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Zigler CK, Adeyemi O, Boyd AD, Braciszewski JM, Cheville A, Cuthel AM, Dailey DL, Del Fiol G, Ezenwa MO, Faurot KR, Justice M, Ho PM, Lawrence K, Marsolo K, Patil CL, Paek H, Richesson RL, Staman KL, Schlaeger JM, O'Brien EC. Collecting patient-reported outcome measures in the electronic health record: Lessons from the NIH pragmatic trials Collaboratory. Contemp Clin Trials 2024; 137:107426. [PMID: 38160749 PMCID: PMC10922303 DOI: 10.1016/j.cct.2023.107426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Revised: 12/15/2023] [Accepted: 12/26/2023] [Indexed: 01/03/2024]
Abstract
The NIH Pragmatic Trials Collaboratory supports the design and conduct of 27 embedded pragmatic clinical trials, and many of the studies collect patient reported outcome measures as primary or secondary outcomes. Study teams have encountered challenges in the collection of these measures, including challenges related to competing health care system priorities, clinician's buy-in for adoption of patient-reported outcome measures, low adoption and reach of technology in low resource settings, and lack of consensus and standardization of patient-reported outcome measure selection and administration in the electronic health record. In this article, we share case examples and lessons learned, and suggest that, when using patient-reported outcome measures for embedded pragmatic clinical trials, investigators must make important decisions about whether to use data collected from the participating health system's electronic health record, integrate externally collected patient-reported outcome data into the electronic health record, or collect these data in separate systems for their studies.
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Affiliation(s)
- Christina K Zigler
- Duke University School of Medicine, Durham, NC, United States of America.
| | - Oluwaseun Adeyemi
- New York University Grossman School of Medicine, Ronald O. Perelman Department of Emergency Medicine, New York, NY, United States of America
| | - Andrew D Boyd
- Department of Biomedical and Health Information Sciences, University of Illinois Chicago, Chicago, IL, United States of America
| | | | - Andrea Cheville
- Mayo Clinic Comprehensive Cancer Center, Rochester, MN, United States of America
| | - Allison M Cuthel
- New York University Grossman School of Medicine, Ronald O. Perelman Department of Emergency Medicine, New York, NY, United States of America
| | - Dana L Dailey
- St. Ambrose University, Davenport, IA, and University of Iowa, Iowa City, IA, United States of America
| | - Guilherme Del Fiol
- Department of Biomedical Informatics, University of Utah School of Medicine, Salt Lake City, UT, United States of America
| | - Miriam O Ezenwa
- University of Florida College of Nursing, Gainesville, FL, United States of America
| | - Keturah R Faurot
- Department of Physical Medicine and Rehabilitation, University of North Carolina School of Medicine, Chapel Hill, NC, United States of America
| | - Morgan Justice
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, United States of America
| | - P Michael Ho
- Division of Cardiology, University of Colorado School of Medicine, Aurora, CO, United States of America
| | - Katherine Lawrence
- Department of Population Health, New York University Grossman School of Medicine, New York, NY, United States of America
| | - Keith Marsolo
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, United States of America
| | - Crystal L Patil
- University of Michigan, School of Nursing, Ann Arbor, MI, United States of America
| | - Hyung Paek
- Yale University, New Haven, CT, United States of America
| | - Rachel L Richesson
- Department of Learning Health Sciences, University of Michigan Medical School, Ann Arbor, MI, United States of America
| | - Karen L Staman
- Duke Clinical Research Institute, Durham, NC, United States of America
| | - Judith M Schlaeger
- University of Illinois Chicago, College of Nursing, Chicago, IL, United States of America
| | - Emily C O'Brien
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, United States of America
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Swirsky ES, Boyd AD, Gu C, Burke LA, Doorenbos AZ, Ezenwa MO, Knisely MR, Leigh JW, Li H, Mandernach MW, Molokie RE, Patil CL, Steffen AD, Shah N, deMartelly VA, Staman KL, Schlaeger JM. Monitoring and responding to signals of suicidal ideation in pragmatic clinical trials: Lessons from the GRACE trial for Chronic Sickle Cell Disease Pain. Contemp Clin Trials Commun 2023; 36:101218. [PMID: 37842321 PMCID: PMC10569945 DOI: 10.1016/j.conctc.2023.101218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Revised: 09/11/2023] [Accepted: 10/01/2023] [Indexed: 10/17/2023] Open
Abstract
Sickle cell disease (SCD) is a hemoglobin disorder and the most common genetic disorder that affects 100,000 Americans and millions worldwide. Adults living with SCD have pain so severe that it often requires opioids to keep it in control. Depression is a major global public health concern associated with an increased risk in chronic medical disorders, including in adults living with sickle cell disease (SCD). A strong relationship exists between suicidal ideation, suicide attempts, and depression. Researchers enrolling adults living with SCD in pragmatic clinical trials are obligated to design their methods to deliberately monitor and respond to symptoms related to depression and suicidal ideation. This will offer increased protection for their participants and help clinical investigators meet their fiduciary duties. This article presents a review of this sociotechnical milieu that highlights, analyzes, and offers recommendations to address ethical considerations in the development of protocols, procedures, and monitoring activities related to suicidality in depressed patients in a pragmatic clinical trial.
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Affiliation(s)
| | | | - Carol Gu
- University of Illinois Chicago, Chicago, IL, USA
| | | | | | | | | | | | - Hongjin Li
- University of Illinois Chicago, Chicago, IL, USA
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3
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Boyd AD, Gonzalez-Guarda R, Lawrence K, Patil CL, Ezenwa MO, O’Brien EC, Paek H, Braciszewski JM, Adeyemi O, Cuthel AM, Darby JE, Zigler CK, Ho PM, Faurot KR, Staman KL, Leigh JW, Dailey DL, Cheville A, Del Fiol G, Knisely MR, Grudzen CR, Marsolo K, Richesson RL, Schlaeger JM. Potential bias and lack of generalizability in electronic health record data: reflections on health equity from the National Institutes of Health Pragmatic Trials Collaboratory. J Am Med Inform Assoc 2023; 30:1561-1566. [PMID: 37364017 PMCID: PMC10436149 DOI: 10.1093/jamia/ocad115] [Citation(s) in RCA: 4] [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: 04/27/2023] [Revised: 06/07/2023] [Accepted: 06/13/2023] [Indexed: 06/28/2023] Open
Abstract
Embedded pragmatic clinical trials (ePCTs) play a vital role in addressing current population health problems, and their use of electronic health record (EHR) systems promises efficiencies that will increase the speed and volume of relevant and generalizable research. However, as the number of ePCTs using EHR-derived data grows, so does the risk that research will become more vulnerable to biases due to differences in data capture and access to care for different subsets of the population, thereby propagating inequities in health and the healthcare system. We identify 3 challenges-incomplete and variable capture of data on social determinants of health, lack of representation of vulnerable populations that do not access or receive treatment, and data loss due to variable use of technology-that exacerbate bias when working with EHR data and offer recommendations and examples of ways to actively mitigate bias.
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Affiliation(s)
- Andrew D Boyd
- Department of Biomedical and Health Information Sciences, University of Illinois Chicago, Chicago, Illinois, USA
| | | | - Katharine Lawrence
- Department of Population Health, New York University Grossman School of Medicine, New York City, New York, USA
| | - Crystal L Patil
- College of Nursing, University of Illinois Chicago, Chicago, Illinois, USA
| | - Miriam O Ezenwa
- University of Florida College of Nursing, Gainesville, Florida, USA
| | - Emily C O’Brien
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
| | - Hyung Paek
- Biostatistics (Health Informatics), Yale University, New Haven, Connecticut, USA
| | | | - Oluwaseun Adeyemi
- Ronald O. Perelman Department of Emergency Medicine, New York University Grossman School of Medicine, New York City, New York, USA
| | - Allison M Cuthel
- Ronald O. Perelman Department of Emergency Medicine, New York University Grossman School of Medicine, New York City, New York, USA
| | - Juanita E Darby
- College of Nursing, University of Illinois Chicago, Chicago, Illinois, USA
| | | | - P Michael Ho
- Division of Cardiology, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Keturah R Faurot
- Department of Physical Medicine and Rehabilitation, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Karen L Staman
- Duke University School of Medicine, Durham, North Carolina, USA
| | - Jonathan W Leigh
- College of Nursing, University of Illinois Chicago, Chicago, Illinois, USA
| | - Dana L Dailey
- Physical Therapy, St. Ambrose University, Davenport, Iowa, USA
- Department of Physical Therapy and Rehabilitation Science Department, University of Iowa, Iowa City, Iowa, USA
| | - Andrea Cheville
- Mayo Clinic Comprehensive Cancer Center, Rochester, Minnesota, USA
| | - Guilherme Del Fiol
- Department of Biomedical Informatics, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | | | - Corita R Grudzen
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York City, New York, USA
| | - Keith Marsolo
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
| | - Rachel L Richesson
- Department of Learning Health Sciences, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Judith M Schlaeger
- College of Nursing, University of Illinois Chicago, Chicago, Illinois, USA
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4
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Staman KL, Check DK, Zatzick D, Mor V, Fritz JM, Sluka K, DeBar LL, Jarvik JG, Volandes A, Coronado GD, Chambers DA, Weinfurt KP, George SZ. Intervention delivery for embedded pragmatic clinical trials: Development of a tool to measure complexity. Contemp Clin Trials 2023; 126:107105. [PMID: 36708968 PMCID: PMC10126825 DOI: 10.1016/j.cct.2023.107105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2022] [Revised: 01/03/2023] [Accepted: 01/23/2023] [Indexed: 01/27/2023]
Abstract
BACKGROUND Conducting an embedded pragmatic clinical trial in the workflow of a healthcare system is a complex endeavor. The complexity of the intervention delivery can have implications for study planning, ability to maintain fidelity to the intervention during the trial, and/or ability to detect meaningful differences in outcomes. METHODS We conducted a literature review, developed a tool, and conducted two rounds of phone calls with NIH Pragmatic Trials Collaboratory Demonstration Project principal investigators to develop the Intervention Delivery Complexity Tool. After refining the tool, we piloted it with Collaboratory demonstration projects and developed an online version of the tool using the R Shiny application (https://duke-som.shinyapps.io/ICT-ePCT/). RESULTS The 6-item tool consists of internal and external factors. Internal factors pertain to the intervention itself and include workflow, training, and the number of intervention components. External factors are related to intervention delivery at the system level including differences in healthcare systems, the dependency on setting for implementation, and the number of steps between the intervention and the outcome. CONCLUSION The Intervention Delivery Complexity Tool was developed as a standard way to overcome communication challenges of intervention delivery within an embedded pragmatic trial. This version of the tool is most likely to be useful to the trial team and its health system partners during trial planning and conduct. We expect further evolution of the tool as more pragmatic trials are conducted and feedback is received on its performance outside of the NIH Pragmatic Trials Collaboratory.
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Affiliation(s)
- Karen L Staman
- Duke Clinical Research Institute, CHB Wordsmith, Inc, Raleigh, NC, USA
| | - Devon K Check
- Population Health Sciences and Duke Clinical Research Institute, Durham, NC, USA
| | | | | | | | | | - Lynn L DeBar
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
| | | | | | | | | | - Kevin P Weinfurt
- Population Health Sciences and Duke Clinical Research Institute, Durham, NC, USA
| | - Steven Z George
- Department of Orthopaedic Surgery and Duke Clinical Research Institute, Durham, NC, USA.
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5
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Marsolo KA, Weinfurt KP, Staman KL, Hammill BG. Moving From Idealism to Realism With Data Sharing. Ann Intern Med 2023; 176:402-403. [PMID: 36716450 DOI: 10.7326/m22-2973] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Affiliation(s)
- Keith A Marsolo
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina (K.A.M., K.P.W., K.L.S., B.G.H.)
| | - Kevin P Weinfurt
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina (K.A.M., K.P.W., K.L.S., B.G.H.)
| | - Karen L Staman
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina (K.A.M., K.P.W., K.L.S., B.G.H.)
| | - Bradley G Hammill
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina (K.A.M., K.P.W., K.L.S., B.G.H.)
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6
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Curtis LH, Dember LM, Vazquez MA, Murray D, DeBar L, Staman KL, Septimus E, Mor V, Volandes A, Wells BL, Huang SS, Green BB, Coronado G, Meyers CM, Tuzzio L, Hernandez AF, Sugarman J. Addressing guideline and policy changes during pragmatic clinical trials. Clin Trials 2019; 16:431-437. [PMID: 31084378 DOI: 10.1177/1740774519845682] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
While conducting a set of large-scale multi-site pragmatic clinical trials involving high-impact public health issues such as end-stage renal disease, opioid use, and colorectal cancer, there were substantial changes to both policies and guidelines relevant to the trials. These external changes gave rise to unexpected challenges for the trials, including decisions regarding how to respond to new clinical practice guidelines, increased difficulty in implementing trial interventions, achieving separation between treatment groups, and differential responses across sites. In this article, we describe these challenges and the approaches used to address them. When deliberating appropriate action in the face of external changes during a pragmatic clinical trial, we recommend considering the well-being of the participants, clinical equipoise, and the strength and quality of the evidence associated with the change; involving those charged with data and safety monitoring; and where possible, planning for potential external changes as the trial is being designed. Any solution must balance the primary obligation to protect the well-being of participants with the secondary obligation to protect the integrity of the trial in order to gain meaningful answers to important public health questions.
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Affiliation(s)
| | - Laura M Dember
- 2 Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Miguel A Vazquez
- 3 University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - David Murray
- 4 National Institutes of Health, Bethesda, MD, USA
| | - Lynn DeBar
- 5 Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
| | | | - Edward Septimus
- 7 Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA, USA
| | - Vincent Mor
- 8 Department of Health Services, Policy, and Practice, School of Public Health, Brown University and Providence Veterans Administration Medical Center, Providence, RI, USA
| | | | - Barbara L Wells
- 10 Division of Cardiovascular Sciences, NHLBI, National Institutes of Health, Bethesda, MD, USA
| | - Susan S Huang
- 11 Irvine School of Medicine, University of California, Irvine, CA, USA
| | - Beverly B Green
- 5 Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
| | - Gloria Coronado
- 12 Kaiser Permanente Center for Health Research, Portland, OR, USA
| | - Catherine M Meyers
- 13 Office of Clinical and Regulatory Affairs, National Center for Complementary and Integrative Health (NCCIH), Bethesda, MD, USA
| | - Leah Tuzzio
- 5 Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
| | | | - Jeremy Sugarman
- 14 Johns Hopkins Berman Institute of Bioethics and Department of Medicine, The Johns Hopkins University, Baltimore, MD, USA
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7
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Simon GE, Coronado G, DeBar LL, Dember LM, Green BB, Huang SS, Jarvik JG, Mor V, Ramsberg J, Septimus EJ, Staman KL, Vazquez MA, Vollmer WM, Zatzick D, Hernandez AF, Platt R. Data Sharing and Embedded Research. Ann Intern Med 2017; 167:668-670. [PMID: 28973353 PMCID: PMC5811187 DOI: 10.7326/m17-0863] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Gregory E Simon
- From Kaiser Permanente Washington Health Research Institute, University of Washington, and University of Washington School of Medicine, Seattle, Washington; Kaiser Permanente Center for Health Research, Portland, Oregon; University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania; University of California, Irvine School of Medicine, Orange, California; Brown University, Providence, Rhode Island; Harvard Pilgrim Health Care Institute and Harvard Medical School, Boston, Massachusetts; Hospital Corporation of America, Nashville, Tennessee; Texas A&M College of Medicine, Houston, Texas; CHB Wordsmith, Raleigh, North Carolina; University of Texas Southwestern Medical Center, Dallas, Texas; and Duke University School of Medicine, Durham, North Carolina
| | - Gloria Coronado
- From Kaiser Permanente Washington Health Research Institute, University of Washington, and University of Washington School of Medicine, Seattle, Washington; Kaiser Permanente Center for Health Research, Portland, Oregon; University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania; University of California, Irvine School of Medicine, Orange, California; Brown University, Providence, Rhode Island; Harvard Pilgrim Health Care Institute and Harvard Medical School, Boston, Massachusetts; Hospital Corporation of America, Nashville, Tennessee; Texas A&M College of Medicine, Houston, Texas; CHB Wordsmith, Raleigh, North Carolina; University of Texas Southwestern Medical Center, Dallas, Texas; and Duke University School of Medicine, Durham, North Carolina
| | - Lynn L DeBar
- From Kaiser Permanente Washington Health Research Institute, University of Washington, and University of Washington School of Medicine, Seattle, Washington; Kaiser Permanente Center for Health Research, Portland, Oregon; University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania; University of California, Irvine School of Medicine, Orange, California; Brown University, Providence, Rhode Island; Harvard Pilgrim Health Care Institute and Harvard Medical School, Boston, Massachusetts; Hospital Corporation of America, Nashville, Tennessee; Texas A&M College of Medicine, Houston, Texas; CHB Wordsmith, Raleigh, North Carolina; University of Texas Southwestern Medical Center, Dallas, Texas; and Duke University School of Medicine, Durham, North Carolina
| | - Laura M Dember
- From Kaiser Permanente Washington Health Research Institute, University of Washington, and University of Washington School of Medicine, Seattle, Washington; Kaiser Permanente Center for Health Research, Portland, Oregon; University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania; University of California, Irvine School of Medicine, Orange, California; Brown University, Providence, Rhode Island; Harvard Pilgrim Health Care Institute and Harvard Medical School, Boston, Massachusetts; Hospital Corporation of America, Nashville, Tennessee; Texas A&M College of Medicine, Houston, Texas; CHB Wordsmith, Raleigh, North Carolina; University of Texas Southwestern Medical Center, Dallas, Texas; and Duke University School of Medicine, Durham, North Carolina
| | - Beverly B Green
- From Kaiser Permanente Washington Health Research Institute, University of Washington, and University of Washington School of Medicine, Seattle, Washington; Kaiser Permanente Center for Health Research, Portland, Oregon; University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania; University of California, Irvine School of Medicine, Orange, California; Brown University, Providence, Rhode Island; Harvard Pilgrim Health Care Institute and Harvard Medical School, Boston, Massachusetts; Hospital Corporation of America, Nashville, Tennessee; Texas A&M College of Medicine, Houston, Texas; CHB Wordsmith, Raleigh, North Carolina; University of Texas Southwestern Medical Center, Dallas, Texas; and Duke University School of Medicine, Durham, North Carolina
| | - Susan S Huang
- From Kaiser Permanente Washington Health Research Institute, University of Washington, and University of Washington School of Medicine, Seattle, Washington; Kaiser Permanente Center for Health Research, Portland, Oregon; University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania; University of California, Irvine School of Medicine, Orange, California; Brown University, Providence, Rhode Island; Harvard Pilgrim Health Care Institute and Harvard Medical School, Boston, Massachusetts; Hospital Corporation of America, Nashville, Tennessee; Texas A&M College of Medicine, Houston, Texas; CHB Wordsmith, Raleigh, North Carolina; University of Texas Southwestern Medical Center, Dallas, Texas; and Duke University School of Medicine, Durham, North Carolina
| | - Jeffrey G Jarvik
- From Kaiser Permanente Washington Health Research Institute, University of Washington, and University of Washington School of Medicine, Seattle, Washington; Kaiser Permanente Center for Health Research, Portland, Oregon; University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania; University of California, Irvine School of Medicine, Orange, California; Brown University, Providence, Rhode Island; Harvard Pilgrim Health Care Institute and Harvard Medical School, Boston, Massachusetts; Hospital Corporation of America, Nashville, Tennessee; Texas A&M College of Medicine, Houston, Texas; CHB Wordsmith, Raleigh, North Carolina; University of Texas Southwestern Medical Center, Dallas, Texas; and Duke University School of Medicine, Durham, North Carolina
| | - Vincent Mor
- From Kaiser Permanente Washington Health Research Institute, University of Washington, and University of Washington School of Medicine, Seattle, Washington; Kaiser Permanente Center for Health Research, Portland, Oregon; University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania; University of California, Irvine School of Medicine, Orange, California; Brown University, Providence, Rhode Island; Harvard Pilgrim Health Care Institute and Harvard Medical School, Boston, Massachusetts; Hospital Corporation of America, Nashville, Tennessee; Texas A&M College of Medicine, Houston, Texas; CHB Wordsmith, Raleigh, North Carolina; University of Texas Southwestern Medical Center, Dallas, Texas; and Duke University School of Medicine, Durham, North Carolina
| | - Joakim Ramsberg
- From Kaiser Permanente Washington Health Research Institute, University of Washington, and University of Washington School of Medicine, Seattle, Washington; Kaiser Permanente Center for Health Research, Portland, Oregon; University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania; University of California, Irvine School of Medicine, Orange, California; Brown University, Providence, Rhode Island; Harvard Pilgrim Health Care Institute and Harvard Medical School, Boston, Massachusetts; Hospital Corporation of America, Nashville, Tennessee; Texas A&M College of Medicine, Houston, Texas; CHB Wordsmith, Raleigh, North Carolina; University of Texas Southwestern Medical Center, Dallas, Texas; and Duke University School of Medicine, Durham, North Carolina
| | - Edward J Septimus
- From Kaiser Permanente Washington Health Research Institute, University of Washington, and University of Washington School of Medicine, Seattle, Washington; Kaiser Permanente Center for Health Research, Portland, Oregon; University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania; University of California, Irvine School of Medicine, Orange, California; Brown University, Providence, Rhode Island; Harvard Pilgrim Health Care Institute and Harvard Medical School, Boston, Massachusetts; Hospital Corporation of America, Nashville, Tennessee; Texas A&M College of Medicine, Houston, Texas; CHB Wordsmith, Raleigh, North Carolina; University of Texas Southwestern Medical Center, Dallas, Texas; and Duke University School of Medicine, Durham, North Carolina
| | - Karen L Staman
- From Kaiser Permanente Washington Health Research Institute, University of Washington, and University of Washington School of Medicine, Seattle, Washington; Kaiser Permanente Center for Health Research, Portland, Oregon; University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania; University of California, Irvine School of Medicine, Orange, California; Brown University, Providence, Rhode Island; Harvard Pilgrim Health Care Institute and Harvard Medical School, Boston, Massachusetts; Hospital Corporation of America, Nashville, Tennessee; Texas A&M College of Medicine, Houston, Texas; CHB Wordsmith, Raleigh, North Carolina; University of Texas Southwestern Medical Center, Dallas, Texas; and Duke University School of Medicine, Durham, North Carolina
| | - Miguel A Vazquez
- From Kaiser Permanente Washington Health Research Institute, University of Washington, and University of Washington School of Medicine, Seattle, Washington; Kaiser Permanente Center for Health Research, Portland, Oregon; University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania; University of California, Irvine School of Medicine, Orange, California; Brown University, Providence, Rhode Island; Harvard Pilgrim Health Care Institute and Harvard Medical School, Boston, Massachusetts; Hospital Corporation of America, Nashville, Tennessee; Texas A&M College of Medicine, Houston, Texas; CHB Wordsmith, Raleigh, North Carolina; University of Texas Southwestern Medical Center, Dallas, Texas; and Duke University School of Medicine, Durham, North Carolina
| | - William M Vollmer
- From Kaiser Permanente Washington Health Research Institute, University of Washington, and University of Washington School of Medicine, Seattle, Washington; Kaiser Permanente Center for Health Research, Portland, Oregon; University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania; University of California, Irvine School of Medicine, Orange, California; Brown University, Providence, Rhode Island; Harvard Pilgrim Health Care Institute and Harvard Medical School, Boston, Massachusetts; Hospital Corporation of America, Nashville, Tennessee; Texas A&M College of Medicine, Houston, Texas; CHB Wordsmith, Raleigh, North Carolina; University of Texas Southwestern Medical Center, Dallas, Texas; and Duke University School of Medicine, Durham, North Carolina
| | - Douglas Zatzick
- From Kaiser Permanente Washington Health Research Institute, University of Washington, and University of Washington School of Medicine, Seattle, Washington; Kaiser Permanente Center for Health Research, Portland, Oregon; University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania; University of California, Irvine School of Medicine, Orange, California; Brown University, Providence, Rhode Island; Harvard Pilgrim Health Care Institute and Harvard Medical School, Boston, Massachusetts; Hospital Corporation of America, Nashville, Tennessee; Texas A&M College of Medicine, Houston, Texas; CHB Wordsmith, Raleigh, North Carolina; University of Texas Southwestern Medical Center, Dallas, Texas; and Duke University School of Medicine, Durham, North Carolina
| | - Adrian F Hernandez
- From Kaiser Permanente Washington Health Research Institute, University of Washington, and University of Washington School of Medicine, Seattle, Washington; Kaiser Permanente Center for Health Research, Portland, Oregon; University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania; University of California, Irvine School of Medicine, Orange, California; Brown University, Providence, Rhode Island; Harvard Pilgrim Health Care Institute and Harvard Medical School, Boston, Massachusetts; Hospital Corporation of America, Nashville, Tennessee; Texas A&M College of Medicine, Houston, Texas; CHB Wordsmith, Raleigh, North Carolina; University of Texas Southwestern Medical Center, Dallas, Texas; and Duke University School of Medicine, Durham, North Carolina
| | - Richard Platt
- From Kaiser Permanente Washington Health Research Institute, University of Washington, and University of Washington School of Medicine, Seattle, Washington; Kaiser Permanente Center for Health Research, Portland, Oregon; University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania; University of California, Irvine School of Medicine, Orange, California; Brown University, Providence, Rhode Island; Harvard Pilgrim Health Care Institute and Harvard Medical School, Boston, Massachusetts; Hospital Corporation of America, Nashville, Tennessee; Texas A&M College of Medicine, Houston, Texas; CHB Wordsmith, Raleigh, North Carolina; University of Texas Southwestern Medical Center, Dallas, Texas; and Duke University School of Medicine, Durham, North Carolina
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8
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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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9
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Abstract
With pragmatic clinical trials, an opportunity exists to answer important questions about the relative risks, burdens, and benefits of therapeutic interventions. However, concerns about protecting the privacy of this information are significant and must be balanced with the imperative to learn from the data gathered in routine clinical practice. Traditional privacy protections for research uses of identifiable information rely disproportionately on informed consent or authorizations, based on a presumption that this is necessary to fulfill ethical principles of respect for persons. But frequently, the ideal of informed consent is not realized in its implementation. Moreover, the principle of respect for persons—which encompasses their interests in health information privacy—can be honored through other mechanisms. Data anonymization also plays a role in protecting privacy but is not suitable for all research, particularly pragmatic clinical trials. In this article, we explore both the ethical foundation and regulatory framework intended to protect privacy in pragmatic clinical trials. We then review examples of novel approaches to respecting persons in research that may have the added benefit of honoring patient privacy considerations.
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Affiliation(s)
- Deven McGraw
- Manatt, Phelps & Phillips, LLP, Washington, DC, USA
| | - Sarah M Greene
- Patient-Centered Outcomes Research Institute, Washington, DC, USA
| | | | | | | | - Alan Rubel
- University of Wisconsin-Madison, Madison, WI, USA
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10
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Finkelstein JA, Brickman AL, Capron A, Ford DE, Gombosev A, Greene SM, Iafrate RP, Kolaczkowski L, Pallin SC, Pletcher MJ, Staman KL, Vazquez MA, Sugarman J. Oversight on the borderline: Quality improvement and pragmatic research. Clin Trials 2015; 12:457-66. [PMID: 26374685 DOI: 10.1177/1740774515597682] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Pragmatic research that compares interventions to improve the organization and delivery of health care may overlap, in both goals and methods, with quality improvement activities. When activities have attributes of both research and quality improvement, confusion often arises about what ethical oversight is, or should be, required. For routine quality improvement, in which the delivery of health care is modified in minor ways that create only minimal risks, oversight by local clinical or administrative leaders utilizing institutional policies may be sufficient. However, additional consideration should be given to activities that go beyond routine, local quality improvement to first determine whether such non-routine activities constitute research or quality improvement and, in either case, to ensure that independent oversight will occur. This should promote rigor, transparency, and protection of patients' and clinicians' rights, well-being, and privacy in all such activities. Specifically, we recommend that (1) health care organizations should have systematic policies and processes for designating activities as routine quality improvement, non-routine quality improvement, or quality improvement research and determining what oversight each will receive. (2) Health care organizations should have formal and explicit oversight processes for non-routine quality improvement activities that may include input from institutional quality improvement experts, health services researchers, administrators, clinicians, patient representatives, and those experienced in the ethics review of health care activities. (3) Quality improvement research requires review by an institutional review board; for such review to be effective, institutional review boards should develop particular expertise in assessing quality improvement research. (4) Stakeholders should be included in the review of non-routine quality improvement and quality improvement-related research proposals. Only by doing so will we optimally leverage both pragmatic research on health care delivery and local implementation through quality improvement as complementary activities for improving health.
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Affiliation(s)
- Jonathan A Finkelstein
- Division of General Pediatrics, Boston Children's Hospital, Departments of Pediatrics and Population Medicine, Harvard Medical School, Boston, MA, USA
| | | | - Alexander Capron
- Gould School of Law and Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Daniel E Ford
- Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Adrijana Gombosev
- School of Medicine, University of California, Irvine, Irvine, CA, USA
| | - Sarah M Greene
- Patient-Centered Outcomes Research Institute, Washington, DC, USA
| | | | - Laura Kolaczkowski
- Multiple Sclerosis Patient-Powered Research Network, University of Dayton, Dayton, OH, USA
| | | | | | | | - Miguel A Vazquez
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Jeremy Sugarman
- Johns Hopkins Berman Institute of Bioethics, Baltimore, MD, USA
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11
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Smalley JB, Merritt MW, Al-Khatib SM, McCall D, Staman KL, Stepnowsky C. Ethical responsibilities toward indirect and collateral participants in pragmatic clinical trials. Clin Trials 2015; 12:476-84. [PMID: 26374687 DOI: 10.1177/1740774515597698] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Pragmatic clinical trials are designed to inform decision makers about the benefits, burdens, and risks of health interventions in real-world settings. Pragmatic clinical trials often use for research purposes data collected in the course of clinical practice. The distinctive features of pragmatic clinical trials demand fresh thinking about what is required to act properly toward people affected by their conduct, in ways that go beyond ensuring the protection of rights and welfare for "human research subjects" under conventional research ethics regulations. To stimulate such work, we propose to distinguish among categories of research participants in pragmatic clinical trials as follows: Direct participants: (1) individuals being directly intervened upon and/or (2) individuals from whom personal identifiable data are being collected for the purposes of the pragmatic clinical trial. Indirect participants: individuals who are (1) not identified as direct participants and (2) whose rights and welfare may be affected by the intervention through their routine exposure to the environment in which the intervention is being deployed. Collateral participants: patient groups and other stakeholder communities who may be otherwise affected by the occurrence and findings of the pragmatic clinical trial. We illustrate these distinctions with case examples and discuss the distinctive responsibilities of researchers and pragmatic clinical trial leadership toward each type of participant. We suggest that pragmatic clinical trial investigators, institutional review boards, health systems leaders, and others engaged in the research enterprise work together to identify these participants. For indirect participants, risks and benefits to which they are exposed should be weighed to ensure that their rights and welfare are protected accordingly, and communication strategies should be considered to help them make well-informed decisions. Collateral participants could provide input on the design, planning, and conduct of a pragmatic clinical trial and offer insights regarding the best way to communicate the trial's results to their constituencies.
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Affiliation(s)
- Jaye Bea Smalley
- Patient-Centered Outcomes Research Institute (PCORI), Washington, DC, USA
| | - Maria W Merritt
- Berman Institute of Bioethics and Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
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12
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Stone GW, Ohman EM, Miller MF, Joseph DL, Christenson JT, Cohen M, Urban PM, Reddy RC, Freedman RJ, Staman KL, Ferguson JJ. Contemporary utilization and outcomes of intra-aortic balloon counterpulsation in acute myocardial infarction: the benchmark registry. J Am Coll Cardiol 2003; 41:1940-5. [PMID: 12798561 DOI: 10.1016/s0735-1097(03)00400-5] [Citation(s) in RCA: 160] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
OBJECTIVES We sought to examine contemporary utilization patterns and clinical outcomes in patients with acute myocardial infarction (AMI) requiring intra-aortic balloon pump (IABP) counterpulsation. BACKGROUND Despite increasing experience with and broadened indications for intra-aortic counterpulsation, the current indications, associated complications, and clinical outcomes of IABP use in AMI are unknown. METHODS Between June 1996 and August 2001, data were prospectively collected from 22,663 consecutive patients treated with aortic counterpulsation at 250 medical centers worldwide; 5,495 of these patients had AMI. RESULTS Placement of an IABP in AMI patients was most frequently indicated for cardiogenic shock (27.3%), hemodynamic support during catheterization and/or angioplasty (27.2%) or prior to high-risk surgery (11.2%), mechanical complications of AMI (11.7%), and refractory post-myocardial infarction unstable angina (10.0%). Balloon insertions were successful in 97.7% of patients. Diagnostic catheterization was performed in 96% of patients, and 83% underwent coronary revascularization before hospital discharge. The in-hospital mortality rate was 20.0% (38.7% in patients with shock) and varied markedly by indication and use of revascularization procedures. Major IABP complications occurred in only 2.7% of patients, despite median use for three days, and early IABP discontinuation was required in only 2.1% of patients. CONCLUSIONS With contemporary advances in device technology, insertion technique, and operator experience, IABP counterpulsation may be successfully employed for a wide variety of conditions in the AMI setting, providing significant hemodynamic support with rare major complications in a high-risk patient population.
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Affiliation(s)
- Gregg W Stone
- Cardiovascular Research Foundation and Lenox Hill Hospital, 55 East 59th Street, 6th Floor, New York, NY 10022, USA.
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13
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Roe MT, Staman KL, Pollack C, Teaff R, French PA, Peterson ED. A practical guide to understanding the 2002 ACC/AHA guidelines for the management of patients with non-ST segment elevation acute coronary syndromes. Crit Pathw Cardiol 2002; 1:129-149. [PMID: 18340297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Affiliation(s)
- Matthew T Roe
- Duke Clinical Research Institute, Durham, North Carolina 27701, USA.
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14
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