoso, per l'Associazione Alessandro Liberati - Network italiano Cochrane. Farmaci e tecnologie sanitarie: dove collocare la "real world evidence"? Recenti Prog Med 2019; 110:524-5. [PMID: 31808432 DOI: 10.1701/3265.32327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
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Messori A. [Not Available]. Recenti Prog Med 2019; 110:533. [PMID: 31808438 DOI: 10.1701/3265.32354] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
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20
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Casey JD, Vaughan ER, Lloyd BD, Bilas PA, Hall EJ, Toporek AH, Buell KG, Brown RM, Richardson RK, Rooks JC, Wang L, Lindsell CJ, Ely EW, Self WH, Bernard GR, Rice TW, Semler MW. Protocolized Post-Extubation Respiratory Support to prevent reintubation: protocol and statistical analysis plan for a clinical trial. BMJ Open 2019; 9:e030476. [PMID: 31377713 PMCID: PMC6687016 DOI: 10.1136/bmjopen-2019-030476] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [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] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Following extubation from invasive mechanical ventilation, nearly one in seven critically ill adults requires reintubation. Reintubation is independently associated with increased mortality. Postextubation respiratory support (non-invasive ventilation or high-flow nasal cannula applied at the time of extubation) has been reported in small-to-moderate-sized trials to reduce reintubation rates among hypercapnic patients, high-risk patients without hypercapnia and low-risk patients without hypercapnia. It is unknown whether protocolised provision of postextubation respiratory support to every patient undergoing extubation would reduce the overall reintubation rate, compared with usual care. METHODS AND ANALYSIS The Protocolized Post-Extubation Respiratory Support (PROPER) trial is a pragmatic, cluster cross-over trial being conducted between 1 October 2017 and 31 March 2019 in the medical intensive care unit of Vanderbilt University Medical Center. PROPER compares usual care versus protocolized post-extubation respiratory support (a respiratory therapist-driven protocol that advises the provision of non-invasive ventilation or high-flow nasal cannula based on patient characteristics). For the duration of the trial, the unit is divided into two clusters. One cluster receives protocolised support and the other receives usual care. Each cluster crosses over between treatment group assignments every 3 months. All adults undergoing extubation from invasive mechanical ventilation are enrolled except those who received less than 12 hours of mechanical ventilation, have 'Do Not Intubate' orders, or have been previously reintubated during the hospitalisation. The anticipated enrolment is approximately 630 patients. The primary outcome is reintubation within 96 hours of extubation. ETHICS AND DISSEMINATION The trial was approved by the Vanderbilt Institutional Review Board. The results will be submitted for publication in a peer-reviewed journal and presented at one or more scientific conferences. TRIAL REGISTRATION NUMBER NCT03288311.
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Affiliation(s)
- Jonathan Dale Casey
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Erin R Vaughan
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Bradley D Lloyd
- Division of Respiratory Care, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Peter A Bilas
- Department of Anesthesiology, University of Florida, Gainesville, Florida, USA
| | - Eric J Hall
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Alexandra H Toporek
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Kevin G Buell
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Ryan M Brown
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Roger K Richardson
- Division of Respiratory Care, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - J Craig Rooks
- Division of Respiratory Care, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Li Wang
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Christopher J Lindsell
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - E Wesley Ely
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Wesley H Self
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Gordon R Bernard
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Todd W Rice
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Matthew W Semler
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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Divney AA, Lopez PM, Huang TT, Thorpe LE, Trinh-Shevrin C, Islam NS. Research-grade data in the real world: challenges and opportunities in data quality from a pragmatic trial in community-based practices. J Am Med Inform Assoc 2019; 26:847-854. [PMID: 31181144 PMCID: PMC6696500 DOI: 10.1093/jamia/ocz062] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [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: 01/09/2019] [Revised: 04/12/2019] [Accepted: 04/16/2019] [Indexed: 12/17/2022] Open
Abstract
Randomized controlled trials face cost, logistic, and generalizability limitations, including difficulty engaging racial/ethnic minorities. Real-world data (RWD) from pragmatic trials, including electronic health record (EHR) data, may produce intervention evaluation findings generalizable to diverse populations. This case study of Project IMPACT describes unique barriers and facilitators of optimizing RWD to improve health outcomes and advance health equity in small immigrant-serving community-based practices. Project IMPACT tested the effect of an EHR-based health information technology intervention on hypertension control among small urban practices serving South Asian patients. Challenges in acquiring accurate RWD included EHR field availability and registry capabilities, cross-sector communication, and financial, personnel, and space resources. Although using RWD from community-based practices can inform health equity initiatives, it requires multidisciplinary collaborations, clinic support, procedures for data input (including social determinants), and standardized field logic/rules across EHR platforms.
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Affiliation(s)
- Anna A Divney
- CUNY Graduate School of Public Health and Health Policy, Center for Systems and Community Design, New York, New York, USA
- NYU-CUNY Prevention Research Center, New York, New York, USA
| | - Priscilla M Lopez
- NYU-CUNY Prevention Research Center, New York, New York, USA
- Department of Population Health, NYU School of Medicine, New York, New York, USA
| | - Terry T Huang
- CUNY Graduate School of Public Health and Health Policy, Center for Systems and Community Design, New York, New York, USA
- NYU-CUNY Prevention Research Center, New York, New York, USA
| | - Lorna E Thorpe
- NYU-CUNY Prevention Research Center, New York, New York, USA
- Department of Population Health, NYU School of Medicine, New York, New York, USA
| | - Chau Trinh-Shevrin
- NYU-CUNY Prevention Research Center, New York, New York, USA
- Department of Population Health, NYU School of Medicine, New York, New York, USA
| | - Nadia S Islam
- NYU-CUNY Prevention Research Center, New York, New York, USA
- Department of Population Health, NYU School of Medicine, New York, New York, USA
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Holleman MS, Uyl-de Groot CA, Goodall S, van der Linden N. Determining the Comparative Value of Pharmaceutical Risk-Sharing Policies in Non-Small Cell Lung Cancer Using Real-World Data. Value Health 2019; 22:322-331. [PMID: 30832970 DOI: 10.1016/j.jval.2018.08.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/01/2018] [Revised: 08/01/2018] [Accepted: 08/29/2018] [Indexed: 06/09/2023]
Abstract
BACKGROUND Risk-sharing arrangements (RSAs) can be used to mitigate uncertainty about the value of a drug by sharing the financial risk between payer and pharmaceutical company. We evaluated the projected impact of alternative RSAs for non-small cell lung cancer (NSCLC) therapies based on real-world data. METHODS Data on treatment patterns of Dutch NSCLC patients from four different hospitals were used to perform "what-if" analyses, evaluating the costs and benefits likely associated with various RSAs. In the scenarios, drug costs or refunds were based on response evaluation criteria in solid tumors (RECIST) response, survival compared to the pivotal trial, treatment duration, or a fixed cost per patient. Analyses were done for erlotinib, gemcitabine/cisplatin, and pemetrexed/platinum for metastatic NSCLC, and gemcitabine/cisplatin, pemetrexed/cisplatin, and vinorelbine/cisplatin for nonmetastatic NSCLC. RESULTS Money-back guarantees led to moderate cost reductions to the payer. For conditional treatment continuation schemes, costs and outcomes associated with the different treatments were dispersed. When price was linked to the outcome, the payer's drug costs reduced by 2.5% to 26.7%. Discounted treatment initiation schemes yielded large cost reductions. Utilization caps mainly reduced the costs of erlotinib treatment (by 16%). Given a fixed cost per patient based on projected average use of the drug, risk sharing was unfavorable to the payer because of the lower than projected use. The impact of RSAs on a national scale was dispersed. CONCLUSIONS For erlotinib and pemetrexed/platinum, large cost reductions were observed with risk sharing. RSAs can mitigate uncertainty around the incremental cost-effectiveness or budget impact of drugs, but only when the type of arrangement matches the setting and type of uncertainty.
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Affiliation(s)
- Marscha S Holleman
- Erasmus School of Health Policy & Management/Institute for Medical Technology Assessment, Erasmus University Rotterdam, Rotterdam, the Netherlands.
| | - Carin A Uyl-de Groot
- Erasmus School of Health Policy & Management/Institute for Medical Technology Assessment, Erasmus University Rotterdam, Rotterdam, the Netherlands
| | - Stephen Goodall
- Center for Health Economics Research and Evaluation, University of Technology Sydney, Sydney, Australia
| | - Naomi van der Linden
- Center for Health Economics Research and Evaluation, University of Technology Sydney, Sydney, Australia
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Bagel J. Treat to Target in Psoriasis: A Real-World Experience With Biologics and Adjunctive Topical Therapy. J Drugs Dermatol 2018; 17:918. [PMID: 30124735] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
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Shenkman E, Hurt M, Hogan W, Carrasquillo O, Smith S, Brickman A, Nelson D. OneFlorida Clinical Research Consortium: Linking a Clinical and Translational Science Institute With a Community-Based Distributive Medical Education Model. Acad Med 2018; 93:451-455. [PMID: 29045273 PMCID: PMC5839715 DOI: 10.1097/acm.0000000000002029] [Citation(s) in RCA: 64] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/09/2023]
Abstract
PROBLEM Developing a national pragmatic clinical trial infrastructure is central to understanding the effectiveness of interventions applied under usual conditions and where people receive health care. To address this challenge, three Florida universities-the University of Florida Clinical and Translational Science Institute, Florida State University (with its community-based distributive medical education model), and the University of Miami-created (2010-2013) a statewide consortium, the OneFlorida Clinical Research Consortium, to support the conduct of pragmatic clinical trials and provide mentored research experiences for medical and graduate students in real-world practice settings. APPROACH OneFlorida has four programs, which report to a steering committee with membership from each partner, community members, and the state Medicaid agency and Department of Health to ensure shared governance. The Clinical Research Program provides support to conduct research in the network and uses champions to engage community clinicians. The Citizen Scientist Program has community members who provide input on health topics of importance to them, study design, recruitment and retention strategies, and the interpretation of findings. The Data Trust Program contains electronic health record and health care claims data for 10.6 million Floridians. The Minority Education Program, in collaboration with three historically black colleges and universities, offers minority junior faculty mentoring in pragmatic clinical trials and implementation science. OUTCOMES OneFlorida has implemented 27 studies with diverse patient populations and in diverse community practice settings. NEXT STEPS To identify evidence-based best practices from the clinical trials conducted in the network, foster their implementation, and expand research training opportunities.
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Affiliation(s)
- Elizabeth Shenkman
- 1E. Shenkman is professor, Department of Health Outcomes and Policy, College of Medicine, University of Florida, Gainesville, Florida; ORCID: http://orcid.org/0000-0003-4903-1804
| | - Myra Hurt
- 2M. Hurt is professor of biomedical sciences and associate dean for research, College of Medicine, Florida State University, Tallahassee, Florida
| | - William Hogan
- 3W. Hogan is professor and director of biomedical informatics, Department of Health Outcomes and Policy, College of Medicine, University of Florida, Gainesville, Florida
| | - Olveen Carrasquillo
- 4O. Carrasquillo is professor and director of medicine and health services research and policy, Leonard M. Miller School of Medicine, University of Miami, Miami, Florida
| | - Steven Smith
- 5S. Smith is chief scientific officer, Florida Hospital, Orlando, Florida
| | - Andrew Brickman
- 6A. Brickman is director of research, Health Choice Network, Doral, Florida
| | - David Nelson
- 7D. Nelson is professor and director, Clinical and Translational Science Institute, Department of Medicine, College of Medicine, University of Florida, Gainesville, Florida
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Foley TR, Krantz MJ. CHAD is Dead: Pragmatic Utility of the CHA 2DS 2-VASc Score in Non-Valvular Atrial Fibrillation? J Gen Intern Med 2018; 33:7-8. [PMID: 28785989 PMCID: PMC5756154 DOI: 10.1007/s11606-017-4148-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- T Raymond Foley
- Division of Cardiology, University of Colorado School of Medicine, Aurora, CO, USA
- Denver Health Medical Center, Denver, CO, USA
| | - Mori J Krantz
- Division of Cardiology, University of Colorado School of Medicine, Aurora, CO, USA.
- Denver Health Medical Center, Denver, CO, USA.
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Bell KJL, McCullough A, Del Mar C, Glasziou P. What's the uptake? Pragmatic RCTs may be used to estimate uptake, and thereby population impact of interventions, but better reporting of trial recruitment processes is needed. BMC Med Res Methodol 2017; 17:174. [PMID: 29272994 PMCID: PMC5741884 DOI: 10.1186/s12874-017-0443-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [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: 04/03/2017] [Accepted: 11/27/2017] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Effectiveness of interventions in pragmatic trials may not translate directly into population impact, because of limited uptake by clinicians and/or the public. Uptake of an intervention is influenced by a number of factors. METHODS We propose a method for calculating population impact of clinical interventions that accounts for the intervention uptake. We suggest that population impact may be estimated by multiplying the two key components: (1) the effectiveness of the intervention in pragmatic trials (trial effect); and, (2) its uptake in clinical practice. We argue that participation rates in trials may be a valid proxy for uptake in clinical practice and, in combination with trial effectiveness estimates, be used to rank interventions by their likely population impact. We illustrate the method using the example of four interventions to decrease antibiotic prescription for acute respiratory infections in primary care: delayed prescribing, procalcitonin test, C-Reactive Protein, shared decision making. RESULTS In order to estimate uptake of interventions from trial data we need detailed reporting on the recruitment processes used for clinician participation in the trials. In the antibiotic prescribing example, between 75 and 91% of the population would still be prescribed or consume antibiotics because effective interventions were not taken up. Of the four interventions considered, we found that delayed prescribing would have the highest population impact and shared decision making the lowest. CONCLUSION Estimates of uptake and population impact of an intervention may be possible from pragmatic RCTs, provided the recruitment processes for these trials are adequately reported (which currently few of them are). Further validation of this method using empirical data on intervention uptake in the real world would support use of this method to decide on public funding of interventions.
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Affiliation(s)
- Katy J L Bell
- School of Public Health, The University of Sydney, Camperdown, NSW, 2006, Australia.
- Centre for Research in Evidence Based Practice (CREBP), Bond University, Gold coast, QLD, 4229, Australia.
| | - Amanda McCullough
- Centre for Research in Evidence Based Practice (CREBP), Bond University, Gold coast, QLD, 4229, Australia
| | - Chris Del Mar
- Centre for Research in Evidence Based Practice (CREBP), Bond University, Gold coast, QLD, 4229, Australia
| | - Paul Glasziou
- Centre for Research in Evidence Based Practice (CREBP), Bond University, Gold coast, QLD, 4229, Australia
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Courtright KR, Halpern SD, Joffe S, Ellenberg SS, Karlawish J, Madden V, Gabler NB, Szymanski S, Yadav KN, Dember LM. Willingness to participate in pragmatic dialysis trials: the importance of physician decisional autonomy and consent approach. Trials 2017; 18:474. [PMID: 29020994 PMCID: PMC5637128 DOI: 10.1186/s13063-017-2217-8] [Citation(s) in RCA: 4] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2017] [Accepted: 09/26/2017] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Pragmatic clinical trials embedded in routine delivery of clinical care can lead to improvements in quality of care, but often have design features that raise ethical concerns. METHODS We performed a discrete choice experiment and used conjoint analysis to assess how specific attributes of pragmatic dialysis trials influenced patients' and physicians' willingness to have their dialysis facility participate in a hypothetical trial of hypertension management. Electronic survey data were collected from 200 patients enrolled from 11 outpatient hemodialysis units and from 203 nephrologists. The three attributes studied were physicians' treatment autonomy, participants' research burden, and the approach to consent. The influence of each attribute was quantified using mixed-effects logistic regression. RESULTS Similar proportions of patients were willing to have their facilities participate in a trial with high vs. low physician autonomy (77% vs. 79%; p = 0.13) and research burden (76% vs. 80%; p = 0.06). Opt-in, opt-out, and notification-only consent approaches were acceptable to most patients (84%, 82%, and 81%, respectively), but compared to each of these consent approaches, fewer patients (66%) were willing to have their facility participate in a trial that used no notification (p < 0.001 for each 2-way comparison). Among the physicians, similar proportions were willing to participate in trials with high and low physician autonomy (61% and 61%, respectively, p = 0.96) or with low and high burden (60 and 61%, respectively, p = 0.79). However, as for the patients, the consent approach influenced trial acceptability with 77%, 69%, and 62% willing to participate using opt-in, opt-out, and notification-only, respectively, compared to no notification (36%) (p < 0.001 for each 2-way comparison). CONCLUSIONS Curtailing physician's treatment autonomy and increasing the burden associated with participation did not influence patients' or physicians' willingness to participate in the hypothetical research, suggesting that pragmatic dialysis trials are generally acceptable to patients and physicians. Both patients and physicians preferred consent approaches that include at least some level of patient notification, but the majority of patients were still willing to participate in trials that did not notify patients of the research.
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Affiliation(s)
- Katherine R. Courtright
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pennsylvania, Philadelphia, PA USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA USA
| | - Scott D. Halpern
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pennsylvania, Philadelphia, PA USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA USA
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Philadelphia, PA USA
- Department of Medical Ethics and Health Policy, University of Pennsylvania, Philadelphia, PA USA
| | - Steven Joffe
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA USA
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Philadelphia, PA USA
- Department of Medical Ethics and Health Policy, University of Pennsylvania, Philadelphia, PA USA
- Division of Oncology, Children’s Hospital of Philadelphia, Philadelphia, PA USA
| | - Susan S. Ellenberg
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Philadelphia, PA USA
- Department of Medical Ethics and Health Policy, University of Pennsylvania, Philadelphia, PA USA
| | - Jason Karlawish
- Department of Medical Ethics and Health Policy, University of Pennsylvania, Philadelphia, PA USA
- Division of Geriatrics, Department of Medicine, University of Pennsylvania, Philadelphia, PA USA
| | - Vanessa Madden
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Philadelphia, PA USA
| | - Nicole B. Gabler
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Philadelphia, PA USA
| | - Stephanie Szymanski
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Philadelphia, PA USA
| | - Kuldeep N. Yadav
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Philadelphia, PA USA
| | - Laura M. Dember
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Philadelphia, PA USA
- Renal-Electrolyte and Hypertension Division, Department of Medicine, University of Pennsylvania, Philadelphia, PA USA
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Affiliation(s)
- Miguel A Hernán
- From the Departments of Epidemiology and Biostatistics, Harvard T.H. Chan School of Public Health (M.A.H., J.M.R.), and the Harvard-MIT Division of Health Sciences and Technology (M.A.H.), Boston
| | - James M Robins
- From the Departments of Epidemiology and Biostatistics, Harvard T.H. Chan School of Public Health (M.A.H., J.M.R.), and the Harvard-MIT Division of Health Sciences and Technology (M.A.H.), Boston
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Weinfurt KP, Hernandez AF, Coronado GD, DeBar LL, Dember LM, Green BB, Heagerty PJ, Huang SS, James KT, Jarvik JG, Larson EB, Mor V, Platt R, Rosenthal GE, Septimus EJ, Simon GE, Staman KL, Sugarman J, Vazquez M, Zatzick D, Curtis LH. Pragmatic clinical trials embedded in healthcare systems: generalizable lessons from the NIH Collaboratory. BMC Med Res Methodol 2017; 17:144. [PMID: 28923013 PMCID: PMC5604499 DOI: 10.1186/s12874-017-0420-7] [Citation(s) in RCA: 116] [Impact Index Per Article: 16.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2017] [Accepted: 08/31/2017] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND The clinical research enterprise is not producing the evidence decision makers arguably need in a timely and cost effective manner; research currently involves the use of labor-intensive parallel systems that are separate from clinical care. The emergence of pragmatic clinical trials (PCTs) poses a possible solution: these large-scale trials are embedded within routine clinical care and often involve cluster randomization of hospitals, clinics, primary care providers, etc. Interventions can be implemented by health system personnel through usual communication channels and quality improvement infrastructure, and data collected as part of routine clinical care. However, experience with these trials is nascent and best practices regarding design operational, analytic, and reporting methodologies are undeveloped. METHODS To strengthen the national capacity to implement cost-effective, large-scale PCTs, the Common Fund of the National Institutes of Health created the Health Care Systems Research Collaboratory (Collaboratory) to support the design, execution, and dissemination of a series of demonstration projects using a pragmatic research design. RESULTS In this article, we will describe the Collaboratory, highlight some of the challenges encountered and solutions developed thus far, and discuss remaining barriers and opportunities for large-scale evidence generation using PCTs. CONCLUSION A planning phase is critical, and even with careful planning, new challenges arise during execution; comparisons between arms can be complicated by unanticipated changes. Early and ongoing engagement with both health care system leaders and front-line clinicians is critical for success. There is also marked uncertainty when applying existing ethical and regulatory frameworks to PCTS, and using existing electronic health records for data capture adds complexity.
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Affiliation(s)
- Kevin P. Weinfurt
- Department of Population Health Sciences, Duke University School of Medicine, 220 W Main St., Suite 720A, Durham, NC 27705 USA
- Duke Clinical Research Institute, 2400 Pratt St., Durham, NC 27710 USA
- Department of Psychology and Neuroscience, Duke Clinical Research Institute, Durham, NC 27710 USA
| | - Adrian F. Hernandez
- Duke Clinical Research Institute, 2400 Pratt St., Durham, NC 27710 USA
- Duke University School of Medicine, 3115 N. Duke Street, Durham, NC 27704 USA
| | - Gloria D. Coronado
- Kaiser Permanente Center for Health Research, 3800 N. Interstate Avenue, Portland, OR 97227-1098 USA
| | - Lynn L. DeBar
- Kaiser Permanente Center for Health Research, 3800 N. Interstate Avenue, Portland, OR 97227-1098 USA
| | - Laura M. Dember
- Perelman School of MedicineBlockley Hall, Office 920, 423 Guardian Drive, Philadelphia, PA 19104 USA
| | - Beverly B. Green
- Kaiser Permanente Washington Health Research Institute, 1730 Minor Ave, Suite 1600, Seattle, WA 98101-1466 USA
| | - Patrick J. Heagerty
- University of Washington, 325 Ninth Ave, Box 359728, Seattle, WA 98104-2499 USA
| | - Susan S. Huang
- University of California Irvine School of Medicine, 101 The City Drive South, City Tower, Suite 400, Mail Code: 4081, Orange, CA 92868 USA
| | - Kathryn T. James
- University of Washington, 325 Ninth Ave, Box 359728, Seattle, WA 98104-2499 USA
| | - Jeffrey G. Jarvik
- University of Washington, 325 Ninth Ave, Box 359728, Seattle, WA 98104-2499 USA
| | - Eric B. Larson
- Group Health Research Institute, 1730 Minor Ave, Suite 1600, Seattle, WA 98101-1466 USA
| | - Vincent Mor
- Department of Community Health, Brown University, Box G-S121-2, Providence, RI 02912 USA
| | - Richard Platt
- Department of Population Medicine, Harvard Pilgrim Health Care Institute, 401 Park Drive, Suite 401 East, Boston, MA 02215 USA
| | - Gary E. Rosenthal
- Department of Internal Medicine, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, NC 27157 USA
| | - Edward J. Septimus
- Hospital Corporation of America Nashville TN, AND Texas A&M College of Medicine, One Park Plaza, Nashville, TN 37203 USA
| | - Gregory E. Simon
- Kaiser Permanente Washington Health Research Institute, 1730 Minor Ave, Suite 1600, Seattle, WA 98101-1466 USA
| | | | - Jeremy Sugarman
- Johns Hopkins Berman Institute of Bioethics, 1809 Ashland Ave., Room 203, Baltimore, MD 21205 USA
| | - Miguel Vazquez
- University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390-8856 USA
| | - Douglas Zatzick
- University of Washington School of Medicine, 325 9th Ave, Seattle, WA 98104 USA
| | - Lesley H. Curtis
- Duke Clinical Research Institute, 2400 Pratt St., Durham, NC 27710 USA
- Duke University School of Medicine, 3115 N. Duke Street, Durham, NC 27704 USA
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Aves T, Allan KS, Lawson D, Nieuwlaat R, Beyene J, Mbuagbaw L. The role of pragmatism in explaining heterogeneity in meta-analyses of randomised trials: a protocol for a cross-sectional methodological review. BMJ Open 2017; 7:e017887. [PMID: 28871028 PMCID: PMC5588964 DOI: 10.1136/bmjopen-2017-017887] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
INTRODUCTION There has been increasing interest in pragmatic trials methodology. As a result, tools such as the Pragmatic-Explanatory Continuum Indicator Summary-2 (PRECIS-2) are being used prospectively to help researchers design randomised controlled trials (RCTs) within the pragmatic-explanatory continuum. There may be value in applying the PRECIS-2 tool retrospectively in a systematic review setting as it could provide important information about how to pool data based on the degree of pragmatism. OBJECTIVES To investigate the role of pragmatism as a source of heterogeneity in systematic reviews by (1) identifying systematic reviews with meta-analyses of RCTs that have moderate to high heterogeneity, (2) applying PRECIS-2 to RCTs of systematic reviews, (3) evaluating the inter-rater reliability of PRECIS-2, (4) determining how much of this heterogeneity may be explained by pragmatism. METHODS A cross-sectional methodological review will be conducted on systematic reviews of RCTs published in the Cochrane Library from 1 January 2014 to 1 January 2017. Included systematic reviews will have a minimum of 10 RCTs in the meta-analysis of the primary outcome and moderate to substantial heterogeneity (I2≥50%). Of the eligible systematic reviews, a random selection of 10 will be included for quantitative evaluation. In each systematic review, RCTs will be scored using the PRECIS-2 tool, in duplicate. Agreement between raters will be measured using the intraclass correlation coefficient. Subgroup analyses and meta-regression will be used to evaluate how much variability in the primary outcome may be due to pragmatism. DISSEMINATION This review will be among the first to evaluate the PRECIS-2 tool in a systematic review setting. Results from this research will provide inter-rater reliability information about PRECIS-2 and may be used to provide methodological guidance when dealing with pragmatism in systematic reviews and subgroup considerations. On completion, this review will be submitted to a peer-reviewed journal for publication.
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Affiliation(s)
- Theresa Aves
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Katherine S Allan
- Faculty of Health Sciences, School of Nursing, McMaster University, Hamilton, Ontario, Canada
| | - Daeria Lawson
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Robby Nieuwlaat
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Joseph Beyene
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Lawrence Mbuagbaw
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- Faculty of Health Sciences, School of Nursing, McMaster University, Hamilton, Ontario, Canada
- Biostatistics Unit, Father Sean O'Sullivan ResearchCentre, St Joseph's Healthcare, Hamilton, Ontario, Canada
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Berger ML, Sox H, Willke RJ, Brixner DL, Eichler H, Goettsch W, Madigan D, Makady A, Schneeweiss S, Tarricone R, Wang SV, Watkins J, Daniel Mullins C. Good practices for real-world data studies of treatment and/or comparative effectiveness: Recommendations from the joint ISPOR-ISPE Special Task Force on real-world evidence in health care decision making. Pharmacoepidemiol Drug Saf 2017; 26:1033-1039. [PMID: 28913966 PMCID: PMC5639372 DOI: 10.1002/pds.4297] [Citation(s) in RCA: 217] [Impact Index Per Article: 31.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2017] [Revised: 07/26/2017] [Accepted: 07/28/2017] [Indexed: 12/13/2022]
Abstract
PURPOSE Real-world evidence (RWE) includes data from retrospective or prospective observational studies and observational registries and provides insights beyond those addressed by randomized controlled trials. RWE studies aim to improve health care decision making. METHODS The International Society for Pharmacoeconomics and Outcomes Research (ISPOR) and the International Society for Pharmacoepidemiology (ISPE) created a task force to make recommendations regarding good procedural practices that would enhance decision makers' confidence in evidence derived from RWD studies. Peer review by ISPOR/ISPE members and task force participants provided a consensus-building iterative process for the topics and framing of recommendations. RESULTS The ISPOR/ISPE Task Force recommendations cover seven topics such as study registration, replicability, and stakeholder involvement in RWE studies. These recommendations, in concert with earlier recommendations about study methodology, provide a trustworthy foundation for the expanded use of RWE in health care decision making. CONCLUSION The focus of these recommendations is good procedural practices for studies that test a specific hypothesis in a specific population. We recognize that some of the recommendations in this report may not be widely adopted without appropriate incentives from decision makers, journal editors, and other key stakeholders.
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Affiliation(s)
| | - Harold Sox
- Patient‐Centered Outcomes Research InstituteWashingtonDCUSA
| | - Richard J. Willke
- International Society for Pharmacoeconomics and Outcomes ResearchLawrencevilleNJUSA
| | | | | | - Wim Goettsch
- Zorginstituut Nederland and University of UtrechtUtrechtThe Netherlands
| | | | - Amr Makady
- Zorginstituut Nederland and University of UtrechtUtrechtThe Netherlands
| | | | | | - Shirley V. Wang
- Brigham and Women's HospitalHarvard Medical SchoolBostonMAUSA
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Powell GA, Bonnett LJ, Tudur-Smith C, Hughes DA, Williamson PR, Marson AG. Using routinely recorded data in the UK to assess outcomes in a randomised controlled trial: The Trials of Access. Trials 2017; 18:389. [PMID: 28835254 PMCID: PMC5569524 DOI: 10.1186/s13063-017-2135-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2017] [Accepted: 08/03/2017] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND In the UK, routinely recorded data may benefit prospective studies including randomised controlled trials (RCTs). In an on-going study, we aim to assess the feasibility of access and agreement of routinely recorded clinical and non-clinical data compared to data collected during a RCT using standard prospective methods. This paper will summarise available UK routinely recorded data sources and discuss our experience with the feasibility of accessing routinely recorded data for participants of a RCT before finally proposing recommendations for improving the access and implementation of routinely recorded data in RCTs. METHODS Setting: the case study RCT is the Standard and New Antiepileptic Drugs II (SANAD II) trial, a pragmatic, UK, multicentre, phase IV RCT assessing the clinical and cost-effectiveness of antiepileptic drug treatments for newly diagnosed epilepsy. PARTICIPANTS 98 participants have provided written consent to permit the request of routinely recorded data. Study procedures: routinely recorded clinical and non-clinical data were identified and data requested through formal applications from available data holders for the duration that participants have been recruited into SANAD II. The feasibility of accessing routinely recorded data during a RCT is assessed and recommendations for improving access proposed. RESULTS Secondary-care clinical and socioeconomic data is recorded on a national basis and can be accessed, although there are limitations in the application process. Primary-care data are recorded by a number of organisations on a de-identified basis but access for specific individuals has not been feasible. Access to data recorded by non-clinical sources, including The Department for Work and Pensions and The Driving and Vehicle Licensing Agency, was not successful. CONCLUSIONS Recommendations discussed include further research to assess the attributes of routinely recorded data, an assessment of public perceptions and the development of strategies to collaboratively improve access to routinely recorded data for research. TRIAL REGISTRATION International Standard Randomised Controlled Trials, ISRCTN30294119 . Registered on 3 July 2012. EudraCT No: 2012-001884-64. Registered on 9 May 2012.
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Affiliation(s)
- G. A. Powell
- Department of Molecular and Clinical Pharmacology, Clinical Sciences Centre, Lower Lane, Fazakerley, Liverpool, L9 7LJ UK
| | - L. J. Bonnett
- Department of Biostatistics, University of Liverpool, Waterhouse Building, Block F, 1-5 Brownlow Street, Liverpool, L69 3GL UK
| | - C. Tudur-Smith
- Department of Biostatistics, University of Liverpool, Waterhouse Building, Block F, 1-5 Brownlow Street, Liverpool, L69 3GL UK
| | - D. A. Hughes
- Centre for Health Economics and Medicines Evaluation, Institute of Medical and Social Care Research, College of Health and Behavioural Sciences, Bangor University, Ardudwy, Normal Site, Gwynedd, North Wales LL57 2PZ UK
| | - P. R. Williamson
- Department of Biostatistics, University of Liverpool, Waterhouse Building, Block F, 1-5 Brownlow Street, Liverpool, L69 3GL UK
| | - A. G. Marson
- Department of Molecular and Clinical Pharmacology, Clinical Sciences Centre, Lower Lane, Fazakerley, Liverpool, L9 7LJ UK
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Oude Rengerink K, Kalkman S, Collier S, Ciaglia A, Worsley SD, Lightbourne A, Eckert L, Groenwold RHH, Grobbee DE, Irving EA. Series: Pragmatic trials and real world evidence: Paper 3. Patient selection challenges and consequences. J Clin Epidemiol 2017; 89:173-180. [PMID: 28502808 DOI: 10.1016/j.jclinepi.2016.12.021] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2016] [Revised: 12/02/2016] [Accepted: 12/12/2016] [Indexed: 12/29/2022]
Abstract
This paper addresses challenges of identifying, enrolling, and retaining participants in a trial conducted within a routine care setting. All patients who are potential candidates for the treatments in routine clinical practice should be considered eligible for a pragmatic trial. To ensure generalizability, the recruited sample should have a similar distribution of the treatment effect modifiers as the target population. In practice, this can be best achieved by including-within the selected sites-all patients without further selection. If relevant heterogeneity between subgroups is expected, increasing the relative proportion of the subgroup of patients in the heterogeneous trial could be considered (oversampling) or a separate trial in this subgroup can be planned. Selection will nevertheless occur. Low enrollment and loss to follow-up can introduce selection and can jeopardize validity as well as generalizability. Pragmatic trials are conducted in clinical practice rather than in a dedicated research setting, which could reduce recruitment rates. However, if a trial poses a minimal burden to the physician and the patient and routine clinical practice is maximally adhered to, the participation rate may be high and loss to follow-up will not be a specific problem for pragmatic trials.
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Affiliation(s)
- Katrien Oude Rengerink
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Universiteitsweg 100, Utrecht 3584 CG, The Netherlands.
| | - Shona Kalkman
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Universiteitsweg 100, Utrecht 3584 CG, The Netherlands
| | - Susan Collier
- RD Respiratory Fibrosis DPU Clinical Development Pharma Research and Development GSK Stockley Park West, 1-3 Ironbridge Road, Uxbridge, Middlesex UB11 1BT, UK
| | - Antonio Ciaglia
- International Alliance of Patients' Organizations, 49-51 East Road, London N1 6AH, UK
| | - Sally D Worsley
- Real World Study Delivery, GSK Research & Development, Gunnels Wood Rd, Stevenage SG1 2NY, UK
| | - Alison Lightbourne
- International Alliance of Patients' Organizations, 49-51 East Road, London N1 6AH, UK
| | - Laurent Eckert
- Health Economics and Outcome Research, Sanofi Global Maket Access Center of Excellence, Chilly-Mazarin, France
| | - Rolf H H Groenwold
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Universiteitsweg 100, Utrecht 3584 CG, The Netherlands
| | - Diederick E Grobbee
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Universiteitsweg 100, Utrecht 3584 CG, The Netherlands; Julius Clinical, Broederplein 41-43, Zeist 3703 CD, The Netherlands
| | - Elaine A Irving
- Real World Study Delivery, GSK Research & Development, Gunnels Wood Rd, Stevenage SG1 2NY, UK
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Affiliation(s)
- Ian Ford
- From the Robertson Centre for Biostatistics, University of Glasgow, Glasgow (I.F.), and the Centre for Healthcare Randomised Trials, Health Services Research Unit, University of Aberdeen, Aberdeen (J.N.) - both in the United Kingdom
| | - John Norrie
- From the Robertson Centre for Biostatistics, University of Glasgow, Glasgow (I.F.), and the Centre for Healthcare Randomised Trials, Health Services Research Unit, University of Aberdeen, Aberdeen (J.N.) - both in the United Kingdom
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Nipp RD, Yao NA, Lowenstein LM, Buckner JC, Parker IR, Gajra A, Morrison VA, Dale W, Ballman KV. Pragmatic study designs for older adults with cancer: Report from the U13 conference. J Geriatr Oncol 2016; 7:234-41. [PMID: 27197914 DOI: 10.1016/j.jgo.2016.02.005] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [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: 11/01/2015] [Revised: 12/30/2015] [Accepted: 02/10/2016] [Indexed: 11/18/2022]
Abstract
Cancer is a disease occurring disproportionately in older adults. However, the evidence base regarding how best to care for these patients remains limited due to their underrepresentation in cancer clinical trials. Pragmatic clinical trials represent a promising approach for enhancing the evidence base in geriatric oncology by allowing investigators to enroll older, frailer patients onto cancer clinical trials. These trials are more accessible, less resource intensive, and place minimal additional burden on participating patients. Additionally, these trials can be designed to measure endpoints directly relevant to older adults, such as quality of life, functional independence and treatment tolerability which are often not addressed in standard clinical trials. Therefore, pragmatic clinical trials allow researchers to include patients for whom the treatment will ultimately be applied and to utilize meaningful endpoints. Examples of pragmatic studies include both large, simple trials and cluster randomized trials. These study designs allow investigators to conduct clinical trials within the context of everyday practice. Further, researchers can devise these studies to place minimal burden on the patient, the treating clinicians and the participating institutions. In order to be successful, pragmatic trials must efficiently utilize the electronic medical record for data capture while also maximizing patient recruitment, enrollment and retention. Additionally, by strategically utilizing pragmatic clinical trials to test therapies and interventions that have previously shown efficacy in younger, fitter patients, these trials represent a potential mechanism to improve the evidence base in geriatric oncology and enhance care for older adults with cancer.
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Affiliation(s)
- Ryan D Nipp
- Massachusetts General Hospital Cancer Center & Harvard Medical School, Department of Medicine, Division of Hematology & Oncology, Boston, MA, USA.
| | - Nengliang Aaron Yao
- University of Virginia Cancer Center, Department of Public Health Sciences, Charlottesville, VA, USA
| | - Lisa M Lowenstein
- University of Texas MD Anderson Cancer Center, Department of Health Services Research, Division of OVP, Cancer Prevention and Population Sciences, Houston, TX, USA
| | - Jan C Buckner
- Mayo Clinic, Department of Oncology, Division of Medical Oncology, Rochester, MN, USA
| | - Ira R Parker
- Thomas Jefferson University, Philadelphia, PA; La Jolla, CA, USA
| | - Ajeet Gajra
- SUNY Upstate University, Department of Medicine, Syracuse, NY, USA; VA Medical Center, Syracuse, NY, USA
| | - Vicki A Morrison
- University of Minnesota, Veterans Affairs Medical Center, Minneapolis, MN, USA
| | - William Dale
- University of Chicago, Section of Geriatrics & Palliative Medicine, Chicago, IL, USA
| | - Karla V Ballman
- Weill Cornell Medical College, Division of Biostatistics and Epidemiology, New York, NY 10065, USA
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Abstract
Pragmatic clinical trials (PCTs) are today an increasingly prominent means of measuring the 'effectiveness' of healthcare interventions in 'real world' clinical settings, in order to produce evidence on which to base regulatory and clinical decision-making. Although several sociological studies have shown persuasively how PCTs are co-constructed within particular healthcare systems in which they are based, they have tended to focus on relatively later stages in careers of trials. The paper contributes to literature by considering how the 'real world' of the UK National Health Service (NHS) is incorporated into the design of a research protocol. Drawing on a meeting held just prior to patient recruitment for a PCT in maternal health, the paper analyses a trial collective's efforts to purify the messy domain of NHS clinical care into the orderly confines of the protocol (Law 2004), which meant satisfying demands for both scientific and social robustness (c.f. Nowotny et al. 2001). The findings show how efforts to inscribe robustness into the PCT protocol were themselves mediated through epistemic and regulatory conventions surrounding protocols as devices in healthcare research. Finally it is argued that meetings constitute an important epistemic instrument through which to settle various emerging tensions in PCT protocol design.
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Johnson KE, Tachibana C, Coronado GD, Dember LM, Glasgow RE, Huang SS, Martin PJ, Richards J, Rosenthal G, Septimus E, Simon GE, Solberg L, Suls J, Thompson E, Larson EB. A guide to research partnerships for pragmatic clinical trials. BMJ 2014; 349:g6826. [PMID: 25446054 PMCID: PMC4707716 DOI: 10.1136/bmj.g6826] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/02/2014] [Indexed: 11/13/2022]
Affiliation(s)
| | | | - Gloria D Coronado
- Kaiser Permanente Center for Health Research, Portland, OR 97227, USA
| | - Laura M Dember
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104, USA
| | - Russell E Glasgow
- Colorado Health Outcomes Program, University of Colorado School of Medicine, Aurora, CO 80045, USA
| | - Susan S Huang
- University of California Irvine School of Medicine, Irvine, CA 92697, USA
| | - Paul J Martin
- Clinical Research Support, Fred Hutchinson Cancer Research Center, Seattle WA 98109, USA
| | | | - Gary Rosenthal
- Internal Medicine, University of Iowa, Iowa City, IA 52242, USA
| | - Ed Septimus
- Clinical Service Group, Hospital Corporation of America, Nashville, TN 374022, USA
| | | | - Leif Solberg
- HealthPartners Institute for Education and Research, Bloomington, MN 55425, USA
| | - Jerry Suls
- National Cancer Institute, Bethesda, MD 20892, USA
| | - Ella Thompson
- Group Health Research Institute, Seattle, WA 98101, USA
| | - Eric B Larson
- Group Health Research Institute, Seattle, WA 98101, USA
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Affiliation(s)
- Philip Sedgwick
- Institute for Medical and Biomedical Education, St George's, University of London, London, UK
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Abstract
Most phase III clinical trials today are explanatory. Because explanatory, or efficacy, trials test hypotheses under "ideal" conditions, they are not well suited to providing guidance on decisions made in most clinical care contexts. Pragmatic trials, which test hypotheses under "usual" conditions, are often better suited to this task. Yet, pragmatic, or effectiveness, trials are infrequently carried out. This mismatch between the design of clinical trials and the needs of health care professionals is frustrating for everyone involved, and explains some of the challenges inherent in attempts to enhance knowledge translation and encourage evidence-based practice. The situation is more than simply frustrating, however; it is potentially unethical. Clinical trials must be socially valuable in order to (1) warrant the risks they impose on human research subjects and (2) fairly and efficiently assess new clinical interventions. Most bioethicists would agree that trials that have no social value, for instance, because their results do not have the potential to advance clinical care, should not be performed. What is less widely appreciated is that given limited research resources, trials that are more socially valuable should be preferred to trials that are less socially valuable when all else is equal. With respect to clinical trial design, I argue that while explanatory trials often have some social value, many have less social value than their pragmatic counterparts. On the basis of this general ethical assessment, I provide a preliminary defense of the position that clinical researchers should aim to conduct pragmatic trials, that is, that researchers face a burden of justification related to any idealizing elements added to trial designs.
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Affiliation(s)
- Kirstin Borgerson
- Department of Philosophy, Dalhousie University, 6135 University Avenue, PO Box 15000, Halifax, NS, B3H 4R2, Canada.
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Krist AH, Glenn BA, Glasgow RE, Balasubramanian BA, Chambers DA, Fernandez ME, Heurtin-Roberts S, Kessler R, Ory MG, Phillips SM, Ritzwoller DP, Roby DH, Rodriguez HP, Sabo RT, Sheinfeld Gorin SN, Stange KC. Designing a valid randomized pragmatic primary care implementation trial: the my own health report (MOHR) project. Implement Sci 2013; 8:73. [PMID: 23799943 PMCID: PMC3694031 DOI: 10.1186/1748-5908-8-73] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.5] [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: 03/10/2013] [Accepted: 06/05/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND There is a pressing need for greater attention to patient-centered health behavior and psychosocial issues in primary care, and for practical tools, study designs and results of clinical and policy relevance. Our goal is to design a scientifically rigorous and valid pragmatic trial to test whether primary care practices can systematically implement the collection of patient-reported information and provide patients needed advice, goal setting, and counseling in response. METHODS This manuscript reports on the iterative design of the My Own Health Report (MOHR) study, a cluster randomized delayed intervention trial. Nine pairs of diverse primary care practices will be randomized to early or delayed intervention four months later. The intervention consists of fielding the MOHR assessment--addresses 10 domains of health behaviors and psychosocial issues--and subsequent provision of needed counseling and support for patients presenting for wellness or chronic care. As a pragmatic participatory trial, stakeholder groups including practice partners and patients have been engaged throughout the study design to account for local resources and characteristics. Participatory tasks include identifying MOHR assessment content, refining the study design, providing input on outcomes measures, and designing the implementation workflow. Study outcomes include the intervention reach (percent of patients offered and completing the MOHR assessment), effectiveness (patients reporting being asked about topics, setting change goals, and receiving assistance in early versus delayed intervention practices), contextual factors influencing outcomes, and intervention costs. DISCUSSION The MOHR study shows how a participatory design can be used to promote the consistent collection and use of patient-reported health behavior and psychosocial assessments in a broad range of primary care settings. While pragmatic in nature, the study design will allow valid comparisons to answer the posed research question, and findings will be broadly generalizable to a range of primary care settings. Per the pragmatic explanatory continuum indicator summary (PRECIS) framework, the study design is substantially more pragmatic than other published trials. The methods and findings should be of interest to researchers, practitioners, and policy makers attempting to make healthcare more patient-centered and relevant. TRIAL REGISTRATION Clinicaltrials.gov: NCT01825746.
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Affiliation(s)
- Alex H Krist
- Department of Family Medicine and Population Health, Virginia Commonwealth University, PO Box 980251, Richmond, VA 23298-0251, USA
| | - Beth A Glenn
- Department of Health Policy & Management, UCLA Fielding School of Public Health, Los Angeles, CA 90095-1772, USA
| | - Russell E Glasgow
- Implementation Science Team, Division of Cancer Control and Population Sciences, National Cancer Institute, 6130 Executive Blvd, Room 6144, Rockville, MD 20852, USA
| | - Bijal A Balasubramanian
- Division of Epidemiology, Human Genetics, and Environmental Science, University of Texas Health Science Center at Houston, School of Public Health, 5323 Harry Hines Blvd, Dallas, TX 75390, USA
| | - David A Chambers
- Division of Services and Intervention Research, National Institute of Mental Health, 6001 Executive Blvd., Room 7144, Bethesda, MD 20892-9631, USA
| | - Maria E Fernandez
- University of Texas Health Science Center at Houston, School of Public Health, 7000 Fannin Suite 2558, Houston, TX 77030, USA
| | - Suzanne Heurtin-Roberts
- Implementation Science Team, Division of Cancer Control and Population Sciences, National Cancer Institute, 6130 Executive Blvd, Room 6144, Rockville, MD 20852, USA
| | - Rodger Kessler
- Department of Family Medicine, Vermont College of Medicine, S458 Courtyard at Given, 89 Beaumont Ave., Burlington, VT 05405, USA
| | - Marcia G Ory
- Department of Health Promotion and Community Health Sciences, Texas A&M Health Sciences Center School of Rural Public Health, College Station, TX 77843-1266, USA
| | - Siobhan M Phillips
- Implementation Science Team, Division of Cancer Control and Population Sciences, National Cancer Institute, 6130 Executive Blvd, Room 6144, Rockville, MD 20852, USA
| | - Debra P Ritzwoller
- Institute for Health Research, Kaiser Permanente Colorado, 10065 E. Harvard Ave., Denver, CO 80231, USA
| | - Dylan H Roby
- Department of Health Policy & Management, UCLA Fielding School of Public Health, Los Angeles, CA 90095-1772, USA
| | - Hector P Rodriguez
- Department of Health Policy & Management, UCLA Fielding School of Public Health, Los Angeles, CA 90095-1772, USA
| | - Roy T Sabo
- Department of Biostatistics, Virginia Commonwealth University, PO Box 980032, Richmond, VA 23298-0032, USA
| | - Sherri N Sheinfeld Gorin
- SAIC-Frederick, NIH, NCI, DCCPS, 6130 Executive Plaza, Bethesda, MD, USA
- New York Physicians against Cancer (NYPAC), Herbert Irving Comprehensive Cancer Center, New York, NY, USA
| | - Kurt C Stange
- Family Medicine & Community Health, Epidemiology & Biostatistics, Sociology and Oncology, Case Western Reserve University, 11000 Cedar Ave, Suite 402, Cleveland, OH 44106, USA
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