1
|
Iskander R, Moyer H, Vigneault K, Mahmud SM, Kimmelman J. Survival Benefit Associated With Participation in Clinical Trials of Anticancer Drugs: A Systematic Review and Meta-analysis. JAMA 2024:2819132. [PMID: 38767595 PMCID: PMC11106715 DOI: 10.1001/jama.2024.6281] [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] [Received: 11/27/2023] [Accepted: 03/26/2024] [Indexed: 05/22/2024]
Abstract
Importance Many cancer clinical investigators view clinical trials as offering better care for patients than routine clinical care. However, definitive evidence of clinical benefit from trial participation (hereafter referred to as the participation effect) has yet to emerge. Objective To conduct a systematic review and meta-analysis of the evidence examining whether patient participation in cancer trials was associated with greater survival benefit compared with routine care. Data Sources Studies were found through PubMed and Embase (January 1, 2000, until August 31, 2022), as well as backward and forward citation searching. Study Selection Studies were included that compared overall survival of trial participants and routine care patients. Data Extraction and Synthesis Data extraction and methodological quality assessment were completed by 2 independent coders using Covidence software. Data were pooled using a random-effects model and analyzed based on the quality of the comparison between trial participants and routine care patients (ie, extent to which studies controlled for bias and confounders). Main Outcomes and Measures The hazard ratio (HR) for overall survival of trial participants vs routine care patients. Results Thirty-nine publications were included, comprising 85 comparisons of trial participants and routine care patients. The meta-analysis revealed a statistically significant overall survival benefit for trial participants (HR, 0.76 [95% CI, 0.69-0.82]) when all studies were pooled, regardless of design or quality. However, survival benefits diminished in study subsets that matched trial participants and routine care patients for eligibility criteria (HR, 0.85 [95% CI, 0.75-0.97]) and disappeared when only high-quality studies were pooled (HR, 0.91 [95% CI, 0.80-1.05]). They also disappeared when estimates were adjusted for potential publication bias (HR, 0.94 [95% CI, 0.86-1.03]). Conclusions and Relevance Many studies suggest a survival benefit for cancer trial participants. However, these benefits were not detected in studies using designs addressing important sources of bias and confounding. Pooled results of high-quality studies are not consistent with a beneficial effect of trial participation on its own.
Collapse
Affiliation(s)
- Renata Iskander
- Department of Equity, Ethics and Policy, McGill University, Montreal, Quebec, Canada
| | - Hannah Moyer
- Department of Medicine, Temple University, Philadelphia, Pennsylvania
| | - Karine Vigneault
- Department of Equity, Ethics and Policy, McGill University, Montreal, Quebec, Canada
| | - Salaheddin M. Mahmud
- Department of Community Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Jonathan Kimmelman
- Department of Equity, Ethics and Policy, McGill University, Montreal, Quebec, Canada
| |
Collapse
|
2
|
Ginnerup-Nielsen E, Christensen R, Bliddal H, Henriksen M. Effect of research participation versus usual clinical care in patients with rheumatic and musculoskeletal disorders: a prospective cohort study. RMD Open 2023; 9:e003414. [PMID: 37797965 PMCID: PMC10551945 DOI: 10.1136/rmdopen-2023-003414] [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: 06/19/2023] [Accepted: 09/11/2023] [Indexed: 10/07/2023] Open
Abstract
OBJECTIVE To compare illness perception (IP), pain, functional level and health-related quality of life (HR-QoL) between patients with musculoskeletal pain who participate versus those who do not participate in clinical research projects. METHODS Data were collected between 1 January 2019 and 31 December 2021 in patients visiting the Outpatient Osteoarthritis Clinic at Frederiksberg Hospital, Copenhagen, as part of either clinical research or regular treatment. Questionnaires were collected at baseline and after 10-18 months. Major outcome measure was the change from baseline to follow-up in the Brief Pain Inventory - Short Form (BPI-SF) item 'Average pain'. Secondary outcome measures included The Brief Illness Perception Questionnaire (B-IPQ), measured only at baseline, the EuroQol (EQ-5D-3L), the Health Assessment Questionnaire Disability Index and PainDETECT. RESULTS 1495 patients were included with 358 (24%) categorised as research participants (exposed) and 1137 (76%) being non-participants (unexposed). The baseline B-IPQ item scores were generally more favourable in the exposed group with statistically significant standardised differences (SD) of 0.2-0.3. Similarly, an SD of 0.3 on the EQ-5D-3L score indicated a better HR-QoL in the exposed group. At follow-up, 24% in the exposed group and 27% in the unexposed group, completed the questionnaires. The mean BPI-sf Average pain between-group difference was: -0.01 points (95% CI: -0.6 to 0.6). Similar clinically irrelevant differences were seen in the other outcomes. CONCLUSIONS Among musculoskeletal pain patients, research participants report more positive IP and better HR-QoL than non-participants. No additional effect of research participation was found in any outcome over time. TRIAL REGISTRATION NUMBER NCT03785561.
Collapse
Affiliation(s)
| | - Robin Christensen
- Bispebjerg and Frederiksberg Hospital, The Parker Institute, Frederiksberg, Copenhagen, Denmark
- Research Unit of Rheumatology, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Henning Bliddal
- Bispebjerg and Frederiksberg Hospital, The Parker Institute, Frederiksberg, Copenhagen, Denmark
| | - Marius Henriksen
- Bispebjerg and Frederiksberg Hospital, The Parker Institute, Frederiksberg, Copenhagen, Denmark
| |
Collapse
|
3
|
Varma T, Jones CP, Oladele C, Miller J. Diversity in clinical research: public health and social justice imperatives. JOURNAL OF MEDICAL ETHICS 2023; 49:200-203. [PMID: 35428737 DOI: 10.1136/medethics-2021-108068] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Accepted: 04/02/2022] [Indexed: 06/14/2023]
Abstract
It is well established that demographic representation in clinical research is important for understanding the safety and effectiveness of novel therapeutics and vaccines in diverse patient populations. In recent years, the National Institutes of Health and Food and Drug Administration have issued guidelines and recommendations for the inclusion of women, older adults, and racial and ethnic minorities in research. However, these guidelines fail to provide an adequate explanation of why racial and ethnic representation in clinical research is important. This article aims to both provide the missing arguments for why adequate representation of racial and ethnic minorities in clinical research is essential and to articulate a number of recommendations for improving diversity going forward.Appropriate racial and ethnic representation and fair inclusion help (1) increase the generalisability of clinical trial results, (2) equitably distribute any benefits of clinical research and (3) enable trust in the research enterprise.
Collapse
Affiliation(s)
- Tanvee Varma
- Yale School of Medicine, New Haven, Connecticut, USA
| | - Camara P Jones
- Department of Community Health and Preventive Medicine, Morehouse School of Medicine, Atlanta, Georgia, USA
- Harvard University Radcliffe Institute for Advanced Study, Cambridge, Massachusetts, USA
| | - Carol Oladele
- Section of General Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Jennifer Miller
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| |
Collapse
|
4
|
Bouzalmate-Hajjaj A, Massó Guijarro P, Khan KS, Bueno-Cavanillas A, Cano-Ibáñez N. Benefits of Participation in Clinical Trials: An Umbrella Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:15368. [PMID: 36430100 PMCID: PMC9691211 DOI: 10.3390/ijerph192215368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Revised: 11/10/2022] [Accepted: 11/17/2022] [Indexed: 06/16/2023]
Abstract
Participation in randomised clinical trials (RCTs) entails taking part in the discovery of effects of health care interventions. The question of whether participants' outcomes are different to those of non-participants remains controversial. This umbrella review was aimed at assessing whether there are health benefits of participation in RCTs, compared to non-participation. After prospective registration (PROSPERO CRD42021287812), we searched the Medline, Scopus, Web of Science and Cochrane Library databases from inception to June 2022 to identify relevant systematic reviews with or without meta-analyses. Data extraction and study quality assessment (AMSTAR-2) were performed by two independent reviewers. Of 914 records, six systematic reviews summarising 380 comparisons of RCT participants with non-participants met the inclusion criteria. In two reviews, the majority of comparisons were in favour of participation in RCTs. Of the total of comparisons, 69 (18.7%) were in favour of participation, reporting statistically significant better outcomes for patients treated within RCTs, 264 (71.7%) comparisons were not statistically significant, and 35 (9.5%) comparisons were in favour of non-participation. None of the reviews found a harmful effect of participation in RCTs. Our findings suggest that taking part in RCTs may be beneficial compared to non-participation.
Collapse
Affiliation(s)
- Amira Bouzalmate-Hajjaj
- Department of Preventive Medicine and Public Health, Faculty of Medicine, University of Granada, 18016 Granada, Spain
| | - Paloma Massó Guijarro
- Department of Preventive Medicine and Public Health, Faculty of Medicine, University of Granada, 18016 Granada, Spain
- Preventive Medicine Unit, Universitary Hospital Virgen de las Nieves, 18014 Granada, Spain
- Instituto de Investigación Biosanitaria de Granada (IBS.GRANADA), 18012 Granada, Spain
| | - Khalid Saeed Khan
- Department of Preventive Medicine and Public Health, Faculty of Medicine, University of Granada, 18016 Granada, Spain
- CIBER de Epidemiología y Salud Pública (CIBERESP-Spain), 28029 Madrid, Spain
| | - Aurora Bueno-Cavanillas
- Department of Preventive Medicine and Public Health, Faculty of Medicine, University of Granada, 18016 Granada, Spain
- Instituto de Investigación Biosanitaria de Granada (IBS.GRANADA), 18012 Granada, Spain
- CIBER de Epidemiología y Salud Pública (CIBERESP-Spain), 28029 Madrid, Spain
| | - Naomi Cano-Ibáñez
- Department of Preventive Medicine and Public Health, Faculty of Medicine, University of Granada, 18016 Granada, Spain
- Instituto de Investigación Biosanitaria de Granada (IBS.GRANADA), 18012 Granada, Spain
- CIBER de Epidemiología y Salud Pública (CIBERESP-Spain), 28029 Madrid, Spain
| |
Collapse
|
5
|
A systematic review and meta-analysis of weight loss in control group participants of lifestyle randomized trials. Sci Rep 2022; 12:12252. [PMID: 35851070 PMCID: PMC9293970 DOI: 10.1038/s41598-022-15770-x] [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: 02/10/2022] [Accepted: 06/29/2022] [Indexed: 12/03/2022] Open
Abstract
Randomized clinical trials (RCTs) of lifestyle modification have reported beneficial effects of interventions, compared to control. Whether participation in the control group has benefits is unknown. To determine whether control group participants experience weight loss during the course of RCTs. After prospective registration (PROSPERO CRD42021233070), we conducted searches in Medline, Scopus, Web of Science, Cochrane library and Clinicaltrials.gov databases from inception to May 2021 without language restriction to capture RCTs on dietary advice or physical activity interventions in adults with overweight, obesity or metabolic syndrome. Data extraction and study quality assessment was performed by two independent reviewers. Weight loss in the control group, i.e., the difference between baseline and post-intervention, was pooled using random effects model generating mean difference and 95% confidence interval (CI). Heterogeneity was assessed using the I2 statistical test. Subgroup meta-analysis was performed stratifying by follow-up period, type of control group protocols and high-quality studies. Among the 22 included studies (4032 participants), the risk of bias was low in 9 (40%) studies. Overall, the controls groups experienced weight loss of − 0.41 kg (95% CI − 0.53 to − 0.28; I2 = 73.5% p < 0.001). To identify a result that is an outlier, we inspected the forest plot for spread of the point estimates and the confidence intervals. The magnitude of the benefit was related to the duration of follow-up (− 0.51 kg, 95% CI − 0.68, − 0.3, for 1–4 months follow-up; − 0.32 kg, 95% CI − 0.58, − 0.07, 5–12 months; − 0.20 kg, 95% CI − 0.49, 0.10, ≥ 12 months). In high-quality studies we found an overall weight loss mean difference of − 0.16 (95% CI − 0.39, 0.09) with a considerable heterogeneity (I2 = 74%; p < 0.000). Among studies including control group in waiting lists and combining standard care, advice and material, no heterogeneity was found (I2 = 0%, p = 0.589) and (I2 = 0%, p = 0.438); and the mean difference was − 0.84 kg (95% CI − 2.47, 0.80) and − 0.65 kg (95% CI − 1.03, − 0.27) respectively. Participation in control groups of RCTs of lifestyle interventions had a benefit in terms of weight loss in meta-analysis with heterogeneity. These results should be used to interpret the benefits observed with respect to intervention effect in trials. That control groups accrue benefits should be included in patient information sheets to encourage participation in future trials among patients with overweight and obesity.
Collapse
|
6
|
Roumen RMH, Schuurman MS, Aarts MJ, Maaskant-Braat AJG, Vreugdenhil G, Louwman WJ. Survival of sentinel node biopsy versus observation in intermediate-thickness melanoma: A Dutch population-based study. PLoS One 2021; 16:e0252021. [PMID: 34033662 PMCID: PMC8148374 DOI: 10.1371/journal.pone.0252021] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Accepted: 05/07/2021] [Indexed: 02/05/2023] Open
Abstract
Background The Multicenter Selective Lymphadenectomy Trial (MSLT-1) comparing survival after a sentinel lymph node biopsy (SLNB) versus nodal observation in melanoma patients did not show a significant benefit favoring SLNB. However, in subgroup analyses melanoma-specific survival among patients with nodal metastases seemed better. Aim To evaluate the association of performing a SLNB with overall survival in intermediate thickness melanoma patients in a Dutch population-based daily clinical setting. Methods Survival, excess mortality adjusted for age, gender, Breslow-thickness, ulceration, histological subtype, location, co-morbidity and socioeconomic status were calculated in a population of 1,989 patients diagnosed with malignant cutaneous melanoma (1.2–3.5 mm) on the trunk or limb between 2000–2016 in ten hospitals in the South East area, The Netherlands. Results A SLNB was performed in 51% of the patients (n = 1008). Ten-year overall survival after SLNB was 75% (95%CI, 71%-78%) compared to 61% (95%CI 57%-64%) following observation. After adjustment for risk factors, a lower risk on death (HR = 0.80, 95%CI 0.66–0.96) was found after SLNB compared to observation only. Conclusions SLNB in patients with intermediate-thickness melanoma on trunk or limb resulted in a 14% absolute and significant 10-year survival difference compared to those without SLNB.
Collapse
Affiliation(s)
- R. M. H. Roumen
- Department of Surgery, Máxima Medical Center, Eindhoven/Veldhoven, The Netherlands
- GROW–School for Oncology and Developmental Biology, Maastricht University Medical Centre, Maastricht, The Netherlands
- * E-mail:
| | - M. S. Schuurman
- Netherlands Comprehensive Cancer Organization, IKNL, Utrecht, The Netherlands
| | - M. J. Aarts
- Netherlands Comprehensive Cancer Organization, IKNL, Utrecht, The Netherlands
| | | | - G. Vreugdenhil
- Department of Medical Oncology, Máxima Medical Center, Eindhoven/Veldhoven, The Netherlands
| | - W. J. Louwman
- Netherlands Comprehensive Cancer Organization, IKNL, Utrecht, The Netherlands
| |
Collapse
|
7
|
Neelapu SS, Adkins S, Ansell SM, Brody J, Cairo MS, Friedberg JW, Kline JP, Levy R, Porter DL, van Besien K, Werner M, Bishop MR. Society for Immunotherapy of Cancer (SITC) clinical practice guideline on immunotherapy for the treatment of lymphoma. J Immunother Cancer 2020; 8:e001235. [PMID: 33361336 PMCID: PMC7768967 DOI: 10.1136/jitc-2020-001235] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/10/2020] [Indexed: 02/07/2023] Open
Abstract
The recent development and clinical implementation of novel immunotherapies for the treatment of Hodgkin and non-Hodgkin lymphoma have improved patient outcomes across subgroups. The rapid introduction of immunotherapeutic agents into the clinic, however, has presented significant questions regarding optimal treatment scheduling around existing chemotherapy/radiation options, as well as a need for improved understanding of how to properly manage patients and recognize toxicities. To address these challenges, the Society for Immunotherapy of Cancer (SITC) convened a panel of experts in lymphoma to develop a clinical practice guideline for the education of healthcare professionals on various aspects of immunotherapeutic treatment. The panel discussed subjects including treatment scheduling, immune-related adverse events (irAEs), and the integration of immunotherapy and stem cell transplant to form recommendations to guide healthcare professionals treating patients with lymphoma.
Collapse
Affiliation(s)
- Sattva S Neelapu
- Department of Lymphoma and Myeloma, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Sherry Adkins
- Department of Lymphoma and Myeloma, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Stephen M Ansell
- Division of Hematology, Department of Internal Medicine, Mayo Clinic Cancer Center, Rochester, Minnesota, USA
| | - Joshua Brody
- Hematology and Oncology, Icahn School of Medicine at Mount Sinai, New York City, New York, USA
| | - Mitchell S Cairo
- Department of Pediatrics, Medicine, Pathology, Microbiology and Immunology and Cell Biology, New York Medical College At Maria Fareri Children's Hospital, New York City, New York, USA
| | - Jonathan W Friedberg
- Department of Medicine, Hematology-Oncology Division, Wilmot Cancer Institute University of Rochester Medical Center, Rochester, New York, USA
| | - Justin P Kline
- Department of Medicine Section of Hematology/Oncology, University of Chicago, Chicago, Illinois, USA
| | - Ronald Levy
- Division of Oncology, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - David L Porter
- Cell Therapy and Transplant and Division of Hematology Oncology, Abramson Cancer Center, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Koen van Besien
- Division of Hematology/Oncology, Weill Cornell Medical College, New York City, New York, USA
| | | | - Michael R Bishop
- Department of Medicine Section of Hematology/Oncology, University of Chicago, Chicago, Illinois, USA
| |
Collapse
|
8
|
Gnesin F, Thuesen ACB, Kähler LKA, Madsbad S, Hemmingsen B. Metformin monotherapy for adults with type 2 diabetes mellitus. Cochrane Database Syst Rev 2020; 6:CD012906. [PMID: 32501595 PMCID: PMC7386876 DOI: 10.1002/14651858.cd012906.pub2] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Worldwide, there is an increasing incidence of type 2 diabetes mellitus (T2DM). Metformin is still the recommended first-line glucose-lowering drug for people with T2DM. Despite this, the effects of metformin on patient-important outcomes are still not clarified. OBJECTIVES To assess the effects of metformin monotherapy in adults with T2DM. SEARCH METHODS We based our search on a systematic report from the Agency for Healthcare Research and Quality, and topped-up the search in CENTRAL, MEDLINE, Embase, WHO ICTRP, and ClinicalTrials.gov. Additionally, we searched the reference lists of included trials and systematic reviews, as well as health technology assessment reports and medical agencies. The date of the last search for all databases was 2 December 2019, except Embase (searched up 28 April 2017). SELECTION CRITERIA We included randomised controlled trials (RCTs) with at least one year's duration comparing metformin monotherapy with no intervention, behaviour changing interventions or other glucose-lowering drugs in adults with T2DM. DATA COLLECTION AND ANALYSIS Two review authors read all abstracts and full-text articles/records, assessed risk of bias, and extracted outcome data independently. We resolved discrepancies by involvement of a third review author. For meta-analyses we used a random-effects model with investigation of risk ratios (RRs) for dichotomous outcomes and mean differences (MDs) for continuous outcomes, using 95% confidence intervals (CIs) for effect estimates. We assessed the overall certainty of the evidence by using the GRADE instrument. MAIN RESULTS We included 18 RCTs with multiple study arms (N = 10,680). The percentage of participants finishing the trials was approximately 58% in all groups. Treatment duration ranged from one to 10.7 years. We judged no trials to be at low risk of bias on all 'Risk of bias' domains. The main outcomes of interest were all-cause mortality, serious adverse events (SAEs), health-related quality of life (HRQoL), cardiovascular mortality (CVM), non-fatal myocardial infarction (NFMI), non-fatal stroke (NFS), and end-stage renal disease (ESRD). Two trials compared metformin (N = 370) with insulin (N = 454). Neither trial reported on all-cause mortality, SAE, CVM, NFMI, NFS or ESRD. One trial provided information on HRQoL but did not show a substantial difference between the interventions. Seven trials compared metformin with sulphonylureas. Four trials reported on all-cause mortality: in three trials no participant died, and in the remaining trial 31/1454 participants (2.1%) in the metformin group died compared with 31/1441 participants (2.2%) in the sulphonylurea group (very low-certainty evidence). Three trials reported on SAE: in two trials no SAE occurred (186 participants); in the other trial 331/1454 participants (22.8%) in the metformin group experienced a SAE compared with 308/1441 participants (21.4%) in the sulphonylurea group (very low-certainty evidence). Two trials reported on CVM: in one trial no CVM was observed and in the other trial 4/1441 participants (0.3%) in the metformin group died of cardiovascular reasons compared with 8/1447 participants (0.6%) in the sulphonylurea group (very low-certainty evidence). Three trials reported on NFMI: in two trials no NFMI occurred, and in the other trial 21/1454 participants (1.4%) in the metformin group experienced a NFMI compared with 15/1441 participants (1.0%) in the sulphonylurea group (very low-certainty evidence). One trial reported no NFS occurred (very low-certainty evidence). No trial reported on HRQoL or ESRD. Seven trials compared metformin with thiazolidinediones (very low-certainty evidence for all outcomes). Five trials reported on all-cause mortality: in two trials no participant died; the overall RR was 0.88, 95% CI 0.55 to 1.39; P = 0.57; 5 trials; 4402 participants). Four trials reported on SAE, the RR was 0,95, 95% CI 0.84 to 1.09; P = 0.49; 3208 participants. Four trials reported on CVM, the RR was 0.71, 95% CI 0.21 to 2.39; P = 0.58; 3211 participants. Three trial reported on NFMI: in two trials no NFMI occurred and in one trial 21/1454 participants (1.4%) in the metformin group experienced a NFMI compared with 25/1456 participants (1.7%) in the thiazolidinedione group. One trial reported no NFS occurred. No trial reported on HRQoL or ESRD. Three trials compared metformin with dipeptidyl peptidase-4 inhibitors (one trial each with saxagliptin, sitagliptin, vildagliptin with altogether 1977 participants). There was no substantial difference between the interventions for all-cause mortality, SAE, CVM, NFMI and NFS (very low-certainty evidence for all outcomes). One trial compared metformin with a glucagon-like peptide-1 analogue (very low-certainty evidence for all reported outcomes). There was no substantial difference between the interventions for all-cause mortality, CVM, NFMI and NFS. One or more SAEs were reported in 16/268 (6.0%) of the participants allocated to metformin compared with 35/539 (6.5%) of the participants allocated to a glucagon-like peptide-1 analogue. HRQoL or ESRD were not reported. One trial compared metformin with meglitinide and two trials compared metformin with no intervention. No deaths or SAEs occurred (very low-certainty evidence) no other patient-important outcomes were reported. No trial compared metformin with placebo or a behaviour changing interventions. Four ongoing trials with 5824 participants are likely to report one or more of our outcomes of interest and are estimated to be completed between 2018 and 2024. Furthermore, 24 trials with 2369 participants are awaiting assessment. AUTHORS' CONCLUSIONS There is no clear evidence whether metformin monotherapy compared with no intervention, behaviour changing interventions or other glucose-lowering drugs influences patient-important outcomes.
Collapse
Affiliation(s)
- Filip Gnesin
- Department of Endocrinology, Diabetes and Metabolism, Department 7652, Rigshospitalet, Copenhagen, Denmark
| | - Anne Cathrine Baun Thuesen
- Steno Diabetes Center Copenhagen, Gentofte, Denmark
- Faculty of Health and Medical Sciences, University of Copenhagen, Novo Nordisk Foundation Center for Basic Metabolic Research, Copenhagen, Denmark
| | | | - Sten Madsbad
- Department of Endocrinology, Hvidovre Hospital, University of Copenhagen, Hvidovre, Denmark
| | - Bianca Hemmingsen
- Cochrane Metabolic and Endocrine Disorders Group, Institute of General Practice, Medical Faculty of the Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| |
Collapse
|
9
|
Aguilera B, DeGrazia D, Rid A. Regulating international clinical research: an ethical framework for policy-makers. BMJ Glob Health 2020; 5:e002287. [PMID: 32461225 PMCID: PMC7259867 DOI: 10.1136/bmjgh-2020-002287] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Revised: 04/13/2020] [Accepted: 04/14/2020] [Indexed: 11/03/2022] Open
Abstract
The global distribution of clinical trials is shifting to low-income and middle-income countries (LMICs), and adequate regulations are essential for protecting the rights and interests of research participants in these countries. However, policy-makers in LMICs can face an ethical trade-off: stringent regulatory protections for participants can lead researchers or sponsors to conduct their research elsewhere, potentially depriving the local population of the opportunity to benefit from international clinical research. In this paper, we propose a three-step ethical framework that helps policy-makers to navigate this trade-off. We use a recent set of regulatory protections in Chile to illustrate the practical value of our proposed framework, providing original ethical analysis and previously unpublished data from Chile obtained through freedom of information requests.
Collapse
Affiliation(s)
- Bernardo Aguilera
- Department of Bioethics, The Clinical Center, National Institutes of Health, Bethesda, Maryland, USA
| | - David DeGrazia
- Department of Bioethics, The Clinical Center, National Institutes of Health, Bethesda, Maryland, USA
- Department of Philosophy, George Washington University, Washington, DC, USA
| | - Annette Rid
- Department of Bioethics, The Clinical Center, National Institutes of Health, Bethesda, Maryland, USA
| |
Collapse
|
10
|
Madsen KS, Chi Y, Metzendorf M, Richter B, Hemmingsen B. Metformin for prevention or delay of type 2 diabetes mellitus and its associated complications in persons at increased risk for the development of type 2 diabetes mellitus. Cochrane Database Syst Rev 2019; 12:CD008558. [PMID: 31794067 PMCID: PMC6889926 DOI: 10.1002/14651858.cd008558.pub2] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND The projected rise in the incidence of type 2 diabetes mellitus (T2DM) could develop into a substantial health problem worldwide. Whether metformin can prevent or delay T2DM and its complications in people with increased risk of developing T2DM is unknown. OBJECTIVES To assess the effects of metformin for the prevention or delay of T2DM and its associated complications in persons at increased risk for the T2DM. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials, MEDLINE, Scopus, ClinicalTrials.gov, the World Health Organization (WHO) International Clinical Trials Registry Platform and the reference lists of systematic reviews, articles and health technology assessment reports. We asked investigators of the included trials for information about additional trials. The date of the last search of all databases was March 2019. SELECTION CRITERIA We included randomised controlled trials (RCTs) with a duration of one year or more comparing metformin with any pharmacological glucose-lowering intervention, behaviour-changing intervention, placebo or standard care in people with impaired glucose tolerance, impaired fasting glucose, moderately elevated glycosylated haemoglobin A1c (HbA1c) or combinations of these. DATA COLLECTION AND ANALYSIS Two review authors read all abstracts and full-text articles and records, assessed risk of bias and extracted outcome data independently. We used a random-effects model to perform meta-analysis and calculated risk ratios (RRs) for dichotomous outcomes and mean differences (MDs) for continuous outcomes, using 95% confidence intervals (CIs) for effect estimates. We assessed the certainty of the evidence using GRADE. MAIN RESULTS We included 20 RCTs randomising 6774 participants. One trial contributed 48% of all participants. The duration of intervention in the trials varied from one to five years. We judged none of the trials to be at low risk of bias in all 'Risk of bias' domains. Our main outcome measures were all-cause mortality, incidence of T2DM, serious adverse events (SAEs), cardiovascular mortality, non-fatal myocardial infarction or stroke, health-related quality of life and socioeconomic effects.The following comparisons mostly reported only a fraction of our main outcome set. Fifteen RCTs compared metformin with diet and exercise with or without placebo: all-cause mortality was 7/1353 versus 7/1480 (RR 1.11, 95% CI 0.41 to 3.01; P = 0.83; 2833 participants, 5 trials; very low-quality evidence); incidence of T2DM was 324/1751 versus 529/1881 participants (RR 0.50, 95% CI 0.38 to 0.65; P < 0.001; 3632 participants, 12 trials; moderate-quality evidence); the reporting of SAEs was insufficient and diverse and meta-analysis could not be performed (reported numbers were 4/118 versus 2/191; 309 participants; 4 trials; very low-quality evidence); cardiovascular mortality was 1/1073 versus 4/1082 (2416 participants; 2 trials; very low-quality evidence). One trial reported no clear difference in health-related quality of life after 3.2 years of follow-up (very low-quality evidence). Two trials estimated the direct medical costs (DMC) per participant for metformin varying from $220 to $1177 versus $61 to $184 in the comparator group (2416 participants; 2 trials; low-quality evidence). Eight RCTs compared metformin with intensive diet and exercise: all-cause mortality was 7/1278 versus 4/1272 (RR 1.61, 95% CI 0.50 to 5.23; P = 0.43; 2550 participants, 4 trials; very low-quality evidence); incidence of T2DM was 304/1455 versus 251/1505 (RR 0.80, 95% CI 0.47 to 1.37; P = 0.42; 2960 participants, 7 trials; moderate-quality evidence); the reporting of SAEs was sparse and meta-analysis could not be performed (one trial reported 1/44 in the metformin group versus 0/36 in the intensive exercise and diet group with SAEs). One trial reported that 1/1073 participants in the metformin group compared with 2/1079 participants in the comparator group died from cardiovascular causes. One trial reported that no participant died due to cardiovascular causes (very low-quality evidence). Two trials estimated the DMC per participant for metformin varying from $220 to $1177 versus $225 to $3628 in the comparator group (2400 participants; 2 trials; very low-quality evidence). Three RCTs compared metformin with acarbose: all-cause mortality was 1/44 versus 0/45 (89 participants; 1 trial; very low-quality evidence); incidence of T2DM was 12/147 versus 7/148 (RR 1.72, 95% CI 0.72 to 4.14; P = 0.22; 295 participants; 3 trials; low-quality evidence); SAEs were 1/51 versus 2/50 (101 participants; 1 trial; very low-quality evidence). Three RCTs compared metformin with thiazolidinediones: incidence of T2DM was 9/161 versus 9/159 (RR 0.99, 95% CI 0.41 to 2.40; P = 0.98; 320 participants; 3 trials; low-quality evidence). SAEs were 3/45 versus 0/41 (86 participants; 1 trial; very low-quality evidence). Three RCTs compared metformin plus intensive diet and exercise with identical intensive diet and exercise: all-cause mortality was 1/121 versus 1/120 participants (450 participants; 2 trials; very low-quality evidence); incidence of T2DM was 48/166 versus 53/166 (RR 0.55, 95% CI 0.10 to 2.92; P = 0.49; 332 participants; 2 trials; very low-quality evidence). One trial estimated the DMC of metformin plus intensive diet and exercise to be $270 per participant compared with $225 in the comparator group (94 participants; 1 trial; very-low quality evidence). One trial in 45 participants compared metformin with a sulphonylurea. The trial reported no patient-important outcomes. For all comparisons there were no data on non-fatal myocardial infarction, non-fatal stroke or microvascular complications. We identified 11 ongoing trials which potentially could provide data of interest for this review. These trials will add a total of 17,853 participants in future updates of this review. AUTHORS' CONCLUSIONS Metformin compared with placebo or diet and exercise reduced or delayed the risk of T2DM in people at increased risk for the development of T2DM (moderate-quality evidence). However, metformin compared to intensive diet and exercise did not reduce or delay the risk of T2DM (moderate-quality evidence). Likewise, the combination of metformin and intensive diet and exercise compared to intensive diet and exercise only neither showed an advantage or disadvantage regarding the development of T2DM (very low-quality evidence). Data on patient-important outcomes such as mortality, macrovascular and microvascular diabetic complications and health-related quality of life were sparse or missing.
Collapse
Affiliation(s)
- Kasper S Madsen
- University of CopenhagenFaculty of Health and Medical SciencesBlegdamsvej 3BCopenhagen NDenmark2200
| | - Yuan Chi
- University Hospital Zurich and University of ZurichInstitute for Complementary and Integrative MedicineSonneggstrasse 6ZurichBeijingSwitzerland8006
| | - Maria‐Inti Metzendorf
- Institute of General Practice, Medical Faculty of the Heinrich‐Heine‐University DüsseldorfCochrane Metabolic and Endocrine Disorders GroupMoorenstr. 5DüsseldorfGermany40225
| | - Bernd Richter
- Institute of General Practice, Medical Faculty of the Heinrich‐Heine‐University DüsseldorfCochrane Metabolic and Endocrine Disorders GroupMoorenstr. 5DüsseldorfGermany40225
| | - Bianca Hemmingsen
- Institute of General Practice, Medical Faculty of the Heinrich‐Heine‐University DüsseldorfCochrane Metabolic and Endocrine Disorders GroupMoorenstr. 5DüsseldorfGermany40225
| | | |
Collapse
|
11
|
Cook JA, Julious SA, Sones W, Hampson LV, Hewitt C, Berlin JA, Ashby D, Emsley R, Fergusson DA, Walters SJ, Wilson EC, MacLennan G, Stallard N, Rothwell JC, Bland M, Brown L, Ramsay CR, Cook A, Armstrong D, Altman D, Vale LD. Practical help for specifying the target difference in sample size calculations for RCTs: the DELTA 2 five-stage study, including a workshop. Health Technol Assess 2019; 23:1-88. [PMID: 31661431 PMCID: PMC6843113 DOI: 10.3310/hta23600] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND The randomised controlled trial is widely considered to be the gold standard study for comparing the effectiveness of health interventions. Central to its design is a calculation of the number of participants needed (the sample size) for the trial. The sample size is typically calculated by specifying the magnitude of the difference in the primary outcome between the intervention effects for the population of interest. This difference is called the 'target difference' and should be appropriate for the principal estimand of interest and determined by the primary aim of the study. The target difference between treatments should be considered realistic and/or important by one or more key stakeholder groups. OBJECTIVE The objective of the report is to provide practical help on the choice of target difference used in the sample size calculation for a randomised controlled trial for researchers and funder representatives. METHODS The Difference ELicitation in TriAls2 (DELTA2) recommendations and advice were developed through a five-stage process, which included two literature reviews of existing funder guidance and recent methodological literature; a Delphi process to engage with a wider group of stakeholders; a 2-day workshop; and finalising the core document. RESULTS Advice is provided for definitive trials (Phase III/IV studies). Methods for choosing the target difference are reviewed. To aid those new to the topic, and to encourage better practice, 10 recommendations are made regarding choosing the target difference and undertaking a sample size calculation. Recommended reporting items for trial proposal, protocols and results papers under the conventional approach are also provided. Case studies reflecting different trial designs and covering different conditions are provided. Alternative trial designs and methods for choosing the sample size are also briefly considered. CONCLUSIONS Choosing an appropriate sample size is crucial if a study is to inform clinical practice. The number of patients recruited into the trial needs to be sufficient to answer the objectives; however, the number should not be higher than necessary to avoid unnecessary burden on patients and wasting precious resources. The choice of the target difference is a key part of this process under the conventional approach to sample size calculations. This document provides advice and recommendations to improve practice and reporting regarding this aspect of trial design. Future work could extend the work to address other less common approaches to the sample size calculations, particularly in terms of appropriate reporting items. FUNDING Funded by the Medical Research Council (MRC) UK and the National Institute for Health Research as part of the MRC-National Institute for Health Research Methodology Research programme.
Collapse
Affiliation(s)
- Jonathan A Cook
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Steven A Julious
- Medical Statistics Group, School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - William Sones
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Lisa V Hampson
- Statistical Methodology and Consulting, Novartis Pharma AG, Basel, Switzerland
| | - Catherine Hewitt
- York Trials Unit, Department of Health Sciences, University of York, York, UK
| | | | - Deborah Ashby
- Imperial Clinical Trials Unit, Imperial College London, London, UK
| | - Richard Emsley
- Department of Biostatistics and Health Informatics, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Dean A Fergusson
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Stephen J Walters
- Medical Statistics Group, School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Edward Cf Wilson
- Cambridge Centre for Health Services Research, Cambridge Clinical Trials Unit University of Cambridge, Cambridge, UK
- Health Economics Group, Norwich Medical School, University of East Anglia, Norwich, UK
| | - Graeme MacLennan
- Centre for Healthcare Randomised Trials, University of Aberdeen, Aberdeen, UK
| | - Nigel Stallard
- Warwick Medical School, Statistics and Epidemiology, University of Warwick, Coventry, UK
| | - Joanne C Rothwell
- Medical Statistics Group, School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Martin Bland
- Department of Health Sciences, University of York, York, UK
| | - Louise Brown
- MRC Clinical Trials Unit, Institute of Clinical Trials and Methodology, University College London, London, UK
| | - Craig R Ramsay
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Andrew Cook
- Wessex Institute, University of Southampton, Southampton, UK
| | - David Armstrong
- School of Population Health and Environmental Sciences, King's College London, London, UK
| | - Douglas Altman
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Luke D Vale
- Health Economics Group, Institute of Health & Society, Newcastle University, Newcastle upon Tyne, UK
| |
Collapse
|
12
|
|
13
|
Madsen KS, Kähler P, Kähler LKA, Madsbad S, Gnesin F, Metzendorf M, Richter B, Hemmingsen B. Metformin and second- or third-generation sulphonylurea combination therapy for adults with type 2 diabetes mellitus. Cochrane Database Syst Rev 2019; 4:CD012368. [PMID: 30998259 PMCID: PMC6472662 DOI: 10.1002/14651858.cd012368.pub2] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND The number of people with type 2 diabetes mellitus (T2DM) is increasing worldwide. The combination of metformin and sulphonylurea (M+S) is a widely used treatment. Whether M+S shows better or worse effects in comparison with other antidiabetic medications for people with T2DM is still controversial. OBJECTIVES To assess the effects of metformin and sulphonylurea (second- or third-generation) combination therapy for adults with type 2 diabetes mellitus. SEARCH METHODS We updated the search of a recent systematic review from the Agency for Healthcare Research and Quality (AHRQ). The updated search included CENTRAL, MEDLINE, Embase, ClinicalTrials.gov and WHO ICTRP. The date of the last search was March 2018. We searched manufacturers' websites and reference lists of included trials, systematic reviews, meta-analyses and health technology assessment reports. We asked investigators of the included trials for information about additional trials. SELECTION CRITERIA We included randomised controlled trials (RCTs) randomising participants 18 years old or more with T2DM to M+S compared with metformin plus another glucose-lowering intervention or metformin monotherapy with a treatment duration of 52 weeks or more. DATA COLLECTION AND ANALYSIS Two review authors read all abstracts and full-text articles and records, assessed risk of bias and extracted outcome data independently. We used a random-effects model to perform meta-analysis, and calculated risk ratios (RRs) for dichotomous outcomes and mean differences (MDs) for continuous outcomes, using 95% confidence intervals (CIs) for effect estimates. We assessed the certainty of the evidence using the GRADE instrument. MAIN RESULTS We included 32 RCTs randomising 28,746 people. Treatment duration ranged between one to four years. We judged none of these trials as low risk of bias for all 'Risk of bias' domains. Most important events per person were all-cause and cardiovascular mortality, serious adverse events (SAE), non-fatal stroke (NFS), non-fatal myocardial infarction (MI) and microvascular complications. Most important comparisons were as follows:Five trials compared M+S (N = 1194) with metformin plus a glucagon-like peptide 1 analogue (N = 1675): all-cause mortality was 11/1057 (1%) versus 11/1537 (0.7%), risk ratio (RR) 1.15 (95% confidence interval (CI) 0.49 to 2.67); 3 trials; 2594 participants; low-certainty evidence; cardiovascular mortality 1/307 (0.3%) versus 1/302 (0.3%), low-certainty evidence; serious adverse events (SAE) 128/1057 (12.1%) versus 194/1537 (12.6%), RR 0.90 (95% CI 0.73 to 1.11); 3 trials; 2594 participants; very low-certainty evidence; non-fatal myocardial infarction (MI) 2/549 (0.4%) versus 6/1026 (0.6%), RR 0.57 (95% CI 0.12 to 2.82); 2 trials; 1575 participants; very low-certainty evidence.Nine trials compared M+S (N = 5414) with metformin plus a dipeptidyl-peptidase 4 inhibitor (N = 6346): all-cause mortality was 33/5387 (0.6%) versus 26/6307 (0.4%), RR 1.32 (95% CI 0.76 to 2.28); 9 trials; 11,694 participants; low-certainty evidence; cardiovascular mortality 11/2989 (0.4%) versus 9/3885 (0.2%), RR 1.54 (95% CI 0.63 to 3.79); 6 trials; 6874 participants; low-certainty evidence; SAE 735/5387 (13.6%) versus 779/6307 (12.4%), RR 1.07 (95% CI 0.97 to 1.18); 9 trials; 11,694 participants; very low-certainty evidence; NFS 14/2098 (0.7%) versus 8/2995 (0.3%), RR 2.21 (95% CI 0.74 to 6.58); 4 trials; 5093 participants; very low-certainty evidence; non-fatal MI 15/2989 (0.5%) versus 13/3885 (0.3%), RR 1.45 (95% CI 0.69 to 3.07); 6 trials; 6874 participants; very low-certainty evidence; one trial in 64 participants reported no microvascular complications were observed (very low-certainty evidence).Eleven trials compared M+S (N = 3626) with metformin plus a thiazolidinedione (N = 3685): all-cause mortality was 123/3300 (3.7%) versus 114/3354 (3.4%), RR 1.09 (95% CI 0.85 to 1.40); 6 trials; 6654 participants; low-certainty evidence; cardiovascular mortality 37/2946 (1.3%) versus 41/2994 (1.4%), RR 0.78 (95% CI 0.36 to 1.67); 4 trials; 5940 participants; low-certainty evidence; SAE 666/3300 (20.2%) versus 671/3354 (20%), RR 1.01 (95% CI 0.93 to 1.11); 6 trials; 6654 participants; very low-certainty evidence; NFS 20/1540 (1.3%) versus 16/1583 (1%), RR 1.29 (95% CI 0.67 to 2.47); P = 0.45; 2 trials; 3123 participants; very low-certainty evidence; non-fatal MI 25/1841 (1.4%) versus 21/1877 (1.1%), RR 1.21 (95% CI 0.68 to 2.14); P = 0.51; 3 trials; 3718 participants; very low-certainty evidence; three trials (3123 participants) reported no microvascular complications (very low-certainty evidence).Three trials compared M+S (N = 462) with metformin plus a glinide (N = 476): one person died in each intervention group (3 trials; 874 participants; low-certainty evidence); no cardiovascular mortality (2 trials; 446 participants; low-certainty evidence); SAE 34/424 (8%) versus 27/450 (6%), RR 1.68 (95% CI 0.54 to 5.21); P = 0.37; 3 trials; 874 participants; low-certainty evidence; no NFS (1 trial; 233 participants; very low-certainty evidence); non-fatal MI 2/215 (0.9%) participants in the M+S group; 2 trials; 446 participants; low-certainty evidence; no microvascular complications (1 trial; 233 participants; low-certainty evidence).Four trials compared M+S (N = 2109) with metformin plus a sodium-glucose co-transporter 2 inhibitor (N = 3032): all-cause mortality was 13/2107 (0.6%) versus 19/3027 (0.6%), RR 0.96 (95% CI 0.44 to 2.09); 4 trials; 5134 participants; very low-certainty evidence; cardiovascular mortality 4/1327 (0.3%) versus 6/2262 (0.3%), RR 1.22 (95% CI 0.33 to 4.41); 3 trials; 3589 participants; very low-certainty evidence; SAE 315/2107 (15.5%) versus 375/3027 (12.4%), RR 1.02 (95% CI 0.76 to 1.37); 4 trials; 5134 participants; very low-certainty evidence; NFS 3/919 (0.3%) versus 7/1856 (0.4%), RR 0.87 (95% CI 0.22 to 3.34); 2 trials; 2775 participants; very low-certainty evidence; non-fatal MI 7/890 (0.8%) versus 8/1374 (0.6%), RR 1.43 (95% CI 0.49 to 4.18; 2 trials); 2264 participants; very low-certainty evidence; amputation of lower extremity 1/437 (0.2%) versus 1/888 (0.1%); very low-certainty evidence.Trials reported more hypoglycaemic episodes with M+S combination compared to all other metformin-antidiabetic agent combinations. Results for M+S versus metformin monotherapy were inconclusive. There were no RCTs comparing M+S with metformin plus insulin. We identified nine ongoing trials and two trials are awaiting assessment. Together these trials will include approximately 16,631 participants. AUTHORS' CONCLUSIONS There is inconclusive evidence whether M+S combination therapy compared with metformin plus another glucose-lowering intervention results in benefit or harm for most patient-important outcomes (mortality, SAEs, macrovascular and microvascular complications) with the exception of hypoglycaemia (more harm for M+S combination). No RCT reported on health-related quality of life.
Collapse
Affiliation(s)
- Kasper S Madsen
- University of CopenhagenFaculty of Health and Medical SciencesBlegdamsvej 3BCopenhagen NDenmark2200
| | - Pernille Kähler
- Faculty of Health and Medical SciencesCopenhagen Medical UniversityBlegdamsvej 3CopenhagenDenmark2100Ø
| | | | - Sten Madsbad
- Hvidovre Hospital, University of CopenhagenDepartment of EndocrinologyHvidovreDenmark
| | - Filip Gnesin
- Department 7652, RigshospitaletDepartment of Endocrinology, Diabetes and MetabolismBlegdamsvej 9CopenhagenDenmarkDK‐2100
| | - Maria‐Inti Metzendorf
- Institute of General Practice, Medical Faculty of the Heinrich‐Heine‐University DüsseldorfCochrane Metabolic and Endocrine Disorders GroupMoorenstr. 5DüsseldorfGermany40225
| | - Bernd Richter
- Institute of General Practice, Medical Faculty of the Heinrich‐Heine‐University DüsseldorfCochrane Metabolic and Endocrine Disorders GroupMoorenstr. 5DüsseldorfGermany40225
| | - Bianca Hemmingsen
- Institute of General Practice, Medical Faculty of the Heinrich‐Heine‐University DüsseldorfCochrane Metabolic and Endocrine Disorders GroupMoorenstr. 5DüsseldorfGermany40225
| | | |
Collapse
|
14
|
Califf RM. Consent for Research Participation in Practice. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2019; 19:19-21. [PMID: 31544682 DOI: 10.1080/15265161.2019.1574492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
|
15
|
Rich WD, Katheria AC. Waived Consent in Perinatal/Neonatal Research-When Is It Appropriate? Front Pediatr 2019; 7:493. [PMID: 31850290 PMCID: PMC6901905 DOI: 10.3389/fped.2019.00493] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Accepted: 11/12/2019] [Indexed: 11/18/2022] Open
Abstract
Informed consent is a process ensuring that subjects enrolled in research are appropriately informed of the risks and benefits. While this process is well-defined when it is possible and practical to obtain consent prior to the research intervention, it can be less clear in cases of deferred or waived consent. Defining minimal risk, such as when research is attempting to determine which of two currently practiced interventions is safest and/or most effective, is critical to moving forward in establishing appropriate care in newborns. For perinatal/neonatal research the challenge lies between the ethical justification for approaching women in labor or under medication vs. the scientific integrity of excluding a number of subjects that may potentially benefit the most from an intervention. Researchers must work with their IRBs as well as families who have participated in trials to determine the most appropriate method for obtaining informed consent from expectant parents. Clinical researchers and IRBs ultimately need to find a middle ground for the appropriate use of deferred or waived consent.
Collapse
Affiliation(s)
- Wade D Rich
- Neonatal Research Institute, Sharp Mary Birch Hospital for Women & Newborns, San Diego, CA, United States
| | - Anup C Katheria
- Neonatal Research Institute, Sharp Mary Birch Hospital for Women & Newborns, San Diego, CA, United States
| |
Collapse
|
16
|
Macleod MJ, Counsell CE. Stroke: Are care and outcomes better for participants of stroke trials? Nat Rev Neurol 2018; 12:498-9. [PMID: 27562652 DOI: 10.1038/nrneurol.2016.123] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Affiliation(s)
- Mary Joan Macleod
- School of Medicine, Medical Sciences and Nutrition, Polwarth Building, University of Aberdeen, Foresterhill, Aberdeen AB25 2ZN, UK
| | - Carl E Counsell
- School of Medicine, Medical Sciences and Nutrition, Polwarth Building, University of Aberdeen, Foresterhill, Aberdeen AB25 2ZN, UK
| |
Collapse
|
17
|
Ma X, Steensma DP, Scott BL, Kiselev P, Sugrue MM, Swern AS. Selection of patients with myelodysplastic syndromes from a large electronic medical records database and a study of the use of disease-modifying therapy in the United States. BMJ Open 2018; 8:e019955. [PMID: 30037860 PMCID: PMC6059277 DOI: 10.1136/bmjopen-2017-019955] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
OBJECTIVES Treatment patterns for patients with myelodysplastic syndromes (MDS) outside clinical trials are not well described. Our objective was to evaluate treatment patterns and patient characteristics that influence time to disease-modifying therapy in patients with MDS in the USA. DESIGN, PARTICIPANTS AND OUTCOME MEASURES Patients with MDS treated with erythropoiesis-stimulating agents (ESAs), iron chelation therapy, lenalidomide (LEN) and the hypomethylating agents (HMAs) azacitidine and decitabine, were retrospectively identified in the GE Centricity Electronic Medical Record database between January 2006 and February 2014; LEN and HMAs were defined as 'disease-modifying' therapies. Multivariable Cox regression models were used to ascertain patient characteristics associated with time to disease-modifying therapy. RESULTS Of the 5162 patients with MDS, 35.7%, 40.3% and 4.6% received 1, ≥1 and ≥2 therapies, respectively. ESAs were the first-line (72.5%) and only (64.0%) treatment in the majority of patients who received ≥1 therapy. ESA-only patients were older and had more comorbidities, including isolated anaemia. LEN and HMAs were first-line treatment in 12.4% of patients each; 32.7% received LEN or HMAs at any time. The majority of del(5q) patients (77.6%) received ≥1 therapy, most commonly LEN, compared with 40% of patients without del(5q). A shorter time to disease-modifying therapy was significantly associated with absence of comorbidities, diagnosis after February 2008, lower baseline haemoglobin level, age <80 years and male gender (p<0.002 for all). CONCLUSIONS A high proportion of patients diagnosed with MDS in the USA do not receive approved disease-modifying therapies. It is important to improve access to these therapies.
Collapse
Affiliation(s)
- Xiaomei Ma
- Department of Chronic Disease Epidemiology, Yale University School of Public Health and Yale Cancer Center, New Haven, Connecticut, USA
| | - David P Steensma
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Bart L Scott
- Transplantation Biology, Fred Hutchinson Cancer Research Center and University of Washington, Seattle, Washington, USA
| | - Pavel Kiselev
- Department of Statistics and Biostatistics, Celgene Corporation, Summit, New Jersey, USA
| | - Mary M Sugrue
- Formerly Celgene Corporation, Summit, New Jersey, USA
| | - Arlene S Swern
- Department of Statistics and Biostatistics, Celgene Corporation, Summit, New Jersey, USA
| |
Collapse
|
18
|
Toxopeus E, van der Schaaf M, van Lanschot J, Lagergren J, Lagergren P, van der Gaast A, Wijnhoven B. Outcome of Patients Treated Within and Outside a Randomized Clinical Trial on Neoadjuvant Chemoradiotherapy Plus Surgery for Esophageal Cancer: Extrapolation of a Randomized Clinical Trial (CROSS). Ann Surg Oncol 2018; 25:2441-2448. [PMID: 29948420 PMCID: PMC6029046 DOI: 10.1245/s10434-018-6554-y] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2017] [Indexed: 12/11/2022]
Abstract
Background Randomized clinical trials (RCTs) can provide a high level of evidence for medical decision making, but it is unclear if the results apply to patients treated outside such trials. Objective The aim of this study was to retrospectively compare outcomes of patients with esophageal cancer treated within and outside an RCT.
Methods All patients receiving neoadjuvant chemoradiotherapy (nCRT) plus surgery for esophageal cancer between 2002 and 2008 (ChemoRadiotherapy for Esophageal cancer followed by Surgery Study [CROSS] cohort) who participated in multicenter, phase II–III trials were compared with patients who underwent the same treatment outside the trial between 2008 and 2013 (post-CROSS cohort). The differences between these cohorts were analyzed using t tests, while logistic regression models were used to evaluate adverse events. Overall and disease-free survival were calculated using the Kaplan–Meier method and Cox regression analyses. Results A total of 208 CROSS patients and 173 post-CROSS patients were included in this study. Patients from the post-CROSS cohort were older, had more co morbidities, and had poorer performance status. Clinical N stage, but not cT stage, was worse in the post-CROSS cohort. There were no statistically significant differences in adverse events (pulmonary, cardiac, or anastomotic complications) or survival between the comparison cohorts. Conclusion The outcomes of patients treated with nCRT plus esophagectomy for cancer have a high external consistency and can be extrapolated to the daily practice of physicians involved in the treatment and care of esophageal cancer patients. Electronic supplementary material The online version of this article (10.1245/s10434-018-6554-y) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Eelke Toxopeus
- Department of Surgery, Erasmus MC - University Medical Center, Rotterdam, Rotterdam, The Netherlands.
| | - Maartje van der Schaaf
- Department of Molecular Medicine and Surgery, Karolinska University Hospital, 171 76, Stockholm, Sweden
| | - Jan van Lanschot
- Department of Surgery, Erasmus MC - University Medical Center, Rotterdam, Rotterdam, The Netherlands
| | - Jesper Lagergren
- Department of Molecular Medicine and Surgery, Karolinska University Hospital, 171 76, Stockholm, Sweden.,Division of Cancer Studies, King's College London, London, UK
| | - Pernilla Lagergren
- Department of Molecular Medicine and Surgery, Karolinska University Hospital, 171 76, Stockholm, Sweden
| | - Ate van der Gaast
- Department of Medical Oncology, Erasmus MC - University Medical Center, Rotterdam, Rotterdam, The Netherlands
| | - Bas Wijnhoven
- Department of Surgery, Erasmus MC - University Medical Center, Rotterdam, Rotterdam, The Netherlands
| |
Collapse
|
19
|
Enrolling children with acute lymphoblastic leukaemia on a clinical trial improves event-free survival: a population-based study. Br J Cancer 2018; 118:744-749. [PMID: 29381687 PMCID: PMC5846068 DOI: 10.1038/bjc.2017.462] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2017] [Revised: 11/22/2017] [Accepted: 11/23/2017] [Indexed: 11/24/2022] Open
Abstract
Background: The objectives of this study were to describe the impact of trial enrollment at diagnosis on event-free and overall survival in paediatric acute lymphoblastic leukaemic (ALL) using a population-based approach. Methods: We conducted a retrospective cohort study that included children newly diagnosed with ALL between 1 and 14 years of age. The data source was the Cancer in Young People in Canada (CYP-C) national paediatric cancer population-based database. We conducted univariate and multiple Cox proportional hazards models. Results: There were 2569 children with ALL; 1408 (54.8%) were enrolled on a clinical trial at initial diagnosis. Event-free survival at 5 years was 89.8%±0.9 vs 84.1%±1.2. (P<0.0001) for those enrolled and not enrolled on a clinical trial, respectively. Overall survival at 5 years was higher for those enrolled (94.1%±0.7) vs not enrolled (90.5%±1.0; P=0.001). In a model that adjusted for demographic, leukaemic and socioeconomic factors, enrollment on trials was significantly associated with better event-free survival (hazard ratio (HR) 0.67, 95% confidence interval (CI) 0.47–0.95; P=0.023), but not overall survival (HR 0.69, 95% CI 0.44–1.08; P=0.102). Conclusions: Event-free survival was significantly better in children with ALL enrolled on a clinical trial. Future research should identify barriers to clinical trial enrollment for children with ALL.
Collapse
|
20
|
Hemmingsen B, Gimenez‐Perez G, Mauricio D, Roqué i Figuls M, Metzendorf M, Richter B. Diet, physical activity or both for prevention or delay of type 2 diabetes mellitus and its associated complications in people at increased risk of developing type 2 diabetes mellitus. Cochrane Database Syst Rev 2017; 12:CD003054. [PMID: 29205264 PMCID: PMC6486271 DOI: 10.1002/14651858.cd003054.pub4] [Citation(s) in RCA: 103] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND The projected rise in the incidence of type 2 diabetes mellitus (T2DM) could develop into a substantial health problem worldwide. Whether diet, physical activity or both can prevent or delay T2DM and its associated complications in at-risk people is unknown. OBJECTIVES To assess the effects of diet, physical activity or both on the prevention or delay of T2DM and its associated complications in people at increased risk of developing T2DM. SEARCH METHODS This is an update of the Cochrane Review published in 2008. We searched the CENTRAL, MEDLINE, Embase, ClinicalTrials.gov, ICTRP Search Portal and reference lists of systematic reviews, articles and health technology assessment reports. The date of the last search of all databases was January 2017. We continuously used a MEDLINE email alert service to identify newly published studies using the same search strategy as described for MEDLINE up to September 2017. SELECTION CRITERIA We included randomised controlled trials (RCTs) with a duration of two years or more. DATA COLLECTION AND ANALYSIS We used standard Cochrane methodology for data collection and analysis. We assessed the overall quality of the evidence using GRADE. MAIN RESULTS We included 12 RCTs randomising 5238 people. One trial contributed 41% of all participants. The duration of the interventions varied from two to six years. We judged none of the included trials at low risk of bias for all 'Risk of bias' domains.Eleven trials compared diet plus physical activity with standard or no treatment. Nine RCTs included participants with impaired glucose tolerance (IGT), one RCT included participants with IGT, impaired fasting blood glucose (IFG) or both, and one RCT included people with fasting glucose levels between 5.3 to 6.9 mmol/L. A total of 12 deaths occurred in 2049 participants in the diet plus physical activity groups compared with 10 in 2050 participants in the comparator groups (RR 1.12, 95% CI 0.50 to 2.50; 95% prediction interval 0.44 to 2.88; 4099 participants, 10 trials; very low-quality evidence). The definition of T2DM incidence varied among the included trials. Altogether 315 of 2122 diet plus physical activity participants (14.8%) developed T2DM compared with 614 of 2389 comparator participants (25.7%) (RR 0.57, 95% CI 0.50 to 0.64; 95% prediction interval 0.50 to 0.65; 4511 participants, 11 trials; moderate-quality evidence). Two trials reported serious adverse events. In one trial no adverse events occurred. In the other trial one of 51 diet plus physical activity participants compared with none of 51 comparator participants experienced a serious adverse event (low-quality evidence). Cardiovascular mortality was rarely reported (four of 1626 diet plus physical activity participants and four of 1637 comparator participants (the RR ranged between 0.94 and 3.16; 3263 participants, 7 trials; very low-quality evidence). Only one trial reported that no non-fatal myocardial infarction or non-fatal stroke had occurred (low-quality evidence). Two trials reported that none of the participants had experienced hypoglycaemia. One trial investigated health-related quality of life in 2144 participants and noted that a minimal important difference between intervention groups was not reached (very low-quality evidence). Three trials evaluated costs of the interventions in 2755 participants. The largest trial of these reported an analysis of costs from the health system perspective and society perspective reflecting USD 31,500 and USD 51,600 per quality-adjusted life year (QALY) with diet plus physical activity, respectively (low-quality evidence). There were no data on blindness or end-stage renal disease.One trial compared a diet-only intervention with a physical-activity intervention or standard treatment. The participants had IGT. Three of 130 participants in the diet group compared with none of the 141 participants in the physical activity group died (very low-quality evidence). None of the participants died because of cardiovascular disease (very low-quality evidence). Altogether 57 of 130 diet participants (43.8%) compared with 58 of 141 physical activity participants (41.1%) group developed T2DM (very low-quality evidence). No adverse events were recorded (very low-quality evidence). There were no data on non-fatal myocardial infarction, non-fatal stroke, blindness, end-stage renal disease, health-related quality of life or socioeconomic effects.Two trials compared physical activity with standard treatment in 397 participants. One trial included participants with IGT, the other trial included participants with IGT, IFG or both. One trial reported that none of the 141 physical activity participants compared with three of 133 control participants died. The other trial reported that three of 84 physical activity participants and one of 39 control participants died (very low-quality evidence). In one trial T2DM developed in 58 of 141 physical activity participants (41.1%) compared with 90 of 133 control participants (67.7%). In the other trial 10 of 84 physical activity participants (11.9%) compared with seven of 39 control participants (18%) developed T2DM (very low-quality evidence). Serious adverse events were rarely reported (one trial noted no events, one trial described events in three of 66 physical activity participants compared with one of 39 control participants - very low-quality evidence). Only one trial reported on cardiovascular mortality (none of 274 participants died - very low-quality evidence). Non-fatal myocardial infarction or stroke were rarely observed in the one trial randomising 123 participants (very low-quality evidence). One trial reported that none of the participants in the trial experienced hypoglycaemia. One trial investigating health-related quality of life in 123 participants showed no substantial differences between intervention groups (very low-quality evidence). There were no data on blindness or socioeconomic effects. AUTHORS' CONCLUSIONS There is no firm evidence that diet alone or physical activity alone compared to standard treatment influences the risk of T2DM and especially its associated complications in people at increased risk of developing T2DM. However, diet plus physical activity reduces or delays the incidence of T2DM in people with IGT. Data are lacking for the effect of diet plus physical activity for people with intermediate hyperglycaemia defined by other glycaemic variables. Most RCTs did not investigate patient-important outcomes.
Collapse
Affiliation(s)
- Bianca Hemmingsen
- Herlev University HospitalDepartment of Internal MedicineHerlev Ringvej 75HerlevDenmarkDK‐2730
| | - Gabriel Gimenez‐Perez
- Hospital General de Granollers and School of Medicine and Health Sciences. Universitat Internacional de Catalunya (UIC)Medicine DepartmentFrancesc Ribas s/nGranollersSpain08402
| | - Didac Mauricio
- Hospital Universitari Germans Trias i Pujol ‐ CIBERDEMDepartment of Endocrinology and NutritionCarretera Canyet S/NBadalonaSpain08916
| | - Marta Roqué i Figuls
- CIBER Epidemiología y Salud Pública (CIBERESP)Iberoamerican Cochrane Centre, Biomedical Research Institute Sant Pau (IIB Sant Pau)Sant Antoni Maria Claret 171Edifici Casa de ConvalescènciaBarcelonaCatalunyaSpain08041
| | - Maria‐Inti Metzendorf
- Institute of General Practice, Medical Faculty of the Heinrich‐Heine‐University DüsseldorfCochrane Metabolic and Endocrine Disorders GroupMoorenstr. 5DüsseldorfGermany40225
| | - Bernd Richter
- Institute of General Practice, Medical Faculty of the Heinrich‐Heine‐University DüsseldorfCochrane Metabolic and Endocrine Disorders GroupMoorenstr. 5DüsseldorfGermany40225
| | | |
Collapse
|
21
|
Hemmingsen B, Sonne DP, Metzendorf M, Richter B. Dipeptidyl-peptidase (DPP)-4 inhibitors and glucagon-like peptide (GLP)-1 analogues for prevention or delay of type 2 diabetes mellitus and its associated complications in people at increased risk for the development of type 2 diabetes mellitus. Cochrane Database Syst Rev 2017; 5:CD012204. [PMID: 28489279 PMCID: PMC6481586 DOI: 10.1002/14651858.cd012204.pub2] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND The projected rise in the incidence of type 2 diabetes mellitus (T2DM) could develop into a substantial health problem worldwide. Whether dipeptidyl-peptidase (DPP)-4 inhibitors or glucagon-like peptide (GLP)-1 analogues are able to prevent or delay T2DM and its associated complications in people at risk for the development of T2DM is unknown. OBJECTIVES To assess the effects of DPP-4 inhibitors and GLP-1 analogues on the prevention or delay of T2DM and its associated complications in people with impaired glucose tolerance, impaired fasting blood glucose, moderately elevated glycosylated haemoglobin A1c (HbA1c) or any combination of these. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials; MEDLINE; PubMed; Embase; ClinicalTrials.gov; the World Health Organization (WHO) International Clinical Trials Registry Platform; and the reference lists of systematic reviews, articles and health technology assessment reports. We asked investigators of the included trials for information about additional trials. The date of the last search of all databases was January 2017. SELECTION CRITERIA We included randomised controlled trials (RCTs) with a duration of 12 weeks or more comparing DPP-4 inhibitors and GLP-1 analogues with any pharmacological glucose-lowering intervention, behaviour-changing intervention, placebo or no intervention in people with impaired fasting glucose, impaired glucose tolerance, moderately elevated HbA1c or combinations of these. DATA COLLECTION AND ANALYSIS Two review authors read all abstracts and full-text articles and records, assessed quality and extracted outcome data independently. One review author extracted data which were checked by a second review author. We resolved discrepancies by consensus or the involvement of a third review author. For meta-analyses, we planned to use a random-effects model with investigation of risk ratios (RRs) for dichotomous outcomes and mean differences (MDs) for continuous outcomes, using 95% confidence intervals (CIs) for effect estimates. We assessed the overall quality of the evidence using the GRADE instrument. MAIN RESULTS We included seven completed RCTs; about 98 participants were randomised to a DPP-4 inhibitor as monotherapy and 1620 participants were randomised to a GLP-1 analogue as monotherapy. Two trials investigated a DPP-4 inhibitor and five trials investigated a GLP-1 analogue. A total of 924 participants with data on allocation to control groups were randomised to a comparator group; 889 participants were randomised to placebo and 33 participants to metformin monotherapy. One RCT of liraglutide contributed 85% of all participants. The duration of the intervention varied from 12 weeks to 160 weeks. We judged none of the included trials at low risk of bias for all 'Risk of bias' domains and did not perform meta-analyses because there were not enough trials.One trial comparing the DPP-4 inhibitor vildagliptin with placebo reported no deaths (very low-quality evidence). The incidence of T2DM by means of WHO diagnostic criteria in this trial was 3/90 participants randomised to vildagliptin versus 1/89 participants randomised to placebo (very low-quality evidence). Also, 1/90 participants on vildagliptin versus 2/89 participants on placebo experienced a serious adverse event (very low-quality evidence). One out of 90 participants experienced congestive heart failure in the vildagliptin group versus none in the placebo group (very low-quality evidence). There were no data on non-fatal myocardial infarction, stroke, health-related quality of life or socioeconomic effects reported.All-cause and cardiovascular mortality following treatment with GLP-1 analogues were rarely reported; one trial of exenatide reported that no participant died. Another trial of liraglutide 3.0 mg showed that 2/1501 in the liraglutide group versus 2/747 in the placebo group died after 160 weeks of treatment (very low-quality evidence).The incidence of T2DM following treatment with liraglutide 3.0 mg compared to placebo after 160 weeks was 26/1472 (1.8%) participants randomised to liraglutide versus 46/738 (6.2%) participants randomised to placebo (very low-quality evidence). The trial established the risk for (diagnosis of) T2DM as HbA1c 5.7% to 6.4% (6.5% or greater), fasting plasma glucose 5.6 mmol/L or greater to 6.9 mmol/L or less (7.0 mmol/L or greater) or two-hour post-load plasma glucose 7.8 mmol/L or greater to 11.0 mmol/L (11.1 mmol/L). Altogether, 70/1472 (66%) participants regressed from intermediate hyperglycaemia to normoglycaemia compared with 268/738 (36%) participants in the placebo group. The incidence of T2DM after the 12-week off-treatment extension period (i.e. after 172 weeks) showed that five additional participants were diagnosed T2DM in the liraglutide group, compared with one participant in the placebo group. After 12-week treatment cessation, 740/1472 (50%) participants in the liraglutide group compared with 263/738 (36%) participants in the placebo group had normoglycaemia.One trial used exenatide and 2/17 participants randomised to exenatide versus 1/16 participants randomised to placebo developed T2DM (very low-quality evidence). This trial did not provide a definition of T2DM. One trial reported serious adverse events in 230/1524 (15.1%) participants in the liraglutide 3.0 mg arm versus 96/755 (12.7%) participants in the placebo arm (very low quality evidence). There were no serious adverse events in the trial using exenatide. Non-fatal myocardial infarction was reported in 1/1524 participants in the liraglutide arm and in 0/55 participants in the placebo arm at 172 weeks (very low-quality evidence). One trial reported congestive heart failure in 1/1524 participants in the liraglutide arm and in 1/755 participants in the placebo arm (very low-quality evidence). Participants receiving liraglutide compared with placebo had a small mean improvement in the physical component of the 36-item Short Form scale showing a difference of 0.87 points (95% CI 0.17 to 1.58; P = 0.02; 1 trial; 1791 participants; very low-quality evidence). No trial evaluating GLP-1-analogues reported data on stroke, microvascular complications or socioeconomic effects. AUTHORS' CONCLUSIONS There is no firm evidence that DPP-4 inhibitors or GLP-1 analogues compared mainly with placebo substantially influence the risk of T2DM and especially its associated complications in people at increased risk for the development of T2DM. Most trials did not investigate patient-important outcomes.
Collapse
Affiliation(s)
- Bianca Hemmingsen
- Herlev University HospitalDepartment of Internal MedicineHerlev Ringvej 75HerlevDenmarkDK‐2730
| | - David P Sonne
- Gentofte Hospital, University of CopenhagenCenter for Diabetes Research, Department of MedicineKildegaardsvej 28HellerupDenmarkDK‐2900
| | - Maria‐Inti Metzendorf
- Institute of General Practice, Medical Faculty of the Heinrich‐Heine‐University DüsseldorfCochrane Metabolic and Endocrine Disorders GroupMoorenstr. 5DüsseldorfGermany40225
| | - Bernd Richter
- Institute of General Practice, Medical Faculty of the Heinrich‐Heine‐University DüsseldorfCochrane Metabolic and Endocrine Disorders GroupMoorenstr. 5DüsseldorfGermany40225
| | | |
Collapse
|
22
|
McDonald T, Bhattarai J, Akin B. Predictors of Consent in a Randomized Field Study in Child Welfare. ACTA ACUST UNITED AC 2017; 14:243-265. [PMID: 28486033 DOI: 10.1080/23761407.2017.1319774] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
PURPOSE Randomized controlled trials (RCTs) are often viewed as the "gold standard" for proving the efficacy and effectiveness of new interventions. However, some are skeptical of the generalizability of the findings that RCTs produce. The characteristics of those willing to participate in research studies have the potential to affect the generalizability of its findings. This study examined factors that could influence consent among families recruited to participate in a randomized field trial in a real-world child welfare setting. METHODS This study tested the Parent Management Training Oregon Model for children in foster care with serious emotional disturbance. It employed a post-randomization consent design, whereby the entire sample of eligible participants, not just those who are willing to consent to randomization, are included in the sample. Initial eligibility assessment data and data from the federally mandated reporting system for public child welfare agencies provided the pool of potential predictors of consent. Bivariate and multivariate analyses were conducted to identify statistically significant predictors of consent. RESULTS Being a dual reunification family was the most significant factor in predicting consent. Unmarried individuals, younger, female parents, cases where parental incarceration was the reason for removal and cases where the removal reason was not due to their children's behavioral problem(s) were also more likely to participate. DISCUSSION As one of the first research studies to examine predictors of consent to a randomized field study in child welfare settings, results presented here can act as a preliminary guide for conducting RCTs in child welfare settings.
Collapse
Affiliation(s)
- Tom McDonald
- a School of Social Welfare, University of Kansas , Lawrence , Kansas , USA
| | - Jackie Bhattarai
- a School of Social Welfare, University of Kansas , Lawrence , Kansas , USA
| | - Becci Akin
- a School of Social Welfare, University of Kansas , Lawrence , Kansas , USA
| |
Collapse
|
23
|
Almutairi KM, Alonazi WB, Alodhayani AA, Vinluan JM, Moussa M, Al-Ajlan AS, Alsaleh K, Alruwaimi D, Alotaibi NE. Barriers to Cancer Clinical Trial Participation Among Saudi Nationals: A Cross-Sectional Study. JOURNAL OF RELIGION AND HEALTH 2017; 56:623-634. [PMID: 27631996 DOI: 10.1007/s10943-016-0306-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
This study aims to determine the factors that act as barriers to Saudi cancer patients in participating in a clinical trial (CT). A total of 244 patients from two different tertiary level hospitals (King Khalid University Hospital and King Fahad Medical City Hospital) in Riyadh, Saudi Arabia, participated in this cross-sectional study. The participants were interviewed by a trained researcher between September and November 2015. All respondents answered a three-part questionnaire which includes demographics, clinical information, and questions related to awareness of CTs, willingness to participate, and factors affecting participation in CTs. The mean age of the participants was 50.83, and 57 % of the participants were females. Most of the participants (63.5 %) were currently being treated for cancer, and 28 % were diagnosed with breast cancer followed by colorectal cancer. Health status or quality of life was self-reported as acceptable by 27.9 % of the participants, and 25 % of the participants at stage II of cancer. The factors that act as barriers to Saudi cancer patients in participating in a CT can be categorized into patient- and physician-related factors. Patient factors include lack of awareness, misconception and fear in participating in CTs; physician-related factors comprise of lack of encouragement from physician to patients in participating in a CT. The study identified few major barriers to participation in CTs. Increased patient awareness and recruitment strategies are required to increase accrual of patients including training for physicians and disseminating easy-to-read tools to the public.
Collapse
Affiliation(s)
- Khalid M Almutairi
- Department of Community Health Science, College of Applied Medical Science, King Saud University, Riyadh, Saudi Arabia.
| | - Wadi B Alonazi
- College of Business Administration, King Saud University, Riyadh, Saudi Arabia
| | - Abdulaziz A Alodhayani
- Department of Family and Community Medicine, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Jason M Vinluan
- Department of Community Health Science, College of Applied Medical Science, King Saud University, Riyadh, Saudi Arabia
| | - Mahaman Moussa
- Medical Surgical Department, College of Nursing, King Saud University, Riyadh, Saudi Arabia
| | - Abdulrahman S Al-Ajlan
- Clinical Laboratories Sciences, College of Applied Medical Sciences, King Saud University, Riyadh, Saudi Arabia
| | - Khalid Alsaleh
- College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Duna Alruwaimi
- Clinical Laboratories Sciences, College of Applied Medical Sciences, King Saud University, Riyadh, Saudi Arabia
| | - Nader E Alotaibi
- College of Business Administration, King Saud University, Riyadh, Saudi Arabia
| |
Collapse
|
24
|
Downing A, Morris EJA, Corrigan N, Sebag-Montefiore D, Finan PJ, Thomas JD, Chapman M, Hamilton R, Campbell H, Cameron D, Kaplan R, Parmar M, Stephens R, Seymour M, Gregory W, Selby P. High hospital research participation and improved colorectal cancer survival outcomes: a population-based study. Gut 2017; 66:89-96. [PMID: 27797935 PMCID: PMC5256392 DOI: 10.1136/gutjnl-2015-311308] [Citation(s) in RCA: 83] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2015] [Revised: 08/18/2016] [Accepted: 08/25/2016] [Indexed: 12/08/2022]
Abstract
OBJECTIVE In 2001, the National Institute for Health Research Cancer Research Network (NCRN) was established, leading to a rapid increase in clinical research activity across the English NHS. Using colorectal cancer (CRC) as an example, we test the hypothesis that high, sustained hospital-level participation in interventional clinical trials improves outcomes for all patients with CRC managed in those research-intensive hospitals. DESIGN Data for patients diagnosed with CRC in England in 2001-2008 (n=209 968) were linked with data on accrual to NCRN CRC studies (n=30 998). Hospital Trusts were categorised by the proportion of patients accrued to interventional studies annually. Multivariable models investigated the relationship between 30-day postoperative mortality and 5-year survival and the level and duration of study participation. RESULTS Most of the Trusts achieving high participation were district general hospitals and the effects were not limited to cancer 'centres of excellence', although such centres do make substantial contributions. Patients treated in Trusts with high research participation (≥16%) in their year of diagnosis had lower postoperative mortality (p<0.001) and improved survival (p<0.001) after adjustment for casemix and hospital-level variables. The effects increased with sustained research participation, with a reduction in postoperative mortality of 1.5% (6.5%-5%, p<2.2×10-6) and an improvement in survival (p<10-19; 5-year difference: 3.8% (41.0%-44.8%)) comparing high participation for ≥4 years with 0 years. CONCLUSIONS There is a strong independent association between survival and participation in interventional clinical studies for all patients with CRC treated in the hospital study participants. Improvement precedes and increases with the level and years of sustained participation.
Collapse
Affiliation(s)
- Amy Downing
- Leeds Institute of Cancer and Pathology, University of Leeds, St James's University Hospital, Leeds, UK
- Cancer Research UK Centre, University of Leeds, St James's University Hospital, Leeds, UK
| | - Eva JA Morris
- Leeds Institute of Cancer and Pathology, University of Leeds, St James's University Hospital, Leeds, UK
- Cancer Research UK Centre, University of Leeds, St James's University Hospital, Leeds, UK
- MRC Bioinformatics Centre, Leeds, UK
| | - Neil Corrigan
- Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - David Sebag-Montefiore
- Leeds Institute of Cancer and Pathology, University of Leeds, St James's University Hospital, Leeds, UK
- Cancer Research UK Centre, University of Leeds, St James's University Hospital, Leeds, UK
- Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Paul J Finan
- Leeds Teaching Hospitals NHS Trust, Leeds, UK
- National Cancer Intelligence Network, London, UK
| | | | | | | | - Helen Campbell
- Department of Health, Research and Development, London, UK
- Clinical Research Facilities, and Cancer Research, University of Exeter Medical School, Exeter, UK
| | - David Cameron
- NIHR Cancer Research Network, Leeds, UK
- Edinburgh Cancer Research Centre, University of Edinburgh, Western General Hospital, Edinburgh, UK
| | - Richard Kaplan
- NIHR Cancer Research Network, Leeds, UK
- MRC Clinical Trials Unit at University College London, London, UK
| | - Mahesh Parmar
- MRC Clinical Trials Unit at University College London, London, UK
| | - Richard Stephens
- NCRI Consumer Liaison Group, NIHR Cancer Research Network, Leeds, UK
| | - Matt Seymour
- Leeds Institute of Cancer and Pathology, University of Leeds, St James's University Hospital, Leeds, UK
- Cancer Research UK Centre, University of Leeds, St James's University Hospital, Leeds, UK
- Leeds Teaching Hospitals NHS Trust, Leeds, UK
- NIHR Cancer Research Network, Leeds, UK
| | - Walter Gregory
- Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Peter Selby
- Leeds Institute of Cancer and Pathology, University of Leeds, St James's University Hospital, Leeds, UK
- Cancer Research UK Centre, University of Leeds, St James's University Hospital, Leeds, UK
- Leeds Teaching Hospitals NHS Trust, Leeds, UK
| |
Collapse
|
25
|
Estcourt S, Epton J, Epton T, Vaidya B, Daly M. Exploring the motivations of patients with type 2 diabetes to participate in clinical trials: a qualitative analysis. RESEARCH INVOLVEMENT AND ENGAGEMENT 2016; 2:34. [PMID: 29507768 PMCID: PMC5831891 DOI: 10.1186/s40900-016-0050-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/21/2016] [Accepted: 12/06/2016] [Indexed: 06/08/2023]
Abstract
PLAIN ENGLISH SUMMARY Certain patient groups are reluctant to engage with clinical research and consequently findings are not always truly representative of the wider population. With the emphasis on evidence-based clinical practice, clinical research as a core activity for the National Health Service (NHS) and the rising prevalence of diabetes within the United Kingdom (UK) it is important to understand what motivates people to volunteer for research in diabetes and identify the barriers to this involvement. This research interviewed 12 people with type 2 diabetes who had previously taken part in diabetes clinical trials. The transcripts of these interviews were analysed to identify themes that informed the study findings.There were wide ranging reasons for participating in clinical trials. Both altruistic and self-interest motivation were universally expressed. The thought of helping others was a powerful experience but for some there was a sense of duty to volunteer especially if they had benefited from NHS care. Participating was empowering, with extra access to healthcare professionals, practical information and support for their condition. Coping with the logistics of being in a trial relied upon a strong network of family and friends. Some felt anxious at the end of the trial having been supported during the research and appreciating the camaraderie of belonging to a group or team.This study provides insights into the motivations and barriers to involvement in clinical research in type 2 diabetes helping researchers to encourage and support more volunteers in clinical trials. ABSTRACT Background Certain patient groups are reluctant to engage with clinical research and consequently findings of the research are not always truly representative of the wider population. This, together with a growing prominence of evidence-based clinical practice, an increasing emphasis of clinical research as a core activity for the NHS and the rising prevalence of diabetes within the UK population, requires an understanding of motivations and barriers for patients consenting to participate in diabetes clinical trials.Methods To understand patients' motivations for participating in clinical trials in type 2 diabetes. We conducted a qualitative study involving 12 participants with type 2 diabetes with previous involvement in clinical trials. Individual, tape-recorded, semi structured interviews were conducted to explore motivations and experiences of the participants. We carried out thematic content analysis to identify themes, from which theoretical interpretations were formed.Results There were wide ranging reasons for participating in clinical trials. We identified 3 key themes: (1) Motivations ranged from altruism to self-interest; (2) participation in clinical trials was an empowering experience; and (3) key to participation was a strong network of support.Conclusion Patients are motivated to participate in clinical trials by a sense of altruism coupled with self-interest. This self-interest centres on the belief that participation would be an informative and empowering experience with increased access to healthcare professionals. However the ability to cope with the logistics of being in clinical trials relies upon an extensive and reliable network of support from family, friends, work colleagues and employers, together with a collaborative approach to their care from the researchers and their usual healthcare providers.
Collapse
Affiliation(s)
- Stephanie Estcourt
- Department of Research & Development, Royal Devon & Exeter Hospital, G9 Child Health Building, Barrack Road, Exeter, EX2 5DW UK
| | - Jill Epton
- Patient Public Involvement Group Representatives, Exeter, UK
| | - Tom Epton
- Patient Public Involvement Group Representatives, Exeter, UK
| | - Bijay Vaidya
- MacLeod Diabetes & Endocrine Centre, Royal Devon & Exeter Hospital, Exeter, UK
| | - Mark Daly
- MacLeod Diabetes & Endocrine Centre, Royal Devon & Exeter Hospital, Exeter, UK
| |
Collapse
|
26
|
Hemmingsen B, Sonne DP, Metzendorf M, Richter B. Insulin secretagogues for prevention or delay of type 2 diabetes mellitus and its associated complications in persons at increased risk for the development of type 2 diabetes mellitus. Cochrane Database Syst Rev 2016; 10:CD012151. [PMID: 27749986 PMCID: PMC6461156 DOI: 10.1002/14651858.cd012151.pub2] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND The projected rise in the incidence of type 2 diabetes mellitus (T2DM) could develop into a substantial health problem worldwide. Whether insulin secretagogues (sulphonylureas and meglitinide analogues) are able to prevent or delay T2DM and its associated complications in people at risk for the development of T2DM is unknown. OBJECTIVES To assess the effects of insulin secretagogues on the prevention or delay of T2DM and its associated complications in people with impaired glucose tolerance, impaired fasting blood glucose, moderately elevated glycosylated haemoglobin A1c (HbA1c) or any combination of these. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials, MEDLINE, PubMed, Embase, ClinicalTrials.gov, the World Health Organization International Clinical Trials Registry Platform, and the reference lists of systematic reviews, articles and health technology assessment reports. We asked investigators of the included trials for information about additional trials. The date of the last search of all databases was April 2016. SELECTION CRITERIA We included randomised controlled trials (RCTs) with a duration of 12 weeks or more comparing insulin secretagogues with any pharmacological glucose-lowering intervention, behaviour-changing intervention, placebo or no intervention in people with impaired fasting glucose, impaired glucose tolerance, moderately elevated HbA1c or combinations of these. DATA COLLECTION AND ANALYSIS Two review authors read all abstracts and full-text articles/records, assessed quality and extracted outcome data independently. One review author extracted data which were checked by a second review author. We resolved discrepancies by consensus or the involvement of a third review author. For meta-analyses we used a random-effects model with investigation of risk ratios (RRs) for dichotomous outcomes and mean differences (MDs) for continuous outcomes, using 95% confidence intervals (CIs) for effect estimates. We carried out trial sequential analyses (TSAs) for all outcomes that could be meta-analysed. We assessed the overall quality of the evidence by using the GRADE instrument. MAIN RESULTS We included six RCTs with 10,018 participants; 4791 participants with data on allocation to intervention groups were randomised to a second- or third-generation sulphonylurea or a meglitinide analogue as monotherapy and 29 participants were randomised to a second-generation sulphonylurea plus metformin. Three trials investigated a second-generation sulphonylurea, two trials investigated a third-generation sulphonylurea and one trial a meglitinide analogue. A total of 4873 participants with data on allocation to control groups were randomised to a comparator group; 4820 participants were randomised to placebo, 23 to diet and exercise, and 30 participants to metformin monotherapy. One RCT of nateglinide contributed 95% of all participants. The duration of the intervention varied from six months to five years. We judged none of the included trials as at low risk of bias for all 'Risk of bias' domains.All-cause and cardiovascular mortality following sulphonylurea (glimepiride) treatment were rarely observed (very low-quality evidence). The RR for incidence of T2DM comparing glimepiride monotherapy with placebo was 0.75; 95% CI 0.54 to 1.04; P = 0.08; 2 trials; 307 participants; very low-quality evidence. One of the trials reporting on the incidence of T2DM did not define the diagnostic criteria used. The other trial diagnosed T2DM as two consecutive fasting blood glucose values ≥ 6.1 mmol/L. TSA showed that only 4.5% of the diversity-adjusted required information size was accrued so far. No trial reported data on serious adverse events, non-fatal myocardial infarction (MI), non-fatal stroke, congestive heart failure (HF), health-related quality of life or socioeconomic effects.One trial with a follow-up of five years compared a meglitinide analogue (nateglinide) with placebo. A total of 310/4645 (6.7%) participants allocated to nateglinide died compared with 312/4661 (6.7%) participants allocated to placebo (hazard ratio (HR) 1.00; 95% CI 0.85 to 1.17; P = 0.98; moderate-quality evidence). The two main criteria for diagnosing T2DM were a fasting plasma glucose level ≥ 7.0 mmol/L or a 2-hour post challenge glucose ≥ 11.1 mmol/L. T2DM developed in 1674/4645 (36.0%) participants in the nateglinide group and in 1580/4661 (33.9%) in the placebo group (HR 1.07; 95% CI 1.00 to 1.15; P = 0.05; moderate-quality evidence). One or more serious adverse event was reported in 2066/4602 (44.9%) participants allocated to nateglinide compared with 2089/4599 (45.6%) participants allocated to placebo. A total of 126/4645 (2.7%) participants allocated to nateglinide died because of cardiovascular disease compared with 118/4661 (2.5%) participants allocated to placebo (HR 1.07; 95% CI 0.83 to 1.38; P = 0.60; moderate-quality evidence). Comparing participants receiving nateglinide with those receiving placebo for the outcomes MI, non-fatal stroke and HF gave the following event rates: MI 116/4645 (2.5%) versus 122/4661 (2.6%), stroke 100/4645 (2.2%) versus 110/4661 (2.4%) and numbers hospitalised for HF 85/4645 (1.8%) versus 100/4661 (2.1%) - (HR 0.85; 95% CI 0.64 to 1.14; P = 0.27). The quality of the evidence was moderate for all these outcomes. Health-related quality of life or socioeconomic effects were not reported. AUTHORS' CONCLUSIONS There is insufficient evidence to demonstrate whether insulin secretagogues compared mainly with placebo reduce the risk of developing T2DM and its associated complications in people at increased risk for the development of T2DM. Most trials did not investigate patient-important outcomes.
Collapse
Affiliation(s)
- Bianca Hemmingsen
- Herlev University HospitalDepartment of Internal MedicineHerlev Ringvej 75HerlevDenmarkDK‐2730
| | - David Peick Sonne
- Gentofte Hospital, University of CopenhagenCenter for Diabetes Research, Department of MedicineKildegaardsvej 28HellerupDenmarkDK‐2900
| | - Maria‐Inti Metzendorf
- Institute of General Practice, Medical Faculty of the Heinrich‐Heine‐University DüsseldorfCochrane Metabolic and Endocrine Disorders GroupMoorenstr. 5DüsseldorfGermany40225
| | - Bernd Richter
- Institute of General Practice, Medical Faculty of the Heinrich‐Heine‐University DüsseldorfCochrane Metabolic and Endocrine Disorders GroupMoorenstr. 5DüsseldorfGermany40225
| | | |
Collapse
|
27
|
Barnett W, Brittain K, Sorsdahl K, Zar HJ, Stein DJ. Maternal participant experience in a South African birth cohort study enrolling healthy pregnant women and their infants. Philos Ethics Humanit Med 2016; 11:3. [PMID: 27435596 PMCID: PMC4952056 DOI: 10.1186/s13010-016-0036-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2015] [Accepted: 06/23/2016] [Indexed: 06/06/2023] Open
Abstract
BACKGROUND Critical to conducting high quality research is the ability to attract and retain participants, especially for longitudinal studies. Understanding participant experiences and motivators or barriers to participating in clinical research is crucial. There are limited data on healthy participant experiences in longitudinal research, particularly in low- and middle-income countries. This study aims to investigate quantitatively participant experiences in a South African birth cohort study. METHODS Maternal participant experience was evaluated by a self-administered survey in the Drakenstein Child Health Study, a longitudinal birth cohort study investigating the early life determinants of child health. Pregnant mothers, enrolled during the second trimester, were followed through childbirth and the early childhood years. Satisfaction scores were derived from the participant experience survey and quantitatively analyzed; associations between satisfaction scores and sociodemographic variables were then investigated using a linear regression model. RESULTS Data were included from 585 pregnant mothers (median age 26.6 years), who had participated in the study for a median time of 16 months. Overall participant satisfaction was high (median score 51/60) and associated with increased attendance of study visits. Reasons for participating were a belief that involvement would improve their health, their child's health or the health of family and friends. Potential reasons for leaving the study were inconvenience, not receiving clinical or study results, and unexpected changes in study visits or procedures. Variables associated with higher overall satisfaction scores were no prior participation in research, higher socioeconomic status, less intensive follow-up schedules and having experienced stressful life events in the past year. CONCLUSIONS Satisfaction scores were high and associated with increased visit attendance. Participants' perceived benefits of study participation, most notably the potential for an improvement in the health of their child, were a significant motivator to enroll and remain in the study. The consistent theme of perceived health benefits as a motivator to join and remain in the study raises the question of whether participation in research results in actual improvements in health.
Collapse
Affiliation(s)
- Whitney Barnett
- />Department of Paediatrics and Child Health, Red Cross War Memorial Children’s Hospital, and Medical Research Council Unit on Child & Adolescent Health, University of Cape Town, Cape Town, South Africa
| | - Kirsty Brittain
- />Department of Paediatrics and Child Health, Red Cross War Memorial Children’s Hospital, and Medical Research Council Unit on Child & Adolescent Health, University of Cape Town, Cape Town, South Africa
| | - Katherine Sorsdahl
- />Alan J. Flisher Centre for Public Mental Health, Department of Psychiatry, University of Cape Town, Cape Town, South Africa
| | - Heather J. Zar
- />Department of Paediatrics and Child Health, Red Cross War Memorial Children’s Hospital, and Medical Research Council Unit on Child & Adolescent Health, University of Cape Town, Cape Town, South Africa
| | - Dan J. Stein
- />Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa
- />Medical Research Council Unit on Anxiety & Stress Disorders, Cape Town, South Africa
| |
Collapse
|
28
|
Denburg A, Rodriguez-Galindo C, Joffe S. Clinical Trials Infrastructure as a Quality Improvement Intervention in Low- and Middle-Income Countries. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2016; 16:3-11. [PMID: 27216089 DOI: 10.1080/15265161.2016.1170230] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Abstract
Mounting evidence suggests that participation in clinical trials confers neither advantage nor disadvantage on those enrolled. Narrow focus on the question of a "trial effect," however, distracts from a broader mechanism by which patients may benefit from ongoing clinical research. We hypothesize that the existence of clinical trials infrastructure-the organizational culture, systems, and expertise that develop as a product of sustained participation in cooperative clinical trials research-may function as a quality improvement lever, improving the quality of care and outcomes of all patients within an institution or region independent of their individual participation in trials. We further contend that this "infrastructure effect" can yield particular benefits for patients in low- and middle-income countries (LMICs). The hypothesis of an infrastructure effect as a quality improvement intervention, if correct, justifies enhanced research capacity in LMIC as a pillar of health system development.
Collapse
Affiliation(s)
- Avram Denburg
- a The Hospital for Sick Children and McMaster University
| | | | - Steven Joffe
- c University of Pennsylvania Perelman School of Medicine
| |
Collapse
|
29
|
Sacristán JA, Aguarón A, Avendaño-Solá C, Garrido P, Carrión J, Gutiérrez A, Kroes R, Flores A. Patient involvement in clinical research: why, when, and how. Patient Prefer Adherence 2016; 10:631-40. [PMID: 27175063 PMCID: PMC4854260 DOI: 10.2147/ppa.s104259] [Citation(s) in RCA: 196] [Impact Index Per Article: 24.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
The development of a patient-centered approach to medicine is gradually allowing more patients to be involved in their own medical decisions. However, this change is not happening at the same rate in clinical research, where research generally continues to be carried out on patients, but not with patients. This work describes the why, when, and how of more active patient participation in the research process. Specific measures are proposed to improve patient involvement in 1) setting priorities, 2) study leadership and design, 3) improved access to clinical trials, 4) preparation and oversight of the information provided to participants, 5) post-study evaluation of the patient experience, and 6) the dissemination and application of results. In order to achieve these aims, the relative emphases on the ethical principles underlying research need to be changed. The current model based on the principle of beneficence must be left behind, and one that upholds the ethical principles of autonomy and non maleficence should be embraced. There is a need to improve the level of information that patients and society as a whole have on research objectives and processes; the goal is to promote the gradual emergence of the expert patient.
Collapse
Affiliation(s)
| | | | | | - Pilar Garrido
- Oncology Department, Hospital Ramón y Cajal, Madrid, Spain
| | - Juan Carrión
- FEDER (Spanish Federation for Rare Diseases), Madrid, Spain
| | | | - Robert Kroes
- Clinical Open Innovation, Lilly Europe, Amsterdam, the Netherlands
| | | |
Collapse
|
30
|
Royle P, Mistry H, Auguste P, Shyangdan D, Freeman K, Lois N, Waugh N. Pan-retinal photocoagulation and other forms of laser treatment and drug therapies for non-proliferative diabetic retinopathy: systematic review and economic evaluation. Health Technol Assess 2016; 19:v-xxviii, 1-247. [PMID: 26173799 DOI: 10.3310/hta19510] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Diabetic retinopathy is an important cause of visual loss. Laser photocoagulation preserves vision in diabetic retinopathy but is currently used at the stage of proliferative diabetic retinopathy (PDR). OBJECTIVES The primary aim was to assess the clinical effectiveness and cost-effectiveness of pan-retinal photocoagulation (PRP) given at the non-proliferative stage of diabetic retinopathy (NPDR) compared with waiting until the high-risk PDR (HR-PDR) stage was reached. There have been recent advances in laser photocoagulation techniques, and in the use of laser treatments combined with anti-vascular endothelial growth factor (VEGF) drugs or injected steroids. Our secondary questions were: (1) If PRP were to be used in NPDR, which form of laser treatment should be used? and (2) Is adjuvant therapy with intravitreal drugs clinically effective and cost-effective in PRP? ELIGIBILITY CRITERIA Randomised controlled trials (RCTs) for efficacy but other designs also used. DATA SOURCES MEDLINE and EMBASE to February 2014, Web of Science. REVIEW METHODS Systematic review and economic modelling. RESULTS The Early Treatment Diabetic Retinopathy Study (ETDRS), published in 1991, was the only trial designed to determine the best time to initiate PRP. It randomised one eye of 3711 patients with mild-to-severe NPDR or early PDR to early photocoagulation, and the other to deferral of PRP until HR-PDR developed. The risk of severe visual loss after 5 years for eyes assigned to PRP for NPDR or early PDR compared with deferral of PRP was reduced by 23% (relative risk 0.77, 99% confidence interval 0.56 to 1.06). However, the ETDRS did not provide results separately for NPDR and early PDR. In economic modelling, the base case found that early PRP could be more effective and less costly than deferred PRP. Sensitivity analyses gave similar results, with early PRP continuing to dominate or having low incremental cost-effectiveness ratio. However, there are substantial uncertainties. For our secondary aims we found 12 trials of lasers in DR, with 982 patients in total, ranging from 40 to 150. Most were in PDR but five included some patients with severe NPDR. Three compared multi-spot pattern lasers against argon laser. RCTs comparing laser applied in a lighter manner (less-intensive burns) with conventional methods (more intense burns) reported little difference in efficacy but fewer adverse effects. One RCT suggested that selective laser treatment targeting only ischaemic areas was effective. Observational studies showed that the most important adverse effect of PRP was macular oedema (MO), which can cause visual impairment, usually temporary. Ten trials of laser and anti-VEGF or steroid drug combinations were consistent in reporting a reduction in risk of PRP-induced MO. LIMITATION The current evidence is insufficient to recommend PRP for severe NPDR. CONCLUSIONS There is, as yet, no convincing evidence that modern laser systems are more effective than the argon laser used in ETDRS, but they appear to have fewer adverse effects. We recommend a trial of PRP for severe NPDR and early PDR compared with deferring PRP till the HR-PDR stage. The trial would use modern laser technologies, and investigate the value adjuvant prophylactic anti-VEGF or steroid drugs. STUDY REGISTRATION This study is registered as PROSPERO CRD42013005408. FUNDING The National Institute for Health Research Health Technology Assessment programme.
Collapse
Affiliation(s)
- Pamela Royle
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Hema Mistry
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Peter Auguste
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Deepson Shyangdan
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Karoline Freeman
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | | | - Norman Waugh
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| |
Collapse
|
31
|
Khera N. From evidence to clinical practice in blood and marrow transplantation. Blood Rev 2015; 29:351-7. [PMID: 25934009 PMCID: PMC4610823 DOI: 10.1016/j.blre.2015.04.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2014] [Revised: 03/04/2015] [Accepted: 04/14/2015] [Indexed: 10/23/2022]
Abstract
Clinical practice in the field of blood and marrow transplantation (BMT) has evolved over time, as a result of thousands of basic and clinical research studies. While it appears that scientific discovery and adaptive clinical research may be well integrated in case of BMT, there is lack of sufficient literature to definitively understand the process of translation of evidence to practice and if it may be selective . In this review, examples from BMT and other areas of medicine are used to highlight the state of and potential barriers to evidence uptake. Strategies to help improve knowledge transfer are discussed and the role of existing framework provided by the Center for International Blood and Marrow Transplant Registry (CIBMTR) to monitor uptake and BMT Clinical Trials Network (BMT CTN) to enhance translation of evidence into practice is highlighted.
Collapse
Affiliation(s)
- Nandita Khera
- College of Medicine, Mayo Clinic, 5777 E Mayo Blvd, Phoenix, AZ 85054, USA.
| |
Collapse
|
32
|
Hemmingsen B, Schroll JB, Lund SS, Wetterslev J, Gluud C, Vaag A, Sonne DP, Lundstrøm LH, Almdal TP. WITHDRAWN: Sulphonylurea monotherapy for patients with type 2 diabetes mellitus. Cochrane Database Syst Rev 2015; 2015:CD009008. [PMID: 26222249 PMCID: PMC10631380 DOI: 10.1002/14651858.cd009008.pub3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
The Cochrane Metabolic and Endocrine Disorders Group withdrew this review as of Issue 7, 2015 because of the involvement of one author (SS Lund) being employed in a pharmaceutical company. The authors of the review and the Cochrane Metabolic and Endocrine Disorders Group did not find that this was a breach of the rules of the Cochrane Collaboration at the time when it was published. However, after the publication of the review, the Cochrane Collaboration requested withdrawal of the review due to the employment of the author. A new protocol for a review to cover this topic will be published. This will have a new title and a markedly improved protocol fulfilling new and important developments and standards within the Cochrane Collaboration as well as an improved inclusion and search strategy making it necessary to embark on a completely new review project. The editorial group responsible for this previously published document have withdrawn it from publication.
Collapse
Affiliation(s)
- Bianca Hemmingsen
- Department 7812, Rigshospitalet, Copenhagen University HospitalCopenhagen Trial Unit, Centre for Clinical Intervention ResearchBlegdamsvej 9CopenhagenDenmarkDK‐2100
| | - Jeppe B Schroll
- RigshospitaletNordic Cochrane CenterBlegdamsvej 9KøbenhavnDenmark2100
| | - Søren S Lund
- Boehringer Ingelheim Pharma GmbH & Co. KGIngelheimGermany
| | - Jørn Wetterslev
- Department 7812, Rigshospitalet, Copenhagen University HospitalCopenhagen Trial Unit, Centre for Clinical Intervention ResearchBlegdamsvej 9CopenhagenDenmarkDK‐2100
| | - Christian Gluud
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812, Rigshospitalet, Copenhagen University HospitalThe Cochrane Hepato‐Biliary GroupBlegdamsvej 9CopenhagenDenmarkDK‐2100
| | - Allan Vaag
- Rigshospitalet and Copenhagen UniversityDepartment of Endocrinology, Diabetes and MetabolismAfsnit 7652København NDenmark2200
| | - David Peick Sonne
- Gentofte Hospital, University of CopenhagenDepartment of Internal Medicine FNiels Andersens Vej 65HellerupDenmark2900
| | - Lars H Lundstrøm
- Hillerød HospitalDepartment of AnaesthesiologyDyrehavevej 29HillerødDenmark3400
| | - Thomas P Almdal
- Copenhagen University Hospital GentofteDepartment of Medicine FHellerupDenmark2900
| | | |
Collapse
|
33
|
Foglia EE, Nolen TL, DeMauro SB, Das A, Bell EF, Stoll BJ, Schmidt B. Short-term Outcomes of Infants Enrolled in Randomized Clinical Trials vs Those Eligible but Not Enrolled. JAMA 2015; 313:2377-9. [PMID: 26080344 PMCID: PMC4720434 DOI: 10.1001/jama.2015.5734] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
| | - Tracy L Nolen
- Social, Statistical, and Environmental Sciences Unit, RTI International, Research Triangle Park, North Carolina
| | - Sara B DeMauro
- Department of Pediatrics, University of Pennsylvania, Philadelphia
| | - Abhik Das
- Social, Statistical, and Environmental Sciences Unit, RTI International, Rockville, Maryland
| | - Edward F Bell
- Department of Pediatrics, University of Iowa, Iowa City
| | - Barbara J Stoll
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia
| | - Barbara Schmidt
- Department of Pediatrics, University of Pennsylvania, Philadelphia
| | | |
Collapse
|
34
|
Khera N, Majhail NS, Brazauskas R, Wang Z, He N, Aljurf MD, Akpek G, Atsuta Y, Beattie S, Bredeson CN, Burns LJ, Dalal JD, Freytes CO, Gupta V, Inamoto Y, Lazarus HM, LeMaistre CF, Steinberg A, Szwajcer D, Wingard JR, Wirk B, Wood WA, Joffe S, Hahn TE, Loberiza FR, Anasetti C, Horowitz MM, Lee SJ. Comparison of Characteristics and Outcomes of Trial Participants and Nonparticipants: Example of Blood and Marrow Transplant Clinical Trials Network 0201 Trial. Biol Blood Marrow Transplant 2015; 21:1815-22. [PMID: 26071866 DOI: 10.1016/j.bbmt.2015.06.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2015] [Accepted: 06/04/2015] [Indexed: 11/30/2022]
Abstract
Controversy surrounds the question of whether clinical trial participants have better outcomes than comparable patients who are not treated on a trial. We explored this question using a recent large, randomized, multicenter study comparing peripheral blood (PB) with bone marrow transplantation from unrelated donors, conducted by the Blood and Marrow Transplant Clinical Trials Network (BMT CTN). We compared characteristics and outcomes of study participants (n = 494) and nonparticipants (n = 1384) who appeared eligible and received similar treatment without enrolling on the BMT CTN trial at participating centers during the study time period. Data were obtained from the Center for International Blood and Marrow Transplant Research. Outcomes were compared between the 2 groups using Cox proportional hazards regression models. No significant differences in age, sex, disease distribution, race/ethnicity, HLA matching, comorbidities, and interval from diagnosis to hematopoietic cell transplantation were seen between the participants and nonparticipants. Nonparticipants were more likely to have lower performance status, lower risk disease, and older donors, and to receive myeloablative conditioning and antithymocyte globulin. Nonparticipants were also more likely to receive PB grafts, the intervention tested in the trial (66% versus 50%, P < .001). Overall survival, transplantation-related mortality, and incidences of acute or chronic graft-versus-host disease were comparable between the 2 groups though relapse was higher (hazard ratio, 1.22; 95% confidence interval, 1.02 to 1.46; P = .028) in nonparticipants. Despite differences in certain baseline characteristics, survival was comparable between study participants and nonparticipants. The results of the BMT CTN trial appear generalizable to the population of trial-eligible patients.
Collapse
Affiliation(s)
- Nandita Khera
- Department of Hematology/Oncology, Mayo Clinic, Phoenix, Arizona.
| | - Navneet S Majhail
- Blood and Marrow Transplant Program, Cleveland Clinic, Taussig Cancer Institute, Cleveland, Ohio
| | - Ruta Brazauskas
- Center for International Blood and Marrow Transplant Research, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin; Division of Biostatistics, Institute of Health and Society, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Zhiwei Wang
- Center for International Blood and Marrow Transplant Research, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Naya He
- Center for International Blood and Marrow Transplant Research, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Mahmoud D Aljurf
- Department of Oncology, King Faisal Specialist Hospital Center and Research, Riyadh, Saudi Arabia
| | - Görgün Akpek
- Section of Hematology Oncology, Banner MD Anderson Cancer Center, Gilbert, Arizona
| | - Yoshiko Atsuta
- Japanese Data Center for Hematopoietic Cell Transplantation, Nagoya, Japan; Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Sara Beattie
- School of Psychology, University of Ottawa, Ottawa, Ontario, Canada
| | - Christopher N Bredeson
- Ottawa Hospital Blood and Marrow Transplant Program and the Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Linda J Burns
- Health Services Research, National Marrow Donor Program/Be The Match, Minneapolis, Minnesota
| | - Jignesh D Dalal
- Bone Marrow Transplantation, Pediatric Hematology/Oncology, The Children's Mercy Hospitals and Clinics, Kansas City, Missouri
| | - César O Freytes
- South Texas Veterans Health Care System and University of Texas Health Science Center San Antonio, San Antonio, Texas
| | - Vikas Gupta
- Blood and Marrow Transplant Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Yoshihiro Inamoto
- Division of Hematopoietic Stem Cell Transplantation, National Cancer Center Hospital, Tokyo, Japan
| | - Hillard M Lazarus
- Seidman Cancer Center, University Hospitals Case Medical Center, Cleveland, Ohio
| | | | - Amir Steinberg
- Department of Hematology-Oncology, Mount Sinai Hospital, New York, New York
| | - David Szwajcer
- Department of Hematology, CancerCare Manitoba/University of Manitoba, Winnipeg, Manitoba, Canada
| | - John R Wingard
- Division of Hematology and Oncology, Department of Medicine, University of Florida, Gainesville, Florida
| | - Baldeep Wirk
- Department of Internal Medicine, Stony Brook University Medical Center, Stony Brook, New York
| | - William A Wood
- Division of Hematology/Oncology, Department of Medicine, University of North Carolina, Chapel Hill, North Carolina
| | - Steven Joffe
- Department of Medical Ethics and Health Policy, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Theresa E Hahn
- Department of Medicine, Roswell Park Cancer Institute, Buffalo, New York
| | - Fausto R Loberiza
- Department of Internal Medicine, Nebraska Medical Center, Omaha, Nebraska
| | - Claudio Anasetti
- Bone Marrow Transplant Program, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Mary M Horowitz
- Center for International Blood and Marrow Transplant Research, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Stephanie J Lee
- Clinical Transplant Research, Fred Hutchinson Cancer Research Center, Seattle, Washington
| |
Collapse
|
35
|
Wendler D. "Targeted" consent for pragmatic clinical trials. J Gen Intern Med 2015; 30:679-82. [PMID: 25586870 PMCID: PMC4395600 DOI: 10.1007/s11606-014-3169-2] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2014] [Revised: 12/10/2014] [Accepted: 12/24/2014] [Indexed: 11/30/2022]
Abstract
Research on interventions within the standard of care has enormous potential, yet it also raises several ethical and regulatory challenges. Perhaps the most important is determining what consent process is needed for these "pragmatic" clinical trials. Some argue that pragmatic clinical trials need to obtain in-depth research consent. This approach ensures that patients are informed, but may introduce substantial selection bias and disruption of clinical care. Others argue that trials limited to interventions within the standard of care do not need to obtain research consent at all. While this approach avoids the problems with in-depth consent, it results in patients not knowing whether they are in research. The present manuscript proposes a way to avoid both sets of concerns. It argues that consent for research needs to supplement appropriate consent for standard care only to the extent that the research differs from standard care. Hence, pragmatic trials designed to mirror clinical care can obtain consent with only minimal additions to consent for standard care. This conclusion suggests that it may be possible for many pragmatic trials to obtain consent that is ethically appropriate, satisfies research regulations, and does not introduce substantial selection bias or clinical disruption.
Collapse
Affiliation(s)
- David Wendler
- Department of Bioethics, NIH Clinical Center, Building 10, Room 1C118, Bethesda, MD, 20892-1156, USA,
| |
Collapse
|
36
|
Sacristán JA. Clinical research and medical care: towards effective and complete integration. BMC Med Res Methodol 2015; 15:4. [PMID: 25575454 PMCID: PMC4323129 DOI: 10.1186/1471-2288-15-4] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2014] [Accepted: 01/02/2015] [Indexed: 11/17/2022] Open
Abstract
Background Despite their close relationship, clinical research and medical care have become separated by clear boundaries. The purpose of clinical research is to generate generalizable knowledge useful for future patients, whereas medical care aims to promote the well-being of individual patients. The evolution towards patient-centered medicine and patient-oriented research, and the gradual standardization of medicine are contributing to closer ties between clinical research and medical practice. But the integration of both activities requires addressing important ethical and methodological challenges. Discussion From an ethical perspective, clinical research should evolve from a position of paternalistic beneficence to a situation in which the principle of non-maleficence and patient autonomy predominate. The progressive adoption of “patient-oriented informed consent”, “patient equipoise”, and “altruism-based research”, and the application of risk-based ethical oversight, in which the level of regulatory scrutiny is adapted to the potential risk for patients, are crucial steps to achieve the integration between research and care. From a methodological standpoint, careful and systematic observations should have greater relevance in clinical research, and experiments should be embedded into usual clinical practice. Clinical research should focus on individuals through the development of patient-oriented research. In a complementary way, the integration of experiments into medical practice through the systematic application of “point of care research” could help to generate knowledge for the individuals and for the populations. Summary The integration of clinical research and medical care will require researchers, clinicians, health care managers, and patients to reevaluate the way they understand both activities. The development of an integrated learning health care system will contribute to generating and applying clinically relevant medical knowledge, producing benefits for present and future patients.
Collapse
|
37
|
Fernandes N, Bryant D, Griffith L, El-Rabbany M, Fernandes NM, Kean C, Marsh J, Mathur S, Moyer R, Reade CJ, Riva JJ, Somerville L, Bhatnagar N. Outcomes for patients with the same disease treated inside and outside of randomized trials: a systematic review and meta-analysis. CMAJ 2014; 186:E596-609. [PMID: 25267774 PMCID: PMC4216275 DOI: 10.1503/cmaj.131693] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND It is unclear whether participation in a randomized controlled trial (RCT), irrespective of assigned treatment, is harmful or beneficial to participants. We compared outcomes for patients with the same diagnoses who did ("insiders") and did not ("outsiders") enter RCTs, without regard to the specific therapies received for their respective diagnoses. METHODS By searching the MEDLINE (1966-2010), Embase (1980-2010), CENTRAL (1960-2010) and PsycINFO (1880-2010) databases, we identified 147 studies that reported the health outcomes of "insiders" and a group of parallel or consecutive "outsiders" within the same time period. We prepared a narrative review and, as appropriate, meta-analyses of patients' outcomes. RESULTS We found no clinically or statistically significant differences in outcomes between "insiders" and "outsiders" in the 23 studies in which the experimental intervention was ineffective (standard mean difference in continuous outcomes -0.03, 95% confidence interval [CI] -0.1 to 0.04) or in the 7 studies in which the experimental intervention was effective and was received by both "insiders" and "outsiders" (mean difference 0.04, 95% CI -0.04 to 0.13). However, in 9 studies in which an effective intervention was received only by "insiders," the "outsiders" experienced significantly worse health outcomes (mean difference -0.36, 95% CI -0.61 to -0.12). INTERPRETATION We found no evidence to support clinically important overall harm or benefit arising from participation in RCTs. This conclusion refutes earlier claims that trial participants are at increased risk of harm.
Collapse
Affiliation(s)
- Natasha Fernandes
- Faculty of Medicine (Natasha Fernandes, Mathur), University of Ottawa, Ottawa, Ont.; Faculty of Health Sciences (Bryant, Marsh, Moyer) and Schulich School of Medicine and Dentistry (Bryant), The University of Western Ontario, London, Ont.; Department of Clinical Epidemiology and Biostatistics (Bryant, Griffith), Department of Medicine (Nisha Fernandes), Health Sciences Library (Bhatnagar), Department of Family Medicine (Riva) and Division of Gynecologic Oncology (Reade), McMaster University, Hamilton, Ont.; Faculty of Dentistry (El-Rabbany), University of Toronto, Toronto, Ont.; School of Medical and Applied Sciences (Kean), Central Queensland University, Rockhampton, Australia; Department of Orthopaedic Surgery (Somerville), London Health Sciences Centre, London, Ont.
| | - Dianne Bryant
- Faculty of Medicine (Natasha Fernandes, Mathur), University of Ottawa, Ottawa, Ont.; Faculty of Health Sciences (Bryant, Marsh, Moyer) and Schulich School of Medicine and Dentistry (Bryant), The University of Western Ontario, London, Ont.; Department of Clinical Epidemiology and Biostatistics (Bryant, Griffith), Department of Medicine (Nisha Fernandes), Health Sciences Library (Bhatnagar), Department of Family Medicine (Riva) and Division of Gynecologic Oncology (Reade), McMaster University, Hamilton, Ont.; Faculty of Dentistry (El-Rabbany), University of Toronto, Toronto, Ont.; School of Medical and Applied Sciences (Kean), Central Queensland University, Rockhampton, Australia; Department of Orthopaedic Surgery (Somerville), London Health Sciences Centre, London, Ont
| | - Lauren Griffith
- Faculty of Medicine (Natasha Fernandes, Mathur), University of Ottawa, Ottawa, Ont.; Faculty of Health Sciences (Bryant, Marsh, Moyer) and Schulich School of Medicine and Dentistry (Bryant), The University of Western Ontario, London, Ont.; Department of Clinical Epidemiology and Biostatistics (Bryant, Griffith), Department of Medicine (Nisha Fernandes), Health Sciences Library (Bhatnagar), Department of Family Medicine (Riva) and Division of Gynecologic Oncology (Reade), McMaster University, Hamilton, Ont.; Faculty of Dentistry (El-Rabbany), University of Toronto, Toronto, Ont.; School of Medical and Applied Sciences (Kean), Central Queensland University, Rockhampton, Australia; Department of Orthopaedic Surgery (Somerville), London Health Sciences Centre, London, Ont
| | - Mohamed El-Rabbany
- Faculty of Medicine (Natasha Fernandes, Mathur), University of Ottawa, Ottawa, Ont.; Faculty of Health Sciences (Bryant, Marsh, Moyer) and Schulich School of Medicine and Dentistry (Bryant), The University of Western Ontario, London, Ont.; Department of Clinical Epidemiology and Biostatistics (Bryant, Griffith), Department of Medicine (Nisha Fernandes), Health Sciences Library (Bhatnagar), Department of Family Medicine (Riva) and Division of Gynecologic Oncology (Reade), McMaster University, Hamilton, Ont.; Faculty of Dentistry (El-Rabbany), University of Toronto, Toronto, Ont.; School of Medical and Applied Sciences (Kean), Central Queensland University, Rockhampton, Australia; Department of Orthopaedic Surgery (Somerville), London Health Sciences Centre, London, Ont
| | - Nisha M Fernandes
- Faculty of Medicine (Natasha Fernandes, Mathur), University of Ottawa, Ottawa, Ont.; Faculty of Health Sciences (Bryant, Marsh, Moyer) and Schulich School of Medicine and Dentistry (Bryant), The University of Western Ontario, London, Ont.; Department of Clinical Epidemiology and Biostatistics (Bryant, Griffith), Department of Medicine (Nisha Fernandes), Health Sciences Library (Bhatnagar), Department of Family Medicine (Riva) and Division of Gynecologic Oncology (Reade), McMaster University, Hamilton, Ont.; Faculty of Dentistry (El-Rabbany), University of Toronto, Toronto, Ont.; School of Medical and Applied Sciences (Kean), Central Queensland University, Rockhampton, Australia; Department of Orthopaedic Surgery (Somerville), London Health Sciences Centre, London, Ont
| | - Crystal Kean
- Faculty of Medicine (Natasha Fernandes, Mathur), University of Ottawa, Ottawa, Ont.; Faculty of Health Sciences (Bryant, Marsh, Moyer) and Schulich School of Medicine and Dentistry (Bryant), The University of Western Ontario, London, Ont.; Department of Clinical Epidemiology and Biostatistics (Bryant, Griffith), Department of Medicine (Nisha Fernandes), Health Sciences Library (Bhatnagar), Department of Family Medicine (Riva) and Division of Gynecologic Oncology (Reade), McMaster University, Hamilton, Ont.; Faculty of Dentistry (El-Rabbany), University of Toronto, Toronto, Ont.; School of Medical and Applied Sciences (Kean), Central Queensland University, Rockhampton, Australia; Department of Orthopaedic Surgery (Somerville), London Health Sciences Centre, London, Ont
| | - Jacquelyn Marsh
- Faculty of Medicine (Natasha Fernandes, Mathur), University of Ottawa, Ottawa, Ont.; Faculty of Health Sciences (Bryant, Marsh, Moyer) and Schulich School of Medicine and Dentistry (Bryant), The University of Western Ontario, London, Ont.; Department of Clinical Epidemiology and Biostatistics (Bryant, Griffith), Department of Medicine (Nisha Fernandes), Health Sciences Library (Bhatnagar), Department of Family Medicine (Riva) and Division of Gynecologic Oncology (Reade), McMaster University, Hamilton, Ont.; Faculty of Dentistry (El-Rabbany), University of Toronto, Toronto, Ont.; School of Medical and Applied Sciences (Kean), Central Queensland University, Rockhampton, Australia; Department of Orthopaedic Surgery (Somerville), London Health Sciences Centre, London, Ont
| | - Siddhi Mathur
- Faculty of Medicine (Natasha Fernandes, Mathur), University of Ottawa, Ottawa, Ont.; Faculty of Health Sciences (Bryant, Marsh, Moyer) and Schulich School of Medicine and Dentistry (Bryant), The University of Western Ontario, London, Ont.; Department of Clinical Epidemiology and Biostatistics (Bryant, Griffith), Department of Medicine (Nisha Fernandes), Health Sciences Library (Bhatnagar), Department of Family Medicine (Riva) and Division of Gynecologic Oncology (Reade), McMaster University, Hamilton, Ont.; Faculty of Dentistry (El-Rabbany), University of Toronto, Toronto, Ont.; School of Medical and Applied Sciences (Kean), Central Queensland University, Rockhampton, Australia; Department of Orthopaedic Surgery (Somerville), London Health Sciences Centre, London, Ont
| | - Rebecca Moyer
- Faculty of Medicine (Natasha Fernandes, Mathur), University of Ottawa, Ottawa, Ont.; Faculty of Health Sciences (Bryant, Marsh, Moyer) and Schulich School of Medicine and Dentistry (Bryant), The University of Western Ontario, London, Ont.; Department of Clinical Epidemiology and Biostatistics (Bryant, Griffith), Department of Medicine (Nisha Fernandes), Health Sciences Library (Bhatnagar), Department of Family Medicine (Riva) and Division of Gynecologic Oncology (Reade), McMaster University, Hamilton, Ont.; Faculty of Dentistry (El-Rabbany), University of Toronto, Toronto, Ont.; School of Medical and Applied Sciences (Kean), Central Queensland University, Rockhampton, Australia; Department of Orthopaedic Surgery (Somerville), London Health Sciences Centre, London, Ont
| | - Clare J Reade
- Faculty of Medicine (Natasha Fernandes, Mathur), University of Ottawa, Ottawa, Ont.; Faculty of Health Sciences (Bryant, Marsh, Moyer) and Schulich School of Medicine and Dentistry (Bryant), The University of Western Ontario, London, Ont.; Department of Clinical Epidemiology and Biostatistics (Bryant, Griffith), Department of Medicine (Nisha Fernandes), Health Sciences Library (Bhatnagar), Department of Family Medicine (Riva) and Division of Gynecologic Oncology (Reade), McMaster University, Hamilton, Ont.; Faculty of Dentistry (El-Rabbany), University of Toronto, Toronto, Ont.; School of Medical and Applied Sciences (Kean), Central Queensland University, Rockhampton, Australia; Department of Orthopaedic Surgery (Somerville), London Health Sciences Centre, London, Ont
| | - John J Riva
- Faculty of Medicine (Natasha Fernandes, Mathur), University of Ottawa, Ottawa, Ont.; Faculty of Health Sciences (Bryant, Marsh, Moyer) and Schulich School of Medicine and Dentistry (Bryant), The University of Western Ontario, London, Ont.; Department of Clinical Epidemiology and Biostatistics (Bryant, Griffith), Department of Medicine (Nisha Fernandes), Health Sciences Library (Bhatnagar), Department of Family Medicine (Riva) and Division of Gynecologic Oncology (Reade), McMaster University, Hamilton, Ont.; Faculty of Dentistry (El-Rabbany), University of Toronto, Toronto, Ont.; School of Medical and Applied Sciences (Kean), Central Queensland University, Rockhampton, Australia; Department of Orthopaedic Surgery (Somerville), London Health Sciences Centre, London, Ont
| | - Lyndsay Somerville
- Faculty of Medicine (Natasha Fernandes, Mathur), University of Ottawa, Ottawa, Ont.; Faculty of Health Sciences (Bryant, Marsh, Moyer) and Schulich School of Medicine and Dentistry (Bryant), The University of Western Ontario, London, Ont.; Department of Clinical Epidemiology and Biostatistics (Bryant, Griffith), Department of Medicine (Nisha Fernandes), Health Sciences Library (Bhatnagar), Department of Family Medicine (Riva) and Division of Gynecologic Oncology (Reade), McMaster University, Hamilton, Ont.; Faculty of Dentistry (El-Rabbany), University of Toronto, Toronto, Ont.; School of Medical and Applied Sciences (Kean), Central Queensland University, Rockhampton, Australia; Department of Orthopaedic Surgery (Somerville), London Health Sciences Centre, London, Ont
| | - Neera Bhatnagar
- Faculty of Medicine (Natasha Fernandes, Mathur), University of Ottawa, Ottawa, Ont.; Faculty of Health Sciences (Bryant, Marsh, Moyer) and Schulich School of Medicine and Dentistry (Bryant), The University of Western Ontario, London, Ont.; Department of Clinical Epidemiology and Biostatistics (Bryant, Griffith), Department of Medicine (Nisha Fernandes), Health Sciences Library (Bhatnagar), Department of Family Medicine (Riva) and Division of Gynecologic Oncology (Reade), McMaster University, Hamilton, Ont.; Faculty of Dentistry (El-Rabbany), University of Toronto, Toronto, Ont.; School of Medical and Applied Sciences (Kean), Central Queensland University, Rockhampton, Australia; Department of Orthopaedic Surgery (Somerville), London Health Sciences Centre, London, Ont
| |
Collapse
|
38
|
Making trials work in practice: please mind the gap. Eur Urol 2014; 67:250-1. [PMID: 25457498 DOI: 10.1016/j.eururo.2014.10.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2014] [Accepted: 10/02/2014] [Indexed: 11/22/2022]
|
39
|
Tyson JE, Walsh M, D’Angio CT. Comparative effectiveness trials: generic misassumptions underlying the SUPPORT controversy. Pediatrics 2014; 134:651-4. [PMID: 25201795 PMCID: PMC8194469 DOI: 10.1542/peds.2013-4176] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Affiliation(s)
- Jon E. Tyson
- University of Texas Health Science Center at Houston, Houston, Texas
| | - Michele Walsh
- Case Western Reserve University, Cleveland, Ohio; and
| | | |
Collapse
|
40
|
Colli A, Pagliaro L, Duca P. The ethical problem of randomization. Intern Emerg Med 2014; 9:799-804. [PMID: 25194693 DOI: 10.1007/s11739-014-1118-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2014] [Accepted: 08/12/2014] [Indexed: 01/06/2023]
Abstract
The Fondazione Umberto Veronesi ethics committee recently published a statement concerning the inherent ethical issues of randomized clinical trials (RCTs), mainly focusing on randomization, raising many questions, and suggesting possible solutions. The main concern is that the patients enrolled in a RCT are used to improve medical knowledge, but they cannot be the beneficiaries of the results of the trials in which they are participating. Possible solutions come from a wider use of clinical and administrative databases, and an early termination of trials. We discuss this statement, emphasizing that the scientific and ethical reason for embarking on a clinical trial is uncertainty. The uncertainty regarding the comparative benefits and harms of each compared treatment (clinical equipoise) warrants equity in allocation. Randomization allows one to obtain unbiased evidence that we cannot know in advance. The expected probability of a new treatment to be successful describes the limits within which a study can be acceptable both from an ethical as well as a scientific point of view. Most people accept enrollment in a RCT if the probability of success of the experimental treatment is between 50 and 70%. The assumption and concern that there is a conflict between "scientific" and "ethical" aspects of a clinical trial due to randomization should at least be mitigated, considering that only scientifically sounded studies can be considered ethical. Randomization remains the appropriate approach to ensure the study's internal validity. Different aspects seem to be more important, from the ethical point of view, considering RCT and their publication.
Collapse
Affiliation(s)
- Agostino Colli
- Medical Department, Ospedale A Manzoni AO Provincia di Lecco, Via Eremo 9/11, 23900, Lecco, Italy,
| | | | | |
Collapse
|
41
|
Mediation analysis of the relationship between institutional research activity and patient survival. BMC Med Res Methodol 2014; 14:9. [PMID: 24447677 PMCID: PMC3917547 DOI: 10.1186/1471-2288-14-9] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2013] [Accepted: 01/14/2014] [Indexed: 11/10/2022] Open
Abstract
Background Recent studies have suggested that patients treated in research-active institutions have better outcomes than patients treated in research-inactive institutions. However, little attention has been paid to explaining such effects, probably because techniques for mediation analysis existing so far have not been applicable to survival data. Methods We investigated the underlying mechanisms using a recently developed method for mediation analysis of survival data. Our analysis of the effect of research activity on patient survival was based on 352 patients who had been diagnosed with advanced ovarian cancer at 149 hospitals in 2001. All hospitals took part in a quality assurance program of the German Cancer Society. Patient outcomes were compared between hospitals participating in clinical trials and non-trial hospitals. Surgical outcome and chemotherapy selection were explored as potential mediators of the effect of hospital research activity on patient survival. Results The 219 patients treated in hospitals participating in clinical trials had more complete surgical debulking, were more likely to receive the recommended platinum-taxane combination, and had better survival than the 133 patients treated in non-trial hospitals. Taking into account baseline confounders, the overall adjusted hazard ratio of death was 0.58 (95% confidence interval: 0.42 to 0.79). This effect was decomposed into a direct effect of research activity of 0.67 and two indirect effects of 0.93 each mediated through either optimal surgery or chemotherapy. Taken together, about 26% of the beneficial effect of research activity was mediated through the proposed pathways. Conclusions Mediation analysis allows proceeding from the question “Does it work?” to the question “How does it work?” In particular, we have shown that the research activity of a hospital contributes to superior patient survival through better use of surgery and chemotherapy. This methodology may be applied to analyze direct and indirect natural effects for almost any combination of variable types.
Collapse
|
42
|
Rochon J, du Bois A, Lange T. Mediation analysis of the relationship between institutional research activity and patient survival. BMC Med Res Methodol 2014. [PMID: 24447677 DOI: 10.1186/1471‐2288‐14‐9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Recent studies have suggested that patients treated in research-active institutions have better outcomes than patients treated in research-inactive institutions. However, little attention has been paid to explaining such effects, probably because techniques for mediation analysis existing so far have not been applicable to survival data. METHODS We investigated the underlying mechanisms using a recently developed method for mediation analysis of survival data. Our analysis of the effect of research activity on patient survival was based on 352 patients who had been diagnosed with advanced ovarian cancer at 149 hospitals in 2001. All hospitals took part in a quality assurance program of the German Cancer Society. Patient outcomes were compared between hospitals participating in clinical trials and non-trial hospitals. Surgical outcome and chemotherapy selection were explored as potential mediators of the effect of hospital research activity on patient survival. RESULTS The 219 patients treated in hospitals participating in clinical trials had more complete surgical debulking, were more likely to receive the recommended platinum-taxane combination, and had better survival than the 133 patients treated in non-trial hospitals. Taking into account baseline confounders, the overall adjusted hazard ratio of death was 0.58 (95% confidence interval: 0.42 to 0.79). This effect was decomposed into a direct effect of research activity of 0.67 and two indirect effects of 0.93 each mediated through either optimal surgery or chemotherapy. Taken together, about 26% of the beneficial effect of research activity was mediated through the proposed pathways. CONCLUSIONS Mediation analysis allows proceeding from the question "Does it work?" to the question "How does it work?" In particular, we have shown that the research activity of a hospital contributes to superior patient survival through better use of surgery and chemotherapy. This methodology may be applied to analyze direct and indirect natural effects for almost any combination of variable types.
Collapse
Affiliation(s)
- Justine Rochon
- Institute of Medical Biometry and Informatics, University of Heidelberg, Im Neuenheimer Feld 305, Heidelberg 69120, Germany.
| | | | | |
Collapse
|
43
|
Al-Shahi Salman R, Beller E, Kagan J, Hemminki E, Phillips RS, Savulescu J, Macleod M, Wisely J, Chalmers I. Increasing value and reducing waste in biomedical research regulation and management. Lancet 2014; 383:176-85. [PMID: 24411646 PMCID: PMC3952153 DOI: 10.1016/s0140-6736(13)62297-7] [Citation(s) in RCA: 308] [Impact Index Per Article: 30.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
After identification of an important research question and selection of an appropriate study design, waste can arise from the regulation, governance, and management of biomedical research. Obtaining regulatory and governance approval has become increasingly burdensome and disproportionate to the conceivable risks to research participants. Regulation and governance involve interventions that are assumed to be justified in the interests of patients and the public, but they can actually compromise these interests. Inefficient management of the procedural conduct of research is wasteful, especially if it results in poor recruitment and retention of participants in well designed studies addressing important questions. These sources of waste can be minimised if the following four recommendations are addressed. First, regulators should use their influence to reduce other causes of waste and inefficiency in research. Second, regulators and policy makers should work with researchers, patients, and health professionals to streamline and harmonise the laws, regulations, guidelines, and processes that govern whether and how research can be done, and ensure that they are proportionate to the plausible risks associated with the research. Third, researchers and research managers should increase the efficiency of recruitment, retention, data monitoring, and data sharing in research through use of research designs known to reduce inefficiencies, and further research should be done to learn how efficiency can be increased. Finally, everyone, particularly those responsible for health-care systems, should promote integration of research into everyday clinical practice. Regulators and researchers should monitor adherence to each of these recommendations and publish metrics.
Collapse
Affiliation(s)
- Rustam Al-Shahi Salman
- Division of Clinical Neurosciences, Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK.
| | - Elaine Beller
- Centre for Research in Evidence-Based Practice, Bond University, Robina, QLD, Australia
| | - Jonathan Kagan
- Division of Clinical Research, National Institute of Allergy and Infectious Diseases, Bethesda, MD, USA
| | - Elina Hemminki
- National Institute for Health and Welfare, Helsinki, Finland
| | | | | | - Malcolm Macleod
- Division of Clinical Neurosciences, Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | | | | |
Collapse
|
44
|
Peinemann F, Tushabe DA, Kleijnen J. Using multiple types of studies in systematic reviews of health care interventions--a systematic review. PLoS One 2013; 8:e85035. [PMID: 24416098 PMCID: PMC3887134 DOI: 10.1371/journal.pone.0085035] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2013] [Accepted: 11/23/2013] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND A systematic review may evaluate different aspects of a health care intervention. To accommodate the evaluation of various research questions, the inclusion of more than one study design may be necessary. One aim of this study is to find and describe articles on methodological issues concerning the incorporation of multiple types of study designs in systematic reviews on health care interventions. Another aim is to evaluate methods studies that have assessed whether reported effects differ by study types. METHODS AND FINDINGS We searched PubMed, the Cochrane Database of Systematic Reviews, and the Cochrane Methodology Register on 31 March 2012 and identified 42 articles that reported on the integration of single or multiple study designs in systematic reviews. We summarized the contents of the articles qualitatively and assessed theoretical and empirical evidence. We found that many examples of reviews incorporating multiple types of studies exist and that every study design can serve a specific purpose. The clinical questions of a systematic review determine the types of design that are necessary or sufficient to provide the best possible answers. In a second independent search, we identified 49 studies, 31 systematic reviews and 18 trials that compared the effect sizes between randomized and nonrandomized controlled trials, which were statistically different in 35%, and not different in 53%. Twelve percent of studies reported both, different and non-different effect sizes. CONCLUSIONS Different study designs addressing the same question yielded varying results, with differences in about half of all examples. The risk of presenting uncertain results without knowing for sure the direction and magnitude of the effect holds true for both nonrandomized and randomized controlled trials. The integration of multiple study designs in systematic reviews is required if patients should be informed on the many facets of patient relevant issues of health care interventions.
Collapse
Affiliation(s)
- Frank Peinemann
- University of Maastricht, School for Public Health and Primary Care, Maastricht, The Netherlands
- Children's Hospital, University of Cologne, Cologne, Germany
- * E-mail:
| | - Doreen Allen Tushabe
- University of Birmingham, Department of Public Health, Epidemiology & Biostatistics, Birmingham, United Kingdom
| | - Jos Kleijnen
- University of Maastricht, School for Public Health and Primary Care, Maastricht, The Netherlands
- Kleijnen Systematic Reviews Ltd, York, United Kingdom
| |
Collapse
|
45
|
Seruga B, Sadikov A, Cazap EL, Delgado LB, Digumarti R, Leighl NB, Meshref MM, Minami H, Robinson E, Yamaguchi NH, Pyle D, Cufer T. Barriers and challenges to global clinical cancer research. Oncologist 2013; 19:61-7. [PMID: 24323390 DOI: 10.1634/theoncologist.2013-0290] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND There are concerns about growing barriers to cancer research. We explored the characteristics of and barriers to global clinical cancer research. METHODS The American Society of Clinical Oncology International Affairs Committee invited 300 selected oncologists with research experience from 25 countries to complete a Web-based survey. Fisher's exact test was used to compare answers between participants from high-income countries (HICs) and low- and middle-income countries (LMICs). Barriers to clinical cancer research were ranked from 1 (most important) to 8 (least important). Mann-Whitney's nonparametric test was used to compare the ranks describing the importance of investigated obstacles. RESULTS Eighty oncologists responded, 41 from HICs and 39 from LMICs. Most responders were medical oncologists (62%) at academic hospitals (90%). Researchers from HICs were more involved with academic and industry-driven research than were researchers from LMICs. Significantly higher proportions of those who considered their ability to conduct academic research and industry-driven research over the past 5 years more difficult were from HICs (73% vs. 27% and 70% vs. 30%, respectively). Concerning academic clinical cancer research, a lack of funding was ranked the most important (score: 3.16) barrier, without significant differences observed between HICs and LMICs. Lack of time or competing priorities and procedures from competent authorities were the second most important barriers to conducting academic clinical research in HICs and LMICs, respectively. CONCLUSION Lack of funding, lack of time and competing priorities, and procedures from competent authorities might be the main global barriers to academic clinical cancer research.
Collapse
Affiliation(s)
- Bostjan Seruga
- Institute of Oncology Ljubljana, Ljubljana, Slovenia; Faculty of Computer and Information Science, University of Ljubljana, Ljubljana, Slovenia; Latin American-Caribbean Society of Medical Oncology, Buenos Aires, Argentina; Hospital de Clínicas, University of Uruguay, Montevideo, Uruguay; Nizam's Institute of Medical Sciences, Hyderabad, India; Princess Margaret Cancer Center, Toronto, Ontario, Canada; Faculty of Medicine, Cairo University, Cairo, Egypt; Division of Medical Oncology/Hematology, Kobe University Hospital, Kobe, Japan; Faculty of Medicine, Technion, Haifa, Israel; Institute of Advances in Medicine and University of São Paulo, São Paulo, Brazil; American Society of Clinical Oncology, Alexandria, Virginia, USA; University Clinic Golnik, Golnik, Slovenia
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
46
|
|
47
|
Wootton SH, Evans PW, Tyson JE. Unproven therapies in clinical research and practice: the necessity to change the regulatory paradigm. Pediatrics 2013; 132:599-601. [PMID: 24043278 PMCID: PMC3784293 DOI: 10.1542/peds.2013-0778] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Affiliation(s)
| | | | - Jon E. Tyson
- Department of Pediatrics, and,Center for Clinical Research and Evidence-Based Medicine, University of Texas Health Science Center, Houston, Texas; and
| |
Collapse
|
48
|
Hanney S, Boaz A, Jones T, Soper B. Engagement in research: an innovative three-stage review of the benefits for health-care performance. HEALTH SERVICES AND DELIVERY RESEARCH 2013. [DOI: 10.3310/hsdr01080] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BackgroundThere is a widely held assumption that research engagement improves health-care performance at various levels, but little direct empirical evidence.ObjectivesTo conduct a theoretically and empirically grounded synthesis to map and explore plausible mechanisms through which research engagement might improve health services performance. A review of the effects on patients of their health-care practitioner's or institution's participation in clinical trials was published after submission of the proposal for this review. It identified only 13 relevant papers and, overall, suggested that the evidence that research engagement improves health-care performance was less strong than some thought. We aimed to meet the need for a wider review.MethodsAn hourglass review was developed, consisting of three stages: (1) a planning and mapping stage; (2) a focused review concentrating on the core question of whether or not research engagement improves health care; and (3) a wider (but less systematic) review of papers identified during the two earlier stages. Studies were included inthe focused review if the concept of ‘engagementinresearch’ was an input and some measure of ‘performance’ an output. The search strategy covered the period 1990 to March 2012. MEDLINE, EMBASE, PsycINFO, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Web of Science and other relevant databases were searched. A total of 10,239 papers were identified through the database searches, and 159 from other sources. A further relevance and quality check on 473 papers was undertaken, and identified 33 papers for inclusion in the review. A standard meta-analysis was not possible on the heterogeneous mix of papers in the focused review. Therefore an explanatory matrix was developed to help characterise the circumstances in which research engagement might improve health-care performance and the mechanisms that might be at work, identifying two main dimensions along which to categorise the studies:the degree of intentionalityandthe scope of the impact.ResultsOf the 33 papers in the focused review, 28 were positive (of which six were positive/mixed) in relation to the question of whether or not research engagement improves health-care performance. Five papers were negative (of which two were negative/mixed). Seven out of 28 positive papers reported some improvement in health outcomes. For the rest, the improved care took the form of improved processes of care. Nine positive papers were at a clinician level and 19 at an institutional level. The wider review demonstrated, for example, how collaborative and action research can encourage some progress along the pathway from research engagement towards improved health-care performance. There is also evidence that organisations in which the research function is fully integrated into the organisational structure out-perform other organisations that pay less formal heed to research and its outputs. The focused and wider reviews identified the diversity in the mechanisms through which research engagement might improve health care: there are many circumstances and mechanisms at work, more than one mechanism is often operative, and the evidence available for each one is limited.LimitationsTo address the complexities of this evidence synthesis of research we needed to spend significant time mapping the literature, and narrowed the research question to make it feasible. We excluded many potentially relevant papers (though we partially addressed this by conducting a wider additional synthesis). Studies assessing the impact made on clinician behaviour by small, locally conducted pieces of research could be difficult to interpret without full knowledge of the context.ConclusionsDrawing on the focused and wider reviews, it is suggested that when clinicians and health-care organisations engage in research there is the likelihood of a positive impact on health-care performance. Organisations that have deliberately integrated the research function into organisational structures demonstrate how research engagement can, among other factors, contribute to improved health-care performance. Further explorations are required of research networks and schemes to promote the engagement of clinicians and managers in research. Detailed observational research focusing on research engagement within organisations would build up an understanding of mechanisms.Study registrationPROSPERO: CRD42012001990.FundingThe National Institute for Health Research Health Services and Delivery Research programme.
Collapse
Affiliation(s)
- S Hanney
- Health Economics Research Group, Brunel University, Uxbridge, UK
| | - A Boaz
- Faculty of Health, Social Care and Education, St George's, University of London and Kingston University, London, UK
| | - T Jones
- Health Economics Research Group, Brunel University, Uxbridge, UK
| | - B Soper
- Health Economics Research Group, Brunel University, Uxbridge, UK
| |
Collapse
|
49
|
Sackett DL. Six pairs of things to celebrate on International Clinical Trials Day. Trials 2013; 14:128. [PMID: 23688068 PMCID: PMC3720288 DOI: 10.1186/1745-6215-14-128] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2013] [Accepted: 05/03/2013] [Indexed: 11/23/2022] Open
Abstract
The Editor has invited me to mark the occasion with a few words "on the development and/or impact of randomised trials over the last decade, or perhaps some thoughts about the future." I do so here by citing some recent developments that give me cause for both pride about the present state of randomised controlled trials (RCTs) and optimism about their future. Respecting the sample size of James Lind's trial and the space allotted me by the Editor, they appear in six pairs.
Collapse
|
50
|
Hemmingsen B, Schroll JB, Lund SS, Wetterslev J, Gluud C, Vaag A, Sonne DP, Lundstrøm LH, Almdal T. Sulphonylurea monotherapy for patients with type 2 diabetes mellitus. Cochrane Database Syst Rev 2013:CD009008. [PMID: 23633364 DOI: 10.1002/14651858.cd009008.pub2] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Type 2 diabetes mellitus (T2DM) is a growing health problem worldwide. Whether sulphonylureas show better, equal or worse therapeutic effects in comparison with other antidiabetic interventions for patients with T2DM remains controversial. OBJECTIVES To assess the effects of sulphonylurea monotherapy versus placebo, no intervention or other antidiabetic interventions for patients with T2DM. SEARCH METHODS We searched publications in The Cochrane Library, MEDLINE, EMBASE, Science Citation Index Expanded, LILACS and CINAHL (all until August 2011) to obtain trials fulfilling the inclusion criteria for our review. SELECTION CRITERIA We included clinical trials that randomised patients 18 years old or more with T2DM to sulphonylurea monotherapy with a duration of 24 weeks or more. DATA COLLECTION AND ANALYSIS Two authors independently assessed the risk of bias. The primary outcomes were all-cause and cardiovascular mortality. Secondary outcomes were other patient-important outcomes and metabolic variables. Where possible, we used risk ratios (RR) with 95% confidence intervals (95% CI) to analyse the treatment effect of dichotomous outcomes. We used mean differences with 95% CI to analyse the treatment effect of continuous outcomes. We evaluated the risk of bias. We conducted trial sequential analyses to assess whether firm evidence could be established for a 10% relative risk reduction (RRR) between intervention groups. MAIN RESULTS We included 72 randomised controlled trials (RCTs) with 22,589 participants; 9707 participants randomised to sulphonylureas versus 12,805 participants randomised to control interventions. The duration of the interventions varied from 24 weeks to 10.7 years. We judged none of the included trials as low risk of bias for all bias domains. Patient-important outcomes were seldom reported.First-generation sulphonylureas (FGS) versus placebo or insulin did not show statistical significance for all-cause mortality (versus placebo: RR 1.46, 95% CI 0.87 to 2.45; P = 0.15; 2 trials; 553 participants; high risk of bias (HRB); versus insulin: RR 1.18, 95% CI 0.88 to 1.59; P = 0.26; 2 trials; 1944 participants; HRB). FGS versus placebo showed statistical significance for cardiovascular mortality in favour of placebo (RR 2.63, 95% CI 1.32 to 5.22; P = 0.006; 2 trials; 553 participants; HRB). FGS versus insulin did not show statistical significance for cardiovascular mortality (RR 1.36, 95% CI 0.68 to 2.71; P = 0.39; 2 trials; 1944 participants; HRB). FGS versus alpha-glucosidase inhibitors showed statistical significance in favour of FGS for adverse events (RR 0.63, 95% CI 0.52 to 0.76; P = 0.01; 2 trials; 246 participants; HRB) and for drop-outs due to adverse events (RR 0.28, 95% CI 0.12 to 0.67; P = 0.004; 2 trials; 246 participants; HRB).Second-generation sulphonylureas (SGS) versus metformin (RR 0.98, 95% CI 0.61 to 1.58; P = 0.68; 6 trials; 3528 participants; HRB), thiazolidinediones (RR 0.92, 95% CI 0.60 to 1.41; P = 0.70; 7 trials; 4955 participants; HRB), insulin (RR 0.96, 95% CI 0.79 to 1.18; P = 0.72; 4 trials; 1642 participants; HRB), meglitinides (RR 1.44, 95% CI 0.47 to 4.42; P = 0.52; 7 trials; 2038 participants; HRB), or incretin-based interventions (RR 1.39, 95% CI 0.52 to 3.68; P = 0.51; 2 trials; 1503 participants; HRB) showed no statistically significant effects regarding all-cause mortality in a random-effects model. SGS versus metformin (RR 1.47; 95% CI 0.54 to 4.01; P = 0.45; 6 trials; 3528 participants; HRB), thiazolidinediones (RR 1.30, 95% CI 0.55 to 3.07; P = 0.55; 7 trials; 4955 participants; HRB), insulin (RR 0.96, 95% CI 0.73 to 1.28; P = 0.80; 4 trials; 1642 participants; HRB) or meglitinide (RR 0.97, 95% CI 0.27 to 3.53; P = 0.97; 7 trials, 2038 participants, HRB) showed no statistically significant effects regarding cardiovascular mortality. Mortality data for the SGS versus placebo were sparse. SGS versus thiazolidinediones and meglitinides did not show statistically significant differences for a composite of non-fatal macrovascular outcomes. SGS versus metformin showed statistical significance in favour of SGS for a composite of non-fatal macrovascular outcomes (RR 0.67, 95% CI 0.48 to 0.93; P = 0.02; 3018 participants; 3 trials; HRB). The definition of non-fatal macrovascular outcomes varied among the trials. SGS versus metformin, thiazolidinediones and meglitinides showed no statistical significance for non-fatal myocardial infarction. No meta-analyses could be performed for microvascular outcomes. SGS versus placebo, metformin, thiazolidinediones, alpha-glucosidase inhibitors or meglitinides showed no statistical significance for adverse events. SGS versus alpha-glucosidase inhibitors showed statistical significance in favour of SGS for drop-outs due to adverse events (RR 0.48, 95% CI 0.24 to 0.96; P = 0.04; 9 trials; 870 participants; HRB). SGS versus meglitinides showed no statistical significance for the risk of severe hypoglycaemia. SGS versus metformin and thiazolidinediones showed statistical significance in favour of metformin (RR 5.64, 95% CI 1.22 to 26.00; P = 0.03; 4 trials; 3637 participants; HRB) and thiazolidinediones (RR 6.11, 95% CI 1.57 to 23.79; P = 0.009; 6 trials; 5660 participants; HRB) for severe hypoglycaemia.Third-generation sulphonylureas (TGS) could not be included in any meta-analysis of all-cause mortality, cardiovascular mortality or non-fatal macro- or microvascular outcomes. TGS versus thiazolidinediones showed statistical significance regarding adverse events in favour of TGS (RR 0.88, 95% CI 0.78 to 0.99; P = 0.03; 3 trials; 510 participants; HRB). TGS versus thiazolidinediones did not show any statistical significance for drop-outs due to adverse events. TGS versus other comparators could not be performed due to lack of data.For the comparison of SGS versus FGS no meta-analyses of all-cause mortality, cardiovascular mortality, non-fatal macro- or microvascular outcomes, or adverse events could be performed.Health-related quality of life and costs of intervention could not be meta-analysed due to lack of data.In trial sequential analysis, none of the analyses of mortality outcomes, vascular outcomes or severe hypoglycaemia met the criteria for firm evidence of a RRR of 10% between interventions. AUTHORS' CONCLUSIONS There is insufficient evidence from RCTs to support the decision as to whether to initiate sulphonylurea monotherapy. Data on patient-important outcomes are lacking. Therefore, large-scale and long-term randomised clinical trials with low risk of bias, focusing on patient-important outcomes are required.
Collapse
Affiliation(s)
- Bianca Hemmingsen
- CopenhagenTrialUnit,Centre forClinical InterventionResearch,Department 7812,Rigshospitalet,CopenhagenUniversityHospital,Copenhagen,Denmark.
| | | | | | | | | | | | | | | | | |
Collapse
|