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Chen CC, Chiu CC, Hao WR, Hsu MH, Liu JC, Lin JL. Sex differences in clinical characteristics and long-term clinical outcomes in Asian hospitalized heart failure patients. ESC Heart Fail 2024. [PMID: 38863210 DOI: 10.1002/ehf2.14888] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2024] [Revised: 04/28/2024] [Accepted: 05/09/2024] [Indexed: 06/13/2024] Open
Abstract
AIMS Sex differences in long-term post-discharge clinical outcomes in Asian patients hospitalized for acute decompensated heart failure (HF) persist despite the world-wide implementation of guideline-directed medical therapy for decades. The present study aims to elucidate the puzzling dilemma and to depict the directions of solution. METHODS AND RESULTS Between 2011 and 2020, a total of 12 428 patients (6518 men and 5910 women, mean age 73.50 ± 14.85) hospitalized for acute decompensated HF were retrospectively enrolled from a university HF cohort. Compared with men, women hospitalized for acute decompensated HF were older in age (76.40 ± 13.43 vs. 71.20 ± 15.67 years old, P < 0.0001) with more coexisting hypertension, diabetes, hyperlipidaemia and moderate to severe chronic kidney disease, but less with ischaemic heart disease, cerebrovascular disease and chronic obstructive pulmonary disease (P < 0.0001). In echocardiography measurement parameters, women had smaller left ventricular and left atrial dimensions, higher left ventricular mass index, higher left ventricular ejection fraction (LVEF) and more in HF with preserved ejection fraction (EF) category (LVEF > 50%) than men (P < 0.0001). In HF therapy, women compared with men received more guideline-directed medical HF therapies including angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, angiotensin receptor-neprilysin inhibitors and sodium-glucose cotransporter-2 inhibitors, but similar beta-blockers and mineralocorticoid receptor antagonists (P < 0.0001). Post-discharge long-term clinical outcomes after multivariate-adjusted analysis revealed that women compared with men had lower all-cause mortality [adjusted hazard ratio (aHR): 0.89, 95% confidence interval (CI): 0.84-0.93], lower cardiovascular mortality (aHR: 0.89, 95% CI: 0.80-0.99) and lower 1 year mortality (aHR: 0.91, 95% CI: 0.84-0.99) but similar HF rehospitalization rate (aHR: 1.02, 95% CI: 0.95-1.09) over 8 years of follow-up. The superiority of women over men in all-cause mortality was shown in HF with preserved EF (>50%) and HF with mildly reduced EF (40%-50%), but not in HF with reduced EF (<40%) category. Subgroup forest plot analysis showed body mass index, coexisting hypertension and chronic obstructive pulmonary disease as significant interacting factors. CONCLUSIONS With more coronary risk factors and medical comorbidities, less cardiac remodelling and better adherence to guideline-directed HF therapy, women hospitalized for acute decompensated HF demonstrated superiority over men in long-term post-discharge clinical outcomes, including all-cause mortality, cardiovascular mortality and 1 year mortality, and mainly in HF with preserved and mid-range EF categories, in the Asian HF cohort.
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Affiliation(s)
- Chun-Chao Chen
- Division of Cardiology, Department of Internal Medicine, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan
- Division of Cardiology, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
- Graduate Institute of Medical Sciences, College of Medicine, Taipei Medical University, Taipei, Taiwan
- Taipei Heart Institute, Taipei Medical University, Taipei, Taiwan
| | - Chun-Chih Chiu
- Division of Cardiology, Department of Internal Medicine, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan
- Taipei Heart Institute, Taipei Medical University, Taipei, Taiwan
| | - Wen-Rui Hao
- Division of Cardiology, Department of Internal Medicine, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan
- Division of Cardiology, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
- Taipei Heart Institute, Taipei Medical University, Taipei, Taiwan
| | - Min-Huei Hsu
- Graduate Institute of Data Science, College of Management, Taipei Medical University, Taipei, Taiwan
- Department of Neurosurgery, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
| | - Ju-Chi Liu
- Division of Cardiology, Department of Internal Medicine, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan
- Division of Cardiology, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
- Taipei Heart Institute, Taipei Medical University, Taipei, Taiwan
| | - Jiunn-Lee Lin
- Division of Cardiology, Department of Internal Medicine, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan
- Division of Cardiology, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
- Taipei Heart Institute, Taipei Medical University, Taipei, Taiwan
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Prasun MA, Hubbell A, Rathman L, Stamp KD. The Heart Failure Patient Foundation Position Statement on Research and Patient Involvement. Heart Lung 2024; 66:A1-A4. [PMID: 38584011 DOI: 10.1016/j.hrtlng.2024.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2024] [Accepted: 04/02/2024] [Indexed: 04/09/2024]
Abstract
BACKGROUND Heart Failure (HF) is a growing global public health problem affecting approximately 64 million people worldwide. OBJECTIVES The Heart Failure Patient Foundation developed a position statement to advocate for adult patients with HF to be an active participant in research and for HF leaders to integrate patients throughout the research process. METHODS A review of the literature and best practices was conducted. Based on the evidence, the HF Patient Foundation made recommendations regarding the inclusion of adult patients with HF throughout the research process. RESULTS Healthcare clinicians, researchers and funding agencies have a role to ensure rigorous quality research is performed and implemented into practice. Inclusion of adult patients with HF throughout the research process can improve the lives of patients and families while advancing HF science. CONCLUSIONS The HF Patient Foundation strongly advocates that patients with HF be involved in research from inception of the project through dissemination of findings to improve patient outcomes.
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Affiliation(s)
- Marilyn A Prasun
- Illinois State University, Mennonite College of Nursing, Normal, IL, USA.
| | - Annette Hubbell
- Illinois State University, Mennonite College of Nursing, Normal, IL, USA
| | - Lisa Rathman
- Heart Failure Program, Penn Medicine, Lancaster General Health, Lancaster, PL, USA
| | - Kelly D Stamp
- University of Colorado Anschutz, College of Nursing, Aurora, CO, USA
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Kerwagen F, Ohlmeier C, Evers T, Herrmann S, Bayh I, Michel A, Kruppert S, Wilfer J, Wachter R, Böhm M, Störk S. Real-world characteristics and use patterns of patients treated with vericiguat: A nationwide longitudinal cohort study in Germany. Eur J Clin Pharmacol 2024; 80:931-940. [PMID: 38472389 PMCID: PMC11098883 DOI: 10.1007/s00228-024-03654-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Accepted: 02/19/2024] [Indexed: 03/14/2024]
Abstract
PURPOSE Vericiguat reduced clinical endpoints in patients experiencing worsening heart failure in clinical trials, but its implementation outside trials is unclear. METHODS This retrospective analysis of longitudinally collected data was based on the IQVIA™ LRx database, which includes ~ 80% of the prescriptions of the 73 million people covered by the German statutory health insurance. RESULTS Between September 2021 and December 2022, vericiguat was initiated in 2916 adult patients. Their mean age was 73 ± 13 years and 28% were women. While approximately 70% were uptitrated beyond 2.5 mg, only 36% reached 10 mg. Median time to up-titration from 2.5 mg to 5 mg was 17 (quartiles: 11-33) days, and from 2.5 to 10 mg 37 (25-64) days, respectively. In 87% of the patients, adherence to vericiguat was high as indicated by a medication possession ratio of ≥ 80%, and 67% of the patients persistently used vericiguat during the first year. Women and older patients reached the maximal dose of 10 mg vericiguat less often and received other substance classes of guideline-recommended therapy (GDMT) less frequently. The proportion of patients receiving four pillars of GDMT increased from 29% before vericiguat initiation to 44% afterwards. CONCLUSION In a real-world setting, despite higher age than in clinical trials, adherence and persistence of vericiguat appeared satisfactory across age categories. Initiation of vericiguat was associated with intensification of concomitant GDMT. Nevertheless, barriers to vericiguat up-titration and implementation of other GDMT, applying in particular to women and elderly patients, need to be investigated further.
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Affiliation(s)
- Fabian Kerwagen
- Department of Clinical Research and Epidemiology, Comprehensive Heart Failure Center, University Hospital Würzburg, D-97080, Würzburg, Germany
- Department of Internal Medicine I, University Hospital Würzburg, D-97080, Würzburg, Germany
| | | | | | | | | | | | | | - Joanna Wilfer
- IQVIA Commercial GmbH & Co. OHG, Frankfurt am Main, Germany
| | - Rolf Wachter
- Department of Cardiology, University Hospital Leipzig, Leipzig, Germany
| | - Michael Böhm
- Department of Internal Medicine Clinic III, Saarland University Hospital, Homburg/Saar, Germany
| | - Stefan Störk
- Department of Clinical Research and Epidemiology, Comprehensive Heart Failure Center, University Hospital Würzburg, D-97080, Würzburg, Germany.
- Department of Internal Medicine I, University Hospital Würzburg, D-97080, Würzburg, Germany.
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Paleoudis EG, Han Z, Gelman S, Arias-Ruiz H, Carter D, Bertrand J, Mastrogiovanni N, Terlecky SR. Improved clinical trial race/ethnicity reporting and updated inclusion profile, 2017-2022: A New Jersey snapshot. GLOBAL EPIDEMIOLOGY 2024; 7:100134. [PMID: 38259323 PMCID: PMC10801241 DOI: 10.1016/j.gloepi.2023.100134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Revised: 11/30/2023] [Accepted: 12/20/2023] [Indexed: 01/24/2024] Open
Abstract
Background Diverse representation in clinical trials is an important goal in the testing of a medical, diagnostic, or therapeutic intervention. To date, the desired level of trial equity and inclusivity has been unevenly achieved. Methods Employing the US National Library of Medicine's Clinicaltrials.gov registry, we examined 481 clinical trials conducted - at least in part - in the state of New Jersey. These trials were initiated after the FDA-mandated Common Rule changes, i.e., between January 2017 and October 2022, were enacted, and had their results posted. We analyzed sex/race/ethnicity reporting as well as applicable enrollment. Using meta-analysis, we estimated group participation proportions of a subset of the 481 identified trials; specifically, the 229 studies that were conducted solely within the US (i.e., without international sites) and compared them to US census data. Findings Within the 481 clinical trials analyzed, over 97% reported on the race and/or ethnicity of their enrollees; all included information on sex. Reporting was not affected by funding source or therapeutic area. Based on the 229 solely US-based studies, the participants overall were 76.7% White; 14.1% Black; 2.7% Asian; and 15% Hispanic. Inclusion of Black participants did not differ from the 2020 US census data; in contrast, the levels of Asian and Hispanic participation were below the corresponding census percentages. Interpretation The past five years have seen an overall uptick in the equity of race/ethnicity reporting and inclusivity of clinical trials, as compared to previously reported data, presaging the potential acquisition of ever more powerful and meaningful results of such interventional studies going forward. Funding Support for this study comes from the Hackensack Meridian Health Research Institute and the Hackensack Meridian School of Medicine. Research in context Evidence before this studyClinical trials are a critical part of determining whether or not a medical (drug/device/biologic) or socio-behavioral intervention is safe and truly effective. Through their use, scientific understanding is advanced and, ideally, human health is improved. To gain the most impactful information from a clinical trial, it should be sufficiently representative, that is, should enroll an adequate number of participants, and include a diverse population. Without such inclusion, the study is of only limited generalizability. Efforts are underway by funders, sites, and other stakeholders, to enhance reporting and promote inclusive enrollment. The extent to which such attempts are yielding results - at least for clinical trials in the state of New Jersey - is the focus of this data-driven analysis. The ClinicalTrials.gov registry database was carefully mined for the information contained in this report.Added value of this studyOur analysis of clinical trials initiated in the state of New Jersey and conducted there or elsewhere in the US reveals several positive trends. Our 5-year snapshot reveals that a very large percentage of trials report on race/ethnicity - and inclusivity is improving. While there is still some way to go to have the demographic numbers in these trials match US census values, our results suggest that recent efforts are having an effect.Implications of all the available evidenceFor myriad reasons, clinical trials have not enjoyed the public's universal trust over the years. In many ways, medicine moves at the speed of trust - without it, the promise of modern healthcare is brought into question. Clinical trials must include a commitment to diverse enrollment pools and equitable reporting under the law. Creating a legacy of trust - through greater inclusivity in clinical trials and more transparent reporting of results - will begin to heal the divide and engender faith in modern medicine and today's healthcare system. It would also allow for the desired far-reaching generalizability of results across patient populations. To better appreciate what needs to be done going forward, we must truly understand the state of clinical trials reporting and demographic inclusion. This report initiates such an analysis, by carefully documenting how New Jersey's clinical trials are performing. By virtue of its location (e.g., proximity to the cities of New York and Philadelphia) the state is part of a large biopharma cluster and healthcare nexus; it is critical that it performs well with respect to adopting/adhering to updated clinical trial guideline mandates. This report provides a glimpse - an important first look - into the state of clinical trials in New Jersey - from 2017 through 2022.
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Affiliation(s)
- Elli Gourna Paleoudis
- Department of Medical Sciences, Hackensack Meridian School of Medicine, Nutley, NJ, USA
- Office of Research Administration, Hackensack Meridian Health Research Institute, Nutley, NJ, USA
| | - Zhiyong Han
- Department of Medical Sciences, Hackensack Meridian School of Medicine, Nutley, NJ, USA
| | - Simon Gelman
- Office of Research Administration, Hackensack Meridian Health Research Institute, Nutley, NJ, USA
| | - Hernan Arias-Ruiz
- Department of Medical Sciences, Hackensack Meridian School of Medicine, Nutley, NJ, USA
| | - Destiney Carter
- Department of Medical Sciences, Hackensack Meridian School of Medicine, Nutley, NJ, USA
| | - Jovan Bertrand
- Department of Medical Sciences, Hackensack Meridian School of Medicine, Nutley, NJ, USA
| | - Nicole Mastrogiovanni
- Department of Medical Sciences, Hackensack Meridian School of Medicine, Nutley, NJ, USA
| | - Stanley R. Terlecky
- Department of Medical Sciences, Hackensack Meridian School of Medicine, Nutley, NJ, USA
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Jin N, Zhang M, Zhou L, Jin S, Cheng H, Li X, Shi Y, Xiang T, Zhang Z, Liu Z, Zhao H, Xie J. Mitochondria transplantation alleviates cardiomyocytes apoptosis through inhibiting AMPKα-mTOR mediated excessive autophagy. FASEB J 2024; 38:e23655. [PMID: 38767449 DOI: 10.1096/fj.202400375r] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2024] [Revised: 04/16/2024] [Accepted: 04/23/2024] [Indexed: 05/22/2024]
Abstract
The disruption of mitochondria homeostasis can impair the contractile function of cardiomyocytes, leading to cardiac dysfunction and an increased risk of heart failure. This study introduces a pioneering therapeutic strategy employing mitochondria derived from human umbilical cord mesenchymal stem cells (hu-MSC) (MSC-Mito) for heart failure treatment. Initially, we isolated MSC-Mito, confirming their functionality. Subsequently, we monitored the process of single mitochondria transplantation into recipient cells and observed a time-dependent uptake of mitochondria in vivo. Evidence of human-specific mitochondrial DNA (mtDNA) in murine cardiomyocytes was observed after MSC-Mito transplantation. Employing a doxorubicin (DOX)-induced heart failure model, we demonstrated that MSC-Mito transplantation could safeguard cardiac function and avert cardiomyocyte apoptosis, indicating metabolic compatibility between hu-MSC-derived mitochondria and recipient mitochondria. Finally, through RNA sequencing and validation experiments, we discovered that MSC-Mito transplantation potentially exerted cardioprotection by reinstating ATP production and curtailing AMPKα-mTOR-mediated excessive autophagy.
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Affiliation(s)
- Ning Jin
- Department of Biochemistry and Molecular Biology, Shanxi Key Laboratory of Birth Defect and Cell Regeneration, Key Laboratory of Coal Environmental Pathogenicity and Prevention, Ministry of Education, Shanxi Medical University, Taiyuan, China
- Department of Histology and Embryology, Shanxi Medical University, Taiyuan, China
| | - Mengyao Zhang
- Department of Biochemistry and Molecular Biology, Shanxi Key Laboratory of Birth Defect and Cell Regeneration, Key Laboratory of Coal Environmental Pathogenicity and Prevention, Ministry of Education, Shanxi Medical University, Taiyuan, China
| | - Li Zhou
- Department of Biochemistry and Molecular Biology, Shanxi Key Laboratory of Birth Defect and Cell Regeneration, Key Laboratory of Coal Environmental Pathogenicity and Prevention, Ministry of Education, Shanxi Medical University, Taiyuan, China
| | - Shanshan Jin
- Department of Biochemistry and Molecular Biology, Shanxi Key Laboratory of Birth Defect and Cell Regeneration, Key Laboratory of Coal Environmental Pathogenicity and Prevention, Ministry of Education, Shanxi Medical University, Taiyuan, China
| | - Haiqin Cheng
- Department of Biochemistry and Molecular Biology, Shanxi Key Laboratory of Birth Defect and Cell Regeneration, Key Laboratory of Coal Environmental Pathogenicity and Prevention, Ministry of Education, Shanxi Medical University, Taiyuan, China
| | - Xuewei Li
- Department of Biochemistry and Molecular Biology, Shanxi Key Laboratory of Birth Defect and Cell Regeneration, Key Laboratory of Coal Environmental Pathogenicity and Prevention, Ministry of Education, Shanxi Medical University, Taiyuan, China
| | - Yaqian Shi
- Department of Biochemistry and Molecular Biology, Shanxi Key Laboratory of Birth Defect and Cell Regeneration, Key Laboratory of Coal Environmental Pathogenicity and Prevention, Ministry of Education, Shanxi Medical University, Taiyuan, China
| | - Tong Xiang
- Department of Biochemistry and Molecular Biology, Shanxi Key Laboratory of Birth Defect and Cell Regeneration, Key Laboratory of Coal Environmental Pathogenicity and Prevention, Ministry of Education, Shanxi Medical University, Taiyuan, China
| | - Zongxiao Zhang
- Department of Biochemistry and Molecular Biology, Shanxi Key Laboratory of Birth Defect and Cell Regeneration, Key Laboratory of Coal Environmental Pathogenicity and Prevention, Ministry of Education, Shanxi Medical University, Taiyuan, China
| | - Zhizhen Liu
- Department of Biochemistry and Molecular Biology, Shanxi Key Laboratory of Birth Defect and Cell Regeneration, Key Laboratory of Coal Environmental Pathogenicity and Prevention, Ministry of Education, Shanxi Medical University, Taiyuan, China
| | - Hong Zhao
- Department of Biochemistry and Molecular Biology, Shanxi Key Laboratory of Birth Defect and Cell Regeneration, Key Laboratory of Coal Environmental Pathogenicity and Prevention, Ministry of Education, Shanxi Medical University, Taiyuan, China
| | - Jun Xie
- Department of Biochemistry and Molecular Biology, Shanxi Key Laboratory of Birth Defect and Cell Regeneration, Key Laboratory of Coal Environmental Pathogenicity and Prevention, Ministry of Education, Shanxi Medical University, Taiyuan, China
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Woods RH. Equitable Representation of Pregnant and Lactating Women in Clinical Research: A Historical Review and Critical Analysis of Proposed Legislation. Am J Perinatol 2024. [PMID: 38631389 DOI: 10.1055/a-2308-3580] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/19/2024]
Abstract
A long history of policymaking and regulation constructed for the purpose of ensuring adequate fetal and infant protections has inadvertently sanctioned the widespread exclusion of pregnant and lactating patients from biomedical research, leaving a paucity of high quality data necessary for clinical decision-making. Although well-intended, the regulatory classification of pregnant women as "vulnerable," in conjunction with burdensome enrollment criteria and other factors weighing against broad inclusion, have ultimately placed the health and safety of these women and their babies in jeopardy. Robust measures are urgently needed to overcome patient and physician reluctance, address substantial evidence gaps, and rectify long-standing disparities which precipitate disproportionately poor health outcomes among this population. In February 2023, the Advancing Safe Medications for Moms and Babies Act of 2023 (the Act) was introduced in the United States House of Representatives with the overarching goal of enabling pregnant and lactating women to achieve equitable participation in clinical research and contribute to developing important biomedical knowledge to guide and improve health care delivered to these patients. This review discusses the historical influence of federal human subject protection regulations on the health and clinical treatment of pregnant and lactating women, outlines and critically analyzes the provisions incorporated into the Act, and reflects on the potential long-term impact the Act would have should it be successful in becoming law. KEY POINTS: · Pregnant and lactating patients are widely excluded from clinical research.. · Evidence guiding the treatment of these patients is limited and of unacceptably low quality.. · Proposed legislation seeks to rectify disparities and empower these patients through improved representation in research..
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Affiliation(s)
- Richard H Woods
- Levin, Papantonio, Rafferty, Proctor, Buchanan, O'Brien, Barr & Mougey, P.A., Pensacola, Florida
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Britez Ferrante E, Blady S, Sheu D, Maitra MR, Drakes J, Lieberman A, Mussell A, Bair EF, Hearn CM, Thorbecke L, Zhu J, Kohn R. Operationalizing Equity, Inclusion, and Access in Research Practice at a Large Academic Institution. J Gen Intern Med 2024; 39:1037-1047. [PMID: 38302812 DOI: 10.1007/s11606-023-08539-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Accepted: 11/15/2023] [Indexed: 02/03/2024]
Abstract
INTRODUCTION Healthcare advances are hindered by underrepresentation in prospective research; sociodemographic, data, and measurement infidelity in retrospective research; and a paucity of guidelines surrounding equitable research practices. OBJECTIVE The Joint Research Practices Working Group was created in 2021 to develop and disseminate guidelines for the conduct of inclusive and equitable research. METHODS Volunteer faculty and staff from two research centers at the University of Pennsylvania initiated a multi-pronged approach to guideline development, including literature searches, center-level feedback, and mutual learning with local experts. RESULTS We developed guidelines for (1) participant payment and incentives; (2) language interpretation and translation; (3) plain language in research communications; (4) readability of study materials; and (5) inclusive language for scientific communications. Key recommendations include (1) offer cash payments and multiple payment options to participants when required actions are completed; (2) identify top languages of your target population, map points of contact, and determine available interpretation and translation resources; (3) assess reading levels of materials and simplify language, targeting 6th- to 8th-grade reading levels; (4) improve readability through text formatting and style, symbols, and visuals; and (5) use specific, humanizing terms as adjectives rather than nouns. CONCLUSIONS Diversity, inclusion, and access are critical values for research conduct that promotes justice and equity. These values can be operationalized through organizational commitment that combines bottom-up and top-down approaches and through partnerships across organizations that promote mutual learning and synergy. While our guidelines represent best practices at one time, we recognize that practices evolve and need to be evaluated continuously for accuracy and relevance. Our intention is to bring awareness to these critical topics and form a foundation for important conversations surrounding equitable and inclusive research practices.
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Affiliation(s)
- Emma Britez Ferrante
- Palliative and Advanced Illness Research (PAIR) Center at the University of Pennsylvania, Philadelphia, PA, USA
| | - Shira Blady
- Palliative and Advanced Illness Research (PAIR) Center at the University of Pennsylvania, Philadelphia, PA, USA
| | - Dorothy Sheu
- Palliative and Advanced Illness Research (PAIR) Center at the University of Pennsylvania, Philadelphia, PA, USA
| | - Medha Romee Maitra
- Palliative and Advanced Illness Research (PAIR) Center at the University of Pennsylvania, Philadelphia, PA, USA
- University of Georgia, Athens, GA, USA
| | - Josiah Drakes
- Palliative and Advanced Illness Research (PAIR) Center at the University of Pennsylvania, Philadelphia, PA, USA
- Xavier University of Louisiana, New Orleans, LA, USA
| | - Adina Lieberman
- Palliative and Advanced Illness Research (PAIR) Center at the University of Pennsylvania, Philadelphia, PA, USA
| | - Adam Mussell
- Center for Health Incentives and Behavioral Economics (CHIBE) at the University of Pennsylvania, Philadelphia, PA, USA
| | - Elizabeth F Bair
- Center for Health Incentives and Behavioral Economics (CHIBE) at the University of Pennsylvania, Philadelphia, PA, USA
- Department of Medical Ethics and Health Policy, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Caleb M Hearn
- Center for Health Incentives and Behavioral Economics (CHIBE) at the University of Pennsylvania, Philadelphia, PA, USA
- Department of Medical Ethics and Health Policy, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Leo Thorbecke
- Department of Computer and Information Science, University of Pennsylvania, Philadelphia, PA, USA
- Center for Digital Health, Penn Medicine Center for Health Care Innovation, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Jingsan Zhu
- Center for Health Incentives and Behavioral Economics (CHIBE) at the University of Pennsylvania, Philadelphia, PA, USA
- Department of Medical Ethics and Health Policy, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Rachel Kohn
- Palliative and Advanced Illness Research (PAIR) Center at the University of Pennsylvania, Philadelphia, PA, USA.
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.
- Leonard Davis Institute of Health Economics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.
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de Tantillo L, McCabe BE, Zdanowicz M, Ortega J, Gonzalez JM, Chaparro S. Implementing Strategies to Recruit and Retain a Diverse Sample of Heart Failure Patients. HISPANIC HEALTH CARE INTERNATIONAL 2024:15404153241248144. [PMID: 38646673 DOI: 10.1177/15404153241248144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/23/2024]
Abstract
Introduction: The increased prevalence, severity, and mortality of heart disease and specifically heart failure among Hispanic and Black populations are a concern for clinicians and researchers. Additionally, patients of poor socioeconomic status also have worse outcomes for cardiovascular disease. To address disparities, it is necessary to address the persistent lack of representation in clinical research of diverse populations, including the Hispanic and Black populations and individuals who are of low socioeconomic status. Method: This study was a pilot randomized trial of a medication adherence intervention for heart failure patients conducted at a safety net hospital and affiliated pharmacy with a diverse patient population. Using an evidence-based multifactorial approach, this investigation implemented and adapted best practices to support the inclusion of Hispanic, Black, and socioeconomically diverse participants. Results: A total of 40 participants were recruited, 58% were Hispanic, 38% Black, and 5% White. A total of 40% reported the need for socioeconomic assistance. At 30 days after discharge, follow-up data were obtained for 37 of 40 (93%) of participants either by interview, electronic record, or both. Conclusion: Findings suggest that a combination of strategies used in this trial can be applied to recruit and retain ethnically and socioeconomically diverse participants.
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Affiliation(s)
- Lila de Tantillo
- Brooks Rehabilitation College of Healthcare Sciences, Keigwin School of Nursing, Jacksonville University, Jacksonville, FL, USA
| | - Brian E McCabe
- Department of Special Education, Rehabilitation, and Counseling (SERC), Auburn University, Auburn, AL, USA
| | | | - Johis Ortega
- School of Nursing and Health Studies, University of Miami, Coral Gables, FL, USA
| | - Juan M Gonzalez
- School of Nursing and Health Studies, University of Miami, Coral Gables, FL, USA
| | - Sandra Chaparro
- Miami Cardiac and Vascular Institute, Baptist Health South Florida, Miami, FL, USA
- Herbert Wertheim School of Medicine, Florida International University, Miami, FL, USA
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Gosselin M, Baroud ML, Denis OR, Gagnon ME, Sirois C. Evidence-based data for newly approved medications' use in older adults: An analysis from clinical trials to monographs. J Am Geriatr Soc 2024; 72:1252-1262. [PMID: 38270204 DOI: 10.1111/jgs.18772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Revised: 12/05/2023] [Accepted: 12/20/2023] [Indexed: 01/26/2024]
Abstract
BACKGROUND Older adults have historically been excluded from clinical trials, limiting evidence-based data. An updated picture of the situation with newly marketed medications is needed. We aimed to describe (1) the recommendations specific to older adults in monographs of newly marketed medications; (2) the representation of older adults in clinical trials of those medications. METHODS In November 2020, we listed all medications that received a notice of compliance from Health Canada between January 2006 and September 2020, excluding those with indications irrelevant to community-dwelling older adults and locally acting medications. We assessed the availability and clarity of recommendations in monographs regarding older adults. Using Clinicaltrials.gov, we identified randomized controlled double-blind Phase III-IV trials led in Canada/United States of a sample of 30 commonly used medications among those previously listed. We extracted information on study design, participants, and efficacy/safety analysis specific to older patients. We used simple linear regression and Chi-square/Fisher's exact tests to analyze time trends in the representation of older adults over different periods. RESULTS A total of 195 monographs were included. Of the 130 monographs reporting a dosing recommendation in older adults, 53 (41%) also reported limited/insufficient data in this population or its subgroups. Of the 373 trials included, 217 (58%) did not integrate a maximum age as an inclusion criterion. However, only 113 (30%) reported including a proportion of older adults representative (or over-representative) of the Canadian older population. Most trials (n = 289; 78%) did not provide efficacy or safety data specific to older adults. In our sample, the number/proportion of older adults in trials seemed to be increasingly reported over time, either explicitly or implicitly (e.g., inclusion criterion specifies <65 years old). CONCLUSIONS Newly marketed medications still appear to under-represent older adults. The resulting lack of clear recommendations in monographs compromises evidence-based practice, thereby perpetuating the risk to older adults' health.
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Affiliation(s)
- Maude Gosselin
- Department of Social and Preventive Medicine, Faculty of Medicine, Université Laval, Quebec, Quebec, Canada
| | | | | | - Marie-Eve Gagnon
- Faculty of Pharmacy, Université Laval, Quebec, Quebec, Canada
- Department of Health Sciences, Université du Québec à Rimouski, Rimouski, Quebec, Canada
| | - Caroline Sirois
- Faculty of Pharmacy, Université Laval, Quebec, Quebec, Canada
- Centre d'excellence sur le vieillissement de Québec, Quebec, Quebec, Canada
- VITAM, Sustainable Health Research Centre, Quebec, Quebec, Canada
- CHU de Québec-Université Laval Research Centre, Quebec, Quebec, Canada
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10
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Sheikh H, Walczak N, Rana H, Tseng NW, Syed MK, Collier C, Rezk M, Gong IY, Tan NS, Ali SH, Yan AT, Randhawa VK, Banks L. Temporal Trends of Enrollment by Sex and Race in Major Cardiovascular Randomized Clinical Trials. CJC Open 2024; 6:454-462. [PMID: 38487060 PMCID: PMC10935985 DOI: 10.1016/j.cjco.2023.10.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 10/24/2023] [Indexed: 03/17/2024] Open
Abstract
Background Women and racialized minorities continue to be underrepresented in cardiovascular (CV) trial outcomes data, despite comprising a significant global burden of CV disease. This study evaluated the impact of trial characteristics on the temporal enrollment of women and racialized minorities in prominent CV trials published in the period 1986-2023. Methods MEDLINE was searched for CV trials published in The Lancet, the Journal of the American Medical Association, and the New England Journal of Medicine. Participant and investigator demographics, types of interventions, clinical indications, and funding sources were compared according to the enrollment of women or racialized minorities. Results From 799 studies, including 4,071,921 patients, the enrollment of women and racialized minorities significantly increased from 1986 to 2023 (both P ≤ 0.001). Although the enrollment of women varied by trial indication, comprising 25.0% of coronary artery disease, 35.2% of noncoronary and/or vascular disease, 13.8% of heart failure, 17.0% of arrhythmia, and 28.7% of other CV trials (P ≤ 0.001), it did not differ by peer-reviewed vs industry funding. First authors who were women were more likely than first authors who were men to enroll significantly more women (P = 0.01). Conclusions Active efforts to increase diverse enrollment, along with improved reporting, including of sex and race, in future CV trials may increase the generalizability of their findings and applicability to global populations.
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Affiliation(s)
- Hassan Sheikh
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Nicole Walczak
- Department of Epidemiology and Biostatistics, University of Western Ontario, London, Ontario, Canada
| | - Haaris Rana
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Nicholas W.H. Tseng
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
| | - Mohammad K. Syed
- Faculty of Health Sciences, Ontario Tech University, Oshawa, Ontario, Canada
| | - Chris Collier
- Faculty of Health Sciences, Ontario Tech University, Oshawa, Ontario, Canada
| | - Moemin Rezk
- Faculty of Health Sciences, Ontario Tech University, Oshawa, Ontario, Canada
| | - Inna Y. Gong
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Nigel S. Tan
- Division of Cardiology, Niagara Health System, Niagara, Ontario, Canada
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Sammy H. Ali
- Department of Medicine, St Mary’s General Hospital, Toronto, Ontario, Canada
| | - Andrew T. Yan
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Terrence Donnelly Heart Centre, St. Michael’s Hospital, Kitchener, Ontario, Canada
| | - Varinder K. Randhawa
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Laura Banks
- Faculty of Health Sciences, Ontario Tech University, Oshawa, Ontario, Canada
- Knowledge, Innovation, Talent, Everywhere (KITE), Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada
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11
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Spacht WA, Lau ES. A disease of her own? Unique features of heart failure in women. Climacteric 2024; 27:32-40. [PMID: 37768321 PMCID: PMC10843094 DOI: 10.1080/13697137.2023.2256673] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 09/03/2023] [Indexed: 09/29/2023]
Abstract
Heart failure (HF) is a significant and growing public health challenge for women. Compared with men, women tend to develop HF later in life and are more likely to experience HF with preserved ejection fraction. There are also significant sex differences in outcomes, with women reporting lower quality of life but overall better survival versus men. In this review, we summarize sex differences in traditional HF risk factors, such as hypertension, diabetes, obesity and coronary artery disease, as well as female-specific HF risk factors including menopause, pregnancy and adverse pregnancy outcomes, and breast cancer therapy. While our understanding of the sex-specific efficacy of HF therapy remains limited by the underrepresentation of women in major clinical trials, there is a suggestion of preferential benefit of specific agents for women. Further work is required to better understand the pathophysiology of HF in women uniquely and to increase representation of women in clinical trials.
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Affiliation(s)
| | - Emily S. Lau
- Cardiovascular Research Center and Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
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12
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Alkalbani M, Psotka MA. Rethinking heart failure clinical trials: the heart failure collaboratory. Front Cardiovasc Med 2024; 11:1350569. [PMID: 38327488 PMCID: PMC10847294 DOI: 10.3389/fcvm.2024.1350569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Accepted: 01/09/2024] [Indexed: 02/09/2024] Open
Abstract
The Heart Failure Collaboratory (HFC) is a consortium of stakeholders in the heart failure (HF) community that aims to improve the infrastructure of clinical research to promote development of novel therapies for patients. Since its launch in 2018, HFC has implemented several solutions to tackle obstacles in HF clinical research including training programs to increase the number of clinicians skilled in conducting clinical trials, novel study designs, and advocacy for a diverse and inclusive HF research ecosystem. We highlight some of the HFC successes since its establishment.
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Affiliation(s)
- Mutaz Alkalbani
- Department of Cardiology, Inova Schar Heart and Vascular, Falls Church, VA, United States
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13
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Gupta A, Skye M, Calma J, Din N, Azizi Z, Hernandez MF, Zheng J, Kalwani NM, Malunjkar S, Schirmer J, Wang P, Rodriguez F, Heidenreich P, Sandhu AT. Patient Representativeness With Virtual Enrollment in the PRO-HF Trial. J Am Heart Assoc 2024; 13:e030903. [PMID: 38226522 PMCID: PMC10926787 DOI: 10.1161/jaha.123.030903] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2023] [Accepted: 10/03/2023] [Indexed: 01/17/2024]
Affiliation(s)
- Anshal Gupta
- Stanford University School of Medicine Stanford CA
| | - Megan Skye
- Division of Cardiovascular Medicine and the Cardiovascular Institute, Department of Medicine Stanford University Stanford CA
- Veterans Affairs Palo Alto Health Care System Palo Alto CA
| | - Jamie Calma
- Division of Cardiovascular Medicine and the Cardiovascular Institute, Department of Medicine Stanford University Stanford CA
| | - Natasha Din
- Veterans Affairs Palo Alto Health Care System Palo Alto CA
- Center for Digital Health, Department of Medicine Stanford University Stanford CA
| | - Zahra Azizi
- Center for Digital Health, Department of Medicine Stanford University Stanford CA
| | | | - Jimmy Zheng
- Stanford University School of Medicine Stanford CA
| | - Neil M Kalwani
- Division of Cardiovascular Medicine and the Cardiovascular Institute, Department of Medicine Stanford University Stanford CA
- Veterans Affairs Palo Alto Health Care System Palo Alto CA
| | | | - Jessica Schirmer
- Division of Cardiovascular Medicine and the Cardiovascular Institute, Department of Medicine Stanford University Stanford CA
| | - Paul Wang
- Division of Cardiovascular Medicine and the Cardiovascular Institute, Department of Medicine Stanford University Stanford CA
- Center for Digital Health, Department of Medicine Stanford University Stanford CA
| | - Fatima Rodriguez
- Division of Cardiovascular Medicine and the Cardiovascular Institute, Department of Medicine Stanford University Stanford CA
- Center for Digital Health, Department of Medicine Stanford University Stanford CA
| | - Paul Heidenreich
- Division of Cardiovascular Medicine and the Cardiovascular Institute, Department of Medicine Stanford University Stanford CA
- Veterans Affairs Palo Alto Health Care System Palo Alto CA
| | - Alexander T Sandhu
- Division of Cardiovascular Medicine and the Cardiovascular Institute, Department of Medicine Stanford University Stanford CA
- Veterans Affairs Palo Alto Health Care System Palo Alto CA
- Center for Digital Health, Department of Medicine Stanford University Stanford CA
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14
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Ekpo E, Balla S, Ngo S, Witting C, Sarraju A, Furst A, Rodriguez F. Underrepresentation of Women in Reduced Ejection Heart Failure Clinical Trials With Improved Mortality or Hospitalization. JACC. ADVANCES 2024; 3:100743. [PMID: 38405270 PMCID: PMC10890822 DOI: 10.1016/j.jacadv.2023.100743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/27/2024]
Abstract
BACKGROUND There are established sex-specific differences in heart failure with reduced ejection fraction (HFrEF) outcomes. Randomized clinical trials (RCTs) based on cardiovascular outcome benefits, typically either reduced cardiovascular mortality or hospitalization for heart failure (HHF), influence current guidelines for therapy. OBJECTIVES The authors evaluate the representation of women in HFrEF RCTs that observed reduced all-cause or cardiovascular mortality or HHF. METHODS We queried Cumulative Index to Nursing and Allied Health Literature, Excerpta Medica dataBASE, Medical Literature Analysis and Retrieval System Online, and PubMed for HFrEF RCTs that reported a statistically significant benefit of intervention resulting in improved mortality or HHF published from 1980 to 2021. We estimated representation using the participation-to-prevalence ratio (PPR). A PPR of 0.8 to 1.2 was considered representative. RESULTS The final analysis included 33 RCTs. Women represented only 23.2% of all enrolled participants (n = 24,366/104,972), ranging from 11.4% to 40.1% per trial. Overall PPR was 0.58, with per-trial PPR estimates ranging from 0.29 to 1.00. Only 5 trials (15.2%) had a PPR of women representative of the disease population. Representation did not change significantly over time. The proportion of women in North American trials was significantly greater than trials conducted in Europe (P = 0.03). The proportion of women was greater in industry trials compared to government-funded trials (P = 0.05). CONCLUSIONS Women are underrepresented in HFrEF RCTs that have demonstrated mortality or HHF benefits and influence current guidelines. Representation is key to further delineation of sex-specific differences in major trial results. Sustained efforts are warranted to ensure equitable and appropriate inclusion of women in HFrEF trials.
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Affiliation(s)
- Eson Ekpo
- Department of Cardiovascular Medicine, Scripps Clinic, La Jolla, California, USA
| | - Sujana Balla
- Department of Internal Medicine, University of California-San Francisco, Fresno, California, USA
| | - Summer Ngo
- Division of Cardiovascular Medicine and Cardiovascular Institute, Stanford University School of Medicine, Stanford, California, USA
| | - Celeste Witting
- Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Ashish Sarraju
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| | - Adam Furst
- Division of Cardiovascular Medicine and Cardiovascular Institute, Stanford University School of Medicine, Stanford, California, USA
- Palo Alto Veterans Institute for Research (PAVIR), Palo Alto, California, USA
| | - Fatima Rodriguez
- Division of Cardiovascular Medicine and Cardiovascular Institute, Stanford University School of Medicine, Stanford, California, USA
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15
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Pabon M, Cunningham J, Claggett B, Felker GM, McMurray JJV, Metra M, Diaz R, Wang X, Arias-Mendoza A, Bonderman D, Crespo-Leiro M, Fonseca C, Goncalvesova E, Lund M, O'Meara E, Sliwa-Hahnle K, Malik FI, Solomon SD, Teerlink JR. Sex Differences in Heart Failure With Reduced Ejection Fraction in the GALACTIC-HF Trial. JACC. HEART FAILURE 2023; 11:1729-1738. [PMID: 37831045 DOI: 10.1016/j.jchf.2023.07.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/12/2023] [Revised: 07/11/2023] [Accepted: 07/25/2023] [Indexed: 10/14/2023]
Abstract
BACKGROUND Women with heart failure with reduced ejection fraction (HFrEF) receive less guideline-recommended therapy and experience worse quality of life than men. OBJECTIVES The authors sought to assess differences in baseline characteristics, outcomes, efficacy, and safety of omecamtiv mecarbil between men and women enrolled in the GALACTIC-HF (Registrational Study With Omecamtiv Mecarbil [AMG 423] to Treat Chronic Heart Failure With Reduced Ejection Fraction) study. METHODS In GALACTIC-HF, patients with symptomatic heart failure with EF of 35% or less, recent heart failure event, and elevated natriuretic peptides were randomized to omecamtiv mecarbil or placebo. The current analysis investigated differences in baseline characteristics, clinical outcomes, and efficacy and safety of omecamtiv mecarbil between men and women. RESULTS Of 8,232 patients analyzed, 21.2% were women. Women more likely self-identified as being Black, had worse symptoms (lower Kansas City Cardiomyopathy Questionnaire Total Symptom Score [KCCQ-TSS]), and were less likely to be treated with angiotensin receptor/neprilysin inhibitor and devices at baseline. Compared with men, women had lower rates of the primary endpoint (adjusted HR: 0.80, 95% CI: 0.73-0.88). Sex did not significantly modify omecamtiv mecarbil's treatment effect (P interaction = 0.68). Women also had 20% less risk of cardiovascular death, heart failure event, and all-cause death. Women participants had lower rates of serious adverse events. CONCLUSIONS Women participants of the GALACTIC-HF trial had worse quality of life and were less likely to be treated with guideline-based therapies at baseline. Despite KCCQ-TSS being predictive of poor outcomes in this population, women had a 20% lower risk of an HF event or cardiovascular death compared with men. The beneficial effect of omecamtiv mecarbil did not significantly differ by sex. (Registrational Study With Omecamtiv Mecarbil [AMG 423] to Treat Chronic Heart Failure With Reduced Ejection Fraction [GALACTIC-HF]; NCT02929329).
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Affiliation(s)
- Maria Pabon
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Jon Cunningham
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Brian Claggett
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - G Michael Felker
- Division of Cardiology, Duke University School of Medicine and Duke Clinical Research Institute, Durham, North Carolina, USA
| | - John J V McMurray
- British Heart Foundation Cardiovascular Research Centre, Glasgow, United Kingdom
| | | | - Rafael Diaz
- Estudios Clínicos Latino América, Rosario, Argentina
| | - Xiaowen Wang
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | | | | | - Maria Crespo-Leiro
- Unidad de Insuficiencia Cardiaca Avanzada y Trasplante Cardiaco, Complexo Hospitalario Universitario A Coruna, CHUAC, INIBIC, UDC, CIBERCV, La Coruna, Spain
| | - Cândida Fonseca
- Department of Internal Medicine, Hospital São Francisco Xavier, Lisbon, Portugal
| | | | | | - Eileen O'Meara
- Montreal Heart Institute and Université de Montréal, Montreal, QC, Canada
| | | | - Fady I Malik
- Cytokinetics Inc, South San Francisco, California, USA
| | - Scott D Solomon
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA.
| | - John R Teerlink
- San Francisco Veterans Affairs Medical Center and School of Medicine, University of California-San Francisco, San Francisco, California, USA
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16
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Amin K, Bethel G, Jackson LR, Essien UR, Sloan CE. Eliminating Health Disparities in Atrial Fibrillation, Heart Failure, and Dyslipidemia: A Path Toward Achieving Pharmacoequity. Curr Atheroscler Rep 2023; 25:1113-1127. [PMID: 38108997 PMCID: PMC11044811 DOI: 10.1007/s11883-023-01180-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/25/2023] [Indexed: 12/19/2023]
Abstract
PURPOSE OF REVIEW Pharmacoequity refers to the goal of ensuring that all patients have access to high-quality medications, regardless of their race, ethnicity, gender, or other characteristics. The goal of this article is to review current evidence on disparities in access to cardiovascular drug therapies across sociodemographic subgroups, with a focus on heart failure, atrial fibrillation, and dyslipidemia. RECENT FINDINGS Considerable and consistent disparities to life-prolonging heart failure, atrial fibrillation, and dyslipidemia medications exist in clinical trial representation, access to specialist care, prescription of guideline-based therapy, drug affordability, and pharmacy accessibility across racial, ethnic, gender, and other sociodemographic subgroups. Researchers, health systems, and policy makers can take steps to improve pharmacoequity by diversifying clinical trial enrollment, increasing access to inpatient and outpatient cardiology care, nudging clinicians to increase prescription of guideline-directed medical therapy, and pursuing system-level reforms to improve drug access and affordability.
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Affiliation(s)
- Krunal Amin
- Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Garrett Bethel
- Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Larry R Jackson
- Department of Medicine, Duke University School of Medicine, Durham, NC, USA
- Duke Clinical Research Institute, Durham, NC, USA
| | - Utibe R Essien
- Department of Medicine, David Geffen School of Medicine at the University of California, Los Angeles, CA, USA
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at the University of California, Los Angeles, CA, USA
- Center for the Study of Healthcare Innovation, Implementation & Policy, Greater Los Angeles VA Healthcare System, Los Angeles, CA, USA
| | - Caroline E Sloan
- Department of Medicine, Duke University School of Medicine, Durham, NC, USA.
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA.
- Duke-Margolis Center for Health Policy, Duke University, Durham, NC, USA.
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17
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Nielsen RR, Anker N, Stødkilde-Jørgensen N, Thrane PG, Hansen MK, Pryds K, Mortensen MB, Olesen KKW, Maeng M. Impact of Coronary Artery Disease in Women With Newly Diagnosed Heart Failure and Reduced Ejection Fraction. JACC. HEART FAILURE 2023; 11:1653-1663. [PMID: 37632494 DOI: 10.1016/j.jchf.2023.07.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Revised: 07/17/2023] [Accepted: 07/19/2023] [Indexed: 08/28/2023]
Abstract
BACKGROUND The representation of women in heart failure studies has been inadequate, resulting in a knowledge gap regarding the prognostic impact of coronary artery disease (CAD) on all-cause mortality in women with newly diagnosed heart failure and reduced ejection fraction (HFrEF). OBJECTIVES This study aims to assess the prognostic impact of CAD in women with HFrEF. METHODS Using the Western Denmark Heart Registry, the authors identified 891 women and 2,403 men referred for first-time coronary angiography because of HFrEF. The authors stratified for presence of CAD, estimated 10-year all-cause mortality, and calculated crude and adjusted HRs (aHRs) with 95% CIs. RESULTS The 10-year mortality was 60% in women with CAD and 27% in women without CAD; for men, the corresponding numbers were 54% and 36%. When adjusted for comorbidities, women without CAD had a lower relative 10-year mortality than men without CAD (aHR: 0.73; 95% CI: 0.58-0.91), whereas women with CAD had similar relative mortality as men with CAD (aHR: 1.00; 95% CI: 0.81-1.24) (Pinteraction = 0.037). Assessed by the number of coronary vessels with significant stenosis, CAD extent was associated with mortality for both women (P < 0.01) and men (P < 0.01). However, compared to those without CAD, the aHR was higher for women with any degree of CAD (aHR ranging from 1.61 [95% CI: 1.09-2.38] for diffuse CAD to 2.01 [95% CI: 1.19-3.40] for 3-vessel disease) than for men with 3-vessel disease (aHR: 1.51; 95% CI: 1.19-1.91). CONCLUSIONS In patients with newly diagnosed HFrEF, the presence and extent of CAD has significantly greater prognostic impact among women than among men.
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Affiliation(s)
- Roni Ranghoej Nielsen
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark; Department of Clinical Medicine, Aarhus University, Health, Aarhus, Denmark.
| | - Nanna Anker
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark; Department of Clinical Medicine, Aarhus University, Health, Aarhus, Denmark
| | - Nina Stødkilde-Jørgensen
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark; Department of Clinical Medicine, Aarhus University, Health, Aarhus, Denmark
| | | | | | - Kasper Pryds
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Martin Bødtker Mortensen
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark; Department of Clinical Medicine, Aarhus University, Health, Aarhus, Denmark; Department of Cardiology, Johns Hopkins, Baltimore, Maryland, USA
| | | | - Michael Maeng
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark; Department of Clinical Medicine, Aarhus University, Health, Aarhus, Denmark
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18
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Gangavelli A, Liu Z, Wang J, Okoh A, Steinberg R, Patel K, Pandey A, Gupta DK, Dickert N, Patel SA, Morris AA. Racial differences in low natriuretic peptide levels: Implications for heart failure clinical trials. Am Heart J 2023; 265:1-10. [PMID: 37343812 PMCID: PMC10592492 DOI: 10.1016/j.ahj.2023.06.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 06/09/2023] [Accepted: 06/13/2023] [Indexed: 06/23/2023]
Abstract
BACKGROUND Some patients with heart failure (HF) have low natriuretic peptide (NP) levels. It is unclear whether specific populations are disproportionately excluded from participation in randomized clinical trials (RCT) with inclusion requirements for elevated NPs. We investigated factors associated with unexpectedly low NP levels in a cohort of patients hospitalized with HF, and the implications on racial diversity in a prototype HF RCT. METHODS We created a retrospective cohort of 31,704 patients (age 72 ± 16 years, 49% female, 52% Black) hospitalized with HF from 2010 to 2020 with B-type natriuretic peptide (BNP) measurements. Factors associated with unexpectedly low BNP levels (<50 pg/mL) were identified using multivariable logistic regression models. We simulated patient eligibility for a prototype HF trial using specific inclusion and exclusion criteria, and varying BNP cut-offs. RESULTS Unexpectedly low BNP levels were observed in 8.9% of the cohort. Factors associated with unexpectedly low BNP levels included HFpEF (aOR 3.76, 95% CI: 3.36, 4.20), obesity (aOR 1.96, 95% CI: 1.73, 2.21), self-identification as Black (aOR 1.53, 95% CI: 1.36, 1.71), and male gender (aOR 1.45, 95% CI: 1.31, 1.60). Applying limited clinical inclusion and exclusion criteria from PARAGLIDE-HF disproportionately excluded Black patients, with impairment in renal function having the greatest impact. Adding thresholds for BNP of ≥35, ≥50, ≥67, ≥100, and ≥150 pg/mL demonstrated the risk of exclusion was higher for Black compared to non-Black patients (RR = 2.03 [95% CI: 1.73, 2.39], 1.90 [95% CI: 1.68, 2.15], 1.63 [95% CI: 1.48, 1.81], 1.38 [95% CI: 1.28, 1.50], and 1.23 [95% CI: 1.15, 1.31], respectively). CONCLUSIONS Nearly 10% of patients hospitalized with HF have unexpectedly low BNP levels. Simulating inclusion into a prototype HFpEF RCT demonstrated that requiring increasingly elevated NP levels disproportionately excludes Black patients.
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Affiliation(s)
- Apoorva Gangavelli
- Division of Cardiology, Emory University School of Medicine, Atlanta, GA.
| | - Zihao Liu
- Department of Epidemiology, Emory Rollins School of Public Health, Atlanta, GA
| | - Jeffrey Wang
- Division of Cardiology, Emory University School of Medicine, Atlanta, GA
| | - Alexis Okoh
- Division of Cardiology, Emory University School of Medicine, Atlanta, GA
| | - Rebecca Steinberg
- Division of Cardiology, Emory University School of Medicine, Atlanta, GA
| | - Krishan Patel
- Division of Cardiology, Emory University School of Medicine, Atlanta, GA
| | - Ambarish Pandey
- Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, TX
| | - Deepak K Gupta
- Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Neal Dickert
- Division of Cardiology, Emory University School of Medicine, Atlanta, GA
| | - Shivani A Patel
- Department of Epidemiology, Emory Rollins School of Public Health, Atlanta, GA
| | - Alanna A Morris
- Division of Cardiology, Emory University School of Medicine, Atlanta, GA
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19
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Wills WB, Athilingam P, Beckie TM. Exercise-based cardiac rehabilitation in women with heart failure: a review of enrollment, adherence, and outcomes. Heart Fail Rev 2023; 28:1251-1266. [PMID: 37059937 DOI: 10.1007/s10741-023-10306-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/26/2023] [Indexed: 04/16/2023]
Abstract
Exercise-based cardiac rehabilitation (CR) is an evidence-based recommendation for patients with stable heart failure (HF). Less clear is how effective exercise-based CR is for women with HF. The aim of this review was to synthesize the evidence for the effects of exercise-based CR on mortality, hospitalizations, exercise capacity, and quality of life (QOL) among women with HF. We identified 18 studies comprising 4917 patients, of which 1714 were women. The interventions evaluated consisted of various combinations of supervised in-hospital and out-patient sessions as well as home-based programs that included aerobic (walking, treadmill, bicycle) and resistance training. The interventions ranged from 12 to 54 weeks, with a frequency of 2-7 sessions per week, lasting from 30 to 105 min per session. Because of a paucity of sex-specific analyses of the outcomes, it was not possible to draw conclusions for women. There was limited evidence for mortality benefit for men or women participating in exercise-based CR. There was more substantial evidence for reductions in hospitalizations for the participants. Generally, exercise training improved exercise capacity. The effects of exercise-based CR on QOL were mixed with most studies favoring CR at 3 months but not at 4, 5, and 12 months. Moreover, generally, the physical dimension of QOL but not the mental dimensions improved. Recommendations for future research to reduce the gap in knowledge about the effects of exercise-based CR for women are offered.
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Affiliation(s)
- Walter B Wills
- College of Nursing, University of South Florida, 12901 Bruce B. Downs Blvd., MDC Box 22, Tampa, FL, 33612, USA
| | - Ponrathi Athilingam
- College of Nursing, University of South Florida, 12901 Bruce B. Downs Blvd., MDC Box 22, Tampa, FL, 33612, USA
| | - Theresa M Beckie
- College of Nursing, University of South Florida, 12901 Bruce B. Downs Blvd., MDC Box 22, Tampa, FL, 33612, USA.
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20
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Auener SL, van Dulmen SA, Atsma F, van der Galiën O, Bellersen L, van Kimmenade R, Westert GP, Jeurissen PPT. Characteristics Associated With Telemonitoring Use Among Patients With Chronic Heart Failure: Retrospective Cohort Study. J Med Internet Res 2023; 25:e43038. [PMID: 37851505 PMCID: PMC10620630 DOI: 10.2196/43038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Revised: 02/28/2023] [Accepted: 08/28/2023] [Indexed: 10/19/2023] Open
Abstract
BACKGROUND Chronic heart failure (HF) is a chronic disease affecting more than 64 million people worldwide, with an increasing prevalence and a high burden on individual patients and society. Telemonitoring may be able to mitigate some of this burden by increasing self-management and preventing use of the health care system. However, it is unknown to what degree telemonitoring has been adopted by hospitals and if the use of telemonitoring is associated with certain patient characteristics. Insight into the dissemination of this technology among hospitals and patients may inform strategies for further adoption. OBJECTIVE We aimed to explore the use of telemonitoring among hospitals in the Netherlands and to identify patient characteristics associated with the use of telemonitoring for HF. METHODS We performed a retrospective cohort study based on routinely collected health care claim data in the Netherlands. Descriptive analyses were used to gain insight in the adoption of telemonitoring for HF among hospitals in 2019. We used logistic multiple regression analyses to explore the associations between patient characteristics and telemonitoring use. RESULTS Less than half (31/84, 37%) of all included hospitals had claims for telemonitoring, and 20% (17/84) of hospitals had more than 10 patients with telemonitoring claims. Within these 17 hospitals, a total of 7040 patients were treated for HF in 2019, of whom 5.8% (409/7040) incurred a telemonitoring claim. Odds ratios (ORs) for using telemonitoring were higher for male patients (adjusted OR 1.90, 95% CI 1.50-2.41) and patients with previous hospital treatment for HF (adjusted OR 1.76, 95% CI 1.39-2.24). ORs were lower for higher age categories and were lowest for the highest age category, that is, patients older than 80 years (OR 0.30, 95% CI 0.21-0.44) compared to the reference age category (18-59 years). Socioeconomic status, degree of multimorbidity, and excessive polypharmacy were not associated with the use of telemonitoring. CONCLUSIONS The use of reimbursed telemonitoring for HF was limited up to 2019, and our results suggest that large variation exists among hospitals. A lack of adoption is therefore not only due to a lack of diffusion among hospitals but also due to a lack of scaling up within hospitals that already deploy telemonitoring. Future studies should therefore focus on both kinds of adoption and how to facilitate these processes. Older patients, female patients, and patients with no previous hospital treatment for HF were less likely to use telemonitoring for HF. This shows that some patient groups are not served as much by telemonitoring as other patient groups. The underlying mechanism of the reported associations should be identified in order to gain a deeper understanding of telemonitoring use among different patient groups.
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Affiliation(s)
- Stefan L Auener
- IQ Healthcare, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, Netherlands
| | - Simone A van Dulmen
- IQ Healthcare, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, Netherlands
| | - Femke Atsma
- IQ Healthcare, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, Netherlands
| | | | - Louise Bellersen
- Department of Cardiology, Radboud University Medical Center, Nijmegen, Netherlands
| | - Roland van Kimmenade
- Department of Cardiology, Radboud University Medical Center, Nijmegen, Netherlands
| | - Gert P Westert
- IQ Healthcare, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, Netherlands
| | - Patrick P T Jeurissen
- IQ Healthcare, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, Netherlands
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21
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Vo AK, Cerdeña JP, Loree JM, Cairns BE, Conklin AI, Kaseweter K, Chondoma L, Cragg JJ, Kramer JLK. Race-based reporting and participation of Black individuals in registered pain clinical trials, United States, 2000 to 2019. Pain 2023; 164:1976-1984. [PMID: 37068160 DOI: 10.1097/j.pain.0000000000002893] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 01/10/2023] [Indexed: 04/19/2023]
Abstract
ABSTRACT There are numerous, well-established racial disparities in the management of pain. The degree to which these are evident at the stage of conducting clinical trials is unknown. To address this knowledge gap, we examined race-based reporting, participation of Black individuals, and the factors associated with reporting and participation in pain clinical trials in the United States. Data were extracted from Clinicaltrials.gov and published articles. One thousand two hundred trials met our inclusion criteria; 482 (40.2%) reported participant race. More recent, publicly funded, and larger trials were more likely to report race. Of 82,468 participants included in pain clinical trials that reported race, 15,101 were Black individuals (18.3%). Participation of Black individuals was significantly associated with pain type (ß = +27% in cardiovascular disease pain compared with acute pain, P < 0.05), study population (ß = +33% and +7% in pain in minoritized populations and women, respectively, compared with general population, P < 0.05), pain intervention (ß = +7.5% for trials of opioid interventions compared with nonopioid interventions, P < 0.05), and a diverse team of investigators (ß = +8.0% for studies incorporating a visible non-White investigator compared with those that did not, P < 0.05). Our results indicate that representation of Black participants in pain clinical trials generally aligns with national demographics in the United States. Increased representation corresponds with health conditions more prevalent among Black individuals (eg, cardiovascular disease) and with a diverse study team composition. Despite these encouraging results, less than half of pain trials reported race, which introduces potential publication bias and limits external validity.
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Affiliation(s)
- Anh Khoa Vo
- Facutly of Pharmaceutical Sciences, University of British Columbia, Vancouver, BC, Canada
- International Collaboration on Repair Discoveries (ICORD), University of British Columbia, Vancouver, BC, Canada
| | - Jessica P Cerdeña
- Yale School of Medicine, Yale University, New Haven, CT, United States
| | | | - Brian E Cairns
- Facutly of Pharmaceutical Sciences, University of British Columbia, Vancouver, BC, Canada
| | - Annalijn I Conklin
- Facutly of Pharmaceutical Sciences, University of British Columbia, Vancouver, BC, Canada
- Centre for Health Evaluation and Outcome Sciences, Providence Health Care Research Institute, St. Paul's Hospital, Vancouver, BC, Canada
| | - Kimberley Kaseweter
- Bill Nelems Pain Research Centre, University of British Columbia, Okanagan Campus, Kelowna, BC, Canada
| | - Lerato Chondoma
- Indigenous Research Support Initiative, VP Research and Innovation, University of British Columbia, Vancouver, BC, Canada
| | - Jacquelyn J Cragg
- Facutly of Pharmaceutical Sciences, University of British Columbia, Vancouver, BC, Canada
- International Collaboration on Repair Discoveries (ICORD), University of British Columbia, Vancouver, BC, Canada
| | - John L K Kramer
- Department of Anesthesiology, Pharmacology, and Therapeutics, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
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22
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Reddy KP, Faggioni M, Eberly LA, Halaby R, Sanghavi M, Lewey J, Mehran R, Coylewright M, Herrmann HC, Giri J, Fanaroff AC, Nathan AS. Enrollment of Older Patients, Women, and Racial and Ethnic Minority Individuals in Valvular Heart Disease Clinical Trials: A Systematic Review. JAMA Cardiol 2023; 8:871-878. [PMID: 37494015 DOI: 10.1001/jamacardio.2023.2098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/27/2023]
Abstract
Importance Inadequate representation of older patients, women, and racial minority individuals in cardiovascular clinical trials limits both the generalizability of trial findings and inclusivity in access to novel therapies and therapeutic strategies. Objective To report on temporal trends in the representation of older patients, women, and racial and ethnic minority individuals in clinical trials studying treatments for valvular heart disease. Evidence Review All published clinical trials enrolling more than 100 adults with any valvular heart disease published between 2005 and 2020 were included after searches with PubMed and ClinicalTrials.gov. Data on age, sex, race, and ethnicity reported in the included studies were collected. Trials were assigned to 4 time periods based on the publication date, and temporal trends were analyzed in the representation of older patients, women, and racial and ethnic minority individuals. Findings A total of 139 clinical trials with 51 527 participants were identified. Of these trials, 103 (74%) investigated aortic valve disease and the remainder mitral valve disease. Overall, 63 trials (45.3%) enrolled patients only in Europe, 24 (17.3%) only in North America, and 19 (13.7%) in multiple geographical regions. The weighted mean (SD) age of enrolled patients was 68.4 (11.4) years, increasing nonsignificantly from 61.9 (5.9) years in 2005-2008 to 72.8 (9.6) years in 2017-2020 (P = .09 for trend). The overall proportion of women enrolled in valvular heart disease trials was 41.1%, with no significant changes over time. Data on race and ethnicity of trial participants were reported in 13 trials (9.4%), in which trial-level representation of American Indian/Alaska Native, Asian, Black/African American, Hispanic, and Native Hawaiian/Pacific Islander patients ranged from 0.27% to 43.9%. There were no significant temporal trends noted in the enrollment of racial and ethnic minority populations. The representation of women in clinical trials was positively associated with enrollment rates of older patients and underrepresented racial and ethnic groups. Conclusions and Relevance This review found that over the past 2 decades, women and racial and ethnic minority individuals have remained underrepresented in North American valvular heart disease clinical trials. Further work is needed to improve the reporting of race and ethnicity data and address barriers to trial enrollment for older patients, women, and racial and ethnic minority individuals.
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Affiliation(s)
- Kriyana P Reddy
- Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center, University of Pennsylvania, Philadelphia
| | - Michela Faggioni
- Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia
| | - Lauren A Eberly
- Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center, University of Pennsylvania, Philadelphia
- Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia
| | - Rim Halaby
- Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia
| | - Monika Sanghavi
- Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia
| | - Jennifer Lewey
- Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia
| | - Roxana Mehran
- Icahn School of Medicine at Mount Sinai, New York, New York
- Associate Editor, JAMA Cardiology
| | | | - Howard C Herrmann
- Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia
| | - Jay Giri
- Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center, University of Pennsylvania, Philadelphia
- Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Alexander C Fanaroff
- Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center, University of Pennsylvania, Philadelphia
- Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ashwin S Nathan
- Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center, University of Pennsylvania, Philadelphia
- Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania
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23
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Rau Steuernagel C, Lam CSP, Greenhalgh T. Countering sex and gender bias in cardiovascular research requires more than equal recruitment and sex disaggregated analyses. BMJ 2023; 382:e075031. [PMID: 37648271 DOI: 10.1136/bmj-2023-075031] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
Affiliation(s)
| | - Carolyn S P Lam
- National Heart Centre Singapore and Duke-National University of Singapore, Singapore
| | - Trisha Greenhalgh
- University of Oxford, Nuffield Department of Primary Care Health Sciences, Oxford, UK
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24
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Davis J, Sanchez LD, Jarman AF, Macias-Konstantopoulos W, Newberry J, Patel S, Hess E, Burner E. 2022 consensus conference on diversity, equity, and inclusion: Developing an emergency medicine research agenda for addressing racism through health care research. Acad Emerg Med 2023; 30:731-741. [PMID: 37078910 PMCID: PMC10467350 DOI: 10.1111/acem.14742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Revised: 04/15/2023] [Accepted: 04/17/2023] [Indexed: 04/21/2023]
Abstract
Racism in emergency medicine (EM) health care research is pervasive but often underrecognized. To understand the current state of research on racism in EM health care research, we developed a consensus working group on this topic, which concluded a year of work with a consensus-building session as part of the overall Society for Academic Emergency Medicine (SAEM) consensus conference on diversity, equity, and inclusion: "Developing a Research Agenda for Addressing Racism in Emergency Medicine," held on May 10, 2022. In this article, we report the development, details of preconference methods and preliminary results, and the final consensus of the Healthcare Research Working Group. Preconference work based on literature review and expert opinion identified 13 potential priority research questions that were refined through an iterative process to a list of 10. During the conference, the subgroup used consensus methodology and a "consensus dollar" (contingent valuation) approach to prioritize research questions. The subgroup identified three research gaps: remedies for racial bias and systematic racism, biases and heuristics in clinical care, and racism in study design, and we derived a list of six high-priority research questions for our specialty.
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Affiliation(s)
- Joshua Davis
- University of Kansas School of Medicine, Wichita, Kansas, USA
| | - Leon D Sanchez
- Department of Emergency Medicine, Brigham and Women’s Faulkner Hospital, Boston, Massachusetts, USA
| | - Angela F Jarman
- Department of Emergency Medicine, University of California Davis, Sacramento, California, USA
| | | | - Jennifer Newberry
- Department of Emergency Medicine, Stanford University, Stanford, California, USA
| | - Shama Patel
- Department of Emergency Medicine University of Florida College of Medicine, Jacksonville, Florida, USA
| | - Erik Hess
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Elizabeth Burner
- Department of Emergency Medicine, Kek School of Medicine of the University of Southern California, Los Angeles, California, USA
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25
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Krishnan PS, Lauer AM, Ward BK, Seal SM, Nieman CL, Andresen NS. Sex and Race Representation in Temporal Bone Histopathology Studies in the United States: A Systematic Review. Ear Hear 2023; 44:661-669. [PMID: 36763469 PMCID: PMC10331314 DOI: 10.1097/aud.0000000000001340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Abstract
OBJECTIVES The author's objective was to evaluate sex and race representation in temporal bone histopathology studies. DESIGN PubMed, Embase, Cochrane, Web of Science, and Scopus were searched for studies written in English examining temporal bone histopathology specimens from U.S.-based institutions from January 1, 1947, to September 1, 2021. Two authors then performed "snowballing" by reviewing references from the initial search and included the studies that fulfilled the inclusion criteria. For each study, the following information was collected: publication details, study design, funding, institution from where temporal bone specimens were procured, number of study specimens, and donor demographical information. RESULTS The authors found that out of 300 studies, 166 (55%) report sex while only 15 (5%) reported race information. Over the past 70 years, the ratio of studies reporting sex to those that do not has increased from 1.00 to 2.19 and the number of female temporal bone histopathology subjects relative to male has increased from 0.67 to 0.75. Over 90% of studies that do report this information feature participant racial compositions that do not reflect the diversity of the U.S. population. CONCLUSIONS Studies of temporal bone histopathology often do not report participant sex or race. The reporting of participant sex and the inclusion of specimens from female donors have both increased over time. However, temporal bone histopathology study cohorts are not representative of the racial diversity of the U.S. population. The otolaryngology community must strive to build temporal bone histopathology libraries that are representative of the diverse U.S. population.
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Affiliation(s)
- Pavan S. Krishnan
- Department of Otolaryngology-Head & Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Virginia Commonwealth University School of Medicine, Richmond, Virginia
| | - Amanda M. Lauer
- Department of Otolaryngology-Head & Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Solomon H. Snyder Department of Neuroscience, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Bryan K. Ward
- Department of Otolaryngology-Head & Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Stella M. Seal
- Welch Medical Library, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Carrie L. Nieman
- Department of Otolaryngology-Head & Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Cochlear Center for Hearing & Public Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland
- Center for Innovative Care in Aging, Johns Hopkins University School of Nursing, Baltimore, Maryland
| | - Nicholas S. Andresen
- Department of Otolaryngology-Head & Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
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26
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Khan MS, Usman MS, Talha KM, Van Spall HGC, Greene SJ, Vaduganathan M, Khan SS, Mills NL, Ali ZA, Mentz RJ, Fonarow GC, Rao SV, Spertus JA, Roe MT, Anker SD, James SK, Butler J, McGuire DK. Leveraging electronic health records to streamline the conduct of cardiovascular clinical trials. Eur Heart J 2023; 44:1890-1909. [PMID: 37098746 DOI: 10.1093/eurheartj/ehad171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2022] [Revised: 02/05/2023] [Accepted: 03/07/2023] [Indexed: 04/27/2023] Open
Abstract
Conventional randomized controlled trials (RCTs) can be expensive, time intensive, and complex to conduct. Trial recruitment, participation, and data collection can burden participants and research personnel. In the past two decades, there have been rapid technological advances and an exponential growth in digitized healthcare data. Embedding RCTs, including cardiovascular outcome trials, into electronic health record systems or registries may streamline screening, consent, randomization, follow-up visits, and outcome adjudication. Moreover, wearable sensors (i.e. health and fitness trackers) provide an opportunity to collect data on cardiovascular health and risk factors in unprecedented detail and scale, while growing internet connectivity supports the collection of patient-reported outcomes. There is a pressing need to develop robust mechanisms that facilitate data capture from diverse databases and guidance to standardize data definitions. Importantly, the data collection infrastructure should be reusable to support multiple cardiovascular RCTs over time. Systems, processes, and policies will need to have sufficient flexibility to allow interoperability between different sources of data acquisition. Clinical research guidelines, ethics oversight, and regulatory requirements also need to evolve. This review highlights recent progress towards the use of routinely generated data to conduct RCTs and discusses potential solutions for ongoing barriers. There is a particular focus on methods to utilize routinely generated data for trials while complying with regional data protection laws. The discussion is supported with examples of cardiovascular outcome trials that have successfully leveraged the electronic health record, web-enabled devices or administrative databases to conduct randomized trials.
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Affiliation(s)
- Muhammad Shahzeb Khan
- Division of Cardiology, Duke University School of Medicine, 2301 Erwin Rd., Durham, NC 27705, USA
| | - Muhammad Shariq Usman
- Department of Medicine, University of Mississippi Medical Center, 2500 N State St, Jackson, MS 39216, USA
| | - Khawaja M Talha
- Department of Medicine, University of Mississippi Medical Center, 2500 N State St, Jackson, MS 39216, USA
| | - Harriette G C Van Spall
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- Population Health Research Institute, Hamilton, ON, Canada
| | - Stephen J Greene
- Division of Cardiology, Duke University School of Medicine, 2301 Erwin Rd., Durham, NC 27705, USA
- Duke Clinical Research Institute, Durham, NC, USA
| | - Muthiah Vaduganathan
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Sadiya S Khan
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Nicholas L Mills
- BHF Centre for Cardiovascular Science, University of Edinburgh, Chancellors Building, Royal Infirmary of Edinburgh, Edinburgh, Scotland, UK
- Usher Institute, University of Edinburgh, Edinburgh, Scotland, UK
| | - Ziad A Ali
- DeMatteis Cardiovascular Institute, St Francis Hospital and Heart Center, Roslyn, NY, USA
| | - Robert J Mentz
- Division of Cardiology, Duke University School of Medicine, 2301 Erwin Rd., Durham, NC 27705, USA
- Duke Clinical Research Institute, Durham, NC, USA
| | - Gregg C Fonarow
- Division of Cardiology, University of California Los Angeles, Los Angeles, CA, USA
| | - Sunil V Rao
- Division of Cardiology, New York University Langone Health System, New York, NY, USA
| | - John A Spertus
- Department of Cardiology, Saint Luke's Mid America Heart Institute, Kansas City, MO, USA
- Kansas City's Healthcare Institute for Innovations in Quality, University of Missouri, Kansas, MO, USA
| | - Matthew T Roe
- Division of Cardiology, Duke University School of Medicine, 2301 Erwin Rd., Durham, NC 27705, USA
- Duke Clinical Research Institute, Durham, NC, USA
| | - Stefan D Anker
- Department of Cardiology (CVK), Berlin Institute of Health Center for Regenerative Therapies (BCRT), and German Centre for Cardiovascular Research (DZHK) Partner Site Berlin, Charité Universitätsmedizin, Berlin, Germany
| | - Stefan K James
- Department of Medical Sciences, Scientific Director UCR, Uppsala University, Uppsala, Uppland, Sweden
| | - Javed Butler
- Department of Medicine, University of Mississippi Medical Center, 2500 N State St, Jackson, MS 39216, USA
- Baylor Scott & White Research Institute, Dallas, TX, USA
| | - Darren K McGuire
- Division of Cardiology, Department of Internal Medicine, UT Southwestern Medical Center and Parkland Health and Hospital System, Dallas, TX, USA
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27
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Mohseni-Alsalhi Z, Vesseur MAM, Wilmes N, Laven SAJS, Meijs DAM, van Luik EM, Vaes EWP, Dikovec CJR, Wiesenberg J, Almutairi MF, Janssen EBNJ, de Haas S, Spaanderman MEA, Ghossein-Doha C. The Representation of Females in Studies on Antihypertensive Medication over the Years: A Scoping Review. Biomedicines 2023; 11:biomedicines11051435. [PMID: 37239106 DOI: 10.3390/biomedicines11051435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 05/04/2023] [Accepted: 05/08/2023] [Indexed: 05/28/2023] Open
Abstract
BACKGROUND The leading global risk factor for cardiovascular-disease-related morbidity and mortality is hypertension. In the past decade, attention has been paid to increase females' representation. The aim of this study is to investigate whether the representation of females and presentation of sex-stratified data in studies investigating the effect of antihypertensive drugs has increased over the past decades. METHODS After systematically searching PubMed and Embase for studies evaluating the effect of the five major antihypertensive medication groups until May 2020, a scoping review was performed. The primary outcome was the proportion of included females. The secondary outcome was whether sex stratification was performed. RESULTS The search resulted in 73,867 articles. After the selection progress, 2046 studies were included for further analysis. These studies included 1,348,172 adults with a mean percentage of females participating of 38.1%. Female participation in antihypertensive studies showed an increase each year by 0.2% (95% CI 0.36-0.52), p < 0.01). Only 75 (3.7%) studies performed sex stratification, and this was the highest between 2011 and 2020 (7.2%). CONCLUSION Female participation showed a slight increase in the past decade but is still underrepresented compared to males. As data are infrequently sex-stratified, more attention is needed to possible sex-related differences in treatment effects to different antihypertensive compounds.
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Affiliation(s)
- Zenab Mohseni-Alsalhi
- Department of Obstetrics and Gynecology, School for Oncology and Developmental Biology (GROW), Maastricht University Medical Center (MUMC+), 6229 ER Maastricht, The Netherlands
- Faculty of Health, Medicine and Life Sciences (FHML), Maastricht University, 6229 ER Maastricht, The Netherlands
| | - Maud A M Vesseur
- Department of Obstetrics and Gynecology, School for Oncology and Developmental Biology (GROW), Maastricht University Medical Center (MUMC+), 6229 ER Maastricht, The Netherlands
- Faculty of Health, Medicine and Life Sciences (FHML), Maastricht University, 6229 ER Maastricht, The Netherlands
| | - Nick Wilmes
- Department of Obstetrics and Gynecology, School for Oncology and Developmental Biology (GROW), Maastricht University Medical Center (MUMC+), 6229 ER Maastricht, The Netherlands
- Faculty of Health, Medicine and Life Sciences (FHML), Maastricht University, 6229 ER Maastricht, The Netherlands
| | - Sophie A J S Laven
- Department of Obstetrics and Gynecology, School for Oncology and Developmental Biology (GROW), Maastricht University Medical Center (MUMC+), 6229 ER Maastricht, The Netherlands
- Faculty of Health, Medicine and Life Sciences (FHML), Maastricht University, 6229 ER Maastricht, The Netherlands
| | - Daniek A M Meijs
- Department of Obstetrics and Gynecology, School for Oncology and Developmental Biology (GROW), Maastricht University Medical Center (MUMC+), 6229 ER Maastricht, The Netherlands
- Faculty of Health, Medicine and Life Sciences (FHML), Maastricht University, 6229 ER Maastricht, The Netherlands
- Department of Intensive Care Medicine, Maastricht University Medical Center (MUMC+), Maastricht University, 6229 HX Maastricht, The Netherlands
| | - Eveline M van Luik
- Department of Obstetrics and Gynecology, School for Oncology and Developmental Biology (GROW), Maastricht University Medical Center (MUMC+), 6229 ER Maastricht, The Netherlands
- Faculty of Health, Medicine and Life Sciences (FHML), Maastricht University, 6229 ER Maastricht, The Netherlands
| | - Esmée W P Vaes
- Department of Obstetrics and Gynecology, School for Oncology and Developmental Biology (GROW), Maastricht University Medical Center (MUMC+), 6229 ER Maastricht, The Netherlands
- Faculty of Health, Medicine and Life Sciences (FHML), Maastricht University, 6229 ER Maastricht, The Netherlands
| | - Cédric J R Dikovec
- Department of Obstetrics and Gynecology, School for Oncology and Developmental Biology (GROW), Maastricht University Medical Center (MUMC+), 6229 ER Maastricht, The Netherlands
- Faculty of Health, Medicine and Life Sciences (FHML), Maastricht University, 6229 ER Maastricht, The Netherlands
| | - Jan Wiesenberg
- Department of Obstetrics and Gynecology, School for Oncology and Developmental Biology (GROW), Maastricht University Medical Center (MUMC+), 6229 ER Maastricht, The Netherlands
- Faculty of Health, Medicine and Life Sciences (FHML), Maastricht University, 6229 ER Maastricht, The Netherlands
| | - Mohamad F Almutairi
- Department of Obstetrics and Gynecology, School for Oncology and Developmental Biology (GROW), Maastricht University Medical Center (MUMC+), 6229 ER Maastricht, The Netherlands
- Faculty of Health, Medicine and Life Sciences (FHML), Maastricht University, 6229 ER Maastricht, The Netherlands
| | - Emma B N J Janssen
- Department of Obstetrics and Gynecology, School for Oncology and Developmental Biology (GROW), Maastricht University Medical Center (MUMC+), 6229 ER Maastricht, The Netherlands
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center (MUMC+), 6229 ER Maastricht, The Netherlands
| | - Sander de Haas
- Department of Obstetrics and Gynecology, School for Oncology and Developmental Biology (GROW), Maastricht University Medical Center (MUMC+), 6229 ER Maastricht, The Netherlands
| | - Marc E A Spaanderman
- Department of Obstetrics and Gynecology, School for Oncology and Developmental Biology (GROW), Maastricht University Medical Center (MUMC+), 6229 ER Maastricht, The Netherlands
- Department of Obstetrics and Gynecology, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands
| | - Chahinda Ghossein-Doha
- Department of Obstetrics and Gynecology, School for Oncology and Developmental Biology (GROW), Maastricht University Medical Center (MUMC+), 6229 ER Maastricht, The Netherlands
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center (MUMC+), 6229 ER Maastricht, The Netherlands
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28
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Zhang A, Liu Y, Pan J, Pontanari F, Chia-Hao Chang A, Wang H, Gao S, Wang C, Chang AC. Delivery of mitochondria confers cardioprotection through mitochondria replenishment and metabolic compliance. Mol Ther 2023; 31:1468-1479. [PMID: 36805084 PMCID: PMC10188643 DOI: 10.1016/j.ymthe.2023.02.016] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Revised: 11/15/2022] [Accepted: 02/16/2023] [Indexed: 02/21/2023] Open
Abstract
Mitochondrial dysfunction is a hallmark of heart failure. Mitochondrial transplantation has been demonstrated to be able to restore heart function, but its mechanism of action remains unresolved. Using an in-house optimized mitochondrial isolation method, we tested efficacy of mitochondria transplantation in two different heart failure models. First, using a doxorubicin-induced heart failure model, we demonstrate that mitochondrial transplantation before doxorubicin challenge protects cardiac function in vivo and prevents myocardial apoptosis, but contraction improvement relies on the metabolic compatibility between transplanted mitochondria and treated cardiomyocytes. Second, using a mutation-driven dilated cardiomyopathic human induced pluripotent stem cell-derived cardiomyocyte model, we demonstrate that mitochondrial transplantation preferentially boosts contraction in the ventricular myocytes. Last, using single-cell RNA-seq, we show that mitochondria transplantation boosts contractility in dystrophic cardiomyocytes with few transcriptomic alterations. Together, we provide evidence that mitochondria transplantation confers myocardial protection and may serve as a potential therapeutic option for heart failure.
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Affiliation(s)
- Alian Zhang
- Department of Cardiology, Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200011, China; Shanghai Institute of Precision Medicine, Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200125, China
| | - Yangyang Liu
- Department of Cardiology, Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200011, China; Shanghai Institute of Precision Medicine, Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200125, China
| | - Jianan Pan
- Department of Cardiology, Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200011, China
| | - Francesca Pontanari
- Shanghai Institute of Precision Medicine, Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200125, China
| | - Andrew Chia-Hao Chang
- Shanghai Institute of Precision Medicine, Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200125, China
| | - Honghui Wang
- Shanghai Institute of Precision Medicine, Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200125, China
| | - Shuang Gao
- Shanghai Institute of Precision Medicine, Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200125, China; Department of Clinical Medicine, Jining Medical University, Jining 272000, China
| | - Changqian Wang
- Department of Cardiology, Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200011, China.
| | - Alex Cy Chang
- Department of Cardiology, Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200011, China; Shanghai Institute of Precision Medicine, Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200125, China.
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29
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Narang N, Reza N. A New Norm for Early-Career Advanced Heart Failure Clinicians. J Card Fail 2023; 29:540-543. [PMID: 36706975 PMCID: PMC10106365 DOI: 10.1016/j.cardfail.2022.12.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Revised: 12/26/2022] [Accepted: 12/27/2022] [Indexed: 01/26/2023]
Affiliation(s)
| | - Nosheen Reza
- Division of Cardiovascular Medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania.
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30
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Filbey L, Zhu JW, D'Angelo F, Thabane L, Khan MS, Lewis E, Patel MR, Powell-Wiley T, Miranda JJ, Zuhlke L, Butler J, Zannad F, Van Spall HGC. Improving representativeness in trials: a call to action from the Global Cardiovascular Clinical Trialists Forum. Eur Heart J 2023; 44:921-930. [PMID: 36702610 DOI: 10.1093/eurheartj/ehac810] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Revised: 11/24/2022] [Accepted: 12/20/2022] [Indexed: 01/28/2023] Open
Abstract
Participants enrolled in cardiovascular disease (CVD) randomized controlled trials are not often representative of the population living with the disease. Older adults, children, women, Black, Indigenous and People of Color, and people living in low- and middle-income countries are typically under-enrolled in trials relative to disease distribution. Treatment effect estimates of CVD therapies have been largely derived from trial evidence generated in White men without complex comorbidities, limiting the generalizability of evidence. This review highlights barriers and facilitators of trial enrollment, temporal trends, and the rationale for representativeness. It proposes strategies to increase representativeness in CVD trials, including trial designs that minimize the research burden on participants, inclusive recruitment practices and eligibility criteria, diversification of clinical trial leadership, and research capacity-building in under-represented regions. Implementation of such strategies could generate better and more generalizable evidence to reduce knowledge gaps and position the cardiovascular trial enterprise as a vehicle to counter existing healthcare inequalities.
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Affiliation(s)
- Lynaea Filbey
- Department of Medicine, McMaster University, 20 Copeland Avenue, David Braley Research Building, Suite C3-117, Hamilton, ON L8L 0A3, Canada
| | - Jie Wei Zhu
- Department of Medicine, McMaster University, 20 Copeland Avenue, David Braley Research Building, Suite C3-117, Hamilton, ON L8L 0A3, Canada
| | - Francesca D'Angelo
- Department of Medicine, McMaster University, 20 Copeland Avenue, David Braley Research Building, Suite C3-117, Hamilton, ON L8L 0A3, Canada
| | - Lehana Thabane
- Research Institute of St. Josephs, St. Joseph's Healthcare Hamilton, 50 Charlton Ave E, Hamilton, ON L8N 4A6, Canada.,Population Health Research Institute, 237 Barton St E, Hamilton ON L8L 2X2, Canada.,Faculty of Health Sciences, University of Johannesburg, 1 Bunting Road, FADA Building, Johannesburg, Gauteng 2092, South Africa.,Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main St W, McMaster University Medical Centre, 2C Area, Hamilton, ON L8S 4K1, Canada
| | - Muhammad Shahzeb Khan
- Division of Cardiology, Duke Clinical Research Institute, 300 W Morgan Street, Duke University School of Medicine, Durham, NC 27701, USA
| | - Eldrin Lewis
- Cardiovascular Division, Stanford University School of Medicine, 291 Campus Drive, Li Ka Shing Building, Stanford, CA 94305-5101, USA
| | - Manesh R Patel
- Division of Cardiology, Duke Clinical Research Institute, 300 W Morgan Street, Duke University School of Medicine, Durham, NC 27701, USA
| | - Tiffany Powell-Wiley
- Social Determinants of Obesity and Cardiovascular Risk Laboratory, Cardiovascular Branch, Division of Intramural Research, National Heart, Lung, and Blood Institute, National Institutes of Health, 31 Center Drive, Building 31, Bethesda, MD 20892, USA.,Intramural Research Program, National Institute on Minority Health and Health Disparities, National Institutes of Health, 6707 Democracy Boulevard, Suite 800, Bethesda, MD 20892-5465, USA
| | - J Jaime Miranda
- CRONICAS Center of Excellence in Chronic Diseases, Av. Armendariz, 2nd floor, Miraflores 15074, Lima, Peru
| | - Liesl Zuhlke
- South African Medical Research Council and Division of Paediatric Cardiology, University of Cape Town and Red Cross Memorial Children's Hospital, Klipfontein Road, Rondebosch, Cape Town, Western Cape 7700, South Africa
| | - Javed Butler
- Department of Medicine, University of Mississippi Medical Center, 2500 North State Street, Jackson, MS 39216, USA.,Baylor Scott and White Research Insistute, 3434 Live Oak St, Suite 501, Dallas, TX 75204, USA
| | - Faiez Zannad
- Centre d'Investigations Cliniques Plurithématique 1433, Université de Lorraine, 4 rue du Morvan, ILM, ground floor, Vandoeuvre-des-Nancy, Meurthe-et-Moselle 54500, France.,Institut National de la Santé et de la Recherche Médicale 1116, Centre Hospitalier Régional, 18 av Mozart, Marseille, Bouches-du-Rhône 13276, France.,Investigation Network Initiative-Cardiovascular and Renal Clinical Trialists, Universitaire de Nancy, French Clinical Research Infrastructure Network, 4 rue de Morvan, Vandoeuvre-des-Nancy, Meurthe-et-Moselle 54500, France
| | - Harriette G C Van Spall
- Department of Medicine, McMaster University, 20 Copeland Avenue, David Braley Research Building, Suite C3-117, Hamilton, ON L8L 0A3, Canada.,Research Institute of St. Josephs, St. Joseph's Healthcare Hamilton, 50 Charlton Ave E, Hamilton, ON L8N 4A6, Canada.,Population Health Research Institute, 237 Barton St E, Hamilton ON L8L 2X2, Canada.,Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main St W, McMaster University Medical Centre, 2C Area, Hamilton, ON L8S 4K1, Canada
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31
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Clark KAA, Nanna MG. Doing Harm by Doing No Harm? Resisting the Urge to Retire GDMT in Older Adults With Heart Failure. J Card Fail 2023; 29:445-447. [PMID: 36841428 DOI: 10.1016/j.cardfail.2023.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Accepted: 02/16/2023] [Indexed: 02/26/2023]
Affiliation(s)
- Katherine A A Clark
- From the Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT.
| | - Michael G Nanna
- From the Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT
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32
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Anti-racist strategies for clinical and translational research: Design, implementation, and lessons learned from a new course. J Clin Transl Sci 2023; 7:e26. [PMID: 36721401 PMCID: PMC9884545 DOI: 10.1017/cts.2022.524] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Revised: 12/03/2022] [Accepted: 12/08/2022] [Indexed: 12/24/2022] Open
Abstract
Translational research should examine racism and bias and improve health equity. We designed and implemented a course for the Master of Science in Clinical Investigation program of the Northwestern University Clinical and Translational Sciences Institute. We describe curriculum development, content, outcomes, and revisions involving 36 students in 2 years of "Anti-Racist Strategies for Clinical and Translational Science." Ninety-six percent of students reported they would recommend the course. Many reported changes in research approaches based on course content. A course designed to teach anti-racist research design is feasible and has a positive short-term impact on learners.
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33
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Coles TM, Lin L, Weinfurt K, Reeve BB, Spertus JA, Mentz RJ, Piña IL, Bocell FD, Tarver ME, Henke DM, Saha A, Caldwell B, Spring S. Do PRO Measures Function the Same Way for all Individuals With Heart Failure? J Card Fail 2023; 29:210-216. [PMID: 35691480 DOI: 10.1016/j.cardfail.2022.05.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Revised: 05/13/2022] [Accepted: 05/31/2022] [Indexed: 11/26/2022]
Abstract
Women diagnosed with heart failure report worse quality of life than men on patient-reported outcome (PRO) measures. An inherent assumption of PRO measures in heart failure is that women and men interpret questions about quality of life the same way. If this is not the case, the risk then becomes that the PRO scores cannot be used for valid comparison or to combine outcomes by subgroups of the population. Inability to compare subgroups validly is a broad issue and has implications for clinical trials, and it also has specific and important implications for identifying and beginning to address health inequities. We describe this threat to validity (the psychometric term is differential item functioning), why it is so important in heart-failure outcomes, the research that has been conducted thus far in this area, the gaps that remain, and what we can do to avoid this threat to validity. PROs bring unique information to clinical decision making, and the validity of PRO measures is key to interpreting differences in heart failure outcomes.
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Affiliation(s)
- Theresa M Coles
- Center for Health Measurement, Department of Population Health Sciences, Duke University, Durham, North Carolina.
| | - Li Lin
- Center for Health Measurement, Department of Population Health Sciences, Duke University, Durham, North Carolina
| | - Kevin Weinfurt
- Center for Health Measurement, Department of Population Health Sciences, Duke University, Durham, North Carolina
| | - Bryce B Reeve
- Center for Health Measurement, Department of Population Health Sciences, Duke University, Durham, North Carolina
| | - John A Spertus
- Saint Luke's Mid America Heart Institute/University of Missouri-Kansas City, Missouri
| | - Robert J Mentz
- Department of Medicine, Division of Cardiology, Duke University Medical Center, Durham, North Carolina
| | - Ileana L Piña
- Wayne State University/Central Michigan University, Center for Devices and Radiological Health, Food and Drug Administration, Detroit, Michigan
| | - Fraser D Bocell
- Wayne State University/Central Michigan University, Center for Devices and Radiological Health, Food and Drug Administration, Detroit, Michigan
| | - Michelle E Tarver
- Wayne State University/Central Michigan University, Center for Devices and Radiological Health, Food and Drug Administration, Detroit, Michigan
| | - Debra M Henke
- Center for Health Measurement, Department of Population Health Sciences, Duke University, Durham, North Carolina
| | - Anindita Saha
- Wayne State University/Central Michigan University, Center for Devices and Radiological Health, Food and Drug Administration, Detroit, Michigan
| | - Brittany Caldwell
- Wayne State University/Central Michigan University, Center for Devices and Radiological Health, Food and Drug Administration, Detroit, Michigan
| | - Silver Spring
- Wayne State University/Central Michigan University, Center for Devices and Radiological Health, Food and Drug Administration, Detroit, Michigan
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34
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Avgerinos I, Karagiannis T, Liakos A, Tsapas A, Bekiari E. Racial, ethnic and sex disparities among participants in cardiovascular outcomes trials in type 2 diabetes: A systematic review and descriptive analysis. Diabetes Obes Metab 2023; 25:618-622. [PMID: 36260699 DOI: 10.1111/dom.14900] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Revised: 10/06/2022] [Accepted: 10/17/2022] [Indexed: 02/02/2023]
Affiliation(s)
- Ioannis Avgerinos
- Clinical Research and Evidence-Based Medicine Unit, Second Medical Department, Aristotle University of Thessaloniki, Thessaloniki, Greece
- Diabetes Centre, Second Medical Department, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Thomas Karagiannis
- Clinical Research and Evidence-Based Medicine Unit, Second Medical Department, Aristotle University of Thessaloniki, Thessaloniki, Greece
- Diabetes Centre, Second Medical Department, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Aris Liakos
- Clinical Research and Evidence-Based Medicine Unit, Second Medical Department, Aristotle University of Thessaloniki, Thessaloniki, Greece
- Diabetes Centre, Second Medical Department, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Apostolos Tsapas
- Clinical Research and Evidence-Based Medicine Unit, Second Medical Department, Aristotle University of Thessaloniki, Thessaloniki, Greece
- Diabetes Centre, Second Medical Department, Aristotle University of Thessaloniki, Thessaloniki, Greece
- Harris Manchester College, University of Oxford, Oxford, UK
| | - Eleni Bekiari
- Clinical Research and Evidence-Based Medicine Unit, Second Medical Department, Aristotle University of Thessaloniki, Thessaloniki, Greece
- Diabetes Centre, Second Medical Department, Aristotle University of Thessaloniki, Thessaloniki, Greece
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35
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Nathan AS, Reddy KP, Yang L, Eberly LA, Dayoub EJ, Khatana SAM, Julien HM, Desai ND, Szeto WY, Herrmann HC, Kobayashi TJ, Fiorilli P, Batchelor WB, Mehran R, Alkhouli MA, Giri J, Groeneveld PW, Fanaroff AC. Characteristics of Clinical Trial Sites for Novel Transcatheter Mitral and Tricuspid Valvular Therapies. JAMA Cardiol 2023; 8:120-128. [PMID: 36477493 PMCID: PMC9856899 DOI: 10.1001/jamacardio.2022.4457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Importance Racial and ethnic minority and socioeconomically disadvantaged patients have been underrepresented in randomized clinical trials. Efforts have focused on enhancing inclusion of minority groups at sites participating at clinical trials; however, there may be differences in the patient populations of the sites that participate in clinical trials. Objective To identify any differences in the racial, ethnic, and socioeconomic composition of patient populations among candidate sites in the US that did vs did not participate in trials for novel transcatheter therapies. Design, Setting, and Participants This cross-sectional analysis used Medicare Provider Claims from 2019 for patients admitted to hospitals in the US. All clinical trials for transcatheter mitral and tricuspid valve therapies and the hospitals participating in each of the trials were identified using ClinicalTrials.gov. Hospitals with active cardiac surgical programs that did not participate in the trials were also identified. Data analysis was performed between July 2021 and July 2022. Exposures Multivariable linear regression models were used to identify differences in racial, ethnic, and socioeconomic characteristics among patients undergoing cardiac surgery or transcatheter aortic valve replacement at trial vs nontrial hospitals. Main Outcome and Measures The main outcome of the study was participation in a clinical trial for novel transcatheter mitral or tricuspid valve therapies. Results A total of 1050 hospitals with cardiac surgery programs were identified, of which 121 (11.5%) participated in trials for transcatheter mitral or tricuspid therapies. Patients treated in trial hospitals had a higher median zip code-based household income (difference of $5261; 95% CI, $2986-$7537), a lower Distressed Communities Index score (difference of 5.37; 95% CI, 2.59-8.15), and no significant difference in the proportion of patients dual eligible for Medicaid (difference of 0.86; 95% CI, -2.38 to 0.66). After adjusting for each of the socioeconomic indicators separately, there was less than 1% difference in the proportion of Black and Hispanic patients cared for at hospitals participating vs not participating in clinical trials. Conclusions and Relevance In this cohort study among candidate hospitals for clinical trials for transcatheter mitral or tricuspid valve therapies, trial hospitals took care of a more socioeconomically advantaged population than nontrial hospitals, with a similar proportion of Black and Hispanic patients. These data suggest that site selection efforts may improve enrollment of socioeconomically disadvantaged patients but may not improve the enrollment of Black and Hispanic patients.
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Affiliation(s)
- Ashwin S Nathan
- Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia.,Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center, University of Pennsylvania, Philadelphia.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia.,Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania
| | - Kriyana P Reddy
- Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center, University of Pennsylvania, Philadelphia
| | - Lin Yang
- Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center, University of Pennsylvania, Philadelphia.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
| | - Lauren A Eberly
- Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia.,Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center, University of Pennsylvania, Philadelphia.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
| | - Elias J Dayoub
- Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia.,Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center, University of Pennsylvania, Philadelphia.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
| | - Sameed A M Khatana
- Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia.,Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center, University of Pennsylvania, Philadelphia.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia.,Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania
| | - Howard M Julien
- Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia.,Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center, University of Pennsylvania, Philadelphia.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia.,Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania
| | - Nimesh D Desai
- Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center, University of Pennsylvania, Philadelphia.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia.,Division of Cardiac Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Wilson Y Szeto
- Division of Cardiac Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Howard C Herrmann
- Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia
| | - Taisei J Kobayashi
- Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia.,Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center, University of Pennsylvania, Philadelphia.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia.,Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania
| | - Paul Fiorilli
- Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia.,Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania
| | | | - Roxana Mehran
- Icahn School of Medicine at Mount Sinai, New York, New York
| | | | - Jay Giri
- Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia.,Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center, University of Pennsylvania, Philadelphia.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia.,Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania
| | - Peter W Groeneveld
- Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center, University of Pennsylvania, Philadelphia.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia.,Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania.,Division of General Internal Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Alexander C Fanaroff
- Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia.,Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center, University of Pennsylvania, Philadelphia.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
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36
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Kittleson MM. TRANSFORM-HF-Can We Close the Loop on Diuretics in Heart Failure? JAMA 2023; 329:211-213. [PMID: 36648482 DOI: 10.1001/jama.2022.21692] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Affiliation(s)
- Michelle M Kittleson
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
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37
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Demographic recruitment bias of adults in United States randomized clinical trials by disease categories between 2008 to 2019: a systematic review and meta-analysis. Sci Rep 2023; 13:42. [PMID: 36593228 PMCID: PMC9807581 DOI: 10.1038/s41598-022-23664-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2022] [Accepted: 11/03/2022] [Indexed: 01/03/2023] Open
Abstract
To promote health equity within the United States (US), randomized clinical trials should strive for unbiased representation. Thus, there is impetus to identify demographic disparities overall and by disease category in US clinical trial recruitment, by trial phase, level of masking, and multi-center status, relative to national demographics. A systematic review and meta-analysis were conducted using MEDLINE, Embase, CENTRAL, and ClinicalTrials.gov, between 01/01/2008 to 12/30/2019. Clinical trials (N = 5,388) were identified based on the following inclusion criteria: study type, location, phase, and participant age. Each clinical trial was independently screened by two researchers. Data was pooled using a random-effects model. Median proportions for gender, race, and ethnicity of each trial were compared to the 2010 US Census proportions, matched by age. A second analysis was performed comparing gender, race, and ethnicity proportions by trial phase, multi-institutional status, quality, masking, and study start year. 2977 trials met inclusion criteria (participants, n = 607,181) for data extraction. 36% of trials reported ethnicity and 53% reported race. Three trials (0.10%) included transgender participants (n = 5). Compared with 2010 US Census data, females (48.3%, 95% CI 47.2-49.3, p < 0.0001), Hispanics (11.6%, 95% CI 10.8-12.4, p < 0.0001), American Indians and Alaskan Natives (AIAN, 0.19%, 95% CI 0.15-0.23, p < 0.0001), Asians (1.27%, 95% CI 1.13-1.42, p < 0.0001), Whites (77.6%, 95% CI 76.4-78.8, p < 0.0001), and multiracial participants (0.25%, 95% CI 0.21-0.31, p < 0.0001) were under-represented, while Native Hawaiians and Pacific Islanders (0.76%, 95% CI 0.71-0.82, p < 0.0001) and Blacks (17.0%, 95% CI 15.9-18.1, p < 0.0001) were over-represented. Inequitable representation was mirrored in analysis by phase, institutional status, quality assessment, and level of masking. Between 2008 to 2019 representation improved for only females and Hispanics. Analysis stratified by 44 disease categories (i.e., psychiatric, obstetric, neurological, etc.) exhibited significant yet varied disparities, with Asians, AIAN, and multiracial individuals the most under-represented. These results demonstrate disparities in US randomized clinical trial recruitment between 2008 to 2019, with the reporting of demographic data and representation of most minorities not having improved over time.
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38
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Li G, Zhang J, Chen B, Li L, Thabane L, Sun X. Racial and ethnic subgroup reporting in diabetes randomized controlled trials published from 2000 to 2020: A survey. Diabetes Metab Res Rev 2023; 39:e3588. [PMID: 36309818 DOI: 10.1002/dmrr.3588] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Accepted: 10/21/2022] [Indexed: 01/10/2023]
Abstract
BACKGROUND It remained unknown about the status of and trends in racial/ethnic subgroup reporting in the diabetes trials over the past two decades. OBJECTIVES In this survey, we aimed to evaluate the current state of and temporal trends in subgroup reporting by race/ethnicity regarding the effects of interventions in diabetes randomized controlled trials (RCTs) from year 2000-2020 and to explore the potential trial factors in relation to racial/ethnic subgroup reporting. METHODS We searched electronic databases for eligible diabetes RCTs. The outcome was whether the trials had the event of racial/ethnic subgroup reporting regarding the intervention effects on trial primary outcomes. Poisson regression was used to assess the temporal trends in racial/ethnic subgroup reporting, and univariable logistic regression models were employed for evaluating trial factors related to racial/ethnic subgroup reporting. RESULTS A total of 405 diabetes RCTs were eligible for inclusion. There were 26 (6.42%) trials with racial/ethnic subgroup reporting. A chronological trend towards increased rates of racial/ethnic subgroup reporting was observed; however, the trend was not statistically significant (p = 0.07). Advanced patients' age (Odds ratio [OR] = 2.92, 95% confidence interval [CI]: 1.24-6.88), follow-up duration (OR = 3.53, 95% CI: 1.13-11.00), and BIPOC (Black, Indigenous, and People of Colour) enrolment (OR = 2.39, 95% CI: 1.01-5.62) were found to positively relate with racial/ethnic subgroup reporting, while the industrial funding was associated with decreased reporting (OR = 0.43, 95% CI: 0.19-0.97). Less than one fourth of the trials with racial/ethnic subgroup reporting predefined the subgroup analysis. CONCLUSIONS The majority of diabetes RCTs did not report intervention effects by racial/ethnic subgroup, which was not temporally improved over the past two decades. More efforts and strategies are needed to improve the racial/ethnic subgroup consideration and reporting in diabetes trials.
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Affiliation(s)
- Guowei Li
- Center for Clinical Epidemiology and Methodology (CCEM), Guangdong Second Provincial General Hospital, Guangzhou, China
- Department of Health Research Methods, Evidence, and Impact (HEI), McMaster University, Hamilton, Ontario, Canada
| | - Jingyi Zhang
- Center for Clinical Epidemiology and Methodology (CCEM), Guangdong Second Provincial General Hospital, Guangzhou, China
| | - Bo Chen
- Department of Endocrinology, Guangdong Second Provincial General Hospital, Guangzhou, China
| | - Likang Li
- Center for Clinical Epidemiology and Methodology (CCEM), Guangdong Second Provincial General Hospital, Guangzhou, China
| | - Lehana Thabane
- Department of Health Research Methods, Evidence, and Impact (HEI), McMaster University, Hamilton, Ontario, Canada
- Faculty of Health Sciences, University of Johannesburg, Johannesburg, South Africa
| | - Xin Sun
- Chinese Evidence-based Medicine Center and Cochrane China Center, West China Hospital, Sichuan University, Chengdu, China
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Butt JH, Docherty KF, Claggett BL, Desai AS, Fang JC, Petersson M, Langkilde AM, de Boer RA, Cabrera Honorio JW, Hernandez AF, Inzucchi SE, Kosiborod MN, Køber L, Lam CSP, Martinez FA, Ponikowski P, Sabatine MS, Vardeny O, O'Meara E, Saraiva JFK, Shah SJ, Vaduganathan M, Jhund PS, Solomon SD, McMurray JJV. Dapagliflozin in Black and White Patients With Heart Failure Across the Ejection Fraction Spectrum. JACC. HEART FAILURE 2022; 11:375-388. [PMID: 36881399 DOI: 10.1016/j.jchf.2022.11.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 11/21/2022] [Accepted: 11/22/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND Black people have a higher incidence and prevalence of heart failure (HF) than White people, and once HF has developed, they may have worse outcomes. There is also evidence that the response to several pharmacologic therapies may differ between Black and White patients. OBJECTIVES The authors sought to examine the outcomes and response to treatment with dapagliflozin according to Black or White race in a pooled analysis of 2 trials comparing dapagliflozin to placebo in patients with heart failure with reduced ejection fraction (DAPA-HF [Dapagliflozin and Prevention of Adverse Outcomes in Heart Failure]) and heart failure with Mildly reduced ejection fraction/heart failure with preserved ejection fraction (DELIVER [Dapagliflozin Evaluation to Improve the Lives of Patients With Preserved Ejection Fraction Heart Failure]). METHODS Because most self-identified Black patients were enrolled in the Americas, the comparator group was White patients randomized in the same regions. The primary outcome was the composite of worsening HF or cardiovascular death. RESULTS Of the 3,526 patients randomized in the Americas, 2,626 (74.5%) identified as White and 381 (10.8%) as Black. The primary outcome occurred at a rate of 16.8 (95% CI: 13.8-20.4) in Black patients compared with 11.6 (95% CI: 10.6-12.7) per 100 person-years in White patients (adjusted HR: 1.27; 95% CI: 1.01-1.59). Compared with placebo, dapagliflozin decreased the risk of the primary endpoint to the same extent in Black (HR: 0.69; 95% CI: 0.47-1.02) and White patients (HR: 0.73 [95% CI: 0.61-0.88]; Pinteraction = 0.73). The number of patients needed to treat with dapagliflozin to prevent one event over the median follow-up was 17 in White and 12 in Black patients. The beneficial effects and favorable safety profile of dapagliflozin were consistent across the range of left ventricular ejection fractions in both Black and White patients. CONCLUSIONS The relative benefits of dapagliflozin were consistent in Black and White patients across the range of left ventricular ejection fraction, with greater absolute benefits in Black patients. (Dapagliflozin and Prevention of Adverse Outcomes in Heart Failure [DAPA-HF]; NCT03036124) (Dapagliflozin Evaluation to Improve the Lives of Patients With Preserved Ejection Fraction Heart Failure [DELIVER]; NCT03619213).
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Affiliation(s)
- Jawad H Butt
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom; Department of Cardiology, Rigshospitalet Copenhagen University Hospital, Copenhagen, Denmark
| | - Kieran F Docherty
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom
| | - Brian L Claggett
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Akshay S Desai
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - James C Fang
- University of Utah Medical Center, Salt Lake City, Utah, USA
| | - Magnus Petersson
- Late-Stage Development, Cardiovascular, Renal, and Metabolism, BioPharmaceuticals R and D, AstraZeneca, Gothenburg, Sweden
| | - Anna Maria Langkilde
- Late-Stage Development, Cardiovascular, Renal, and Metabolism, BioPharmaceuticals R and D, AstraZeneca, Gothenburg, Sweden
| | | | | | | | | | - Mikhail N Kosiborod
- Saint Luke's Mid America Heart Institute, University of Missouri-Kansas City, Kansas City, Missouri, USA
| | - Lars Køber
- Department of Cardiology, Rigshospitalet Copenhagen University Hospital, Copenhagen, Denmark
| | - Carolyn S P Lam
- National Heart Centre Singapore and Duke-National University of Singapore, Singapore
| | | | - Piotr Ponikowski
- Center for Heart Diseases, University Hospital, Wroclaw Medical University, Wroclaw, Poland
| | - Marc S Sabatine
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Orly Vardeny
- The Minneapolis Veterans Affairs Center for Care Delivery and Outcomes Research, University of Minnesota, Minneapolis, USA
| | - Eileen O'Meara
- Institut de Cardiologie de Montréal, Université de Montréal, Québec, Canada
| | - Jose F K Saraiva
- Cardiovascular Division, Instituto de Pesquisa Clínica de Campinas, Campinas, Brazil
| | - Sanjiv J Shah
- Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Muthiah Vaduganathan
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Pardeep S Jhund
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom
| | - Scott D Solomon
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - John J V McMurray
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom.
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Collister D, Pyne L, Bhasin AA, Ahmed SB, Smyth B, Herrington W, Jardine M, Walsh M. Sex and Gender in Randomized Controlled Trials of Adults Receiving Maintenance Dialysis: A Meta-epidemiologic Study. Am J Kidney Dis 2022; 81:575-582.e1. [PMID: 36535536 DOI: 10.1053/j.ajkd.2022.10.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Accepted: 10/25/2022] [Indexed: 12/23/2022]
Abstract
RATIONALE & OBJECTIVE How sex and gender concepts are incorporated into randomized controlled trials (RCTs) in adults with kidney failure receiving maintenance dialysis is largely unknown. We describe these practices in published journal articles as well as investigate the proportion of women and female participants in these studies. STUDY DESIGN Meta-epidemiologic study. SETTING & STUDY POPULATIONS RCTs in maintenance dialysis. SELECTION CRITERIA FOR STUDIES Trials published in high-impact journals in 2000-2020. DATA EXTRACTION Implemented in duplicate with conflicts resolved by a third reviewer. ANALYTICAL APPROACH Meta-regression was performed to identify trial characteristics independently associated with the proportion of women and female participants. RESULTS Among 561 included RCTs, 69.7% were parallel and 28.0% were crossover in design; 80.6% were conducted in the hemodialysis population; and 25% of trials compared the treatment of interest with a placebo arm, 25% with a usual care treatment arm, and 50% with an active alternative therapy arm. Of the RCTS, 37.6% were masked. The median size was 60 (IQR, 26-151) participants, and the median follow-up period was 154 (IQR, 42-365) days. The mean proportion of women or female participants was 0.40±0.13 (SD): 39.0% of trials reported sex, and 26.6% reported the gender of the participants. Also, 56.2% referred to participants as females, 25.3% referred to participants as women, and 15.5% referred to both females and women. No trial characteristic other than region (β of 0.062 [95% CI, 0.007-0.117] for Asia) was associated with the proportion of women or female participants. Considering trial design and conduct, 2.7% of trials used sex and/or gender as an inclusion criterion, 26.6% as an exclusion criterion, 4.5% for randomization, 4.8% for subgroup analyses, and 15.7% for covariate adjustment. LIMITATIONS Only high-impact journal articles were studied; and the included studies lacked pediatric trials, those addressing chronic kidney disease or kidney transplantation, any trials from Africa and underrepresentation of other regions, and missing data. CONCLUSIONS RCTs in dialysis are representative of the general dialysis population with regard to sex and gender but they uncommonly report both and often do not include either in their reporting or analysis.
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Affiliation(s)
- David Collister
- Population Health Research Institute, Hamilton; Division of Nephrology, Department of Medicine, University of Alberta, Edmonton, Canada.
| | - Lonnie Pyne
- Department of Health Research Methodology, Evidence & Impact, McMaster University, Hamilton; Division of Nephrology, Department of Medicine, McMaster University, Hamilton; Population Health Research Institute, Hamilton
| | - Arrti A Bhasin
- Department of Health Research Methodology, Evidence & Impact, McMaster University, Hamilton
| | - Sofia B Ahmed
- Section of Nephrology, Department of Medicine, University of Calgary, Calgary
| | - Brendan Smyth
- NHMRC Clinical Trials Centre, University of Sydney, Camperdown; Department of Renal Medicine, St George Hospital, Kogarah
| | - William Herrington
- MRC Population Health Research Unit, Clinical Trial Service Unit and Epidemiological Studies Unit, University of Oxford, Oxford, United Kingdom
| | - Meg Jardine
- NHMRC Clinical Trials Centre, University of Sydney, Camperdown; Department of Renal Medicine, Concord Repatriation General Hospital, Sydney, Australia
| | - Michael Walsh
- Department of Health Research Methodology, Evidence & Impact, McMaster University, Hamilton; Division of Nephrology, Department of Medicine, McMaster University, Hamilton; Population Health Research Institute, Hamilton
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Ye F, Nelson MB, Bertoni AG, Ditzenberger GL, Duncan P, Mentz RJ, Reeves G, Whellan D, Chen H, Upadhya B, Kitzman DW, Pastva AM. Severity of functional impairments by race and sex in older patients hospitalized with acute decompensated heart failure. J Am Geriatr Soc 2022; 70:3447-3457. [PMID: 36527410 PMCID: PMC9759671 DOI: 10.1111/jgs.18006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Revised: 06/17/2022] [Accepted: 07/16/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Older patients hospitalized with acute decompensated heart failure (ADHF) have marked functional impairments, which may contribute to their delayed and incomplete recovery and persistently poor outcomes. However, whether impairment severity differs by race and sex is unknown. METHODS REHAB-HF trial participants (≥60 years) were assessed just before discharge home from ADHF hospitalization. Physical function [Short Physical Performance Battery; 6-min walk distance (6MWD)], frailty (Fried criteria), cognition [Montreal Cognitive Assessment (MoCA)], quality-of-life [Kansas City Cardiomyopathy Questionnaire, Short-Form-12, EuroQol-5D-5L], and depression [Geriatric Depression Scale (GDS)] were examined by race and sex. RESULTS This prespecified subgroup cross-sectional analysis included 337 older adults (52% female, 50% Black). Black participants were on average younger than White participants (70.3 ± 7.2 vs. 74.7 ± 8.3 years). After age, body mass index, ejection fraction, comorbidity, and education adjustment, and impairments were similarly common and severe across groups except: Black male and Black and White female participants had more severely impaired walking function compared with White male participants [6MWD (m) 187 ± 12, 168 ± 9170 ± 11 vs. 239 ± 9, p < 0.001]; gait speed (m/s) (0.61 ± 0.03, 0.56 ± 0.02, 0.55 ± 0.02 vs. 0.69 ± 0.02, p < 0.001); White female participants had the highest frailty prevalence (72% vs. 47%-51%, p = 0.007); and Black participants had lower MoCA scores compared with White participants (20.9 ± 4.5 vs. 22.8 ± 3.9, p < 0.001). Depressive symptoms were common overall (43% GDS ≥5), yet underrecognized clinically (18%), especially in Black male participants compared with White male participants (7% vs. 20%). CONCLUSION Among older patients hospitalized for ADHF, frailty and functional impairments with high potential to jeopardize patient HF self-management, safety, and independence were common and severe across all race and sex groups. Impairment severity was often worse in Black participant and female participant groups. Formal screening across frailty and functional domains may identify those who may require greater support and more tailored care to reduce the risk of adverse events and excess hospitalizations and death.
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Affiliation(s)
- Fan Ye
- Section on Cardiovascular Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - M. Benjamin Nelson
- Section on Cardiovascular Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Alain G. Bertoni
- Department of Epidemiology and Prevention, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Grace L. Ditzenberger
- Department of Orthopaedic Surgery, Physical Therapy Division, Duke University School of Medicine, Durham, North Carolina, USA
| | - Pamela Duncan
- Departments of Neurology, Sticht Center on Aging, Gerontology, and Geriatric Medicine (P.W.D.), Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Robert J. Mentz
- Department of Medicine, Cardiology Division, Duke University School of Medicine, Durham, North Carolina, USA
| | - Gordon Reeves
- Novant Health Heart & Vascular Institute, Charlotte, North Carolina, USA
| | - David Whellan
- Department of Medicine, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Haiying Chen
- Department of Biostatistics and Data Science, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Bharathi Upadhya
- Department of Epidemiology and Prevention, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Dalane W. Kitzman
- Section on Cardiovascular Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Amy M. Pastva
- Department of Orthopaedic Surgery, Physical Therapy Division, Duke University School of Medicine, Durham, North Carolina, USA
- Claude D. Pepper Older Americans Independence Center, Duke University School of Medicine, Durham, North Carolina, USA
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42
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Filippatos G, Anker SD, Butler J, Farmakis D, Ferreira JP, Gollop ND, Brueckmann M, Iwata T, Pocock S, Zannad F, Packer M. Effects of empagliflozin on cardiovascular and renal outcomes in heart failure with reduced ejection fraction according to age: a secondary analysis of EMPEROR-Reduced. Eur J Heart Fail 2022; 24:2297-2304. [PMID: 36194680 PMCID: PMC10092219 DOI: 10.1002/ejhf.2707] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Revised: 09/26/2022] [Accepted: 09/28/2022] [Indexed: 01/18/2023] Open
Abstract
AIMS Empagliflozin improves cardiovascular and renal outcomes in patients with heart failure (HF) and reduced ejection fraction (HFrEF), but its efficacy and safety across patient's age is not well established. METHODS AND RESULTS We assessed the effects of empagliflozin (10 mg daily) versus placebo, on top of standard HF therapy, in symptomatic HFrEF patients with a left ventricular ejection fraction ≤40% and increased natriuretic peptides stratified by age (<65, 65-74, ≥75 years). The primary endpoint was a composite of cardiovascular death or HF hospitalization. Key secondary endpoints included first and recurrent HF hospitalizations and slope of change in estimated glomerular filtration rate (eGFR); the latter was supported by an analysis of a renal composite endpoint (chronic dialysis or renal transplantation or profound and sustained reduction in eGFR). Of 3730 patients, 38% were <65 years, 35% were 65-74 years and 27% were ≥75 years. Compared with placebo, empagliflozin reduced the primary endpoint consistently across the three age groups (hazard ratio 0.71 [95% confidence interval 0.57-0.89] for <65 years, 0.72 [0.57-0.93] for 65-74 years, 0.86 [0.67-1.10] for ≥75 years, interaction p-trend test = 0.24). The effects of empagliflozin were also consistent across age groups for key secondary endpoints of first and recurrent HF hospitalization (p-trend = 0.30), the rate of decline in eGFR (p-trend = 0.78) and the renal composite (p-trend = 0.94). Adverse events (AEs), serious AEs and AEs leading to drug discontinuation increased with age in both treatment arms, but empagliflozin did not increase their incidence over placebo within each age group. CONCLUSION The efficacy and safety of empagliflozin in improving cardiovascular and renal outcomes in HFrEF was consistent across the spectrum of age, including older patients (aged ≥75).
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Affiliation(s)
- Gerasimos Filippatos
- Second Department of CardiologyAthens University Hospital Attikon, National and Kapodistrian University of Athens Medical SchoolAthensGreece
| | - Stefan D. Anker
- Department of Cardiology, Berlin Institute of Health Center for Regenerative Therapies, German Centre for Cardiovascular Research partner site BerlinCharité Universitätsmedizin BerlinGermany
| | - Javed Butler
- Baylor Scott and White Research Institute, Dallas, TX, USA and University of Mississippi Medical CenterJacksonMSUSA
| | | | - João Pedro Ferreira
- Université de Lorraine, INSERM, Centre d'Investigations Cliniques 1433, CHRUNancyFrance
- UnIC@RISE, Cardiovascular Research and Development Center, Department of Surgery and Physiology, Faculty of MedicineUniversity of PortoPortoPortugal
| | | | - Martina Brueckmann
- Boehringer Ingelheim International GmbHIngelheimGermany
- First Department of Medicine, Faculty of Medicine MannheimUniversity of HeidelbergGermany
| | - Tomoko Iwata
- Boehringer Ingelheim Pharma International GmbH & Co. KGBiberachGermany
| | - Stuart Pocock
- Department of Medical StatisticsLondon School of Hygiene & Tropical MedicineLondonUK
| | - Faiez Zannad
- Université de Lorraine, INSERM, Centre d'Investigations Cliniques 1433, CHRUNancyFrance
| | - Milton Packer
- Baylor Heart and Vascular InstituteBaylor University Medical CenterDallasTXUSA
- Imperial CollegeLondonUK
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Nagamine T, Gillette B, Kahoun J, Burghaus R, Lippert J, Saxena M. Data-driven identification of heart failure disease states and progression pathways using electronic health records. Sci Rep 2022; 12:17871. [PMID: 36284167 PMCID: PMC9596465 DOI: 10.1038/s41598-022-22398-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 10/13/2022] [Indexed: 01/20/2023] Open
Abstract
Heart failure (HF) is a leading cause of morbidity, healthcare costs, and mortality. Guideline based segmentation of HF into distinct subtypes is coarse and unlikely to reflect the heterogeneity of etiologies and disease trajectories of patients. While analyses of electronic health records show promise in expanding our understanding of complex syndromes like HF in an evidence-driven way, limitations in data quality have presented challenges for large-scale EHR-based insight generation and decision-making. We present a hypothesis-free approach to generating real-world characteristics and progression patterns of HF. Patient disease state snapshots are extracted from the complaints mentioned in unstructured clinical notes. Typical disease states are generated by clustering and characterized in terms of their distinguishing features, temporal relationships, and risk of important clinical events. Our analysis generates a comprehensive "disease phenome" of real-world patients computed from large, noisy, secondary-use EHR datasets created in a routine clinical setting.
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Affiliation(s)
| | - Brian Gillette
- grid.137628.90000 0004 1936 8753Department of Surgery, NYU Langone Long Island, Mineola, NY USA ,Department of Foundations of Medicine, NYU Long Island School of Medicine, Mineola, NY USA
| | - John Kahoun
- Droice Research, New York, NY USA ,Clinical Informatics, CityMD, New York, NY USA
| | - Rolf Burghaus
- grid.420044.60000 0004 0374 4101Bayer AG, Wuppertal, Germany
| | - Jörg Lippert
- grid.420044.60000 0004 0374 4101Bayer AG, Wuppertal, Germany
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Deshpande SB, Deshpande AK. Race/Ethnicity, Gender, and Socioeconomic Status Representation in U.S.-Based Randomized Controlled Trials of Tinnitus: A Systematic Review. Am J Audiol 2022; 31:1320-1333. [PMID: 36170574 DOI: 10.1044/2022_aja-21-00244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
PURPOSE The purpose of this study was to investigate if peer-reviewed randomized controlled trials (RCTs) for the management/treatment of tinnitus conducted in the United States include diverse participants in terms of gender, race/ethnicity, education, occupation, and income. METHOD We performed a comprehensive and systematic literature search via PubMed, Web of Science, Clinical-Trials.gov, and the Cochrane Central Register of Controlled Trials. Our goal was to identify prospective RCTs of tinnitus intervention conducted in the United States from January 1994 to September 2021 and published in peer-reviewed journals. RESULTS A total of 2,584 studies were retrieved. Thirty-two peer-reviewed articles met all inclusion criteria. Of the included studies, approximately 96% reported participants' gender. Approximately 15% studies reported race/ethnicity information in alignment with the U.S. Census Bureau. However, an underrepresentation of both females and people of color was evident across studies. Reporting of socioeconomic status information of participants was also scarce, with only 25% studies reporting education and/or occupation of participants and 0% reporting income levels. CONCLUSIONS This study indicates underrepresentation and underreporting of diverse participant pools in tinnitus research. Reasons for such underrepresentation are explored. Additionally, this systematic review indicates that recent research in tinnitus portrays an optimistic trend in terms of reporting and recruitment of diverse participant groups. Sustainable strategies for including diverse research participants are essential for hearing health care equity. Research and strategies to promote this goal are discussed.
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Affiliation(s)
- Shruti Balvalli Deshpande
- Department of Communication Sciences and Disorders, St. John's University, Queens, NY.,Long Island Doctor of Audiology Consortium, Garden City, NY
| | - Aniruddha K Deshpande
- Long Island Doctor of Audiology Consortium, Garden City, NY.,The Hear-Ring Lab, Department of Speech-Language-Hearing Sciences, Hofstra University, Hempstead, NY
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45
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Zhang J, Van Spall HGC, Wang Y, Thabane L, Wang R, Li G. Twenty-year trends in racial and ethnic enrollment in large diabetes randomized controlled trials. BMC Med 2022; 20:294. [PMID: 36109742 PMCID: PMC9479279 DOI: 10.1186/s12916-022-02501-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 07/27/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Lack of representativeness in Black, Indigenous, and People of Colour (BIPOC) enrollment could compromise the generalizability of study results and health equity. This study aimed to examine trends in BIPOC groups enrollment in diabetes randomized controlled trials (RCTs) and to explore the association between trial factors and high-enrollment of BIPOC groups. METHODS We systematically searched the literature on large diabetes RCTs with a sample size of ≥ 400 participants published between 2000 and 2020. We assessed temporal trends in enrollment of racial and ethnic groups in the included trials. Logistic and linear regression analyses were used to explore the relationship between trial factors and the high-enrollment defined by median enrollment rate. RESULTS A total of 405 RCTs were included for analyses. The median enrollment rate of BIPOC groups was 24.0%, with 6.4% for the Black group, 11.2% for Hispanic, 8.5% for Asian, and 3.0% for other BIPOC groups respectively. Over the past 20 years, the BIPOC enrollment showed an increased trend in the diabetes RCTs, ranging from 20.1 to 28.4% (P for trend = 0.041). A significant trend towards increased enrollment for Asian group was observed. We found that weekly or daily intervention frequency (OR = 0.48, 95% CI: 0.26, 0.91) and duration of intervention > 6.5 month (OR = 0.59, 95% CI: 0.37, 0.95) were significantly related to decreased odds of high-enrollment, while type 2 diabetes (OR = 1.44, 95% CI: 1.04, 1.99) was associated with high-enrollment of BIPOC groups. CONCLUSIONS The enrollment of BIPOC was found to increase in large diabetes RCTs over the past two decades; some trial factors may be significantly associated with BIPOC enrollment. These findings may highlight the importance of enrollment of BIPOC groups and provide insights into the design and implementation of future clinical trials in diabetes.
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Affiliation(s)
- Jingyi Zhang
- Center for Clinical Epidemiology and Methodology (CCEM), Guangdong Second Provincial General Hospital, Guangzhou, China
| | - Harriette G C Van Spall
- Department of Health Research Methods, Evidence, and Impact (HEI), McMaster University, Hamilton, ON, Canada.,Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Yaoyao Wang
- Department of Epidemiology, School of Medicine, Jinan University, Guangzhou, China
| | - Lehana Thabane
- Department of Health Research Methods, Evidence, and Impact (HEI), McMaster University, Hamilton, ON, Canada.,St Joseph's Healthcare Hamilton, ON, Hamilton, Canada.,Faculty of Health Sciences, University of Johannesburg, Johannesburg, South Africa
| | - Ruoting Wang
- Center for Clinical Epidemiology and Methodology (CCEM), Guangdong Second Provincial General Hospital, Guangzhou, China
| | - Guowei Li
- Center for Clinical Epidemiology and Methodology (CCEM), Guangdong Second Provincial General Hospital, Guangzhou, China. .,Department of Health Research Methods, Evidence, and Impact (HEI), McMaster University, Hamilton, ON, Canada.
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Li G, Zhang J, Van Spall HGC, Douglas PS, Wang Y, Sun X, Thabane L. Exploring ethnic representativeness in diabetes clinical trial enrolment from 2000 to 2020: a chronological survey. Diabetologia 2022; 65:1461-1472. [PMID: 35705796 PMCID: PMC9200441 DOI: 10.1007/s00125-022-05736-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Accepted: 04/07/2022] [Indexed: 02/05/2023]
Abstract
AIMS/HYPOTHESIS Ethnic representativeness of participant enrolment in diabetes RCTs involving multiple ethnicities remains unknown. The aims of this study were to evaluate the status and temporal trend of ethnic representativeness in enrolment to diabetes RCTs, and to assess under-enrolment of non-white ethnic groups and explore trial characteristics associated with under-enrolment. METHODS We conducted a chronological survey by systematically searching the literature to include eligible RCTs published between January 2000 and December 2020. We assessed temporal trends in enrolment of ethnic groups in the included trials. Univariable logistic regression was used to explore the association between trial characteristics and under-enrolment of non-white groups, using a participant to prevalence ratio of <0.8 to define under-enrolment. This study was registered in PROSPERO (CRD42021229100). RESULTS We included 405 RCTs for analysis (327 multi-country trials, 69 conducted in the USA and nine conducted in the UK). The median enrolment rate of all non-white groups was 24.0% in the overall RCTs. Trials conducted in the USA and the UK had median enrolment rates of 29.0% and 12.0% for all non-white groups, respectively. There was a temporal trend towards increased participation of non-white ethnic groups in the overall RCTs; however, no significant improvement over time was found in the US or UK trials. Non-white groups were under-enrolled in most included trials: 62.3% (43/69) in US trials and 77.8% (7/9) in UK trials. The US trials with a high female proportion were associated with lower odds of under-enrolment of all non-white groups (OR 0.22; 95% CI 0.07, 0.65), while trials receiving funding from industry showed increased odds of under-enrolment (OR 4.64; 95% CI 1.50, 14.35). Outpatient enrolment and intervention duration were significantly associated with under-enrolment of Black participants. Only a small proportion of trials reported subgroup results or explored the effect modification by ethnicity. CONCLUSIONS/INTERPRETATION A temporal trend towards increased non-white ethnic enrolment was found in diabetes RCTs globally, but not in the USA or the UK. Non-white ethnic groups were under-represented in the majority of diabetes trials conducted in the USA and the UK. Some trial characteristics may be associated with non-white under-enrolment in diabetes trials. These findings provide some evidence for non-white ethnic representativeness in diabetes trials over the past two decades, and highlight the need for more effective strategies and endeavours to alleviate under-enrolment of non-white ethnic groups.
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Affiliation(s)
- Guowei Li
- Center for Clinical Epidemiology and Methodology, Guangdong Second Provincial General Hospital, Guangzhou, China.
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada.
| | - Jingyi Zhang
- Center for Clinical Epidemiology and Methodology, Guangdong Second Provincial General Hospital, Guangzhou, China
| | - Harriette G C Van Spall
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Pamela S Douglas
- Duke University Clinical Research Institute, Duke University, Durham, NC, USA
| | - Yaoyao Wang
- Department of Epidemiology, School of Medicine, Jinan University, Guangzhou, China
| | - Xin Sun
- Chinese Evidence-Based Medicine Center and Cochrane China Center, West China Hospital, Sichuan University, Chengdu, China.
| | - Lehana Thabane
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
- St Joseph's Healthcare Hamilton, Hamilton, ON, Canada
- Faculty of Health Sciences, University of Johannesburg, Johannesburg, South Africa
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Nguyen AB, Cavallari LH, Rossi JS, Stouffer GA, Lee CR. Evaluation of race and ethnicity disparities in outcome studies of CYP2C19 genotype-guided antiplatelet therapy. Front Cardiovasc Med 2022; 9:991646. [PMID: 36082121 PMCID: PMC9445150 DOI: 10.3389/fcvm.2022.991646] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Accepted: 08/05/2022] [Indexed: 11/15/2022] Open
Abstract
Dual antiplatelet therapy with a P2Y12 inhibitor (clopidogrel, prasugrel, or ticagrelor) and aspirin remains the standard of care for all patients undergoing percutaneous coronary intervention (PCI). It is well-established that patients carrying CYP2C19 no function alleles have impaired capacity to convert clopidogrel into its active metabolite and thus, are at higher risk of major adverse cardiovascular events (MACE). The metabolism and clinical effectiveness of prasugrel and ticagrelor are not affected by CYP2C19 genotype, and accumulating evidence from multiple randomized and observational studies demonstrates that CYP2C19 genotype-guided antiplatelet therapy following PCI improves clinical outcomes. However, most antiplatelet pharmacogenomic outcome studies to date have lacked racial and ethnic diversity. In this review, we will (1) summarize current guideline recommendations and clinical outcome evidence related to CYP2C19 genotype-guided antiplatelet therapy, (2) evaluate the presence of potential racial and ethnic disparities in the major outcome studies supporting current genotype-guided antiplatelet therapy recommendations, and (3) identify remaining knowledge gaps and future research directions necessary to advance implementation of this precision medicine strategy for dual antiplatelet therapy in diverse, real-world clinical settings.
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Affiliation(s)
- Anh B. Nguyen
- Division of Pharmacotherapy and Experimental Therapeutics, Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Larisa H. Cavallari
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics and Precision Medicine, University of Florida, Gainesville, FL, United States
| | - Joseph S. Rossi
- Division of Cardiology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - George A. Stouffer
- Division of Cardiology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Craig R. Lee
- Division of Pharmacotherapy and Experimental Therapeutics, Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
- Division of Cardiology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
- *Correspondence: Craig R. Lee,
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Grant JK, Dangl M, Koester M, Tegegn M, Knijiik L, Singh H, Orringer CE. Under-reporting and Under-representation of Non-Hispanic Black Subjects in Lipid-Lowering Atherosclerotic Cardiovascular Disease Outcomes Trials: A Systematic Review. J Clin Lipidol 2022; 16:608-616. [DOI: 10.1016/j.jacl.2022.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2022] [Revised: 08/10/2022] [Accepted: 08/18/2022] [Indexed: 10/14/2022]
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Morton ME, Sandage MJ. Sex and Race Reporting and Representation in Noncancerous Voice Clinical Trials: A Meta-Analysis of National Institutes of Health-Registered Research Between 1988 and 2021. JOURNAL OF SPEECH, LANGUAGE, AND HEARING RESEARCH : JSLHR 2022; 65:2594-2607. [PMID: 35858261 DOI: 10.1044/2022_jslhr-22-00141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
PURPOSE The purpose of this meta-analysis was to assess the frequency of sex, race, and ethnicity reporting and proportional representation in funded, noncancerous voice clinical trials to determine the state of compliance with National Institutes of Health (NIH) guidelines for inclusivity in clinical research. METHOD Clinical trials registered with the NIH/U.S. National Library of Medicine between January 1988 and September 2021 were analyzed. Primary reports of the trials were obtained from clinicaltrials.gov and PubMed. Outcomes included the proportion of trials reporting sex, race, and ethnicity and the proportion of participants by sex, race, and ethnicity in the trials. Descriptive statistics and chi-square tests were used to analyze the data with 95% confidence intervals (CIs) reported. RESULTS The search yielded 46 research studies. After inclusion and exclusion criteria were applied and attempts to locate studies were conducted, 11 total articles were ultimately evaluated. Descriptively, there were more female subjects, yet overall, no significant difference in sex distribution (χ2 = 0.07, p = .75, 95% CI [-0.25, -0.19]). Race and ethnicity were only reported in two clinical trials. Black participants were underrepresented in one clinical trial (χ2 = 4.93, p = .02, 95% CI [-0.11, -0.02]), whereas Hispanic participants were underrepresented in a second trial (χ2 = 11.27, p < .00, 95% CI [-0.20, - 0.13]). CONCLUSIONS This preliminary analysis highlights the disparities in race and ethnicity recruitment and reporting in noncancerous voice clinical trials. There is a need for strategic recruitment strategies and improved reporting practices to adhere to the NIH inclusivity directives.
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Affiliation(s)
| | - Mary J Sandage
- Department of Speech, Language, and Hearing Sciences, Auburn University, AL
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50
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Turner BE, Steinberg JR, Weeks BT, Rodriguez F, Cullen MR. Race/ethnicity reporting and representation in US clinical trials: a cohort study. LANCET REGIONAL HEALTH. AMERICAS 2022; 11:100252. [PMID: 35875251 PMCID: PMC9302767 DOI: 10.1016/j.lana.2022.100252] [Citation(s) in RCA: 71] [Impact Index Per Article: 35.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
BACKGROUND Systemic progress in improving trial representation is uncertain, and previous analyses of minority trial participation have been limited to small cohorts with limited exploration of driving factors. METHODS We analyzed detailed trial records from all US clinical trials registered in ClinicalTrials.gov from March 2000 to March 2020. Minority enrollment was compared to 2010 US Census demographic estimates using Wilcoxon test. We utilized logistic regression and generalized linear regression with a logit link to assess the association of possible drivers (including trials' funding source, size, phase, and design) with trials' disclosure of and amount of minority enrollment respectively. FINDINGS Among 20,692 US-based trials with reported results (representing ~4·76 million enrollees), only 43% (8,871/20,692) reported any race/ethnicity data. The majority of enrollees were White (median 79·7%; interquartile range [IQR] 61·9-90·0%), followed by Black (10·0%; IQR 2·5-23·5%), Hispanic/Latino (6·0%; IQR 0·43-15·4%), Asian (1·0%; IQR 0·0-4·1%), and American Indian (0·0%; IQR 0·0-0·2%). Median combined enrollment of minority race/ethnicity groups (Black, Hispanic/Latino, Asian, American Indian, Other/Multi) was below census estimates (27·6%) (p<0·001) however increased at an annual rate of 1·7%. Industry and Academic funding were negatively associated with race/ethnicity reporting (Industry adjusted odds ratio [aOR]: 0·42, 95% confidence interval [CI]: 0·38 to 0·46, p<0.0001; Academic aOR: 0·45, CI: 0·41 to 0·50, p<0.0001). Industry also had a negative association with the proportion of minority ethnicity enrollees (aOR: 0·69, CI: 0·60 to 0·79) compared to US Government-funded trials. INTERPRETATION Over the past two decades, the majority of US trials in ClinicalTrials.gov do not report race/ethnicity enrollment data, and minorities are underrepresented in trials with modest improvement over time. FUNDING Stanford Medical Scholars Research Funding, the National Heart, Lung, and Blood Institute, NIH (1K01HL144607) and the American Heart Association/Robert Wood Johnson Medical Faculty Development Program.
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Affiliation(s)
- Brandon E. Turner
- Stanford University School of Medicine, Stanford, CA, USA
- Massachusetts General Hospital, 55 Fruit Street, Lunder Building LL3, Boston, MA 02114, USA
| | | | | | - Fatima Rodriguez
- Division of Cardiovascular Medicine and the Cardiovascular Institute, Stanford University, Stanford, CA, USA
| | - Mark R. Cullen
- Center for Population Health Sciences, Stanford University School of Medicine, Stanford, CA, USA
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